Discussion Week 4 - Assignment Essays

Week 4: Epidemiology & Disaster Management

Part I Epidemiology Discussion:

Find a general news article that pertains to public health either nationally, state, or locally. It is important that your information is not older than approximately 14-30 days and was published in the general mainstream news media, newspapers, general circulation magazines, and website news (not professional literature).

There are enough public health issues in the news so no credit will be given for duplicate articles within groups. Thus, if you know which article you will use, it’s okay to post that information in your group’s discussion prior to your initial post.

1. Attach a link to the original source or copy (control c) and paste it (control v) into the D2L discussion.

2. Describe the issue.

3. Using resources from week 1- identify the role of public health in addressing the issue. Cite sources.

4. Using resources from this week, how will the tools of epidemiology assist in identifying ways to intervene in this problem? Cite sources.

5. Identify and describe one Public Health Intervention (hint 17 wedges pick something other than health education/teaching) that could be used as an action to address this issue.

Part 2 Disaster Management Discussion:

Using three of the topic resources, text, movie, online simulation, or PDF articles, complete the following questions and post to your discussion group. References to at least three separate resources must be cited in your answers and referenced at the end of your posting.

1. Identify and differentiate key strategies used by each WHO, CDC, and State Department of Health in managing a global crisis.

2. Describe the health and safety hazards of disasters and public health emergencies.

3. From your activities or experiences, briefly describe a few safety and infection control measures, including personal protective equipment, you have implemented during the Covid-19 pandemic and why they are essential for public health during a disaster.

4. Emergency preparedness brings up the rights of the individual versus the good of all (ethics/social justice). Identify and discuss an issue from the course resources that illustrate this conflict.

5. As nurses you will be on the front line in emergency preparedness. What are moral/ethical issues that arise for you personally/professionally? Why? Refer to course content.

6. Locate the website for the Public Health Emergency Preparedness Agency (national, state, or local community). Choose one useful topic link and share a summary with your group.

PART I
Foundational Concepts

for Public Health
Nursing Practi

1 Introduction to Public Health Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2 Evidence-Based Public Health Nursing Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

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AN: 1917387 ; Patricia M. Schoon, Carolyn M. Porta, Marjorie A. Schaffer.; Population-Based Public Health Clinical Manual, Third Edition: The Henry Street Model
for Nurses
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‘‘

’’

CHAPTER

1Introduction to Public
Health Nursing Practice

n Patricia M. Schoon
with Marjorie A. Schaffer and Jill Timm

Abby will soon be starting her public health nursing clinical and is struggling with the idea of practicing
nursing outside the hospital. She is talking about public health clinicals with Alberto and Sia at lunch.
“I can’t imagine myself out in someone’s home, or in a school, or in a community center or public health
agency. I’m not sure I know what I’m supposed to do. I also wonder how I will be respected without scrubs
or my uniform. Is it really true that one of the most important skills in public health is listening and that
sometimes that is all that you do? I feel like I should be doing something more.”

Alberto responds, “My friend, Zack, had public health last semester. He said that it was interesting to
consider listening as its own intervention. It was hard to not jump in and ‘teach’ immediately. He often
wanted to do more. After a while, he started to get comfortable and also started to understand the benefits
of really trying to understand the perspectives of clients in the community.”

Sia comments, “I worry about all of this too. I was talking with Jen, a friend of mine who took public
health last year. She said that on her first home visit, she went with her public health nursing preceptor.
This gave her a chance to get a sense for the family’s needs and possible interventions.”

Abby says, “I am really worried about being out alone. I wonder what the neighborhood where my
family lives will be like and whether I will be safe.”

Sia states, “I’m also curious about the various public health nursing roles that we may be able to
observe or do. It seems like the field is so broad and there are so many things to consider.”

ABBY’S NOTEBOOK

USEFUL DEFINITIONS

Client: A client (syn. patient) is the individual/family, community, population or subpopulation, or system that is
the public health nurse’s focus of care.

Community: A community can refer to (a) a group of people or a population group, (b) a physical place and time
in which the population lives and works, or (c) a cultural group that has shared beliefs, values, institutions, and
social systems (Dreher, Shapiro, & Asselin, 2006, p. 23).

Health Determinants: Health determinants are factors that influence the health of individuals, families, and
populations. Health determinants can potentially have a positive (protective factors) or negative (risk factors)
influence on health.

Health Status: Health status refers to the level of health or illness and is the outcome of the interaction of the
multiple health determinants. Health status indicators, also called global measures of population health, include
birth, longevity, and death rates (mortality); illness (morbidity) patterns; perception of wellness and life satisfac-
tion; level of independence; and functional ability.

(continues)

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4 PART I n Foundational Concepts for Public Health Nursing Practice

USEFUL DEFINITIONS (continued)

Holistic Nursing: Holistic nursing is defined as “all nursing practice that has healing the whole person as its goal
and honors relation-centered care and the interconnectedness of self, others, nature, and spirituality; focuses on
protecting, promoting health and wellness…” (Dossey & Keegan, 2016, p. 3).

Levels of Prevention: The levels of prevention comprise a health-intervention framework applied to the stages of
health and disease for individuals and groups (Leavell & Clark, 1958; Stanhope & Lancaster, 2008). The levels of
prevention are (a) primary—the prevention of disease and promotion of health; (b) secondary—early diagnosis
and treatment; and (c) tertiary— limiting of negative effects of disease and restoring of function.

Population: A population is defined as the “total number of people living in a specific geographic area.”
A subpopulation (syn. group or aggregate) “consist[s] of people experiencing a specific health condition;
engaging in behaviors that have potential to negatively affect health; or sharing a common risk factor or ris

exposure, or experiencing an emerging health threat or risk” (American Nurses Association [ANA], 2013, p. 3).

Population-Based Practice: Population-based practice focuses on the population as a whole to determine its
priority needs (Minnesota Department of Health [MDH], 2001).

Public Health: Public health refers to all organized measures (whether public or private) to prevent disease,
promote health, and prolong life among the population as a whole (World Health Organization [WHO], n.d.).

Public Health Nursing: Public health nursing is the practice of promoting and protecting the health of popula-
tions using knowledge from nursing, social, and public health sciences. Public health nursing is a specialty prac-
tice within nursing and public health. It focuses on improving population health by emphasizing prevention and
attending to multiple determinants of health. Often used interchangeably with community health nursing, this
nursing practice includes advocacy, policy development, and planning, which addresses issues of social justice
(American Public Health Association [APHA], Public Health Nursing Section, 2013, p. 1).

Social Determinants of Health: The social determinants of health are the conditions in which people are born,
grow, live, work, and age. The distribution of money, power, and resources at the global, national, and local levels
shape these circumstances. The social determinants of health are mostly responsible for health inequities—
the unfair and avoidable differences in health status seen within and between countries (Modified from
WHO, 2013).

System: A system is an institution or organization that exists within one or multiple communities.

ABBY’S NOTEBOOK

Practicing Nursing Where We All Live
Public health nursing care is provided to individu-
als, families, communities, and populations through a
population-based lens that enables nurses to view their cli-
ents within the context of the community in which they and
their clients live . All aspects of the client’s life are considered
as public health nurses (PHNs) carry out the nursing pro-
cess . PHNs practice in their communities, where they can
make a difference in the lives of their families, the people
they serve, and their communities on a daily basis .

As you practice nursing in a variety of clinical settings,
you will become aware that the health of people in your
families, neighborhoods, and communities affects every-
one in the community both socially and economically .
As you read this chapter, consider the concepts presented
from both your personal and professional perspectives . As
nurses, you are all citizens of the world and have civic and

professional responsibilities to promote health and provide
for a safe environment .

In the case study at the beginning of the chapter, Abby
and her friends are concerned about providing nursing
care in the community . It is difficult for nursing students
to think about practicing nursing outside the acute and
long-term care settings . Many of the skills that nursing stu-
dents learn in the acute or long-term care setting (e .g ., IV
therapy, medication administration, tube care) are part of
the delegated medical functions of nursing practice, which,
by necessity, are priorities when caring for acutely ill, frail,
and elderly individuals . In the community setting, most of
what PHNs do is part of the independent practice of nursing
(e .g ., teaching, counseling, coordinating care), as the focus
of public health nursing practice is primary prevention .
Components of public health nursing can be practiced in
any setting, although they are most often practiced in the

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5CHAPTER 1 n Introduction to Public Health Nursing Practice

whole to determine the community’s priority health needs
(Minnesota Department of Health [MDH], Public Health
Nursing Section, 2000, 2001; MDH, Center for Public Health
Nursing, 2003) . PHNs in a variety of work settings can carry
out population-based practice . To be population based, pub-
lic health nursing practice should meet five criteria:

1. Focus on entire populations possessing similar health
concerns or characteristics

2. Be guided by an assessment of population health
status that is determined through a community
health assessment process

3. Consider the broad determinants of health
4. Consider all levels of prevention, with a preference

for primary prevention
5. Consider all levels of practice (individual/ family,

community, system) (MDH, 2001, pp . 2–3;
MDH, 2003)

PHNs work in homes, clinics, schools, jails, businesses,
religious organizations, homeless shelters, camps, hospitals,
visiting nurse associations, health departments, and Indian
reservations . Public health nursing is defined by its goals,
not by its setting . Although public health nursing is con-
sidered a specialty area of practice, its standards include
expectations for entry-level baccalaureate nursing gradu-
ates . Even at the entry level, PHNs are expected to function
as change agents and to help shape the healthcare system
to meet the public health needs of the 21st century . This
leadership expectation for public health nursing practice is
implicit in the American Nurses Association’s Public Health
Nursing: Scope and Standards of Practice (ANA, 2013) . The
American Public Health Association (APHA) definition of
public health nursing, “the practice of promoting and pro-
tecting the health of populations using knowledge from
nursing, social, and public health sciences” (APHA, 2013,
p . 2), implies the importance of the scientific knowledge
base for PHN practice .

community . Not all nursing practiced in the community
can be described as public health nursing . For example,
home care and hospice care, both very important areas of
nursing, are practiced in the community and exhibit com-
ponents of public health nursing but are not traditionally
categorized as public health nursing . As you work through
this book and engage in nursing activities, think about how
you are integrating the components of public health nursing
into your nursing practice . Also, think about how you prac-
tice nursing where you live and what your civic and pro-
fessional responsibilities are to promote the health of your
community .

Public

Health

The practice of public health nursing includes components
of public health and is a part of the broader field of public
health . It is important to understand the nature and scope
of public health practice . Public health practice focuses on
protecting and promoting the health of entire populations .
This practice includes the prevention of disease and injury
and the promotion of the social conditions and lifestyles
that maintain health and prolong life .

Public health professionals monitor and diagnose the
health concerns of entire communities and promote healthy
practices and behaviors to ensure that populations stay
healthy . The World Health Organization uses the term
“global public health” to recognize that, as a result of glo-
balization, forces that affect public health can and do come
from outside state boundaries . Responding to public health
issues now requires paying attention to cross-border health
risks, including access to dangerous products and environ-
mental change (WHO, n .d .) . PHNs need to take a global
perspective about the nature of population health threats
and issues when practicing in the community .

Public Health Nursing
Public health nursing combines the theory and practice
of nursing and public health . Public health nursing, like
nursing practice everywhere, involves the interaction of the
nurse and client; the health of the client; the influence of the
home, healthcare, and community environment; and the
nursing care provided . One of the unique features of pub-
lic health nursing is that the client can be an individual or
family, a group of people, or a whole community . The client
could also be a system within the community (e .g ., a school,
church, or community health or social service agency) .
PHNs work to improve population health at the local, state,
national, and international levels (ANA, 2013; APHA, 2013) .
Public health nursing goals are to promote and preserve
the health of populations and the public, prevent disease
and disability, and protect the health of the community as
a whole .

Public health nursing practice is considered population-
based because it starts by focusing on the population as a

Definition of Public Health Nursing Practice

Up to this point in your nursing education, you have focused
on nursing care of individuals and families. Public health
nursing is population based and focuses on population
health. “Public health nursing is the practice of promoting
and protecting the health of populations using knowledge
from nursing, social, and public health sciences. Public
health nursing is a specialty practice within nursing and
public health. It focuses on improving population health by
emphasizing prevention, and attending to multiple deter-
minants of health” (APHA, 2013, p. 1). While public health
nursing practices include primary, secondary, and tertiary
prevention, the focus is on primary prevention.

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6 PART I n Foundational Concepts for Public Health Nursing Practice

in 1881 (Kulbok, Thatcher, Park, & Meszaros, 2012; Kub,
Kulbok, & Glick, 2015; see Figure 1 .1) . PHNs saw themselves
not only as caregivers but also as advocates for those living
in unhealthy conditions and experiencing unmet health-
care needs . Care of the ill soon expanded to care of those
at risk for poor health and to populations and entire com-
munities . Disease prevention and health promotion for vul-
nerable or at-risk populations in diverse settings became a
second focus .

Until the late 1960s, PHNs working for governmental
public health agencies generally provided services to two
at-risk populations: mothers and children, and adults living
at home with chronic diseases and disabilities . When Medi-
care legislation was enacted in 1966, home care became a
covered service, and private agencies began to offer home
care services (see Chapter 7) . Many public health agencies
renewed their commitment to the goals of health promotion,
disease prevention, and protection and risk reduction, and
they stopped providing home care to adults with chronic
diseases and disabilities . PHNs increased their efforts to
address the social determinants of health, which are dis-
cussed later in this chapter . Today, public health nurses
often work with community groups as well as individuals
and families . Community engagement, population-based
advocacy, collaboration with other community agencies
and groups, and community organizing are all part of the
scope of practice of public health nurses (see Chapters 2, 5,
and 10) . At the same time, nurses practicing in a variety of
non-traditional public health settings (e .g ., home care, hos-
pice, faith-based nursing, institutional and insurance care
coordination and care management, etc .) use public health
nursing principles and public health interventions in their
practice .

Emerging threats to public health require a dramatic shift
in the focus of healthcare, public health, and public health
nursing . ANA (2013, p . 2) has identified six 21st- century
threats that form a context for the current and future direc-
tions of public health nursing practice:

1. Reemergence of communicable disease and increas-
ing incidence of drug-resistant organisms

2. Environmental hazards
3. Physical or civic barriers to healthy lifestyles (e .g .,

food “deserts”)
4. Overall concern about the structure and function of

the healthcare system
5. Challenges imposed by the presence of modern

public health epidemics, such as pandemic influenza,
obesity, and tobacco-related diseases and deaths

6. Global and emerging crises with increased opportu-
nities for exposure to multiple health threats

Nursing continues to expand its leadership role in
healthcare in all settings, but in public health nursing, that
leadership role often takes place in the community, includ-
ing in the public policy–making arena (ANA, 2003, 2013) .

As students, you have already learned about nursing
core concepts that also shape public health nursing, which
include (Keller, Strohschein, & Schaffer, 2011):
n Care and compassion
n Holistic and relationship-centered practice
n Sensitivity to vulnerable populations
n Independent nursing practice

This book also introduces you to additional public health
core concepts that shape public health nursing, which
include (Keller et al ., 2011):
n Social justice
n Population focus
n Reliance on epidemiology
n Health promotion and prevention
n The greater good
n Long-term commitment to community

Evolution of Public Health Nursing
In this chapter, you will read about how nurses practice pub-
lic health nursing in the community, and you will consider
how important nurses are to the health of communities at
the local, national, and international levels . It is important
to mention two key founders of public health nursing . Since
the time of Florence Nightingale, the first public health
nurse, nurses have always been essential participants in
improving and maintaining the health of individuals, fami-
lies, and communities . Nightingale, who started her nursing
career in 1850, provided leadership for the health of vulner-
able populations by advocating for changes in the organiza-
tions and communities that were responsible for providing
healthcare (Selanders & Crane, 2012) . Nightingale focused
on managing the environment of those who needed care,
whether it was on the Crimean War battlefields or work-
ing with the London poor . Her concerns about the impact
environmental conditions had on health and her work to
advocate for healthful environments is as relevant today as
it was in the 1800s (Davies, 2012) . Lillian Wald, the founder
of modern-day public health nursing, founded the Henry
Street Settlement in 1893 to provide nursing services to the
indigent citizens of New York . In 1903, Wald, in collabo-
ration with Metropolitan Life, started the first insurance
reimbursement for nurse home visiting and demonstrated
its effectiveness (Abrams, 2008; Buhler-Wilkerson, 1993) .
The Henry Street Settlement House continues to provide
health and social services today .

Public health nursing in the United States developed out
of a need to provide nursing services to individuals and
families who had unmet health needs, and started with
Clara Barton, who founded the American Red Cross as a
response to the needs of injured and ill Civil War soldiers

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7CHAPTER 1 n Introduction to Public Health Nursing Practice

‘‘

’’

Cornerstones of Public Health Nursing
The Cornerstones of Public Health Nursing (Minnesota
Department of Health [MDH], Center for Public Health
Nursing, 2007) provide the foundation for population-based
nursing practice (Keller et al ., 2011) . The Cornerstones reflect
the values and beliefs that guide public health nursing prac-
tice, and they are also closely related to the ANA Principles
of Public Health Nursing Practice (ANA, 2013), as repre-
sented in Table 1 .1 .

These Cornerstones are reflected in PHNs’ daily practice
when they:
n Organize their workload and schedule based on priority

health needs of clients and comm

unity

n Take time to establish trust when visiting families in

their homes
n Carry out holistic assessments of individuals and

families within the context of culture, ethnicity, and
communities

n Use evidence-based practice from nursing and pub-
lic health sciences to select appropriate and effective
interventions

n Collaborate with other members of the healthcare team
n Make critical decisions about the needs of their clients

and the selection, implementation, and evaluation of
interventions based on their professional knowledge and
professional licensure

A key principle to keep in mind is that PHNs must place
more importance on goals related to the public good than
goals for the benefit of individuals in the social and eco-
nomic systems (see Chapter 13 for a discussion of social jus-
tice and Chapter 14 for a discussion of public health nursing
leadership) .

“I still don’t really understand how we are going to factor in
community or environmental needs when we are working
with individuals.” Albert sighs.

Sia responds, “What I remember from our public health
theory class this morning is that even though we are meet-
ing people in their homes, we have to take into account the
home environment and the community. Our instructor
also talked about public health nurses having a responsibil-
ity to improve the health of the public at the local, national,
and international levels. She mentioned that this idea can
be overwhelming for nursing students and suggested that
we focus on what we could do to improve the health of indi-
viduals and families as a way to help improve the health of
our community. She used the term ‘glocal,’ which means to
think global, but act local.”

Abby adds, “Maybe we should read more about this in
our textbook and look at some of the websites suggested.”

“Good idea,” says Sia.

FIGURE 1.1 Public Health Nursing in the United States
Sources: Abrams, 2008; Buhler-Wilkerson, 1993; Kub, Kulbok, & Glick, 2015;

Visiting Nurses Association of Western New York, n.d.

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8 PART I n Foundational Concepts for Public Health Nursing Practice

‘‘

’’

and developmental delays. Abby’s PHN preceptor modifies
her home-visiting plan for the day so that she can make
an initial visit to this family at the local family homeless
shelter. The family speaks Spanish but the PHN does not, so
she arranges for an interpreter to accompany them on the
visit to this family. The PHN has Abby gather information
about local homeless shelters and food banks to take to the
visit and has her get some bus passes for the family to use
when they go to different agencies to apply for assistance.
The PHN also brings along important phone numbers so
that she can assist the family with follow-up regarding their
application for cash assistance. After her busy day with her
PHN preceptor, Abby discusses her visit to the homeless
family with Alberto and Sia that evening. Their instructor
has challenged them to identify the Cornerstones of Public
Health Nursing found in their clinical visits that day.

Activity
Keep a log of your nursing activities. Reflect on how you have
demonstrated the cornerstones of public health nursing in your
clinical activities.

Abby is spending the day with her PHN preceptor. Her pre-
ceptor receives a referral to visit a family who just moved
into the community and is homeless. The PHN knows
that a health priority for her community and agency is to
improve the health of homeless populations, particularly
those in the population with young children. Recent data on
the health needs of her county demonstrate that young chil-
dren in homeless families have higher rates of malnutrition

TABLE 1.1 Cornerstones of Public Health Nursing and Related ANA Principles of PHN Practice

Cornerstones of Public Health Nursing ANA Principles of Public Health Nursing Practice

Focuses on the health of entire populations The client or unit of care is the population .

Reflects community priorities and needs The primary obligation is to achieve the greatest good for the greatest
number of people or the population as a whole (also related to the
social justice cornerstone) .

Establishes caring relationships with communities,
systems, individuals, and families

Is grounded in social justice, compassion, sensitivity to
diversity, and respect for the worth of all people, especially
the vulnerable

A public health nurse is obligated to actively identify and reach out to
all who might benefit from a specific activity or service .

Encompasses mental, physical, emotional, social, spiritual,
and environmental aspects of health

Public health nursing focuses on strategies that create healthy envi-
ronmental, social, and economic conditions in which populations
may thrive .

Promotes health through strategies driven by
epidemiological evidence

Optimal use of available resources and creation of new evidence-
based strategies is necessary to ensure the best overall improvement
in the health of the population .

Primary prevention is the priority in selecting appropriate activities .

Collaborates with community resources to achieve those
strategies but can and will work alone if necessary

Public health nurses collaborate with the client as an equal partner .

Collaboration with other professions, populations, organizations, and
stakeholder groups is the most effective way to promote and protect
the health of the people .

Derives its authority for independent action from the
Nurse Practice Act

Sources for Cornerstones: Keller et al ., 2011; MDH, Center for Public Health Nursing, 2007
Source for ANA Principles: ANA, 2013, pp . 8–9

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9CHAPTER 1 n Introduction to Public Health Nursing Practice

Holistic Foundations of
Public Health Nursing
Public health nursing and holistic nursing practice have
common roots . Florence Nightingale, who believed in care
that focused on unity, wellness, and the interrelationship of
human beings and their environment, is considered to be
one of the first holistic nurses . She is known for her global
vision, leadership, and advocacy (Beck, 2010; Dossey &
Keegan, 2016; Selanders & Crane, 2012) . Lillian Wald was
as concerned about the health of the indigent of New York
as she was about their social welfare, the tenement envi-
ronment in which they lived, and the cultural and political
environment that needed to change in order to improve the
health of her clients and her community (Buhler- Wilkerson,
1993) . Both Nightingale’s and Ward’s nursing practices have
informed contemporary holistic public health nursing
practice .

A contemporary nursing theory that reflects the synthe-
sis of nursing and public health and reflects holistic pub-
lic health nursing practice is Watson’s Theory of Human
Caring, in which the nurse and the client exist within a
caring-healing environment . Watson was greatly influenced
by the practice of Florence Nightingale and built upon Night-
ingale’s work in emphasizing the “curative factors” of dis-
ease and illness, embracing the wholeness of the individual .
The Theory of Human Caring reflects an expansive sharing
process that changes the self, others, the culture, and the

environment; respects the beliefs of others; and recognizes
and is open to unexpected life events (Parker & Smith, 2010;
Watson, 2008, p . 34, 2010) . Some of the public health nursing
theoretical perspectives that you will find in later chapters
reflect this synthesis of public health nursing and holistic
nursing into holistic public health nursing practice .

Scope and Standards of
Public Health Nursing Practice
All professional nurses, regardless of their clinical areas of
practice, have a scope of practice . A scope of practice refers
to the boundaries of safe and ethical practice (see Chapter 6
for a discussion of the scope of practice of public health
nursing) and depends on four components: educational
preparation, credentials, state licensure law, and clinical or
employer role description . A PHN’s job description is a good
measure of the nurse’s scope of practice .

Professional nurses are also guided by standards of prac-
tice developed by their professional nursing organizations .
One nationally accepted set of standards for public health
nursing is the American Nurses Association (ANA) publi-
cation Public Health Nursing: Scope and Standards of Prac-
tice (2013); Table 1 .2 lists these standards . Specific criteria
for operationalizing these standards and measuring perfor-
mance are included in the publication .

TABLE 1.2 Standards of Public Health Nursing Practice and Professional Performance

Standards of Public Health Nursing Practice

Standard 1. Assessment: The public health nurse collects comprehensive data pertinent to the health status of populations .

Standard 2. Population Diagnosis and Priorities: The public health nurse analyzes the assessment data to determine the diagnosis
or issues .

Standard 3. Outcomes Identification: The public health nurse identifies expected outcomes for a plan specific to the population or
issues .

Standard 4. Planning: The public health nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes .

Standard 5. Implementation: The public health nurse implements the identified plan .

Standard 5A. Coordination of Care: The public health nurse coordinates care delivery .

Standard 5B. Health Teaching and Health Promotion: The public health nurse employs multiple strategies to promote health and a
safe environment .

Standard 5C. Consultation: The public health nurse provides consultation to influence the identified plan, enhance the abilities of
others, and effect change .

Standard 5D. Prescriptive Authority: Not applicable .

Standard 5E. Regulatory Activities: The public health nurse participates in the application of public health laws, regulations,
and policies .

Standard 6. Evaluation: The public health nurse evaluates progress toward the attainment of outcomes .

Standard 7. Ethics: The public health nurse practices ethically .

(continues)

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10 PART I n Foundational Concepts for Public Health Nursing Practice

Standards of Professional Performance

Standard 8: Education: The public health nurse attains knowledge and competence that reflect current nursing practice .

Standard 9. Evidence-based Practice & Research: The public health nurse integrates evidence and research findings into practice .

Standard 10. Quality of Practice: The public health nurse contributes to quality nursing practice .

Standard 11. Communication: The public health nurse communicates effectively in a variety of formats in all areas of practice .

Standard 12. Leadership: The public health nurse demonstrates leadership in the professional practice setting and the profession .

Standard 13. Collaboration: The public health nurse collaborates with the population and others in the conduct of nursing practice .

Standard 14. Professional Practice Evaluation: The public health nurse evaluates her or his own nursing practice in relation to
professional practice standards and guidelines, relevant statutes, rules, and regulations .

Standard 15. Resource Utilization: The public health nurse utilizes appropriate resources to plan and provide nursing and public
health services that are safe, effective, and financially responsible .

Standard 16. Environmental Health: The public health nurse practices in an environmentally safe, fair, and just manner .

Standard 17. Advocacy: The public health nurse advocates for the protection of the health, safety, and rights of the population .

Source: American Nurses Association, 2013, pp . 28–64

TABLE 1.2 Standards of Public Health Nursing Practice and Professional Performance (continued)

Activity
n Review your preceptor’s job description with your preceptor.

n Share the list of the ANA practice standards for public
health nursing.

n Discuss how your preceptor’s job description and nursing
practice incorporate specific ANA standards.

Global Nature of Public Health Nursing
Public health nurses are citizens of the world as well as
their own communities . Travel, communication technol-
ogy, immigration patterns, the global spread of disease, and
the universality of the social determinants of health in all
geographic areas and cultures have changed the nature of
public health nursing practice .

In 2015, the United Nations (UN) General Assembly
adopted resolution 70/1. Transforming Our World: The 2030
Agenda for Sustainable Development (2015) . This resolution
addresses the social determinants of health at a global level
and sets out an action plan for people, the planet, prosper-
ity, peace, and partnership . This action plan identifies 17
Sustainable Development Goals (SDGs) . These goals, repre-
sented by the following set of icons (see Figure 1 .2), provide
a framework for the public health nursing practice wherever
PHNs practice . Examples of how SDGs are addressed will
be highlighted throughout the chapters of this book .

EVIDENCE EXAMPLE 1.1
Health in All Policies

In 2017, an International Health in All Policies Conference
was convened in Adelaide, Australia to strategize over how
to make progress in achieving the SDGs. A major outcome
of the conference was Health in All Policies: Governance, Part-
nerships and the Sustainable Development Agenda, Adelaide
Statement II on Health in All Policies 2017.
The statement stresses that:

n “Health is a political choice, and as such any political,
economic, social and ecological decision has health and
equity impacts. Mayors play a critical role in agenda
2030 and health.

n The SDGs are indivisible and universal and should not
be addressed in silos but rather through taking into
consideration their interconnectedness.

n The transformative strategies for implementing the
SDGs require joint action and policy coherence through
the various levels of the government. Thus, health
literacy is critical to good governance” (WHO, 2017).

As nurses who care about the social environment in
which you and the populations you serve live, you need to
consider how your nursing practice fits into both the SDGs
and the Health in All Policies approach within your local,
national, and global communities .

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11CHAPTER 1 n Introduction to Public Health Nursing Practice

Ethnic diversity in the community requires a complex ethi-
cal framework that includes the complementary approaches
of rule ethics, virtue ethics, and feminist ethics (Racher,
2007; Volbrecht, 2002) .

Rule ethics uses a framework of guiding principles
for decision-making (Racher, 2007) . Examples of rules
or principles include autonomy, beneficence (promoting
good), nonmaleficence (preventing harm), justice, loyalty,
truth-telling, and respect (Aiken, 2004; Beauchamp & Chil-
dress, 1979; Purtilo, 2005; Scoville Walker, 2004) . Rule eth-
ics is based on a biomedical model of decision-making .

In contrast, virtue ethics is based on good character
(Racher, 2007) . One’s actions are evaluated in the context
of one’s community . Examples of nursing virtues include
compassion, honesty, courage, justice, self-confidence, resil-
ience, practical reasoning, and integrity (Volbrecht, 2002) .

Feminist ethics focuses on building relationships and
reducing oppression in society (Volbrecht, 2002) . Key values
in a feminist ethics approach are inclusion, diversity, partic-
ipation, empowerment, social justice, advocacy, and inter-
dependence (Racher, 2007) . Table 1 .3 provides additional
explanations about these three ethical approaches .

This three-pronged ethical approach is used throughout
the book to highlight ethical concerns and principles related
to specific public health nursing competencies .

Ethical Framework for
Public Health Nursing
The ever-changing healthcare environment, complex health-
care systems, and technological changes require a dual
approach according to Ivanov and Oden (2013) . They recom-
mend that PHNs employ a rights-based approach consistent
with the Universal Declaration of Human Rights passed by
the United Nations (UN) in 1948 (United Nations, 1948) and
an ethical approach based on ethical standards for nursing
practice published by the American Nurses Association . The
International Council of Nurses (ICN), in its position state-
ment on Nurses and Human Rights (2011; p . 1), states that “all
human rights are interdependent and indivisible and that
individuals’ health and wellbeing can be harmed when their
human rights in any category are violated .”

Other authors propose a complementary ethical frame-
work that addresses the diversity of client populations and
settings . PHNs might experience ethical problems when
they have to consider the impact or benefits and burdens
of their decisions on multiple clients, population groups,
and communities (Racher, 2007) . Culturally diverse soci-
eties and communities might have moral standards differ-
ent from each other’s and from those of the PHNs, which
could lead to conflicts between the PHNs and clients .

FIGURE 1.2 UN Sustainable Development Goals With Icons
Source: United Nations General Assembly, 2015

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12 PART I n Foundational Concepts for Public Health Nursing Practice

’’

‘‘

The Cornerstones, health determinants framework, and
levels of prevention are included in this chapter . The pub-
lic health nursing process and Public Health Intervention
Wheel are discussed in Chapter 2 . In the United States,
PHNs and other public health professionals who work for
governmental public health agencies have a scope of prac-
tice that is based on identified core public health functions
and the essential services of public health (IOM, 1988) . Chap-
ter 7 discusses the responsibility and accountability of PHNs
who work in governmental agencies .

“Well, this is all very interesting. But I still don’t have a clue
how I am actually going to practice public health nursing,”
Albert sighs.

Sia responds, “I’m realizing that there are a variety of
roles in public health nursing. Some PHNs might spend
their time working with individual families, but they still
have to consider global impacts on health. Our instruc-
tor told us we would be practicing at the individual/fam-
ily level of practice during most of our clinical time. But, I
know we still need to consider how basic human rights are
impacted by public health nursing work. There are a lot of
good internet videos on human rights. I suppose we could
look at them. And there is additional information in the
textbook itself.”

Abby states, “Great! But I think I want to spend more
time actually doing something. I am going to spend a day
with my preceptor tomorrow. Maybe I can apply some of
what I have read and watched on the web.”

Practicing Public Health Nursing
As a student, you will probably be spending most of your
clinical hours working with individuals and families . How-
ever, the role of the PHN is broader; PHNs also spend time
working with community groups and other members of the
community team . Public health nursing is carried out at
different levels of practice within society: individual/family,
community, and systems (MDH, 2001, pp . 4–5) .

Individual/Family Level of Practice
PHNs work with individuals and families to promote health
and reduce risks . The family is the essential unit of all com-
munities and societies . A family is defined as a social unit
of two or more people who identify themselves as a fam-
ily, share emotional bonds, and carry out the functions of a
family, including managing healthcare (Clark, 2008; Fried-
man, Bowden, & Jones, 2003; Martin, 2005) .

PHNs work with individuals and families in many differ-
ent community settings (see Chapter 3 for information on

TABLE 1.3 Ethical Framework for
Public Health Nursing Practice

Rule Ethics
n Rule ethics defines rules or principles that are based on

perceptions of fairness .
n Ethical principles are standards of conduct that guide

behavior and specify moral duties and obligations
(Racher, 2007) .

n Community rights might be given priority over individual
rights in some situations .

n Resources are given based on need and thus might be
distributed unequally (distributive justice) .

n Those who have been unfairly burdened or harmed are
compensated (compensatory justice) .

Virtue Ethics
n Virtue ethics identifies characteristics of the individual

(moral agent) and that person’s intentions and behaviors .
n An individual is responsible for developing good character

and good community (Volbrecht, 2002) .
n This type of ethics provides the foundation for professional

ethics, which specifies professional values and virtues .

Feminist Ethics
n A core ideal is achieving social justice; feminist ethics

applies social justice and distributive justice to social struc-
tures and context .

n This ethical approach focuses on characteristics of rela-
tionships, strengthens relationships and connectedness,
eliminates oppression, and realigns power imbalances .

n Feminist ethics is committed to restructuring relation-
ships, social practices, and institutions so that people can
live freer and fuller lives (Volbrecht, 2002) .

Key Components of
Public Health Nursing
The key components of public health nursing practice dis-
cussed in this book include:
n Cornerstones of Public Health Nursing (MDH, 2007)
n Core public health functions and essential services of

public health (IOM, 1988)
n The standards of public health nursing practice

(ANA, 2013)
n Health determinants framework (U .S . Department of

Health and Human Services [U .S . DHHS], n .d .-b)
n Levels of prevention (Leavell & Clark, 1958; Stanhope

& Lancaster, 2008)
n Public health nursing process (ANA, 2013; MDH, 2001)
n Public Health Intervention Wheel (MDH, 2001)

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13CHAPTER 1 n Introduction to Public Health Nursing Practice

PHNs practice at the systems level when they work with
providers and professionals like teachers, social workers,
nurses, doctors, government officials, and members of the
business community working for different agencies . If you
are working with members of systems to help these systems
adapt or change their values, health beliefs, or the way they
conduct their business (behaviors) so that they can improve
their capacity to meet the health needs of those they serve,
then you are working at the systems level of practice .

The Relationships Between
Individuals/Families, Communities,
and Systems
Individuals, families, and systems are best understood
within the context of the community in which you live .
Individuals and families interact with, and are influenced
by, their social and physical environments and the systems
that influence their health . For example, families living in
an inner-city neighborhood might not have access to a gro-
cery store with fresh fruits and vegetables or transportation
to the store . The neighborhood’s characteristics influence
family access to quality food and their nutritional well-
being . Figure 1 .3 shows an example of the interrelationships
among families, communities, and systems .

home visiting and family assessment) . Working with fam-
ilies in the community helps you understand the diverse
socioeconomic, cultural, and environmental factors that
influence the health, wellness, and disease of individuals
and families . If you are working with an individual or fam-
ily to help them adapt or change their values, health beliefs,
or behaviors to improve their health status, then you are
working at the individual/family level of practice .

Community Level of Practice
We tend to think of a community as a geographic place, but
a community may refer to any group of people who share
common values, culture, characteristics, and goals, whether
they live in a specific geographical locale or are separated
by distance (Skemp, Dreher, & Lehmann, 2016) . Commu-
nities are composed of people, organizations, and social
patterns of behavior . If you are working with members of
the community to help the community adapt or change its
values, health beliefs, or behaviors to improve the members’
health status, then you are working at the community level
of practice .

PHNs work with two types of populations in the commu-
nity: populations of interest and populations at risk (MDH,
2001, p . 2) . Table 1 .4 defines and provides examples of these
populations .

Systems Level of Practice
A system is an institution or organization that exists within
one or multiple communities . Key systems include health-
care systems, public health systems, schools, churches, gov-
ernment agencies, nonprofit organizations, and businesses .

TABLE 1.4 Populations Served by
Public Health Nurses

Population Examples

Population of Interest:
Population who is
essentially healthy but
could improve factors
that promote or protect
health (MDH, 2001)

n Families who live in urban
areas with little opportunity
for exercise because of lack
of parks, playgrounds, or
bike paths

n College students who have
increased stress because of
study needs and college debts
and are looking for ways to
reduce their stress level

Population at Risk:
Population with a
common identified risk
factor or risk exposure
that poses a threat to
health (MDH, 2001)

n Children who are not immu-
nized for major childhood
illnesses, such as measles and
chickenpox

n Older members of a church
congregation who live alone
and are at risk for falls

FIGURE 1.3 Interrelationships of Families, Communities,
and Systems

Individual/Family—
No access to grocery store
with fresh fruit and vegetables;
no transportation to
supermarket 5 miles away

Community—
No community
action plan
exists to bring
supermarket
or community
market to
inner-city
neighborhood

System—
No for-profit grocery store
chain wants to locate in
inner-city neighborhood

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14 PART I n Foundational Concepts for Public Health Nursing Practice

To make a difference for these families and others in
their inner-city neighborhood, PHNs might carry out the
following interventions:

n Refer families who are eligible for food benefits and
nutrition services to Women, Infants, and Children
(WIC)—individual/family level of practice .

n Work with a community action council to make its
members aware of problems in their inner-city neigh-
borhood and assist them with taking action to obtain
bus service from the neighborhood to a shopping center
or supermarket—community level of practice .

n Help form a coalition of nonprofit organizations and
businesses to bring a cooperative store or other full-
service grocery store to the neighborhood—systems
level of practice .

Table 1 .5 summarizes the three levels of PHN practice
and provides examples of how public health nursing is car-
ried out at these levels . These are all actions that you as a stu-
dent or a newly practicing public health nurse can also take .

TABLE 1.5 Levels of Public Health Nursing Practice

Individual/Family Level Examples

“Population-based, individual-focused practice changes knowl-
edge, attitudes, beliefs, practices, and behaviors of individuals .
This practice level is directed at individuals, alone or as part of
a family, class, or group . Individuals receive services because
they are identified as belonging to a population at-risk” (MDH,
2001, p . 5) .

n Make home visits to newborns and their parents .
n Teach hand-washing to a first-grade class .
n Assess for the presence of lead-based paint in a home with

preschool children .
n Develop a fall-prevention plan for an elderly person living

alone .

Community Level Examples

“Population-based, community-focused practice changes com-
munity norms, community attitudes, community awareness,
community practices, and community behaviors . They [PHNs]
are directed toward entire populations within the community
or occasionally toward target groups within those populations .
Community-focused practice is measured in terms of what pro-
portion of the population actually changes” (MDH, 2001, p . 4) .

n Write a letter to the editor of a local paper to stress the
value of home visits to parents of newborns .

n Create a billboard about the hazards of lead-based paint .
n Participate in a community “town hall” meeting to make

the community aware of safety hazards for elderly people
living alone .

Systems Level Examples

“Population-based, systems-focused practice changes organiza-
tions, policies, laws, and power structures . The focus is not directly
on individuals and communities but on the systems that impact
health . Changing systems is often a more effective and long-lasting
way to impact population health than requiring change from every
single individual in a community” (MDH, 2001, pp . 4–5) .

n Meet with legislators to advocate for reimbursement for
home visits with families of newborns .

n Develop a hand-washing program at an elementary school .
n Teach real-estate agents how to recognize lead-based paint

in a home .
n Develop a fall-prevention protocol for nurses working with

the elderly in the community .

Health Determinants
Public health nurses consider the multiple factors that
determine the health of their clients . Health determinants
are factors that influence the health of individuals, families,
and populations . Health determinants can have a positive or
negative influence on health . Table 1 .6 presents examples of
protective and risk factors at all three levels of practice for
communicable disease in childhood:
n Protective factors are health determinants that pro-

tect a person from illness or assist in improving the
person’s health .

n Risk factors are health determinants that contribute
to the potential for illness to occur or to a decrease in
health or well-being .

Just as holistic nursing practice focuses on the whole,
public health nursing focuses on the whole by identifying
all of the factors that influence the health of individuals,
families, and communities . To ignore this wholeness of the
living condition is to ignore many factors that impact health
and the ability of public health nurses to promote health .
Biological, behavioral, and environmental factors interact

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15CHAPTER 1 n Introduction to Public Health Nursing Practice

TABLE 1.6 Protective and Risk Factors for Childhood Communicable Diseases

Protective Factors by Level of Practice

Individual/Family Level

n Family has insurance that covers

immunizations .
n Children are up to date on

immunizations .
n Parents teach children proper

hand-washing and the benefits of
covering their mouths when coughing .

Community Level

n 95% of children in the community are

immunized (herd immunity) .
n Community billboards urge parents to

immunize their children .
n Low-density housing or single-

dwelling homes reduce contact
between infected and noninfected
children .

Systems
n Immunizations are available at public

health clinics, pharmacies, and medi-
cal clinics .

n Free or low-cost immunizations are
available to the uninsured .

n Childcare center has effective infection
prevention and control practices .

Risk Factors by Level of Practice

Individual/Family Level
n Family is uninsured .
n Family members are not aware of the

need for immunizations .
n Parents are not aware of how to pre-

vent the spread of infectious diseases .

Community Level
n 45% of children in the community are

immunized (no herd immunity) .
n Some community groups oppose

childhood immunizations .
n Many high-density housing and apart-

ment complexes in the community
place people living close together at
greater risk .

Systems
n Immunizations are not available at the

public health clinic .
n Funding for low-cost immunizations

for the uninsured is lacking .
n School district does not track students’

immunization records .

and contribute to the health and illness of individuals, fam-
ilies, and populations (ANA, 2013; Marmot & Wilkinson,
1999; Zahner & Block, 2006) . Individuals and families are
able to influence or control some of their biological and
many of their behavioral health determinants but are not
able to control many of the physical and social environmen-
tal determinants of health that occur at the community and
systems levels . Health determinants shaped by social, eco-
nomic, and political forces, including systems put in place to
deal with illness, are called the social determinants of health .
(See Chapter 13 for further discussion on the social determi-
nants of health .) These social determinants of health affect
population health in all nations of the world .

The social determinants of health are the conditions in
which people are born, grow, live, work, and age . These cir-
cumstances are shaped by the distribution of money, power,
and resources at global, national, and local levels . The social
determinants of health are mostly responsible for health
inequities—the unfair and avoidable differences in health
status seen within and between countries (WHO, 2013) .

Health Status
PHNs use the community assessment process and public
health nursing process (see Chapter 3) to determine the
health statuses of individuals, families, communities, and

populations . Health status refers to the level of health or ill-
ness and is the outcome of the interaction of the multiple
health determinants . Health status indicators are frequently
represented by statistical measures, such as rates and per-
centages . Some common examples of population health
status indicators are teen pregnancy rates, percentage of
low-birthweight babies, neonatal mortality rates, percentage
of malnutrition in a group, and obesity rates . Rates and per-
centages of various population groups can be compared to
determine similarities or differences in the health status of
those groups . Health status comparisons can also be applied
at an individual level, such as identifying a child with mal-
nutrition as having a lower level of health than a child who is
not malnourished . Health status comparisons allow PHNs
to determine their priorities for actions with specific indi-
viduals, families, communities, and populations . Figure 1 .4
illustrates a health determinants model .

All of the Healthy People 2020 health determinants,
including access to healthcare, are represented in Fig-
ure 1 .4 (U .S . DHHS, n .d .-b) . This model represents a holistic
approach to assessment of the protective and risk factors
that determine health status in individuals, families, and
communities . Health determinants, including protective
and risk factors, exist at individual/family, community,
and systems levels, so nursing interventions should address
health determinants at all levels as needed . PHNs can use
this holistic approach to organize and identify the complex
contributors to the health status of specific individuals,

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16 PART I n Foundational Concepts for Public Health Nursing Practice

families, and populations and to develop interventions
to improve health . PHNs collaborate with their clients by
building and strengthening their protective factors and
helping them reduce their risk factors . The social determi-
nants of health that play a significant role in health dispari-
ties are discussed in Chapter 13 .

Activity
Review the following Health Determinants Analysis Case Study:

n Identify the health status indicators for this community.

n Identify health determinants, including protective and
risk factors that contribute to the health status of this
community.

n Determine how you would work with community members to
build on their protective factors and reduce their risk factors.

CASE STUDY
Health Determinants Analysis

A community assessment in a small rural community determines
that more than one-third of the adult residents are overweight
or obese. The assessment reveals that 40% of the adults in this
community report that they have high cholesterol, and 30%
report that they have high blood pressure. The majority of adults
admit to eating out at fast-food restaurants at least five times
a week. This community contains many fast-food restaurants,
and the most common foods sold in them are high in fat, sodium,
sugar, and calories. This community has few outdoor recreational
sites, such as bike and walking paths, and the county board has
voted against increasing tax levies to provide those paths. The
local hospital does provide evening and weekend health educa-
tion classes on modifying diet and exercise to lead a healthier life.
A coalition of healthcare clinics, the public health agency, and
local businesses is working on a plan to increase healthy living
resources in the community.

FIGURE 1.4 A Health Determinants Model for Individuals/Families, Communities, and Populations

Health Status
Levels of Health and/or Illness

Morbidity Rates (illness)
Mortality Rates (death)
Levels of Independence

Life Satisfaction
Comparisons with Others

• biological factors
• physical characteristics
• genetic factors
• health conditions

Biology

Behaviors
• health-seeking actions
• health-limiting actions
• lifestyle patterns
• socioeconomic status
• family, work, and

community roles
• levels of coping and

resilience
• language and literacy
• health literacy

Social Environment
• culture
• government
• education
• commerce
• religion
• health systems
• media
• social & economic

patterns Access to Healthcare

Physical Environment
• geography
• climate
• weather
• natural resources
• agriculture
• urban versus rural
• natural versus

built environment

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17CHAPTER 1 n Introduction to Public Health Nursing Practice

‘‘

’’

Levels of Prevention
The levels of prevention (primary, secondary, and tertiary)
provide a framework for health-promotion and disease-
prevention efforts in the stages of the natural history of dis-
ease (Leavell & Clark, 1958; Stanhope & Lancaster, 2008) .
The health-promotion progression from primary to sec-
ondary to tertiary prevention provides a framework for
population-based public health nursing interventions at all
levels of public health nursing practice (MDH, 2001; Skemp
et al ., 2016) . It is important to determine the health status
of individuals/families, communities, and populations and
to determine the level of prevention for specific health con-
cerns to implement the appropriate interventions . Figure 1 .5
provides an overview of the stages of health, the levels of
prevention, and intervention approaches .

Although the focus of public health nursing is primary
prevention, public health nursing practice encompasses
all three levels . In contrast, within the hospital setting,
the focus of most nursing care is on ill patients and their
family members, and nurses more often provide secondary
and tertiary prevention but may also provide some primary
prevention . Table 1 .7 shows the definition of each level with
examples .

healthypeople.gov

Healthy
People

Healthy People, a program of the U.S.
Department of Health and Human Services,
has established science-based benchmarks
and 10-year national objectives for improving the health of all
Americans. Healthy People 2020 is the third set of national
health priorities identified over the last 3 decades. Its vision is “a
society in which all people live long healthy lives” (U.S. DHHS,
n.d.-b, p. 1). The mission and goals are displayed in Table 1.8.
This national program seeks to involve all Americans by encour-
aging community and organizational collaboration, empowering
individuals to make informed health decisions, and measuring
the outcomes of prevention activities (U.S. DHHS, n.d.-b).

“Okay! Now I understand why public health nurses do what
they do, but I am still not clear about what I am supposed
to do!” Albert states in an exasperated tone of voice.

Sia responds, “I guess we have to assess our clients’
health status, identify their health determinants, and
develop a plan of care that builds on their protective factors
and reduces their risk factors. Now it makes sense that we
would be mostly listening, teaching, and counseling. Did
you know that the words listen and silent have the same
letters? I guess we need to use silence to listen to our clients!”

Abby states, “I really like all the secondary and tertiary
prevention interventions that I do in the hospital setting, so
I am afraid I am going to get bored working in the commu-
nity. I can only sit and listen for so long. I like action!”

Albert reflects, “Primary prevention doesn’t have to
mean you are not doing anything. Just because there isn’t
already an illness or disease doesn’t mean there isn’t work
to do. Primary prevention is the way that we can identify
health determinants and make an impact. Our instructor
says we can apply public health nursing in any nursing
practice setting. Maybe I will think about how I can use
everything I learn in my community clinical in my hospital
practice. But, who knows, maybe I will decide to become a
public health nurse!”

Sia asks, “I understand what we are supposed to focus
on when we work with individuals and families, but I am
not sure how identifying their health statuses and health
needs fits in with the concept of population-based practice.
I guess I need to talk to my preceptor about how our home
visits fit in with the priority health needs of our community.
How do I know whether what we are doing reflects what the
community really wants public health nurses to do?”

FIGURE 1.5 Stages of Health and Disease and Levels of

Prevention

Key
Interventions

Health
Promotion and

Prevention

Screening,
Diagnosis, and

Treatment

Rehabilitation,
Remediation,
Maintenance

Level of
Prevention

Primary Secondary Tertiary

Stage
of Health

Healthy Early Disease
or Injury

Chronic
Disease

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18 PART I n Foundational Concepts for Public Health Nursing Practice

TABLE 1.7 Prevention Continuum With Public Health Nursing Examples

Definitions Examples

Primary prevention promotes health and protects against
threats to it . It is designed to keep problems from occur-
ring in the first place . It promotes resiliency and protective
factors or reduces susceptibility and exposure to risk factors .
Primary prevention occurs before a problem develops . It
targets populations that are essentially well .

PHN Antepartal home visit:
n Teaching parents the importance of taking a newborn home from

the hospital in an approved car seat
n Providing parents with information about approved car seats

PHN Postpartum home visit:
n Checking the car seat to determine that it is correctly installed
n Monitoring the parents’ use of car seat

Secondary prevention detects and treats problems in their
early stages . It keeps problems from causing serious or
long-term effects or from affecting others . It identifies risks
or hazards and modifies, removes, or treats them before a
problem becomes more serious . Secondary prevention is
implemented after a problem has begun, possibly before
signs and symptoms appear . It targets populations that
share common risk factors .

PHN at WIC Clinic:
n Using a growth chart to plot children’s heights and weights
n Identifying children who are outside established norms
n Referring parents and children who are above 95th percentile or

below 5th percentile to a primary care provider for assessment
and to a nutritionist for nutritional education and counseling

Tertiary prevention limits further negative effects from a
problem and aims to keep existing problems from getting
worse . Tertiary prevention is implemented after a disease
or injury has occurred . It alleviates the effects of disease
and injury and restores individuals to their optimal levels
of functioning . It targets populations that have experienced
disease or injury .

School Nurse
Beginning of the school year:

n Identifying students with asthma and obtaining asthma plans
n Working with teaching staff to reduce environmental asthma

triggers in the school building

During the school year:
n Monitoring students with asthma for adherence to their asthma

plans and their health status
n Providing nebulizer treatments in the health office

Source: Modified from MDH, 2001, p . 4

TABLE 1.8 Healthy People 2020 Mission and Goals

Mission—Healthy People 2020 strives to: Overarching Goals

n Identify nationwide health-improvement priorities
n Increase public awareness and understanding of the

determinants of health, disease, and disability and
opportunities for progress

n Provide measurable objectives and goals that are
applicable at the national, state, and local levels

n Engage multiple sectors to take action to strengthen
policies and improve practices that are driven by the best
available evidence and knowledge

n Identify critical research, evaluation, and data- collection
needs

n Attain high-quality, longer lives free of preventable disease,
disability, injury, and premature death

n Achieve health equity, eliminate disparities, and improve the
health of groups

n Create social and physical environments that promote good
health for all

n Promote quality of life, healthy development, and healthy
behaviors across all life stages

Source: U .S . DHHS, n .d .-b

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19CHAPTER 1 n Introduction to Public Health Nursing Practice

BSN Preparation
The need for nurses to be prepared to both work in the
community and have the ability to practice entry-level pub-
lic health nursing has become more urgent as healthcare
moves from the acute care setting to the community and
new models of healthcare and nursing practice emerge . The
challenge of practicing in the community is influenced by
the persistence of health disparities among all age groups
and diverse populations, the aging of the population, and
the continuous increase in healthcare costs . In addition,
healthcare needs and diseases are not isolated by geographic
boundaries but evolve within a global environment . Recog-
nition of the need for nurses to have the ability to improve
the health of populations by taking leadership roles within
the healthcare system and in their communities and by
partnering with other health professionals and community
leaders has resulted in a renewed commitment to increase
the proportion of nurses with baccalaureate degrees and
to enrich the baccalaureate nursing curriculum to prepare
nurses for the challenges that face them (Education Com-
mittee of the Association of Community Health Nurse
Educators [ACHNE], 2010; Institute of Medicine [IOM],
2011; Robert Wood Johnson Foundation, 2013) . ACHNE has
identified 15 basic core knowledge competencies for bacca-
laureate nursing graduates that should be included in the
baccalaureate nursing curriculum (2010):
n Communication
n Epidemiology and biostatistics
n Community/population assessment
n Community/population planning
n Policy development
n Assurance
n Health promotion and risk reduction
n Illness and disease management
n Information and healthcare technology
n Environmental health
n Global health
n Human diversity
n Ethics and social justice
n Coordination and care management
n Emergency preparedness, response, and recovery

Activity
n Which knowledge areas have you already studied?

n What are your knowledge and competency goals for your
public health nursing clinical?

A set of national health priorities titled Leading Health
Indicators (LHIs) is included in Healthy People 2020 (U .S .
DHHS, n .d . -a) . They include 42 health outcomes orga-
nized into 12 health topics . These priorities reflect the great-
est unmet national health needs based on an analysis of
Healthy People 2010 health outcome data . The 12 health top-
ics are listed in the following “Leading Health Indicators”
box . A mid-course review of progress toward achieving the
42 health indicators shows that 21% of the targets have been
achieved and 19% are improving while 11% are getting worse
(U .S . DHHS, 2017) .

OnlineActivity
Go to the Healthy People webpage (http://
www.healthypeople.gov) and search for the LHIs.

n Read about one of the LHI health outcomes that
interests you.

n Find the Healthy People 2010 statistical data that measured
the achievement of that outcome.

n What is the goal for the Healthy People 2020 outcome?
Which statistic would demonstrate improvement of that
outcome?

Activity
n Explore the community health priorities of your state or local

health department. Compare them with the LHIs.

n Identify programs or activities in your clinical agency that are
related to the LHIs.

n Discuss with your preceptor how nurses are involved in these
programs or activities.

n Consider how you might become involved as a citizen or
as a nurse in working on one of the LHI priorities in your
community.

Leading Health Indicators, Healthy People 2020

n Access to Health Services

n Clinical Preventive Services

n Environmental Quality

n Injury and Violence

n Maternal, Infant, and Child Health

n Mental Health

n Nutrition, Physical Activity, and Obesity

n Oral Health

n Reproductive and Sexual Health

n Social Determinants

n Substance Abuse

n Tobacco

Sources: National Center for Health Statistics, 2012; U .S . DHHS, n .d .-a

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20 PART I n Foundational Concepts for Public Health Nursing Practice

Entry-Level Population-Based Public
Health Nursing Competencies
This chapter has given you a lot to think about . Now it is
time to focus on the entry-level public health nursing com-
petencies that you can work to develop in your community
clinical . This book is going to help you focus on the entry-
level competencies expected of baccalaureate nursing grad-
uates and novice nurses entering public health nursing .

Henry Street Entry-Level PHN Competencies
The Henry Street Consortium (HSC) entry-level population-
based public health nursing competencies, initially pub-
lished in 2003 and updated in 2017, are intended for
baccalaureate nursing graduates and novice public health
nurses (Henry Street Consortium, 2017; Schaffer et al ., 2011) .
These 12 competencies are consistent with national bench-
mark standards for entry-level public health nursing (ANA,
2013; Quad Council of Public Health Nursing Organiza-
tions, 2011) . (See Table 1 .9 .) A consortium of practicing pub-
lic health nurses and educators developed these simplified
entry-level standards to facilitate the teaching and learning
of public health nursing knowledge and skills in the clinical
setting (Schaffer et al ., 2011) .

This list presents each competency in broad statements
that are not measurable by themselves . A more complete
outline of each of the HSC competencies, which provides
measures of how to evaluate PHN achievement of each
competency, is found in Appendix A . Chapters 3 to 14 each
cover one of the 12 competencies and provide specific evi-
dence about best practices for each competency . As you read
this book, you will learn how you might meet these entry-
level competencies in your public health clinical learning
activities .

Activity
n Review the competencies and their related activities in

Appendix A. Make a list of activities within each compe-
tency that you would like to practice during your community
clinical.

n Talk with your preceptor about how you might practice these
public health nursing activities.

TABLE 1.9 Henry Street Consortium
Entry-Level Population-Based Public Health
Nursing Competencies

Entry-Level Population-Based Public Health Nursing
Competencies

For the New Graduate or Novice Public Health Nurse

1 . Applies the public health nursing process to communities,
systems, individuals, and families

2 . Utilizes basic epidemiological (the incidence, distribution,
and control of disease in a population) principles in public
health nursing practice

3 . Utilizes the principles and science of environmental
health to promote safe and sustainable environments for
individuals/families, systems, and communities

4 . Practices within the auspices of the Nurse Practice Act

5 . Works within the responsibility and authority of the
governmental public health system

6 . Utilizes collaboration to achieve public health goals

7 . Effectively communicates with communities, systems,
individuals, families, and colleagues

8 . Establishes and maintains caring relationships with
communities, systems, individuals, and families

9 . Incorporates mental, physical, emotional, social, and
spiritual aspects of health into assessment, planning,
implementation, and evaluation

10 . Demonstrates nonjudgmental/unconditional acceptance
of people different from self

11 . Shows evidence of commitment to social justice, the
greater good, and the public health principles

12 . Demonstrates leadership in public health nursing with
communities, systems, individuals, and families

Source: Henry Street Consortium, 2017

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21CHAPTER 1 n Introduction to Public Health Nursing Practice

n Primary prevention is the focus of public health nurs-
ing, but PHNs also provide secondary and tertiary
prevention interventions .

n PHNs work at all three levels of practice: individual/
family, community, and systems .

n Emerging threats and challenges in health and health-
care require changes in and leadership from public
health nursing .

n The HSC Entry-Level Public Health Nursing competen-
cies, based on accepted national standards, provide a
guide for baccalaureate nursing students to achieve the
expected outcomes of baccalaureate nursing education .

KEY POINTS

n Public health nursing combines the theory and practice
of nursing and public health . It is a required component
of baccalaureate nursing education .

n Public health nursing practice is guided by the national
scope of practice standards .

n The goal of public health and public health nursing is to
improve the health of the public at the local, national,
and international levels .

n The Cornerstones of Public Health explain the beliefs
and values of the clinical specialty of public health
nursing practice .

n Public health nursing practice is population-based,
focusing on the priority health needs of populations .

‘‘

’’

REFLECTIVE PRACTICE

Alberto takes a deep breath, closes his eyes as if in deep
thought, and says to Abby and Sia, “Let’s see if I have this
straight. Public health nursing is part of my professional
nursing practice. It can be practiced anywhere, because
public health nursing is shaped by its goal, not by its set-
ting, but it is most often practiced in the community. The
goal of public health nursing is to improve the health of the
public, the health of the communities in which we live. The
client in public health nursing may be an individual, a fam-
ily, the community, or a population within the community.
To improve and protect the public’s health, I need to assess
the health status and identify the health determinants that
affect the health status of individuals, families, communi-
ties, and populations. Then I need to intervene by helping
my clients build on their protective factors and reduce their
risk factors. The interventions I will use most often are
teaching and counseling, but we will learn about more inter-
ventions as we read this book and complete our community
clinical. When I practice in the community, I will probably

be partnering with other members of the healthcare team
as well as community members. I need to demonstrate a
set of entry-level public health nursing competencies to
successfully complete my baccalaureate nursing education.
The Henry Street Consortium Population-Based Public
Health Nursing Competencies focus on what I should be
learning and practicing in my public health clinical activi-
ties. Whew! Do I have that right?”

Abby and Sia respond, “Yes. You’ve got it! You get an ‘A’
for the course!”

1. Think about what Alberto, Abby, and Sia have learned
about public health nursing from their observations
and discussions with their preceptors .

2. How will you analyze what you observe about public
health nursing during your clinical experience?

3. How would you describe public health nursing prac-
tices you observe in your clinical to your classmates?

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22 PART I n Foundational Concepts for Public Health Nursing Practice

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‘‘

’’

CHAPTER

2Evidence-Based Public
Health Nursing Practice

n Patricia M. Schoon and Marjorie A. Schaffer
with Stephanie Rivery

Abby is talking with Jaime, an RN who has returned to school to get his baccalaureate nursing
degree. She is struggling to understand the three levels of public health nursing practice. Abby
asks, “How do you use the nursing process in your hospital work? Did you ever think you could
use it for more than the patients you are caring for?”

Jaime replies, “It still seems kind of strange to me. But I am a member of the Quality Improve-
ment Team. We just finished an audit to look at the incidence of patient falls to find out whether
our unit is meeting the goals set by the hospital to reduce the patient fall rate. Our patient fall rate
is still higher than the goal set by the hospital, so we decided that we need to hold an in-service on
assessing patients for their fall risk and the different protocols we can use to reduce the number of
patient falls. So, I guess if we think of my unit as a community, we are using the nursing process
at more than one level.”

Abby ponders, “I guess I can kind of see that you are using the nursing process to assess the
fall rate. The idea of using the nursing process at the systems level still seems very strange to me.”

Jaime thinks about the idea of nursing at the systems level and finally says, “Maybe if I think
of the nursing staff on my unit as part of the hospital system, then Quality Improvement Team
members can assess what they know about fall risk and prevention and design a program just for
our staff members to improve their skills in that area. What do you think?”

Abby sighs, “I kind of understand how I can use nursing process to assess the health needs of
individuals, families, and communities, but I can’t think how I would assess the health status of
a system. Do systems have a health status?” Abby muses, “If a system, like a public health agency,
doesn’t have enough money to provide the health services that the community needs, then I guess
it wouldn’t be very healthy.”

Jaime says thoughtfully, “Maybe we need to look at a community’s health needs and determine
whether specific community systems, such as hospitals, schools, educational systems, and public
health agencies, have the resources to meet the priority needs of their community. If they don’t
have the resources, then maybe we can plan interventions to help them get the resources or services
they need.”

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26 PART I n Foundational Concepts for Public Health Nursing Practice

’’

‘‘

The application of the nursing process to all three levels of
practice is discussed in Chapter 3.

An easy way to remember the level of practice is to ask
yourself, “Whose knowledge, beliefs, behaviors, and values
am I trying to modify?” For example, if you are teaching
a group of first grade students how to wash their hands,
even though they are in a group, your intention is to modify
the handwashing behaviors of the individual students. So,
you are intervening at the individual/family level of prac-
tice. If you taught the first-grade teachers how to monitor
the handwashing behaviors of their students, you would be
intervening at the systems level of practice. If you handed
out a flyer on the reasons for handwashing and the cor-
rect handwashing procedure at a county fair, you would be
intervening with the community level, hoping to change
community norms for handwashing, not the behaviors of
specific individuals.

Abby comments, “My PHN preceptor told me that we are
going to make a joint visit with the social worker to a family
where a baby has failure to thrive. My preceptor is going
to focus on assessing the health status of the baby, and the
social worker is going to focus on the family support system
and resources in the community for the mother. It will be
interesting to see how they work together.”

Jaime responds, “I am going to an interdisciplinary
child protection team meeting with my preceptor. It is a
county-wide team made up of police, social workers, law-
yers, and public health nurses. It seems like my preceptor is
always working with other people.”

Abby concurs, “It really does seem that PHNs work with
lots of other disciplines. My preceptor says that is the best
way to deal with community-wide health problems.”

Several years ago, a nursing student about to graduate
reflected on what she had learned. She said, “I get it. Nursing
is about critical thinking!” Nursing is a knowledge profes-
sion. That means nurses think before they do (assessment
and planning), while they do (modifying interventions),
and after they do (evaluation). This chapter explains how
to apply the nursing process to public health nursing prac-
tice and to identify and use interventions that support pub-
lic health practice goals. You will learn how to apply what
you already know about evidence-based nursing practice to
your public health nursing practice. PHNs are accountable
to their clients and to the public for practicing effectively
and efficiently to achieve the best outcomes using the least
amount of resources. This chapter discusses how PHNs use
best practice information to improve their clients’ health.

The Public Health Nursing Process
The public health nursing process integrates concepts of
nursing and public health. The steps of the nursing process
are the same: assessment, diagnosis, planning, implemen-
tation, and evaluation. However, the public health nursing
process expands the nursing process in that PHNs focus
their assessment and interventions on three different levels
of practice: individuals and families, communities, and sys-
tems (MDH, 2001). Refer to Chapter 1 for a description of the
three levels of PHN practice. Critical thinking throughout
the PHN process is essential in identifying and modifying
the complex determinants of health that influence the health
status of individuals, families, and communities. This appli-
cation of the nursing process is reflected in the American
Nurses Association’s (ANA’s) Public Health Nursing: Scope
and Standards of Practice (2013), as illustrated in Figure 2.1.

ABBY’S NOTEBOOK

USEFUL DEFINITIONS

Evidence-Based Practice: “A problem-solving approach to clinical decision-making within a healthcare orga-
nization. EBP integrates the best available scientific evidence with the best available experiential (patient and
practitioner) evidence” (Dang & Dearholt, 2018, p. 4).

Evidence-Based Public Health: Making decisions on the best information available and creating interventions
based on that evidence (Barr-Walker, 2017).

Public Health Interventions: Actions that PHNs take on behalf of individuals, families, systems, and communi-
ties to improve or protect their health status (Minnesota Department of Health [MDH Center for Public Health
Nursing], 2001); public health nurses (PHNs) commonly practice all 17 interventions.

Public Health Nursing Process: Integration of concepts of public health, community, and all three levels of the
PHN practice (i.e., individual, community, and systems) into the nursing process (Minnesota Department of
Health [MDH], Center for Public Health Nursing, 2003).

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27CHAPTER 2 n Evidence-Based Public Health Nursing Practice

These interventions are organized in the Public Health
Intervention Wheel illustrated in Figure 2.2. The Public
Health Intervention Wheel is evidence-based and represents
what PHNs do (Keller et al., 2004). PHNs often use more
than one intervention at more than one level of practice
(individual and family, community, or system) to influence
the multiple health risks affecting individuals, families, and
populations.

The 17 interventions are divided into five wedges with
three or four interventions in each wedge. Each group of
wedges reflects a cluster of interventions. The cluster of
interventions within each wedge often occurs either con-
currently or consecutively. The five wedges (also depicted in
specific colors) include the following interventions:

n Wedge 1 (pink): Surveillance, disease and health event
investigation, outreach, and screening (case finding is
the individual level for this wedge)

n Wedge 2 (green): Referral and follow-up, case manage-
ment, and delegation

n Wedge 3 (blue): Health teaching, counseling, and
consultation

n Wedge 4 (orange): Collaboration, coalition building,
and community organizing (no individual level for
coalition building and community organizing)

n Wedge 5 (yellow): Advocacy, social marketing, policy
development, and enforcement

The three inner circles, called segments, represent the
three levels of public health nursing practice (individual/
family, community, and systems). All but three interventions
are carried out at all three levels of practice. Case finding is
only carried out at the individual/family level of practice, so
it is placed inside the individual/family circle in the wheel
diagram. Community organizing and coalition formation
are practiced at the community and systems levels but not
at the individual/family level. Sixteen of the interventions
are independent nursing actions that can be practiced under
your state’s Nurse Practice Act without medical orders. The
seventeenth intervention, delegated functions, can include
medical functions delegated by a medical professional, such
as immunizations. Nursing activities that the PHN delegates
to another health team member, such as vision and hearing
screening, are part of the independent practice of nursing
and usually reflect one of the other PHN interventions.

Definitions and examples of the 17 population-based
public health interventions are outlined in Table 2.1. Inter-
ventions are organized within the five wedges on the Public
Health Intervention Wheel. Nursing students could do all
the intervention examples in the table.

The Public Health Intervention Wheel has been dissemi-
nated to public health nursing students, PHNs, other public
health professionals, and health departments nationally and
internationally. The Wheel is used as a framework for teach-
ing; a guide for planning, documentation, and evaluation in
public health practice; and a model for research on interven-
tion use and effectiveness.

PHNs often work with people in other professions as well
as community members to achieve public health goals. (See
Chapter 8 for a discussion of interprofessional collabora-
tion.) Many of the interventions that PHNs use are also used
by other professionals in the community.

Public Health Intervention Wheel
The Public Health Intervention Wheel is a major concep-
tual model in public health nursing (Keller, Strohschein,
Lia-Hoagberg, & Schaffer, 1998, 2004; Bigbee & Issel, 2012).
Concepts in the Public Health Intervention Wheel include:
population-focus, three levels of practice, three levels of pre-
vention, and 17 interventions that define the shared practice
of public health nursing. Research supporting the use and
effectiveness of many of the interventions in this model are
found in this book. This model is supported by evidence
from literature and validated by more than 200 public
health nurses from a variety of practice settings.

Public health interventions are actions that PHNs take
on behalf of individuals, families, systems, and commu-
nities to improve or protect their health status (MDH,
2001). The Public Health Intervention Wheel identifies 17
population-based interventions specific to public health
practice that are found at three levels: individual/family,
community, and systems (Keller et al., 1998, 2004; MDH,
2001). Because PHN practice occurs at three levels, interven-
tions must also be implemented at all three levels.

FIGURE 2.1 Nursing Process at Three Levels of Public Health
Nursing Practice

Community

System

Individual/
Family

Planning

Im
plem

entation

D
ia

gn
os

Ev
aluation Assessment

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28 PART I n Foundational Concepts for Public Health Nursing Practice

TABLE 2.1 Public Health Nursing Interventions at All Three Levels of Practice

PHN Intervention
Definition

PHN Intervention
Examples

Surveillance (Wedge 1 – Pink)
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
(MDH, 2001, p. 13).

n Investigate and report the incidence and prevalence of sexually
transmitted infections in the local teen population (community
level).

n Work with a school nurse at an elementary school to develop a
tracking program to identify the incidence and prevalence of
student-on-student bullying before and after the implementation of
an anti-bullying curriculum (systems level).

Disease & Health Event Investigation (Wedge 1 – Pink)
Disease and other health event investigation systemati-
cally 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 (p. 29).

n Identify and follow up on cases of sexually transmitted infection in
a high school population to identify sources of infection and provide
treatment (individual/family level).

n Gather information about radon levels in your community and
determine high-risk geographical areas (community level).

FIGURE 2.2 Public Health Intervention Wheel
Source: MDH, Center for Public Health Nursing (2001)

Case Finding

Population-Based

Individual-Focused

Community-Focused

Systems-Focused

Surveillance
Disease &Health EventInvestigation

Outreach

Screening
R

eferral &

Follow
-U

Ca
se

M
an

ag
em

en
t

Dele
gate

Fu
nct

io
ns

Health

Teaching

Counseling

Consultation

Collaboration

Coalition

Building
C

om
m

unity

O
rganizing

A
dv

oc
ac

Socia
l

M
ark

etin
g

Policy

Development &

Enforcement

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29CHAPTER 2 n Evidence-Based Public Health Nursing Practice

PHN Intervention
Definition

PHN Intervention
Examples

Outreach (Wedge 1 – Pink)
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 (p. 41).

n Interview people at a family homeless shelter to determine who
needs information about the location of local food shelves and WIC
clinics (individual/family level).

n Develop brochures for local grocery stores to hand out about nutri-
tional needs for children and the location of local food shelves and
WIC clinics (systems level).

Case Finding (Wedge 1 – Pink)
Case finding locates individuals and families with identi-
fied risk factors and connects them to resources (p. 55).

n Identify new immigrants from southeast Asia who might be at risk
for tuberculosis (TB) (individual/family level).

n Give at-risk immigrants information on where to receive TB
screening (individual/family level).

Screening (Wedge 1 – Pink)
Screening identifies individuals with unrecognized
health risk factors or asymptomatic disease conditions in
populations (p. 63).

n Conduct blood pressure screening for African-American males
( community level)

n Organize a blood pressure screening clinic at a community center
( systems level)

Referral & Follow-up (Wedge 2 – Green)
Referral and follow-up assists individuals, families,
groups, organizations, and communities to utilize
necessary resources to prevent or resolve problems or
concerns (p. 79).

n Give an elderly person who is homebound information about how
to contact a local Meals on Wheels program and then contact the
individual a week later to see if he or she has successfully reached
the Meals on Wheels program (individual/family level).

n Work with Emergency Department (ED) nurses and home visiting
nurses to develop and use a referral process for elderly individuals
seen in the ED that need home healthcare services (systems level).

Case Management (Wedge 2 – Green)
Case management optimizes self-care capabilities of
individuals and families and the capacity of systems and
communities to coordinate and provide services (p. 93).

n Work with parents of a newborn with Down’s Syndrome to iden-
tify services in their community that they can use to help them
( individual/family level).

n Work with a PHN and school nurse to coordinate in-home and
school health services for children with severe developmental delays
(systems level).

Delegated Functions (Wedge 2 – Green)
Delegated functions are direct care tasks a registered
professional nurse carries out under the authority of
a healthcare practitioner, as allowed by law. Delegated
functions also include any direct care tasks a registered
professional nurse entrusts to other appropriate person-
nel to perform (p. 113).

n Provide immunizations at a community flu clinic under standing
orders from medical personnel (individual/family and systems
levels).

n Direct a peer counselor to work with a new diabetic to organize a
grocery list and menu plans (individual/family level).

Health Teaching (Wedge 3 – Blue)
Health teaching communicates facts, ideas, and skills
that change knowledge, attitudes, values, beliefs, behav-
iors, and practices and skills of individuals, families,
systems, and/or communities (p. 121).

n Teach a class for teen moms about how to care for new baby
( individual/family level).

n Develop a program on childcare for new moms at a local high school
(systems level).

(continues)

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30 PART I n Foundational Concepts for Public Health Nursing Practice

PHN Intervention
Definition

PHN Intervention
Examples

Counseling (Wedge 3 – Blue)
Counseling establishes an interpersonal relationship with
a community, system, family, or individual intended to
increase or enhance their capacity for self-care and cop-
ing. Counseling engages the community, system, family,
or individual at an emotional level (p. 151).

n Provide support for parents who are coping with providing care for
their dying child at home (individual/family level).

n Provide crisis management services to a community that has just
experienced a devastating tornado (community level).

Consultation (Wedge 3 – Blue)
Consultation seeks information and generates optional
solutions to perceived problems or issues through
interactive problem-solving with a community, system,
family or individual. The community, system, family or
individual selects and acts on the option best meeting the
circumstances (p. 165).

n Help a recently divorced father who has custody of his two children
to problem solve balancing parenting and work responsibilities
(individual/family level).

n Consult with a peer-counseling group for diabetes management
to help them develop strategies for working with individuals with
diabetes in their community (community level).

Collaboration (Wedge 4 – Orange)
Collaboration commits two or more persons or organiza-
tions to achieving a common goal through enhancing the
capacity of one or more of them to promote and protect
health (p. 177).

n Partner with the nurse and social worker in an adolescent correction
facility in developing a program to help inmates maintain con-
tact with caring individuals in their family or friendship network
( systems level).

n Work with the county parks and playground department and local
young parents group to develop a plan to provide more bike and
walking paths for family use (community and systems level).

Coalition Building (Wedge 4 – Orange)
Coalition building promotes and develops alliances
among organizations or constituencies for a common
purpose. It builds linkages, solves problems, and/or
enhances local leadership to address health concerns
(p. 211).

n Develop an alliance between local environmental groups, waste
management, and recycling organizations to improve community
recycling (community level).

n Establish a network of agencies to work together to develop a
community disaster plan (systems level).

Community Organizing (Wedge 4 – Orange)
Community organizing helps community groups identify
common problems or goals, mobilize resources, and
develop and implement strategies for reaching the goals
they collectively have set (p. 235).

n Organize a group of renters from several low-income housing devel-
opments to work together to improve the safety of their buildings
(community level).

n Help organize a group of low-income housing services organiza-
tions, community homeless shelters, and county human services
to develop strategies to provide a more streamlined program for
placing homeless people in affordable housing (systems level).

Advocacy (Wedge 5 – Yellow)
Advocacy pleads someone’s cause or acts on someone’s
behalf, with a focus on developing the community, sys-
tem, individual, or family’s capacity to plead their own
cause or act on their own behalf (p. 263).

n Help a client file an appeal for an insurance denial for home-care
services when the client meets eligibility criteria stated in insurance
policy (individual/family level).

n Lobby legislators for support of community mental health programs
(systems level).

Social Marketing (Wedge 5 – Yellow)
Social marketing utilizes commercial marketing princi-
ples and technologies for programs designed to influence
the knowledge, attitudes, values, beliefs, behaviors, and
practices of the population of interest (p. 285).

n Create a video for teen parents on how to help their infants and
toddlers meet developmental milestones (individual/family level).

n Participate in a televised panel discussion about the effects of drug
and alcohol use during pregnancy on the fetus (community level).

TABLE 2.1 Public Health Nursing Interventions at All Three Levels of Practice (continued)

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31CHAPTER 2 n Evidence-Based Public Health Nursing Practice

PHN Intervention
Definition

PHN Intervention
Examples

Policy Development & Enforcement (Wedge 5 – Yellow)
Policy development places health issues on decision-
makers’ agendas, acquires a plan of resolution, and
determines needed resources. Policy development results
in laws, rules and regulations, ordinances, and policies.
Policy enforcement compels others to comply with the
laws, rules, regulations, ordinances, and policies created
in conjunction with policy development (p. 313).

n Participate on a county task force to revise county human services
guidelines for mandating reporting of suspected child abuse or
neglect (systems level).

n Talk to a church group about the need to support a bill for commu-
nity nutrition programs for children living in poverty (community
level).

Source: Definitions from MDH, Center for Public Health Nursing (2001)

EVIDENCE EXAMPLE 2.1
Public Health Intervention Wheel

n Over 600 school nurses (SNs), members of the National
Association of School Nurses (NASN), completed an
electronic survey on using public health interventions in
their practice as defined by the Public Health Intervention
Wheel. Most SNs (67%) were not familiar with the Wheel;
however, participants identified interventions that were
consistent with the Wheel. They used screening, referral
and follow-up, case management, and health teaching
more often than other interventions. In estimates of
time spent at specific practices levels, SN practice was
primarily at the individual level (65%). They also provided
community-level interventions 22% of their time and
systems-level interventions 14% of their time. SNs can use
the Wheel to document and explain the interventions they
provide in school nursing practice to address the health of
school populations (Schaffer, Anderson, & Rising, 2016).

n A qualitative study explored how school nurses (n = 43)
understood and used the interventions from Public Health
Intervention Wheel. Data were analyzed from six focus
groups conducted across the state of Minnesota. Ns rep-
resented urban, suburban, and rural schools. The SN prac-
tice stories included all interventions and levels of practice

except for case management and delegation at the com-
munity level. The highest number of practice examples
were for health teaching, case finding, and referral and
follow-up, all at the individual level. The practice stories
provide examples of how SNs can extend their practice to
community and systems levels and affirm school nursing
as a population-focused practice (Anderson et al., 2018).

n McDonald and colleagues (2015) replicated the process
of identifying and defining public health interventions
from the Wheel in the context of public health nursing
in Ireland. Public health nursing leaders in Ireland con-
ducted a literature review and hosted discussions on each
intervention wedge at the 2011 Institute of Community
Health Nursing conference. The aim was to promote
visibility of the PHN role and build a common language
to describe interventions. A key theme of practice stories
was the importance of building trusting relationships with
individuals and communities to support interventions.
The Population Health Interest Group (2013) pub-
lished practice stories from Irish nurses for each of the
17 interventions.

‘‘

’’

Jaime says, “I am going to a meeting with my PHN precep-
tor this afternoon about how the different county agencies
and the school district are working together as a team to try
to reduce smoking among high school students. I guess that
would be an example of collaboration, but I am not sure
which level of practice that would be.”

Abby ponders, “I think maybe when PHNs work with
agencies and school districts, they are practicing at the sys-
tems level. If they use an intervention like social market-
ing to let teens know about the availability of a smoking

cessation program at their school, then they would be prac-
ticing at the community level.”

Jaime responds, “Teens at risk for smoking are a vul-
nerable population within the community, and PHNs
work with populations within the community. If the team’s
goal is to change the smoking behaviors of individual high
school students, even if they were part of a group and PHNs
carried out some health teaching in the classroom, I guess
those actions would be at the individual/family level. This
gets kind of confusing at times.”

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32 PART I n Foundational Concepts for Public Health Nursing Practice

PHNs take a comprehensive approach to dealing with
public health problems in the community. They use mul-
tiple interventions to achieve primary, secondary, and ter-
tiary prevention goals and, when possible, work with other
members of the interdisciplinary team and members of the
community. Table 2.2 outlines how primary, secondary, and
tertiary interventions might be employed at all three levels
of practice to reduce tobacco use in teens. (See Chapter 1 for
a discussion of primary, secondary, and tertiary prevention.)

Evidence-Based Practice
Public health organizations are expected to use evidence-
based approaches in decision-making and in taking actions
based on population-based evidence (Lovelace et al., 2015).
This evidence-based public health approach means that
PHNs use the best information available to create new inter-
ventions (Barr-Walker, 2017). This evidence-based decision
process includes (Brownson, Fielding, & Maylahn, 2009,
p. 177):
n Using the best available scientific evidence
n Systematically using data and information systems

TABLE 2.2 Three Levels of PHN Practice and Three Levels of Prevention With Public Health
Interventions to Reduce Tobacco Use in Teens

Individual/Family Level of Practice

Primary Prevention Secondary Prevention Tertiary Prevention

Health Teaching
n Conduct classroom teaching on the

dangers of tobacco use and strategies
to avoid it.

Case Finding, Referral, and Follow-Up
n Assess the health behaviors, including

tobacco use, of individual students.
n Identify students at risk for tobacco

use and those already using tobacco.
n Refer students who smoke to the

school smoking prevention and
cessation team.

n Follow up with the school nurse.

Case Management and Collaboration
n The school nurse, physical education

teacher, and school psychologist team
up to work with teens using tobacco
and to monitor and implement a
smoking cessation program.

Community Level of Practice

Social Marketing and Outreach
n Staff a teen booth at the county fair

and hand out brochures on the hazards
of tobacco use and available tobacco
prevention and cessation programs.

Screening, Referral, and Follow-Up
n Hold health-behaviors screening,

including tobacco use, for teens and
young adults at the county fair.

Case Management and Social Marketing
n Create a social networking site to

empower teens and for teens to
provide peer support for smoking
cessation.

Systems Level of Practice

Health Teaching/Provider Education
n Develop and present a program to

teachers and school staff about the
hazards of tobacco use and available
smoking prevention and cessation
programs.

Screening, Referral, and Follow-Up
n Develop a health-behaviors screen-

ing, referral, and follow-up program
for middle school and high school
students.

Case Management and Collaboration
n Develop a case management protocol

for the school smoking prevention and
cessation interdisciplinary team.

n Applying program planning frameworks
n Engaging the community in assessment and

decision-making
n Conducting sound evaluation
n Disseminating findings

Public health nurses’ practice is expected to be evidence-
based. This evidence-based approach means that PHNs use
a problem-solving approach to find the best available sci-
entific evidence and the best available experiential evidence
and then integrate this evidence into their practice (Dang &
Dearholt, 2018, p. 4).

The search for credible evidence includes knowledge
gleaned from both research and nonresearch. The lev-
els of evidence at the core of the Johns Hopkins Nursing
Evidence-Based Practice Model (JHNEBP) include research
and nonresearch evidence. There are five levels of evidence
(see Table 2.3). You will find examples from all levels of evi-
dence in the remaining chapters of this book. Although the
levels of evidence are presented in a hierarchical manner in
Table 2.3, this table does not mean that lower levels of evi-
dence should be discounted or that randomized controlled
trials (RCTs) in experimental research should be considered
the only credible or most meaningful forms of evidence

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33CHAPTER 2 n Evidence-Based Public Health Nursing Practice

TABLE 2.3 Best Practices in Public Health Nursing by Level of Evidence

Evidence Level Definition Examples

Level I:

Experimental study, randomized controlled
trials (RCTs)

Explanatory mixed methods design

The Nurse Family Partnership involving intensive structured home visiting by
PHNs reduces repeat childbirths, improves the stability of partner relation-
ships, facilitates children’s academic adjustment to elementary school, and
reduces childhood mortality from preventable causes (Kitzman et al., 2010;
Olds et al., 2004; Olds et al., 2007; Olds et al., 2010).

Level I:

Systematic reviews of RCTs, with or without
meta-analysis

Professional organizations publish systematic reviews of medical and nursing
research
n The Cochrane Database of Systematic Reviews, published online by the

Cochrane Collaboration.
n Worldviews on Evidence-Based Nursing, a peer-reviewed journal published

by Sigma Theta Tau International.
n The Joanna Briggs Institute provides an online listing of systematic reviews

and meta-analysis specific to nursing practice. Systematic reviews of non-
RCT research may be either Level II or Level III evidence.

Level II:

Quasi-experimental study

Explanatory mixed-method design

Systematic review of a combination of RCTs and
quasi-experimental studies or quasi-experimental
studies only

A prospective cohort study evaluated the impact of breastmilk expression in
early postpartum period on breastfeeding duration (Jiang et al., 2015).

Level III:

Nonexperimental study

Systematic reviews of combination of RCTs,
quasi- experimental, and nonexperimental
studies

A descriptive study identified four significant predictors of breastfeeding
attitudes: age, gender, number of breastfeeding observations in childhood, and
breastfeeding beliefs (Vari et al., 2013).

A systematic review using CINAHL (Cumulative Index to Nursing and Allied
Health Literature), PubMed, and Cochrane Library databases identified bar-
riers to breastfeeding in the WIC population to make recommendations for
guidelines for WIC clients (Hedberg, 2013).

Level IV:

Opinion of respected authorities and nationally
recognized expert committees or consensus
panels based on scientific evidence
n Clinical practice guidelines
n Consensus panels/position statements

ANA. (2013). Public Health Nursing: Scope and Standards of Practice (2nd ed.)

Quad Council of Public Health Nursing Organizations. (2011).
The Quad Council competencies for public health nurses

Centers for Disease Control and Prevention. (2017). Immunization Schedules

Level V:

Based on experiential and nonresearch evidence
n Integrative reviews
n Literature reviews
n Quality improvement, program, or financial

evaluation
n Case reports
n Opinion of nationally recognized expert(s)

based on experiential evidence

The Best Start program supporting area-based interventions to increase breast-
feeding was evaluated. Area-based interventions and community partnerships
were found to have a positive influence on breastfeeding rates (Kelaher, Dunt,
Feldman, Nolan, & Raban, 2009).

Source: Definitions of Levels of Evidence from Dang & Dearholt, 2018, Appendix D, pp. 278–279

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34 PART I n Foundational Concepts for Public Health Nursing Practice

‘‘
in public health. It is important to thoughtfully consider
and analyze information from all levels of evidence. For
example, the use of qualitative research, particularly when
studying culture and ethnicity, has led to significant under-
standing of how diverse populations and people view them-
selves and the world around them.

Experiential evidence that may be found in IV and V
evidence levels includes clinical expertise and client’s pref-
erences and values. PHNs know that evidence-based inter-
ventions found in the scientific literature need to fit the
demographics and cultural diversity of their clients at the
individual/family and community levels of practice in order
to be consistent with ethical holistic nursing practice (see
Figure 2.3).

These three interrelated elements occur within the con-
text of the community—where public health nurses are
expected to be lifelong learners who take the initiative to
engage with their community to explore the life experi-
ences, health status, and health determinants of diverse
populations. The information PHNs gather about the indi-
viduals/families and communities they serve leads them to

question how they can positively impact the health of these
individuals/families and communities.

Public health nurses use critical thinking in applying a
deliberative process for identifying and implementing best
practices in a timely manner. The Johns Hopkins Nursing
Evidence-Based Practice Model (JHNEBP) includes three
essential components: inquiry, practice, and learning (Dang
& Dearholt, 2018):
n Inquiry: To question, examine, and collect information

about an issue or problem (p. 36)
n Practice: Reflects on the translation of what nurses

know to what they do (p. 36)
n Learning: A change in the way nurses think and

behave

The movement from inquiry to learning is represented
by the JHNEBP PET Process (see Figure 2.4). This process
is a group effort within or across organizations. In public
health, the team could be formed from members of a spe-
cific organization or be an interprofessional team at the
community level with key stakeholders and community
members involved. The practice team identifies the practice
issue, defines and refines the practice question, searches for
and evaluates the evidence, and determines which evidence
can and should be translated into new or revised practices
in the workplace.

Abby wonders how PHNs know what to do when they work
with their clients. She says, “The PHNs keep talking about
evidence-based practice, but I am not sure exactly what
that is.”

Jaime responds, “Today, my PHN preceptor and I made
a home visit to an elderly woman who lives alone. We did
a fall risk assessment and a home safety check. I asked the
PHN how she selected which risk assessment and home
safety assessment tools to use. She told me that a committee
of PHNs reviewed journal articles to find research reports
on which assessment tools were effective for determining
fall risks in older adults. They also looked at which home
safety tools had been developed specifically for frail older
adults living at home. Then they piloted the home safety
assessment tools themselves and picked the tool that best fit
what their PHNs needed to know about the home environ-
ment and what the elderly adults preferred. I think this is
the way you do evidence-based practice, but I need to read
more about it.”

Abby comments, “One of the PHNs at my agency went
to a fall prevention workshop given by an occupational
therapist and a physical therapist at the local hospital.
They taught the workshop participants how to screen
older adults for fall risk and which types of interventions
would help reduce fall risks, such as using assistive devices,
installing good lighting, removing slippery rugs, and wear-
ing nonskid slippers. Do you think this information could

FIGURE 2.3 Best Practice Approach to Evidence-Based
Practice in Public Health Nursing
Sources: Based on work by Keller & Strohschein, 2009; Melnyk &
Fineout-Overholt, 2014

Credible evidence

Client
preference
and values

Clinical
expertise

FIGURE 2.4 JHNEBP PET Process
Source: Used with permission: Dang & Dearholt, 2018, p. 4

Practice
Question

Evidence Translation

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35CHAPTER 2 n Evidence-Based Public Health Nursing Practice

’’

be considered evidence-based? The two therapists said they
were reporting on what they had found worked best with
their patients.”

Jaime says, “I guess we could review the material on
evidence-based practice in our textbooks and then talk
more to our PHN preceptors.”

“Good idea,” says Abby. “Let’s do it. We can also do a
search using CINAHL to see if there are any studies that
support what the PHN learned at the workshop. Do you
think this information about effective interventions will be
easy to find? What is an effective intervention anyway?”

Effective interventions fit your client’s situation and pref-
erences and result in the desired outcomes. Using inter-
ventions that are known to be effective is important. PHNs
have carried out research to demonstrate the effectiveness

of many interventions provided to individuals, families,
and communities. However, it is not always easy to find sci-
entific literature on the effectiveness of PHN interventions
(Swider, Levin, & Reising, 2017). Although research for
evidence-based practice might be limited in public health
nursing, PHNs should refer to it whenever it exists (Keller &
Strohschein, 2009, from Brownson, Baker, Leet, & Gillespie,
2002). PHNs are accountable to their clients (individuals/
families, communities, and systems) and to the public to
determine the effectiveness of an intervention and to justify
the use of resources. Your own experiences as a nursing stu-
dent can also guide your choices of which interventions you
can carry out effectively. You can use the evidence-based
public health approach—making decisions on the best
information available and creating interventions based on
that evidence (Barr-Walker, 2017). Table 2.4 includes recent
studies that demonstrate effective public health nursing
interventions.

TABLE 2.4 Effectiveness of Selected Public Health Nursing Interventions

Individual/Family Level

Intervention Results

Case management Decreased difficulty and dependence for meal preparation, telephone use, shopping, and ordinary house-
work (Instrumental Activities of Daily Living) were found for elders receiving home visiting in compari-
son with usual care (Li, Liebel, & Friedman, 2013). [Level I]

Case finding
Case management
Health teaching
Consultation
counseling

Significantly higher scores on overall healthy eating and healthy eating subdimensions (i.e., food selection,
preparation, and consumption) were found in elders 60 years and over in comparison to control group
(Meethien, Pothiban, Ostwald, Sucamvang, & Panuthai, 2011). [Level I]

Counseling Socially withdrawn students showed an increase in self-efficacy after participation in group-based coun-
seling interventions led by school nurses (Kvarme et al., 2010). [Level II]

Counseling
Health teaching
Referral and follow-up

Low-income, first-time mothers who participated in the Nurse–Family Partnership (NFP) home visiting
program had more beneficial breastfeeding and immunization outcomes compared to similar clients not
in the program (Thorland, Currie, Wiegand, Walsh, & Mader, 2017). [Level III]

Community Level

Surveillance In response to an online survey of PHNs in 29 states, PHNs reported they conducted ongoing surveillance
for tuberculosis, vaccine-preventable diseases, sexually transmitted diseases, pediculosis, foodborne dis-
eases, and elevated blood lead levels in their communities (Schaffer, Keller, & Reckinger, 2015). [Level III]

Coalition building School nurses participated in an interfaith coalition to respond to youth suicide in the community
(Anderson et al., 2017). [Level III]

Systems Level

Consultation
Screening

A maternal and child health nurse screening program for mothers experiencing domestic violence
(nurse-designed model) increased safety planning among postpartum women (Taft et al., 2015). [Level I]

Collaboration
Outreach

School nurses collaborated with a hospital and a school of nursing to develop and implement an
injury-prevention curriculum for helmet safety in elementary schools. Students from the intervention
group reported increased helmet use after intervention in comparison with the control group (Adams,
Drake, Dang, & Le-Hinds, 2014). [Level II]

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36 PART I n Foundational Concepts for Public Health Nursing Practice

‘‘
’’

Evidence-based practice (EBP)—and nursing interven-
tions—should be both effective and efficient. PHNs use the
evidence-based public health approach and consider all
evidence-based information, including the experiences of
experts. Because resources are limited in both healthcare
and public health, PHNs also need to consider the efficiency
of interventions. Efficient interventions require the least
amount of resources and achieve the desired outcomes in
the shortest period of time.

Evidence-based practice supports efficacy (the ability
to reach a desired result); efficiency (the achievement of a
desired result with minimum expense, time, and effort); and
effectiveness (the ability to produce a desired result). Addi-
tionally, EBP weighs risks, benefits, and costs against a back-
drop of patient preferences (Dang & Dearholt, 2018, p. 4).

Jaime voices his concern that if he knew from the literature
that an intervention was known to achieve a desired out-
come, he might use it even if he did not know if it would
be effective. “How do I know if it is going to work with a
specific client?”

Abby responds, “Well you can ask your preceptor what
type of interventions have worked in the past with your
client. You could also ask the client if he wants to try it.”

Before using an intervention, look at the literature or
consult with expert PHNs to identify specific interventions
that can best meet your clients’ unique needs and charac-
teristics. You also want to consider if the intervention is a
good use of your time and resources and the client’s time
and energy. Questions you can ask to determine effective-
ness and efficiency are listed in Table 2.5.

healthypeople.gov

Healthy
People

Healthy People 2020 identified 11 Leading
Health Indicators (LHIs) as priority health
concerns, including Nutrition, Physical
Activity, and Obesity. Go to the Healthy People 2020 website,
click “Leading Health Indicators,” and then click “Nutrition,
Physical Activity, and Obesity.” Read about the most recent
data and population disparities on nutrition, physical activity,
and obesity. Look for the links to the science-based Dietary
Guidelines for Americans and the Physical Activity Guidelines.
What evidence do you find that supports a healthy eating and
physical activity program for you and your family?

Just because “best practice” evidence is available does not
mean that it will be adopted and used. To create a supportive
evidence-based practice environment, three strategies are
necessary: establishing the EBP culture, building the capac-
ity for EBP, and ensuring sustainability (Dang & Dearholt,
2018, p. 19). A strategic plan and committed leadership are
necessary to develop the organizational resources and sup-
port for a sustainable evidence-based practice culture. Staff

TABLE 2.5 Analyzing Effectiveness and
Efficiency of Interventions

Determining
Intervention
Effectiveness

Determining
Intervention
Efficiency

n Is the intervention
culturally and develop-
mentally congruent with
the client’s status and
situation?

n Is the intervention
acceptable to the client?

n Does the outcome of the
intervention demonstrate
improvement of the
client’s health status?

n What are the costs of the
intervention (money, time,
people involved, and other
resources) for the PHN,
the other members of the
health team, the agencies
involved, and the client?

n Are the costs of imple-
menting the intervention
justified by the health
benefits for the client and
the community?

needs include continuing education on evidence-based
practice as well as initiatives to be implemented. Resources
such as Internet access to useful databases and journals,
evidence-based organizational mentors, and reimbursable
time facilitate integration of evidence into practice.

This chapter presents an overview of evidence-based prac-
tice relevant to public health nursing practice. The term best
practices is often used synonymously with evidence-based
practice. A few points are helpful to keep in mind as you
think about and use evidence of “best practices” in your
community health clinical:
n Experimental research using RCTs is considered uneth-

ical when placing an individual in a control group that
denies that individual treatment or interventions are
already demonstrated to be effective.

n Public health/community health nursing agencies may
be carrying out quasi- and nonexperimental research to
determine the effectiveness of their programs and inter-
ventions. These activities may be a component of their
ongoing quality improvement programs. Sometimes
students participate in these research studies. If you are
asked to participate, ask to see any informed consent or
ethical guidelines that your agency is using.

n The policies and procedures of your public health/
community agency and the professional practice stan-
dards guiding PHN practice may be considered clinical
guidelines. Progress reports and annual agency reports
may be considered organizational experiences.

n The knowledge and experiences of your preceptor and
other PHN agency staff will be reflected in the practice
you observe and the mentoring you receive. These repre-
sent expert opinions and clinical expertise.

n Clinical experiences may include both participant
and nonparticipant observation. When you reflect on
your observations of your preceptor or other public

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37CHAPTER 2 n Evidence-Based Public Health Nursing Practice

health/community health nurses interacting with clients
by using PHN interventions, you are demonstrating
nonparticipant observation. When you use these inter-
ventions yourself and reflect on your practice, you are
demonstrating participant observation. Both types of
experiences add to your clinical expertise.

n Community assessments that are carried out in collabo-
ration with community members and client satisfaction
surveys provide evidence of consumer preferences. See
Chapter 3, Competency #1, for information on commu-
nity assessments.

Database and Internet Searches
The sources of evidence must be as credible as the evidence
itself. That is why PHNs search scientific databases. The
online databases that provide the most relevant journal
articles for nursing are CINAHL and PubMed. CINAHL is
a proprietary database hosted by EBSCO, which means it
is privately owned and available to members of subscribing
institutions who pay a fee for remote access. PubMed is an
open-source database that is free to the public. Other cred-
ible sources include websites maintained by professional
organizations and service providers and governmental web-
sites, such as those run by the National Institutes of Health
(NIH), the U.S. Surgeon General, and the Centers for Disease

Control and Prevention (CDC). The Cochrane Library is an
international database of systematic reviews owned by the
Cochrane Collaboration and is an open-source database
that is free to use. The CDC Stacks, an excellent source for
public health information, is a free digital repository of pub-
lications produced by the CDC.

The NIH provides guidelines for evaluating web-based
health resources that can help you determine whether the
website resource you have found is credible. One example
of a credible website is a government program that reviews
maternal-child health home visiting program effectiveness,
called Home Visiting Evidence of Effectiveness (HOMVEE).
This website includes discussion of models and programs,
whether they meet Department of Health and Human Ser-
vices (DHHS) criteria, their target populations, and whether
research shows positive effectiveness (U.S. Department of
Health and Human Services, n.d.).

The goal of evidence-based practice is not to generate new
knowledge, but to improve practice. Baccalaureate nursing
graduates are expected to be able to find and use best prac-
tice evidence to improve their nursing practice. Hopp & Rit-
tenmeyer (2012, p. 84) identify a five-step process known as
the “5 A’s.” This process works well for students and PHNs
alike and can be used when students partner with public
health nurses during their clinical learning activities in
public health. Table 2.6 outlines a process for public health
nursing students to carry out the “5 A’s.”

TABLE 2.6 Using the 5 A’s for Evidence-Based Practice in Student Clinical Learning Activities

The 5 A’s Students Using the 5 A’s with Community Partners

Ask: To find the right answer, you
need to ask the right question.

n Work with PHNs or other community partners to identify a public health practice issue
about a specific health concern with a specific population and a related knowledge gap
about current best practices.

n Work with PHNs or other community partners to create a specific practice question.
n Identify reasonable client outcomes that you wish to achieve with modified or new best

practice evidence.

Acquire: Search for the answer by
exploring all levels of evidence.

n Work with reference librarian, instructor, and community partners to identify credible
data sources for all five levels of evidence.

n Identify appropriate databases to search and keywords for search.
n Work with instructor and community partners to identify evidence from nonscientific

literature (e.g., credible websites, professional organizations, agency reports, etc.).
n Conduct key informant interviews.
n Conduct search, preferably for the past 5 years (or 10 years if there is little published

information for the past 5 years).

Appraise: Critically evaluate
the evidence and select the “best
practice evidence.”

n Work with fellow students, instructors, and interprofessional teams to critically review
the evidence and determine what evidence answers your practice question and is applica-
ble to the client population.

n Work with community partners to consult practice experts to determine which interven-
tions fit what the experts know about the population and health concern.

n Work with key community stakeholders to determine population preferences and values.

(continues)

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38 PART I n Foundational Concepts for Public Health Nursing Practice

Evidence of Best Practices
PHNs need to be critical consumers of public health and
nursing research. They must use a deliberative problem-
solving approach when making decisions about which
evidence in the literature is strong enough to support a
change in practice (Poe & White, 2010). However, public
health providers often do not have adequate knowledge
about evidence-based practice or the tools and resources
to research current evidence-based best practices (Barr-
Walker, 2017). In addition, published evidence in scientific
journals is limited, and many of the sources used are from
health-related statistics, government reports, and organiza-
tional or professional guidelines.

Much of the evidence for effective public health nursing
comes from Evidence-Based Practice Levels III, IV, and V. It
is often not ethical, possible, or practical to randomly place
people in an experimental or a control group, especially if
placement in either group could have a negative effect on
an individual’s health or well-being. An increasing body of
qualitative research in public health nursing exists. Under-
standing the context of the family, culture, and commu-
nity; the meaning of events; and the impact of these factors
on the clients’ health behaviors and health status is often
best achieved through the use of qualitative research meth-
ods. Public health nurses also learn a great deal from their
practice experiences and those of their colleagues. This
evidence-based information or practice-based knowledge
helps public health nurses translate evidence into practice
in specific clinical care settings (Barr-Walker, 2017). Case
study examples can be found in the literature, shared at
professional conferences, or reported on the Internet. These
anecdotal reports are also part of the practice evidence of
public health nursing.

Framing Your Evidence-Based Practice
With the “5 A’s”
One of the most difficult skills is knowing how to initiate
the evidence-based practice process in a clinical setting. It is
time to return to the “5 A’s” discussed earlier in the chapter

(Hopp & Rittenmeyer, 2012): ask, acquire, appraise, apply,
and assess.

Ask
When you explore the scientific literature for best practice
evidence, it is helpful to first identify your clinical ques-
tion so that you are focused in your search. One helpful
way to frame your clinical practice question is to use the
PICOT approach by identifying the patient population (P),
the intervention of interest (I), the comparison interven-
tion (C), the outcome (O), and the timeframe (T) (Stillwell,
Fineout-Overholt, Melnyk, & Williamson, 2010). For exam-
ple, if you wanted to research the effectiveness of teaching
parents about the “Back to Sleep” program to reduce the risk
of Sudden Infant Death Syndrome (SIDS), you might frame
your PICOT question as outlined in Table 2.7.

The “T” in PICOT may not be necessary to include when
reviewing the literature, but it may be helpful to include the
time element when you plan how and when you are going to
evaluate the outcome of the intervention you have selected
to implement in your clinical setting. Once you find a set of
articles that report on the effectiveness of the intervention
you are interested in, it is time to review them to determine
their usefulness.

Acquire
After writing your PICOT question, you can identify the
keywords in the sentence. A helpful way to identify key-
words is to create a PCO Table (Population, Content, Out-
comes). Table 2.8 demonstrates that using a PCO Table helps
you to identify six keywords or phrases. If you have access
to a reference librarian, you can take your keywords to the
librarian who can then help you create your online literature
strategy and identify the databases to search (Butler, Hall, &
Copnell, 2016). Complete your search using your keywords.

Appraise
The next step is to compare and contrast the studies and
reports you have appraised. Select the best studies or reports
with the most credible evidence that fits your clinical

The 5 A’s Students Using the 5 A’s with Community Partners

Apply: Make the evidence action-
able by using the evidence to
change your practice.

n Report credible evidence from all five levels to community partners.
n Make recommendations for change in practice or new interventions.
n Collaborate with community partners on modifications of current interventions or

development of new interventions.
n Partner with your PHN preceptor to implement the intervention if possible.

Assess: Evaluate the outcomes
of the change in practice in your
clinical setting.

n Identify how and when the client outcomes will be evaluated and determine the
effectiveness and efficiency of the modified or new intervention.

TABLE 2.6 Using the 5 A’s for Evidence-Based Practice in Student Clinical Learning Activities (continued)

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39CHAPTER 2 n Evidence-Based Public Health Nursing Practice

‘‘

’’
situation and addresses your specific question. Think about
how you would present your findings and recommendations
to the PHNs and team you are working with.

Apply
Once you have completed the first three steps and have iden-
tified a best practice intervention, begin working with your
clinical team to translate or apply the evidence into clinical
practice. Before you implement a change in your practice or
your clinical team’s practice, you need to think about how
you will evaluate the effectiveness of the change. Identify
the outcome you would like to achieve.

Assess
The timeframe for assessment of client outcomes after imple-
menting the new intervention will depend on the urgency to

determine efficacy of an intervention as well as a realistic
expectation as to when effectiveness can be evaluated. For
example, if you implemented a community-wide campaign
to increase the flu vaccine in September to decrease the inci-
dence of influenza in the fall, you would probably compare
the incidence of influenza this fall to last fall in December. If
you were evaluating the effectiveness of the “Back to Sleep”
program, you might choose a 6-month timeframe to evalu-
ate the outcome of the program.

It would be important to evaluate both the effectiveness
and the efficiency of the intervention from a cost-benefit
perspective, which would be based on the quality of life as
well as the financial and human resource costs involved.
This is not always easy to do. For example, if the “Back to
Sleep” program reduced the incidence of crib death by one
infant in a 3-month period, would any of your community
partners consider the program effective and efficient?

Jaime comments, “I think I am going to do my intervention
paper on ways to reduce smoking in high school students.
I have to start looking for evidence-based practice articles.
I wonder how I should go about that.”

Abby says, “I have been working with the college refer-
ence librarian to research my topic. She suggested that I
use three databases: CINAHL, PubMed, and the Cochrane
Database of Systematic Reviews. I have found a few good
articles in each database.”

Jaime responds, “Great! I will try those databases, too! I
know that both PubMed and the Cochrane Database are in
the public domain and free to users. CINAHL is privately
owned, and organizations have to pay for employees to
use it. I don’t think my hospital has a contract to access
CINAHL.”

Abby concludes, “Don’t forget to write your PICOT
question first!”

Translating Evidence Into Practice
One of the most difficult skills is knowing how to initiate
the evidence-based practice process in a clinical setting
and to translate best practice evidence into practice, which
means that you use the best practice evidence to evaluate
and update how you practice nursing. PHNs need to make
sure that their recommendations for change in practice are
based on the best evidence and are appropriate and feasible
for their client populations, their agencies, and their com-
munities. Support and funding for PHN practice depends
on documentation and dissemination of evidence that PHN
practice makes a positive difference in the health of its com-
munities. Evidence Example 2.2 shows step-by-step how to
use an evidence-based practice approach to find best prac-
tice evidence.

TABLE 2.7 The PICOT Approach to
Clinical Problem Solving

PICOT Question
Elements Examples

P = Patient population

I = Intervention of interest

C = Comparison interven-
tion of interest

O = Outcome(s) of interest

T = Time it takes the inter-
vention to achieve outcomes

P = Infants at risk for SIDS

I = Teach parents to place
infants on backs to sleep
using “Back to Sleep”
program

C = No purposeful teaching
about safe sleeping position
of infants

O = Percentage of babies
sleeping on back

T = Evaluate at 6 weeks and
3 months

PICOT Question: Will infants (P) whose parents are taught
to place them on their backs to sleep using a “Back to
Sleep” program (I) as opposed to no purposeful teaching
about safe sleeping positions for infants (C) be sleeping on
their backs (O) at 6 weeks and 3 months after receiving the
intervention (T)?

TABLE 2.8 Finding Keywords Using PCO

PCO Elements Examples

P = Patient Population P = Infants at risk for SIDS,
parents, caretakers

C = Context C = Teaching safe sleeping positions

O = Outcome O = Sleeping on back

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40 PART I n Foundational Concepts for Public Health Nursing Practice

EVIDENCE EXAMPLE 2.2
Searching for Best Practice Evidence on Optimal Breastfeeding Initiation
and Translating the Evidence Into Practice

Breastfeeding is initiated in the setting where delivery occurs.
Often that is the hospital. Many new mothers are sent home
from the hospital within 24 hours of delivery. So, it is import-
ant for PHNs to know the best practice evidence to share with
their antepartum clients about what breastfeeding approaches
work best and then to support those practices during the
postpartum period. Public health nurses need to work with
their nursing partners in the hospital setting to prepare their
clients for breastfeeding, advocate for the preferences of the
new mothers with their acute care colleagues, and provide for
a seamless transition in the breastfeeding routine when the
mother returns home through coordination and case manage-
ment interventions. In this example, nurses in a birthing center
searched for best practice evidence for initiation of breast-
feeding immediately after birth. The following example shows
how the “5 A’s” and the PICOT process were used to identify
best practice evidence and translate it into practice. The ques-
tion was whether it was best practice to use a breast pump to
support breastfeeding in the first 72 hours postpartum.

Ask
A PICO(T) question was developed to frame the question to
guide the literature search:

P = Efficacy of use of breast pump in early postpar-
tum period to promote exclusive breastfeeding with
mother’s milk

I = Electric breast pump after breastfeeding during first
24–48 hours

C = Breastfeeding on-demand during first 24–48 hours

O = Baby fed exclusively with mother’s own breastmilk

T = 6 weeks postpartum

The question: Does use of an electric breast pump after
breastfeeding versus breastfeeding on-demand during the
first 24–48 hours postpartum increase the likelihood a baby
will be exclusively fed with a mother’s own breastmilk at
6 weeks postpartum?

Acquire
Ovid Medline, CINAHL, PubMed, and Google Scholar were
searched using a variety of search terms. Although 23 articles
were found, only 3 of these articles addressed the PICOT ques-
tion and the actual practice question.

Appraise
The literature reviewed suggested that while it remains unclear
if pumping has any immediate impact on breastfeeding initia-
tion and milk supply, using a breast pump in the first days and
weeks postpartum is associated with a shorter breastfeeding

duration (Chapman, Young, Ferris, & Perez-Escamilla, 2001;
Felice, Cassano, & Rasmussen, 2016; Jiang et al., 2015).
Other important evidence was identified:

Anticipating return to work and suboptimal long-term lac-
tation support systems increased women’s dependence on
expressing breastmilk with a pump (Chapman et al., 2001;
Felice et al., 2016; Jiang et al., 2015).

Hand expression is more effective at expressing colos-
trum (first days’ breastmilk supply) than an electric pump
( Flaherman et al., 2013).

Developing the nurse-family relationship fosters an
empowering environment where the family can experience
growth and develop the skills needed to achieve successful
infant feeding patterns, including direct breastfeeding and
expressing breastmilk (Raile Alligood, 2010).

After reviewing the scientific evidence, the nursing team at
the birthing center considered the other two evidence com-
ponents: the practice and procedures of the birthing center
and the preferences of the new mothers. The context of the
relationship between the mother and the nursing staff was
considered. The nurses’ caring interaction was considered as
necessary as the evidence-based knowledge to facilitate suc-
cessful breastfeeding initiation.

Apply
Supporting Breastfeeding Guidelines were developed and
implemented based on the evidence. The nurse in the birthing
center who initiated the quality improvement process changed
jobs and became a clinical coordinator in a public health nurs-
ing agency. She was able to share the best practice evidence
about the initiation of breastfeeding with the public health
nursing staff.

Assess
At the birthing center, the new guideline was instituted and
evaluated at both the systems and the individual/family
practice levels. Nursing staff completed a nursing practice
survey before and after implementation of the new guide-
lines. The purpose was to measure the accuracy with which
nurses were able to determine the appropriate interventions
needed to support lactation (when and when not to use an
electric pump) and their confidence levels of decision-making
regarding when to utilize the breast pump to support lactation.
The individual-level change was measured through a patient
survey completed at discharge. The survey measured the
breastfeeding mothers’ confidence levels of continuing their
breastfeeding plan of care when returning home and their per-
ception of nursing support received for their individual infant
feeding goals.

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41CHAPTER 2 n Evidence-Based Public Health Nursing Practice

‘‘

’’

Jamie is continuing to work on his evidence-based practice
search on how to reduce smoking in high school students.

Abby changed her topic. With her PHN preceptor, she
has been co-visiting a first-time mom who has postpartum
depression. The PHN is visiting the mom twice weekly, and
the PHN has asked Abby to research best practices in work-
ing with moms with postpartum depression. Abby is going
to develop her PICOT question, create her PCO Table, and
then consult with her instructor and the reference librarian
on how to go about searching for the best practice evidence.
She is excited to be able to partner with her PHN preceptor
to find the most up-to-date best practice evidence to present
to the Family Health Team.

If you follow through on the steps outlined in this chapter
for researching best practices and taking steps to translate
this evidence into your nursing practice, you will be prac-
ticing nursing from an evidence-based practice framework.
As a professional, you are accountable for your own nursing
practice, so you need to be aware of and use best practices.
You will find that this book presents many levels of evidence
to justify using specific interventions.

ACTIVITY
Imagine that you are the nurse who changed jobs from the
birthing center to the public health agency.

n How would you use this best practice breastfeeding
initiation evidence?

n What would you want to know about the public health
nurses and their antepartum and postpartum clients?

n How would you develop your PICOT question?

n How might you partner with the staff to carry out the
“5 A’s” process?

The evidence-based practice approach does not always
entail a simple, concise process. However, through the use
of various levels of evidence, clinical expertise, local con-
text, and client preference, best practice interventions can
be developed and implemented to promote and protect the
health of individuals, systems, and populations.

n All five levels of evidence are used to identify best
practices.

n Evidence-based practice is a deliberative process start-
ing with a practice question, followed by an appraisal
of the evidence, and then a change in practice based on
credible evidence.

n Using the “5 A’s” and PICOT provides a structure for
practicing from an evidence-based foundation.

KEY POINTS

n The public health nursing process guides the PHN’s
actions.

n PHNs work at all three levels of practice (individual/
family, community, and systems).

n PHNs carry out 17 interventions unique to public health
nursing; 16 of these interventions are practiced inde-
pendently as part of professional nursing practice.

n Public health nursing practice is evidence-based.

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42 PART I n Foundational Concepts for Public Health Nursing Practice

REFLECTIVE PRACTICE

1. What do you think are the major differences between
the nursing process and the public health nursing
process?

l What will you do differently when following the
public health nursing process?

l How will your knowledge about the determinants of
health guide you in your assessments and interven-
tions at the three levels of practice: individual/family,
community, and systems?

2. Which other disciplines will you work with most often
in your public health clinical?

l What additional information do you need to know
about the other health disciplines?

l How will you find out the information that you need?
3. Which public health nursing interventions have you

used in previous clinical experiences?
l How will you carry out these interventions in your

public health clinical?
l How will this experience be the same or different

from what you have done before?

4. Have you used an evidence-based practice approach in
other nursing clinical experiences?

l What have you learned in reading this chapter that
you did not know before?

l How will your past experiences and your new knowl-
edge help you practice evidence-based public health
nursing?

5. Which types of best practice evidence related to a PHN
intervention would you like to explore?

l What is your PICOT question?
l How do you frame this as a PICOT statement?
6. Refer to the Cornerstones of Public Health Nursing in

Chapter 1. Which of the Cornerstones support the use
of evidence-based practice in public health nursing?

APPLICATION OF EVIDENCE

How would you work with your PHN preceptor to identify
an intervention that the staff would like to have researched
to identify any new best practice recommendations?

When you search for best practice evidence, how would
you implement the following steps?
n Determine which databases to use in your search.
n Carry out your literature search. Obtain help from the

reference librarian if you are having difficulty with your
keyword search.

n Select three to five journal articles to review. You may
use articles that represent different levels of evidence.

How would you carry out the following steps to analyze the
evidence?
n Compare and contrast the articles you have appraised.

Are their findings and recommendations similar or
different?

n Identify the articles that have the most credible evidence
that best fits your clinical situation.

n What format would you use to report your
evidence-based finding to the PHN staff?

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http://www.achne.org/files/Quad%20Council/QuadCouncilCompetenciesforPublicHealthNurses

PART II
Entry-Level Population-Based

Public Health Nursing
Competencies

3 COMPETENCY 1: Applies the Public Health Nursing Process to Communities, Systems,
Individuals, and Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4 COMPETENCY 2: Utilizes Basic Epidemiological (The Incidence, Distribution, and
Control of Disease in a Population) Principles in Public Health Nursing Practice . . . . . . . . . . . . . . .

5 COMPETENCY 3: Utilizes the Principles and Science of Environmental Health to Promote
Safe and Sustainable Environments for Individuals/Families, Systems, and Communities . . . . . . .

6 COMPETENCY 4: Practices Within the Auspices of the Nurse Practice Act . . . . . . . . . . . . . . . . . . . . 127
7 COMPETENCY 5: Works Within the Responsibility and Authority of the Governmental

Public Health System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
8 COMPETENCY 6: Utilizes Collaboration to Achieve Public Health Goals . . . . . . . . . . . . . . . . . . . . . 167
9 COMPETENCY 7: Effectively Communicates With Communities, Systems, Individuals,

Families, and Colleagues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
10 COMPETENCY 8: Establishes and Maintains Caring Relationships With Communities,

Systems, Individuals, and Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
11 COMPETENCY 9: Incorporates Mental, Physical, Emotional, Social, and Spiritual Aspects

of Health Into Assessment, Planning, Implementation, and Evaluation . . . . . . . . . . . . . . . . . . . . . . . 221
12 COMPETENCY 10: Demonstrates Nonjudgmental/ Unconditional Acceptance of People

Different From Self . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
13 COMPETENCY 11: Shows Evidence of Commitment to Social Justice, the Greater Good,

and the Public Health Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
14 COMPETENCY 12: Demonstrates Leadership in Public Health Nursing With Communities,

Systems, Individuals, and Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
15 Putting It All Together: What It Means to Be a Public Health Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . 301

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‘‘

’’

CHAPTER

3
COMPETENCY #1
Applies the Public Health Nursing
Process to Communities, Systems,
Individuals, and Families

n Patricia M. Schoon
with Karen S. Martin, Kelly Krumwiede, and Noreen Kleinfehn-Wald

Kristi is listening to Beth, her public health nurse (PHN) preceptor, tell her about the client they are about
to visit for the first time. The local public health agency received a maternal child health visit referral
from a local OB/GYN for a 16-year-old, 20-weeks-gestation primipara. The client, Sara, has been diag-
nosed with anemia and is underweight with poor weight gain. Sara is single and living with her mother,
mother’s boyfriend, and two younger siblings. Sara and her family are uncomfortable with the idea of a
public health nurse who works for the government visiting them in their home.

Beth says, “Well, I think the first thing we do is go and visit them. We need to get them to trust us if we
are to help them.”

Kristi responds, “I have never visited a pregnant teenager or her family in their home. I don’t think I
will feel comfortable. Will the family be okay with me there?”

Beth responds, “I asked Sara’s mother if you could covisit with me and she was okay with that. We
will ask Sara and her mother what their health concerns and goals are and talk with them about how to
arrange our visits and what we can do to help Sara. We will open a case file on Sara and begin to do a
family assessment. You can observe and listen on this visit and take a more active part in future visits.”

Kristi says, “That sounds good to me!”
As they walk to Beth’s car she mentions, “We can start to do a windshield survey on our way to Sara’s

home as part of the community assessment that you and your student work group are going to do of the
local community.”

Kristi responds, “Great. I just happen to have my camera with me.”

KRISTI’S NOTEBOOK
COMPETENCY #1 Applies the Public Health Nursing Process to Communities, Systems, Individuals, and Families

(continues)

A. Identifies the population(s) for which the PHN is accountable

B. Assesses the health status of communities, systems, individuals, and families

1) Uses a health and social determinants framework to determine risk factors and protective factors that
lead to health and illness in communities, systems, individuals, and families

2) Identifies relevant and appropriate data and information sources for the populations to which the PHN is
accountable

a. Familiar with data used in the health department

b. Familiar with data in the programs in which the PHN works

3) Works in partnership with communities, systems, individuals, or families to attach meaning to collected
quantitative and qualitative

data

4) Works in partnership with communities, systems, individuals, and families to establish priorities

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48 PART II n Entry-Level Population-Based Public Health Nursing Competencies

KRISTI’S NOTEBOOK
COMPETENCY #1 (continued)

C. Creates public health strength, risk and asset-based diagnoses for communities, systems, individuals,
and families

D. In partnership with communities, systems, individuals, and families, develops a plan based on priorities
(including nursing care plans for individuals/families)

1) Selects desired outcomes that are measurable, meaningful, and manageable

2) Selects public health interventions that

a. Are supported by current literature as evidence-based

b. Reduce health determinant risk factors and strengthen health determinant protective factors

c. Have the greatest potential for improving the health of the population

d. Respect and are consistent with the culture and ethnic beliefs of the community

e. Are consistent with professional standards, the Nurse Practice Act, existing laws, ordinances, and
policies

3) Selects level(s) of intervention (community, systems, individuals, and families)

4) Selects level(s) of prevention (primary, secondary, tertiary)

E. Implements the plan with communities, systems, individuals, and families

1) Works in partnership with communities, systems, individuals, and families to implement public health
interventions

2) Utilizes best practices when implementing the public health nursing intervention

F. Evaluates

1) Measures outcomes of public health nursing interventions using evidence-based methods and tools

2) Documents public health nursing process by completing forms, records, and charts for communities,
systems, individuals, and families

3) Uses information technology to collect, document, analyze, store, and retrieve the health status of
communities, systems, individuals, and families

Source: Henry Street Consortium, 2017

USEFUL DEFINITIONS

Community: Refers to (a) a group of people or population group; (b) a physical place and time in which the
population lives and works; or (c) a cultural group that has shared beliefs, values, institutions, and social systems
(Skemp, Dreher, & Asselin, 2006, p. 23).

Community Assessment: The process of systematically collecting information about a community’s structure,
processes, and dynamics, its physical and social environment, its populations, and its level of health and wellness
to determine its strengths, its resources, its populations of interest and populations at risk, its health needs, and
its health priorities.

Electronic Health Records (EHRs): “Longitudinal collection of clinical and demographic client-specific data that
are stored in a computer-readable format” (Martin, 2005, p. 461).

Family: A family is defined as a social unit of two or more people who identify themselves as a family, share
emotional bonds, and carry out the functions of a family including managing healthcare (Clark, 2008; Friedman,
Bowden, & Jones, 2003; Martin, 2005), and family is “a group of individuals who are bound by strong emotional
ties, a sense of belonging, and a passion for being involved in one another’s lives” (Wright & Bell, 2009, p. 46).

Family Assessment: The process of systematically collecting information about clients’ family structure, pro-
cesses, and dynamics; their physical and social environments; and their levels of health and illness to determine
their strengths, resources, health needs, and health priorities.

Health Status Indicators: Measures of the level of health or illness of an individual/family, community, or popu-
lation, such as incidence or prevalence of disease, birth and death rates, level of independence, life satisfaction,
and quality of life.

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49CHAPTER 3 n Competency #1

of the students, a recent immigrant, said she thought these
families were fairly well off—they had housing, food, and
were safe in their homes . The country she had emigrated
from was in turmoil . She had seen family members mur-
dered, their cattle slaughtered, homes burned, and people
without food or clothing . These people, she thought, had
truly stressful lives . The other students reflected on her com-
ments and came to realize that people view the world from
their own experiences . Understanding and appreciating the
lived experiences of people is important . Knowing about
and understanding each other helps promote the oppor-
tunity for people to work together in a mutually respectful
manner that can build on each other’s strengths .

PHNs work in partnership with individuals, families,
and communities . Partnerships are mutual relationships
based on trust . PHNs establish trust with individuals, fam-
ilies, and communities by respecting their rights to make
their own health decisions and by adapting the nursing
practice to fit the lived experiences and daily lives of those
individuals, families, and communities . PHNs direct their
efforts to meet the priority health needs their clients iden-
tify . Public health nursing practice includes the “3 E’s”:

n Egalitarian (equal) relationships with individuals,
families, and communities

n Enhancement of individual, family, and community
strengths, resilience, and resources

n Empowerment of individuals, families, and com-
munities to advocate for and manage their own
healthcare needs

Thinking and Doing Population Health—
Nursing Process Leads the Way
PHNs work with individuals and families wherever they
find them in the community and in whatever condition
they find them . The priority for public health nursing is
health promotion and disease prevention, but PHNs also
work with individuals and families who have chronic health
conditions to help them achieve their health potential and,
whenever possible, manage their own lives and healthcare
needs . They need to discover their clients’ potential for self-
care and wellness to help them reach that potential . PHNs
use a strengths-based approach when using the public health
nursing process . Because their clients live in the commu-
nity, PHNs need to find out as much as they can about the
community’s support systems, resources, and resource gaps .

Partnering With Individuals,
Families, and Communities
PHNs need to understand the story, the context of the lives
of the people in the community in which they work . PHNs
must know and understand the history, culture, and life-
style of individuals, families, populations, and the entire
community . For example, in a post-clinical seminar, stu-
dents were discussing the stresses and crises of the families
they were visiting . They stated that they did not understand
how these families could function with so much stress . One

Omaha System: “Research-based approach to practice, documentation, and information management that
incorporates the Problem Classification Scheme, Intervention Scheme, and Problem Rating Scale for Outcomes”
(Martin, 2005, p. 463).

Population: The “total number of people living in a specific geographic area”; subpopulations (syn. groups or
aggregates) “consisting of people experiencing a specific health condition, engaging in behaviors that have
potential to negatively affect health, sharing a common risk factor or risk exposure, or experiencing an emerging
health threat or risk” (American Nurses Association [ANA], 2013, p. 3).

Priority Setting: Organizing health concerns by hazard level so that health risks that place individuals/families,
communities, or populations at greater risk are dealt with first.

Public Health Informatics: Public health informatics is the systematic application of information, computer
science, and technology to public health practice, research, and learning (Centers for Disease Control and
Prevention [CDC], n.d.-b).

Public Health Nursing Process: Integrates concepts of public health, community, and all three levels of PHN
practice (i.e., individual/family, community, system) into the nursing process (i.e., assessment, diagnosis,
planning, implementation, and evaluation) (Minnesota Department of Health [MDH], Center for Public Health
Nursing Practice, 2003).

System: An organization or institution that is part of the social environmental determinant of health
(i.e., healthcare, education, commerce, religion, government).

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50 PART II n Entry-Level Population-Based Public Health Nursing Competencies

third-party payers and accreditors require health depart-
ments to provide evidence that their programs result in
improved client outcomes . Aggregate data are a powerful
tool to demonstrate the value of agency programs and can
be shared with the public, be used to obtain grants and other
funds, and be incorporated into quality improvement and
program evaluation reports . Examples of reports generated
by various agencies are found at www .omahasystem .org/
links .html .

Data Collection, Data Management,
and the Public Health Nursing Process
Data compose the engine that drives the problem-solving
process in nursing practice . Data are used to determine
the health of populations and sub-populations in order to
influence health priorities, health policy, and programs that
promote the health and safety of communities and their pop-
ulations (Allen, Soderberg, Laventure, 2017; Nelson & Stag-
gers, 2018) . A continuum of population data is used by public
health agencies to improve the health of their communities
(see Figure 3 .1) . Accurate and consistent population data can
be transformed to information, which leads to population
health knowledge, and then to wisdom in order to design
public health interventions to create healthier communities .

Therefore, you need to have a system and process for
data collection and management in place at the beginning
of the nursing process . For this reason, we discuss data in
this chapter before we discuss the components of the public
health nursing process . Many public health and community
agencies use electronic health records (EHRs) and auto-
mated health information systems (HIS) . EHRs and HISs
provide ways to collect, store, analyze, and share informa-
tion . Community and population data can be gathered from
a variety of primary (data collected by individuals carrying
out assessment) and secondary (data collected and published
by others) sources .

Although more than one HIS exists, a system created for
public health nursing is useful as an example . The Omaha
System, a standardized terminology initially developed for
use in the community, provides a problem-solving approach
based on the nursing process (see Figure 3 .2) . The Omaha
System is the foundation of the HIS that interprofessional
team members at many health departments and other
community provider sites regularly use to collect, docu-
ment, and analyze individual, family, and population clin-
ical data . The Omaha System allows PHNs to collect and
record their own evidence-based practice data, analyze the
data, and generate meaningful information that can be used
to improve the quality of the care they provide . By using
this approach, PHNs operationalize the data-information-
knowledge- wisdom continuum (Allen et al ., 2017; Martin,
2005; Nelson & Staggers, 2018) . They can tell their data- and
evidence-driven stories about the individuals, families, and
communities they serve . More than 22,000 interprofes-
sional clinicians use the Omaha System globally (Omaha
System, 2017) .

The adoption of EHRs by healthcare providers, includ-
ing health departments, is increasing very rapidly (Amer-
ican Nurses Association [ANA], 2015; Martin, Monsen, &
Bowles, 2011; Office of the National Coordinator for Health
Information Technology, 2017; Omaha System, 2017) .

When health departments use EHRs based on the
Omaha System accurately and consistently, they can aggre-
gate individual and family data into larger data sets so that
patterns can be identified within populations . Increasingly,

FIGURE 3.1 Transforming Data to Practice
Source: Allen et al., 2017; adapted by LaVenture, 2008

PUBLIC HEALTH PRACTIC

HEALTHIER C MMUNITIES

LE
V

EL
O

F
V

A
LU

DATA

INFORMATION

KNOWLEDGE

WISDOM

PRACTICE

FIGURE 3.2 Omaha System Model of the Problem-Solving
Process
Source: Martin, 2005, p. 7, used with permission

INDIVIDUAL,
FAMILY, OR

COMMUNITY

Evaluate
problem
outcome

Collect
and assess

data

Plan
and

intervene

Identify
admission
problem

rating

Identify
interim/
dismissal
problem

rating

State
problem

PRACTITIONER–CLIENT RELATIONSHIP

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http://www.omahasystem.org/links.html

51CHAPTER 3 n Competency #1

‘‘

’’

communities)—The Problem Classification Scheme is a
hierarchy of terms that includes domains; individual-,
family-, and community-centered problems; modifiers;
and signs/symptoms .

n Intervention Scheme (plans, pathways, care activities,
and service delivery terms to improve safety, qual-
ity, and effectiveness)—The Intervention Scheme is a
hierarchy of terms that includes categories, targets, and
client-specific information .

n Problem Rating Scale for Outcomes (evaluation that pro-
vides usable information for measuring and reporting
client progress and change across time)—The Problem
Rating Scale for Outcomes consists of Knowledge,
Behavior, and Status concepts and Likert-type rating
scales . Evidence Example 3 .2 showcases a case study of
the Omaha System used to tell the story of a nurse-client
interaction .

See Appendix B for additional Omaha System resources .

Kristi has just finished reading about the Omaha System.
Her PHN preceptor, Beth, tells her that the public health
nursing agency uses the Omaha System, and Beth wants
Kristi to have a basic understanding of the Omaha System
before she and Beth chart on any of the clients they visit.
Beth gives Kristi the case study about Anna to read to help
her understand the system. Beth asks Kristi if what she
read made sense.

Kristi reflects: “I expected to be confused about the
Omaha System, but the case study helped a lot. I could see the
how the nurse assessed Anna and provided nursing services
to her. She could use the

Problem Rating Scale for Outcomes

to evaluate Anna’s progress when she returns for another
visit. I can see that using this system helps nurses measure
the impact of their care and report how nursing care makes
a difference. The one concern I have is that my instructor
stresses the importance of using a strengths-based approach
and the Omaha System always uses the term ‘problems.’”

Beth comments: “I had the same concern when I started
using the Omaha System, but my supervisor pointed me to
the literature on how ‘problem’ is actually defined in the
Omaha System. Here is the definition of problem that I
found: ‘Unique client concerns, needs, strengths, issues, foci,
or conditions that affect any aspect of the client’s well- being;
nursing diagnosis stated from the client’s perspective’* Also,
I found that the term ‘problem’ can be considered neutral,
not negative, so a problem in the Omaha System can also be
used as part of a strengths-based approach.**

Kristi responds: “That makes me more comfortable.
I am going to share with my classmates that the Omaha
System term ‘problem’ can be used from a strengths-based
perspective.”
* Source: Martin, 2005, p . 465
** Source: Monsen, Vanderboom et al ., 2017

Omaha System terms are used in documentation at
the point of care (i .e ., the time and place that care occurs) .
Because the terms of the Omaha System are not complex
and the structure is relatively simple, nonhealthcare pro-
fessionals can understand it . Clinicians see and use point-
of-care terminologies in their EHRs . In 2014, Minnesota
became the first state to recommend that American Nurses
Association recognized point-of-care terminologies be
included in all EHRs (ANA, 2015; Minnesota Department of
Health [MDH], 2015) . Prior to that, Minnesota Department
of Health staff conducted a survey and found that 96 .5% of
community agencies in all counties used the Omaha System
(Omaha System, 2017) .

The Omaha System enables healthcare providers to ana-
lyze and exchange client-centered coded data that can be
transformed to information, the first two stages of the data-
to-wisdom continuum . The Omaha System was designed to
be used by interprofessional clinicians to guide their prac-
tice and document and communicate information about
clients from admission to discharge . It exists in the public
domain (no fee or license) and is intended for use across
the continuum of care nationally and globally . It is based
on a conceptual model that reflects the pivotal position of
the individual, family, and community as client; interpro-
fessional partnerships; and the value of the problem-solving
approach . The Omaha System encourages critical thinking,
enhances communication, and operationalizes the nursing
process . The problem-solving approach complements the
strengths-based approach that focuses on building devel-
opmental assets and increasing the health of youth and
communities (Martin, 2005; Monsen, Vanderboom, Olson,
Larson, & Holland, 2017; Omaha System, 2017) . The Omaha
System consists of three components:
n Problem Classification Scheme (client-centered

assessment that engages individuals, families, and

EVIDENCE EXAMPLE 3.1
The Omaha System

The Omaha System was developed by the Visiting Nurse
Association of Omaha (Nebraska) and seven test sites to
enhance practice, documentation, and information man-
agement. Four federally funded research studies were
conducted between 1975 and 1993 that validated appro-
priateness and effectiveness of the terminology. DeLanne
Simmons, chief executive officer, envisioned a computer-
ized management information system that incorporated an
integrated, valid, and reliable clinical information system
focused on clients who received services, not on the nurses
and other interprofessional team members who provided
the services (Martin, 2005; Martin et al., 2011; Omaha Sys-
tem, 2017). More than 400 articles, chapters, and books
have been published about the Omaha System; the Listserv
has more than 3,000 members located in the U.S. and 22
other countries (Omaha System, 2017).

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52 PART II n Entry-Level Population-Based Public Health Nursing Competencies

EVIDENCE EXAMPLE 3.2
Omaha System Case Study

Anna K.: Older woman who had a chronic cardiac condition
and attended a screening clinic

First Visit/Encounter Data
Public health nurses at the Dakota County Public Health
Department (Minnesota) developed health clinics for senior
citizens. The clinics offered screening for health concerns, par-
ticularly hypertension, heart disease, and depression; accurate
health information for prevention and treatment; and outreach
and referral coordination for home care, equipment, medical
assistance, and other community services. Because inter-
action time was limited, the nurses developed standardized
protocols and forms based on the Omaha System to increase
the efficiency and effectiveness of assessment, interventions,
and documentation. When new clients visited the clinics, the
nurses considered four problems, Communication with com-
munity resources, Mental health, Circulation, and Medication
regimen. If those problems did not reflect clients’ presenting
data, the nurses selected and documented other pertinent
problems, interventions, and outcome ratings.
When Anna K. came to the senior clinic for the first time,
she reported that she had a history of dizziness and high blood
pressure, but could not recall previous readings. When the
nurse checked her vital signs, her blood pressure was 152/86
sitting and 154/82 standing; her pulse was 60 and regular. Her
weight was 138 pounds, appropriate for her reported height.
They talked about hypertension, blood pressure guidelines,
the Circulation protocol, and Anna’s data. The nurse suggested
strategies to increase Anna’s safety when she was dizzy. The
nurse recorded Anna’s vital signs on a health card, gave the
card to her, and suggested that she have her blood pressure
re-checked monthly and recorded on the card. She asked her
to show the card to her doctor during future appointments.
Anna said she took two “heart” pills fairly regularly. She
agreed to bring them with her when she returned to the Senior
Clinic the following week so she and the nurse could discuss
them. The nurse planned to use the Medication regimen pro-
tocol if appropriate, and record them on Anna’s health card.

Anna’s Answers: Transforming the Story into the Omaha
System assessment, services, and evaluation terms

Domain: Physiological

Problem: Circulation (high priority problem)

Problem Classification Scheme
Modifiers: Individual and Actual
Signs/Symptoms of Actual:

n syncopal-fainting episodes/dizziness

n abnormal blood pressure reading

Intervention Scheme
Category: Teaching, Guidance, and Counseling
Targets and client specific information:

n anatomy/physiology (circulatory system)

n mobility/transfers (avoid falls)

n signs/symptoms-physical (importance of vital signs,
when to notify physician, dizziness)

Category: Case Management
Targets and client specific information:

n continuity of care (show doctor her health card with
monthly blood pressure checks)

Category:

Surveillance

Targets and client specific information:

n medical/dental care (schedule and go to appointments)

n signs/symptoms-physical (vital signs, circulatory status,
weight, blood pressure)

Problem Rating Scale for Outcomes
Knowledge: 2—minimal knowledge (some information about
normal/abnormal blood pressure readings but not impact on
health; did not know previous readings)

Behavior: 4—usually appropriate behavior (usually took
medications, has blood pressure checked periodically, seeks
healthcare)

Status: 3—moderate symptoms (blood pressure exceeded
expected range for non-diabetic client)

Elizabeth A. Vance, BSN, RN, PHN
RN Primary Care
Allina Health Clinics Division
Minneapolis, Minnesota

Carol A. Fish, MS, RN, PHN
Supervisor, Social Services Department
Dakota County Public Health Department
West St. Paul, Minnesota

Source: Vance & Fish, 2017 Omaha System case study . Personal correspondence from Karen S . Martin, Martin Associates, Omaha, NE . December 8, 2017 .

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53CHAPTER 3 n Competency #1

Home Visiting and the Nursing Process
PHNs carry out assessments as part of the nursing process
most often in a community setting, such as a home, a school,
or a clinic . Most of the information is gathered through
observation and listening . When in the home setting, PHNs
are guests of the family members and need to follow their
lead regarding communication methods; timing, length,
and place of visit; and roles of the nurse and family mem-
bers . To assess the family, PHNs must first establish a trust-
ing relationship with family members based on mutual
respect and understanding (Eriksson & Nilsson, 2008;
Martin, 2005; McCann & Baker, 2001) . Answering ques-
tions about personal family matters and health situations
requires families to disclose information they generally do
not share with strangers, so the development of a trusting
relationship needs to precede or occur simultaneously with
the interviewing process . Andrew Gardner (2010) found
that one way to engage clients and help them feel comfort-
able was to start by being open and friendly; this approach

seems obvious but can be challenging for nurses who are
learning to be professional while maintaining boundaries
and creating an environment conducive to effective nurs-
ing practice . An appropriate level of openness certainly can
facilitate a connection and mutual understanding, but this
is sometimes a difficult balancing act, as friendship often
occurs within the professional context of the nurse-client
relationship . The initial visit to a family is critical in estab-
lishing the nurse-client trust relationship (see Evidence
Example 3 .3) .

Home visiting programs may include one or more vis-
its to a client . PHNs follow some families for months and
years, depending on their health risks and needs . So you
should not feel as though you have to get everything done
in one visit . Table 3 .1 demonstrates how a PHN would use
the nursing process in making a series of home visits . The
orientation phase takes one to three visits on average . The
working phase might require multiple visits over a period of
months or years .

EVIDENCE EXAMPLE 3.3
Public Health Nurses’ Views of a Good First Meeting

Swedish researchers used focus groups to determine what
public health nurses believed constituted a good first home
visit with parents of newborns (Jansson, Petersson, & Uden,
2001). A good first visit is considered key to developing an
effective relationship with parents. Three criteria were identi-
fied (Jansson et al., 2001):

1. Creating trust through good contact/reciprocal relation-
ships; listening; being a guest; having an equal role with
parents; and having time, privacy, and peace and quiet

2. Creating a picture of the family’s life situation by getting
a holistic impression of the family, seeing them in their
home environment, getting a picture of what the clients
are like, and taking in, consciously and unconsciously, the
mood and a variety of information about the family

3. Creating a supportive climate by confirming and affirming
parents’ feelings, abilities, and responsibilities and increas-
ing their responsibilities while providing a safety net of
services until family is able to manage on its own

TABLE 3.1 How the Nursing Process Occurs in Home Visits

Home-Visiting Components Nursing Process

Orientation Phase
n Introduction
n Determine purpose of visit and visit activities with client
n Engage in social conversation
n Assessment
n Identify and state client’s problems

Assessment and Diagnosis
n Individual/family and community assessment
n Strengths-based assessment—protective factors identified
n Resources identified
n Health risks and active health problems identified
n Unmet health needs identified

Working Phase: Identification
n Client asks questions and identifies nurse as someone who

can help .
n Client identifies problems .
n Nurse provides health teaching, support and counseling,

follow-up assessment, referral, and advocacy .

Planning and Implementation
n Mutual planning, priority-setting, goal-setting
n Interventions often used include teaching, guidance, and

counseling; treatments and procedures; case management;
surveillance, advocacy, referral, and follow-up .

(continues)

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54 PART II n Entry-Level Population-Based Public Health Nursing Competencies

Home-Visiting Components Nursing Process

Working Phase: Mutual Relationship
n Client uses nurse as resource and accesses community

resources .
n Nurse engages client in mutual problem solving .

Implementation
n Interventions often used are teaching, guidance, and

counseling; treatments and procedures; case management;
surveillance; collaboration; and consultation .

Resolution and Termination
n Problems are solved or ongoing but stable .
n Client becomes independent of nurse or continues to

need support .
n Relationship ends when client no longer needs nurse or no

longer participates in plan (moves or refuses participation
in plan or visits) .

Evaluation
n Evaluation of Knowledge, Behavior, and Status outcomes:

outcomes met, partially met, or not met
n Replan—change in goals, outcomes, or interventions
n New priorities or emerging problems identified and nursing

process continued

Sources: Phases adapted from McNaughton, 2005; Omaha System terms from Martin, 2005; and interventions from Minnesota Department of Health, 2001

TABLE 3.1 How the Nursing Process Occurs in Home Visits (continued)

PHNs carry equipment they need to complete assess-
ments on individual family members . For example, common
equipment used on maternal/child health visits includes a
baby scale, blood pressure cuffs, a stethoscope, paper tape
measures, disposable thermometers, developmental screen-
ing tools, growth grids, and a thermometer for determining
the temperature of bath water .

PHNs carry smartphones, laptops, and other electronic
devices to stay in contact with others, access information,
and enter family data into EHRs during their home visits .
Many PHNs use automated guidelines or clinical path-
ways specific to individual client and family situations . For
example, public health agencies have screening, assessment,
and monitoring databases for newborns, infants, children,
antepartum, postpartum, and family clients . PHNs collect
admitting data on each client during their initial visits to
their clients . They monitor and record health changes at
each visit .

Public Health Nursing Assessment
Public health nursing assessment is a systematic, deliber-
ative, and holistic process of collecting data about a client
(individual, family, community, or system) that leads to an
understanding of the client’s health determinants, health
status, and priority health concerns and needs, as shown
in Figure 3 .3 . PHNs also need to carry out strengths-based
assessments so that intervention plans for health concerns
and problems are based on the clients’ abilities to manage
their own healthcare needs . Strengths-based assessments
identify clients’ abilities, resources, and resilience as well as
health needs (Monsen, Vanderboom et al ., 2017) .

FIGURE 3.3 How PHNs Collect Data About Individuals,
Communities, and Systems

Individual/Family
• Family assessment
• Family health goals

Community
• Strength-based
assessment
• Health assessment and
intervention process

• MAP-IT
• Windshield
survey

System
• Community health priorities
• Community action

plan

• Community intervention plan

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55CHAPTER 3 n Competency #1

‘‘

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Individual/Family Level of Practice
The family is the focus of care when PHNs work at the
individual/family level of practice . The family is the pri-
mary unit of society and is responsible for carrying out the
functions that allow family members to survive and thrive .
In a health sense, the family is a unit of care allowing the
nurse to simultaneously focus on the individual, the family,
and the health issue (Hunt, 2013) . Families come in many
shapes and sizes and in different stages of development .
Family composition is varied and changeable in contempo-
rary society (Kaakinen, Coehlo, Steele, & Robinson, 2018) .
A family is “a group of individuals who are bound by strong
emotional ties, a sense of belonging, and a passion for being
involved in one another’s lives” (Wright & Bell, 2009, p . 46) .

The experience of illness or a health concern is felt by not
just the individual but also by larger systems including fam-
ily members and the community (Marshall, Bell, & Moules,
2010) . Family-focused care has the potential to empower
vulnerable and at-risk families (Rossiter, Fowler, Hopwood,
Lee, & Dunston, 2011) . Family assessment is a holistic pro-
cess in which all the factors that influence a family’s level
of health and wellness are considered . Specifically, a family
unit assessment includes collecting data on the individual,
family, household, and community to identify resources,
strengths, and risks (Meiers, 2016; Meiers, Krumwiede,
Denham, & Bell, 2016) . In addition to considering individ-
ual human development stages, PHNs consider the family’s
stage of development . Transitions between the stages involve
rearrangement of relationships . Although it is important to
note that this is a very traditional model for married fam-
ilies with children and would need to be adapted to a vari-
ety of diverse family structures, Carter and McGoldrick’s
(2005) Family Life Cycle model highlights the development
of the family system over time:
n Leaving home as single young adults
n Joining of families through marriage: the new couple
n Families with young children
n Families with adolescents
n Launching children and moving on
n Families in later life

Each stage is associated with tasks that will foster each
member’s development . Sara’s family falls in the “families
with adolescents” stage . One unique aspect to this stage is
that the parents face a transition with both the adolescent in
terms of growing independence and the adolescent’s aging
grandparents . This stage requires the family to alter its
parent-child relationship to accommodate the adolescent’s
growing independence and autonomy . This awareness of the
family’s stage of development can be helpful for PHNs in
understanding potential family conflict as they are work-
ing through the stages . Table 3 .2 outlines the components
of family assessment typically included in a comprehensive
family assessment using the Healthy People 2020 Health
Determinants Framework .

Beth and Kristi make their first visit to Sara. Her mother,
Patricia, introduces herself at the beginning of the visit and
states that she hopes the public health nurse can straighten
out her daughter and help her daughter understand the
poor choice she made in getting pregnant at such a young
age. She is concerned because Sara is missing so much
school. Sara has poor eye contact with Beth and her mother.
Beth focuses on Sara and asks her what she would like help
with for the rest of her pregnancy. Sara responds that she
is very tired and feels uncomfortable with all of her body
changes that are now becoming visible. She is afraid of how
the other students at school will treat her.

Beth tells Sara and Patricia that she would like to get a
good sense of the family before she begins any work with
Sara. Beth asks if she can visit again next week to finish the
family assessment she was able to start today. Before Beth
and Kristi leave, Beth collects information from Sara so a
case file can be opened. Beth then asks Sara if Kristi can
check her height and weight to get some basic information.
Sara agrees. Kristi finds that Sara weighs 100 lb. and her
height is 5’3″.

After the visit, Kristi writes in her public health nursing
clinical journal. She thinks about what phases of the home
visiting occurred during this first visit. She also analyzes
the visit and asks herself the question, “Was this a good
first visit?” Kristi also reviews the holistic family assess-
ment framework that she and Sara will be using during the
second home visit.

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56 PART II n Entry-Level Population-Based Public Health Nursing Competencies

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‘‘During the second home visit, Kristi works with Beth to
complete the family assessment. She constructs a genogram
with Sara and her mother and they notice that Patricia
and Sara’s grandmother have a history of preterm labor.
During the visit, Jimmy, Patricia’s boyfriend, comes home
early from work and Sara’s sisters, Tara and Kara, 9-year
old twins, come home from school. The home becomes loud
and there are lots of interruptions during the early part of

the visit. Beth asks Patricia if they can continue the visit in
the kitchen and asks the twins to stay in the living room.
Jimmy decides he will take a nap. The visit continues unin-
terrupted. By the end of the visit, information about the
family health determinants of biology and behaviors have
been collected. When Kristi completes her weekly clinical
journal, she organizes the family data by health determi-
nant categories.

Table 3 .3 is what Kristi recorded .

TABLE 3.2 Holistic Family Assessment Framework

Framework Factors

Family Biological and
Genetic Factors

n Age
n Sex or gender identify
n Three-generation genogram
n Family-identified ethnicity
n Health status

Family Behavioral Factors n Lifestyle and daily patterns including nutrition, sleep, exercise, and recreation
n Housing and living arrangements
n Social support/ecomap
n Family and community roles
n Education, employment
n Socioeconomic status (income, poverty)
n Cultural patterns, religious affiliations
n Language and health literacy
n Health-seeking and health-limiting behaviors
n Patterns of coping and resilience
n Patterns of conformity and

nonconformity

Physical Environment
Factors

n Home environment (use a home safety checklist appropriate to family members’ age,
development, and physical and cognitive abilities)

n Immediate neighborhood (observations, walkability, windshield surveys)
n Natural physical environment and weather
n Built environment, including safety
n Maintenance of sidewalks, roads, pedestrian crossing
n Transportation
n Adequate recreational resources
n Access to shopping centers
n Accessible healthcare—see the 5 A’s of accessible healthcare in the community-assessment guide
n Potential or actual environmental hazards such as pollution of air, water, food, or soil

Social Environment
Factors (i.e., social
actions, patterns, systems,
healthcare access)

n Availability of health and social services resources
n Availability of quality schools and daycare
n Availability of fire and police
n Employment opportunities
n Mass media and library availability
n Cultural and social patterns of community, including potential exposure to violence
n Governmental services
n Business community and working conditions

Data Analysis Summary of the family assessment including:
n Major family protective factors, major family risk factors
n Statement of family resilience and ability to manage own healthcare
n Family’s priority health problems or concerns and health goals

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57CHAPTER 3 n Competency #1

TABLE 3.3 Sara’s Family Assessment: Individual/Family Health Determinants

Biological and Genetic Health Determinant Factors

Sara: is 16 years old, 20 weeks gestation, primipara, on a prenatal vitamin, diagnosed with anemia, and underweight with poor
weight gain . She and her family are Caucasian .

Patricia: mother, is 34 years old taking hydrochlorothiazide 12 .5 mg daily for hypertension .

Jimmy: mother’s live-in boyfriend, is 37 years old and has no health conditions .

Siblings: Tara and Kara are 9-year-old twins; both females have attention deficit hyperactivity disorder (ADHD) and take
Adderall XR 1 .25 mg daily . Immunizations are up to date .

Extended family: Sara’s grandparents, Patricia’s parents, live on a farm house 30 miles away . Grandmother, 55 years old, has
hypertension . Grandfather, 57 years old, has type II diabetes .

Samuel: Sara’s boyfriend, is 17 years old, Hispanic, and has no known health conditions .

Behavioral Factors

Socioeconomic Status: Sara is a full-time high school student in 10th grade, unemployed, and with no income . Patricia is a full-time
factory worker and Jimmy is a full-time welder . Both have high school diplomas . Tara and Kara are full-time elementary school
students . Samuel, Sara’s boyfriend, is a full-time 11th-grade student and works part time at a restaurant . Although the family does
not live in poverty, their income is low and they struggle to pay their monthly bills . Patricia has family health insurance and Jimmy
has his own insurance .

Cultural and Religious Affiliation: All family members were born in the United States and are Catholic . The family attends church
most Sundays .

Family Developmental Stage: families with adolescents’ developmental stage (Carter & McGoldrick, 2005)

Family Roles and Function: Patricia takes on leadership and organizer role in the home and schedules Sara’s prenatal check-
ups . Patricia makes the decisions and Jimmy pays the bills and fixes the house . Sara babysits the twins but lacks knowledge of the
difference between being an older sibling and being a parent . Patricia is tired, stressed, guilty for not being available for the family,
and upset that Jimmy is not helping more at home . Samuel doesn’t come over much anymore because Patricia and Jimmy are not
very welcoming .

Family Lifestyle Patterns (disrupted by health concerns): The family is struggling to manage schedules . Sara has been missing
school due to fatigue and does not want anyone to know she is pregnant . Patricia and Jimmy leave for work at 6:00 a .m ., so Sara
routinely takes care of the twins in the morning . Lately, Sara hasn’t been helping the twins get ready for school or to the bus on time .
Patricia has been contacted by both schools due to Sara’s multiple absences and Tara and Kara’s tardiness . Patricia has been working
overtime to pay for Sara’s prenatal care costs . Due to the stress of Sara’s pregnancy and working overtime, the house is messy, meals
are not being made or eaten together, and the twins are not taking their ADHD medication as prescribed .

Ecomap Summary: The family has close relationships with their neighbors and church . The twins’ relationship with their school is
strained due to tardiness . Sara also has a strained relationship with her school and misses Samuel and her friends . She would like to
find a peer support group for pregnant and parenting teens but cannot find one .

Health seeking behaviors: Prior to the recent family disruptions, the family had healthy eating patterns, including eating supper
together . They enjoyed weekly family bike riding . The twins and sometimes Sara got at least 8 hours of sleep most nights . No one in
the family smokes; Sara does not use alcohol or other drugs .

Health Limiting Behaviors: The family lacks time to prepare and share meals and to go bike-riding . The twins often miss their daily
ADHD medications . Sara feels like she is getting fat due to pregnancy, so she eats only one meal a day, typically a peanut butter and
jelly sandwich, chips, and a soda and ice cream as a bedtime snack .

Family Resilience and Coping Patterns: Patricia stated she and her girls are strong and that Jimmy makes the family even stron-
ger . Patricia went through a difficult divorce and feels her family is stronger because of the experience . Patricia and the girls talked
through the experience; they “stuck together .” They have a positive outlook and pray together . Sara’s pregnancy has been stressful
for the family . Sara is scared to give birth and depends on her mom being strong . “She has always been my rock and now I am scared
because my mom is so disappointed in me . We don’t talk anymore; she just yells at me all the time .”

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58 PART II n Entry-Level Population-Based Public Health Nursing Competencies

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‘‘

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Beth and Kristi decide that Kristi could return for a third
family visit to complete the home and neighborhood por-
tions of the family assessment if Sara and her mother are
okay with this. Beth phones Patricia and gets permission
for Kristi to visit. After the visit, Kristi records the data on
the physical and social environmental health determinants
in her clinical journal. Kristi believes that she and Beth
have now completed the Orientation Phase of family visit-
ing. She will confirm this with Beth.

Table 3 .4 shows the notes that Kristi wrote after her visit .

Kristi goes to meet with Beth at the office before their next
scheduled home visit with Sara and her family. Beth and
Kristi review the data analysis of the family assessment and
the summary of the family strengths and risk factors and
identifies what she thinks are the family’s health problems
and priorities.

Beth comments, “It is difficult to focus on the family as
a whole when we opened the case on Sara and now we are
assessing and planning on intervening with the family as a
whole. You did a good job focusing on the family as a unit
and putting Sara in the center of that family.”

Establishing Family Health Goals
The PHN continues the nursing process by moving into iden-
tification of the individual’s or family’s health priorities and
mutual goal-setting . PHNs employ mutual problem-solving
strategies with clients to foster self- efficacy . When working
with families in the community, the PHN partners with the
families in determining priorities, establishing goals, and
developing an intervention plan . The plan should be con-
gruent with and integrated into the family’s culture, life-
style, and daily routine and be within the family’s potential
to achieve . The plan should enhance the family’s potential
for self-care and autonomy . The family care plan should be
realistic, understandable, measurable, behavioral, achiev-
able, and time-limited so that the effectiveness of the plan
and the nursing interventions can be determined . It is pos-
sible to develop and measure Knowledge, Behavior, and
Status outcomes for a family using the Omaha System Prob-
lem Classification Scheme .

TABLE 3.4 Sara’s Family Assessment: Physical and Social Environmental Health Determinants

Physical Environment Health Determinant Factors (Natural and Built Environment)

The family lives together in a 3-bedroom, 1-bath rambler in need of repairs in a low-income neighborhood . The twins share a room .
The home safety checklist findings included: presence of smoke detectors, carbon monoxide detectors, and good lighting through-
out . Cleaning products are in an unlocked cupboard under the sink . This will present a safety hazard for the new baby . Their
neighborhood has sidewalks and is well lit . Traffic is light . There is a grocery store, a farmer’s market, and a park nearby . The family
medical clinic is 5 miles from their home .

Social Environment Health Determinant Factors

The family feels that they live in a good neighborhood and good community . The neighborhood has a neighborhood watch commit-
tee and a few retired neighbors have a Safe Home sign in their window, which means that any child who needs help can go to those
homes . The local schools have good teachers and are safe . Patricia and Sara are relieved that a PHN can come to see Sara at home .
The PHN is working with the school nurse and social worker to plan for Sara’s return to school once she has the baby . There is no
peer support program for pregnant and parenting teens at the school . The City Council has recently started a marketing program to
attract new businesses, which will give Patricia and Jimmy opportunities for better jobs .

Data Analysis—Summary of Family Assessment

Family Strengths (Protective Factors): The family has a good history of resilience and healthy family roles and functions . The
family has good community support systems . Patricia and Jimmy expressed the desire to support Sara in her pregnancy . Sara plans
to complete high school and go to college; she does not use substances such as tobacco, drugs, or alcohol . The family is working with
the PHN, school nurse, and social worker to help Sara achieve her goals .

Family Risk Factors: Sara’s unexpected pregnancy has placed a stress on the family functions that has resulted in interruptions in
some family processes . Key areas for improvement are meal preparation, Sara’s difficulty with caretaking the twins in the morning,
and Sara’s poor eating habits . The family history of preterm labor is an added risk factor for Sara’s pregnancy . Sara has experience
caring for her younger siblings and has a desire to learn about prenatal care; however, she has a lack of knowledge about pregnancy
and caring for an infant . The relationship between Patricia and Sara is strained, and Sara does not feel she is receiving the support
she needs from her mother . The relationship between Samuel and the family is strained . The twins are not receiving their daily
ADHD medications and are often tardy at school, while Sara has frequent absences from her school .

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59CHAPTER 3 n Competency #1

TABLE 3.5 Sara’s Pregnancy and Family Stress in the Omaha System

DOMAIN: Physiological DOMAIN: Psychosocial

PROBLEM: Pregnancy (high-priority problem)
Modifiers: Individual and Actual

Signs/Symptoms of Actual
n Difficulty with prenatal exercise/rest/diet/behaviors
n Difficulty coping with body changes
n Inadequate social support

Problem Rating Scale for Outcomes

Knowledge: 2—Minimal knowledge (interested in information
about appropriate rest, exercise, and diet patterns)
Behavior: 1—Not appropriate behavior (no prenatal care; high-
risk behaviors)
Status: 1—Extreme signs/symptoms (anemia and is underweight
with poor weight gain)

PROBLEM: Interpersonal Relationship
Modifiers: Family and Actual

Signs/Symptoms of Actual:
n Difficulty establishing/maintaining relationships
n Incongruent values/goals/expectations/schedules
n Prolonged, unrelieved tension

Knowledge: 3—Basic knowledge (describes importance of
positive communication but not methods)
Behavior: 3—Inconsistently appropriate behavior (great
decrease in number and increase in length of relationships,
increase in repairing relationship)
Status: 2—Severe symptoms (limited, brief communication
and interaction, often tense)

’’‘‘

‘‘

’’

Kristi and Beth carry out a home visit with Sara and her
family to identify the family’s priority health goals. During
the visit, they work collaboratively with the family to iden-
tify two family health goals and then translate them into
the Omaha System Problems.

• Goal One: Have a healthy baby to add to the
family → Problem: Pregnancy.

• Goal Two: Work on supporting each other by
improving their relationships and communications
and get back into a scheduled routine → Problem:
Interpersonal Relationship.

Kristi and Beth return to the office to input the family
data for their family health goals using the Omaha System
Problem Classification Scheme. In order to measure health
outcome improvements over the time of the home visiting,
Beth assigns a Knowledge, Behavior, and Status (KBS) rat-
ing starting for the primary family health problems.

Kristi’s KBS rating for Sara and her family is shown in
Table 3 .5 .

Beth says, “The next step will be to develop care plans.”
Kristi states, “I just reviewed Anna’s case study and the
Intervention Scheme. Was that a care plan?”

Beth suggests, “The Omaha System Intervention Scheme
is used to describe care plans and services. For simplic-
ity, Anna’s case study documents services so readers can
‘match’ the services to the text in Anna’s story. Why don’t
you take the next half hour and go online to the Omaha Sys-
tem Community of Practice (http://omahasystemmn.org/
data.php)? Watch ‘An Introduction to the Omaha System’

and ‘How to Read an Omaha System Pathway.’ You will see
that the term ‘pathway’ is used to suggest various Interven-
tion Scheme categories, targets, and client-specific infor-
mation for specific problems. Then we can work together
to develop pathways for the Pregnancy and Interpersonal
relationship problems.”

Kristi responds, “That sounds like a great idea. I am
concerned though that Sara has a lot of other health prob-
lems related to her pregnancy: her eating habits and not
gaining any weight, anxiety, isolation from her friends and
her boyfriend, Samuel. The list goes on and on! When will
we deal with those issues?”

Beth responds, “With home visiting, we take things
one small step at a time. We are still in the Identification
Phase of the Home Visiting Process. As we work with Sara
and her family, we will deal with all of these issues using
many interventions. Once we have developed a working
relationship with the family we will move into the Mutual
Relationship Phase. Then we will be able to have more of a
consultative relationship and help them connect with com-
munity resources and decide how they want to manage the
challenges of the birth of Sara’s baby.”

Health teaching, counseling, consultation, and case
management are interventions commonly used to build on
and enhance the families’ strengths and encourage them to
manage their healthcare . PHNs use advocacy to facilitate
the individual’s and family’s ability to access health and
social resources . They also use advocacy when populations
are found to be at risk for a specific health hazard .

Whether individuals live alone or with others, the same
family functions are relevant . If you are working with an
individual who lives alone or whose extended family lives

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60 PART II n Entry-Level Population-Based Public Health Nursing Competencies

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elsewhere, you still need to use the same family assess-
ment approach . Sometimes a complete family assessment is
not needed or impossible to collect . In that case, the PHN
would select the assessment components that relate to the
specific family health problem or priority concern . It would
be important to include the following components in this
focused family assessment: the health problem or issue and
the related risk factors and protective factors, the family goal
related to the health problem or concern, necessary access to
health and social services, and the family’s ability to manage
healthcare needs and resources .

Community Level of Practice
PHNs assess communities to determine their levels of health
and wellness . These assessments are carried out in partner-
ship with the community . Many geographic communities,
such as cities, counties, and states, conduct a community
assessment on a periodic basis . They do this to monitor
changing health conditions of the populations in their com-
munities and to establish community priorities for health
goals, funding, and actions . The governmental agencies
conducting the assessment partner with other community
organizations and members to ensure that the diversity of
the community and all points of view are reflected in the
assessment . PHNs are part of the team that collects and
analyzes the community data .

It is important to conduct a strengths-based assessment
as part of the community-assessment process . PHNs work
to enhance community strengths so that communities can
be as independent as possible in solving their own health-
care problems and managing their own healthcare needs .
See Chapter 8 for a discussion of the formation of com-
munity partnerships and building on community assets
to strengthen the community’s ability to manage its own
healthcare needs .

The population data collected in public health includes
population health status, health differences or health status
gaps between populations (health disparities), and health
determinants (causes of health and illness within the popu-
lation) . Population health status data, also known as global
health status measures, are the “vital signs” of the popula-
tion . These global health measures include:
n Mortality (death rates) data
n Life Expectancy (average years lived for someone born

in a specific year)
n Years of Potential Life Lost (life expectancy–age of

death = YPLL)

n Morbidity (illness rates) data
n Health behaviors data (e .g ., smoking, exercise, obesity,

use of seatbelts)
n Health and life satisfaction data (how satisfied one is

with current health and lifestyle)
n Functional health data (ability to live independently

and manage own healthcare needs)

Kristi is just starting her community-assessment proj-
ect with three of her classmates. They are conducting an
aggregate assessment (focusing on a specific portion of the
population). Because of the home visits to Sara and her
family, Kristi is interested in looking at the needs of preg-
nant and parenting teens and identifying existing resources
and resource gaps. She finds out that Sara’s mother’s church
is considering starting an outreach program for pregnant
and parenting teens. She asks Beth what information the
health department might have to help her and the church
members decide what to do. Did the PHNs have any data
that would help?

Beth responds, “The public health department carries
out a community assessment every five years to determine
the priority health problems of the people living in the com-
munity. We want to know what the major health needs are
and which needs are met and which are unmet. We also
look at the assets or resources of the community to deter-
mine the community’s capacity to manage its own health-
care needs and solve its own problems. Then we prioritize
and decide which services to offer, what the funding should
be, and how to allocate resources to our different programs.
During the last community-assessment process, we found
out that while our teen pregnancy rate had decreased,
we still did not have the outreach and health promotion
services to meet their needs. One area we identified as a
priority was peer support groups for pregnant and parent-
ing teens. Many of our public health nurses provide health
teaching and case management interventions for pregnant
and parenting teens in the home, and they found that
until the teens return to school, they are quite isolated. We
aren’t sure if this is affecting their ability to parent their
newborns. So, we are in the process of using Omaha System
data to see if there are services we need to provide. When
you organize your aggregate assessment, you should con-
sider looking at what other churches and community orga-
nizations are doing or if they have the resources to develop
new programs.”

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61CHAPTER 3 n Competency #1

Community Health Assessment
and Intervention Process
Community assessment and intervention is an inclusive
process that involves all relevant stakeholders such as health
and social services providers, spokespeople for the commu-
nity and its sub-populations, and key decision-makers in the
community . The MAP-IT 5-step process (see Figure 3 .4) is a
Healthy People 2020 tool that helps people unite to improve
the health of their communities (CDC, n .d .-a) . It may be

used as a community-assessment tool and as a commu-
nity planning process tool . MAP-IT resources are found at
http://www .healthypeople .gov/2020/implement/MapIt .aspx .

Before starting the data-collection process, an assess-
ment tool must be selected or developed . The community-
assessment tool presented in Table 3 .6 is based on the
determinants of health (see Chapter 1) . The community-
assessment project you participate in as a student may
include many of these components . Remember that all data
sources, both primary and secondary, must be documented .

TABLE 3.6 Community-Assessment Guide

Part I: Defining Target Population

n Entire Population of a Geographic Area: Population by census track, community, county, state, country
n Sub-Population or Aggregate: Population who share common character (i .e ., ethnic, cultural or religious group, age or

developmental stage, common health risk [potential or actual])
n Population of Interest: Population who is essentially healthy but could improve factors that promote or protect health

(MDH, 2001)
n Population at Risk: Population with a common identified risk factor or risk exposure that poses a threat to health (MDH, 2001)

Part II: Identifying Population Health Status

Levels of Health and Illness
n Birth and Death (Mortality) Rates
n Accidents and Injuries: accidental, intentional, homicide, and suicide
n Communicable and Infectious Disease Incidence and Prevalence Rates
n Acute and Chronic Disease Rates (physical, mental)

Health Risk Behaviors (may also be listed under Behavioral Health Determinants)
n Rates of smoking or chewing, drinking, drug use, obesity, drinking and driving, sexual behaviors and unprotected sex, use of

seatbelts and helmets, interpersonal abuse, participation in antisocial or illegal behaviors

Levels of Independence by age, gender, health status, socioeconomic status

Levels of Life Satisfaction by age, gender, health status, socioeconomic status

(continues)

FIGURE 3.4 Community Planning Process: MAP-IT
Source: Adapted from MAP-IT (CDC, n.d.-a)

Mobilize key people
& organizations

Identify roles
& responsibilities

Form coalition

MOBILIZE

Assess needs
and assets

Start collecting
community data

Work together
as coalition to
set priorities

ASSESS

Develop goals
and objectives

Decide how to
measure progress

& success

Consider
intervention points

where & when
change can occur

PLAN

Create detailed
work plan

Develop a
communication

plan

Identify a single
point of contact to

manage project

IMPLEMENT

Plan regular
evaluations to
measure and

track progress
over time

Share progress
and success

TRACK

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62 PART II n Entry-Level Population-Based Public Health Nursing Competencies

Part III: Assessing Population Determinants of Health

Population Biological and Genetic Factors
n Population at last census and population changes in last decade
n Demographics: Age, gender, race, and ethnicity (may use population pyramids)
n Physical characteristics
n Genetic factors
n Health conditions: Acute and chronic

Physical Environment Factors
n Natural Environment: Geography, climate, weather, air and water and other natural resources, agriculture, animal life, urban,

rural, suburban
n Built Environment: Infrastructure of community (roads, bridges, transportation, public spaces, and recreational areas), public,

and governmental buildings; housing stock and density; industries and workplaces; educational and religious facilities; health-
care facilities; shopping and entertainment; accessibility; and environmental adaptation

Social Environmental Factors: Social Actions and Social Patterns

Population Behavioral Patterns
n History of the community
n Social, economic, and political

patterns
n Socioeconomic status (income,

poverty), education, employment,
and work patterns

n Housing and living arrangements
n Lifestyle patterns
n Cultural patterns, diversity, and

religious affiliations
n Community roles and engagement
n Language
n Health insurance
n Health literacy
n Health-seeking behaviors
n Health-limiting behaviors
n Patterns of coping and resilience
n Patterns of conformity and

nonconformity

Community Systems (Institutions)
n Cultural and ethnic organizations
n Education (public, private, religious)
n Commerce and job opportunities
n Media and forms of communication

including mail delivery, phone, radio,
television, and Internet

n Libraries and public information
n Governmental systems and services:

public health and social services;
police and protective services;
environmental services (water, air
quality, sanitation, waste management,
recycling services, vector control);
emergency preparedness and response

n Laws, regulations, ordinances
n Community safety net programs

( public and private)
n Community support systems

(formal and informal)
n Community networks, coalitions
n Health services and health services

access (physical, mental, chemical,
dental, pharmaceutical)

Access to Healthcare

Assessing the “7 A’s of Access”

(Truglio-Londrigan & Lewenson, 2013,
p . 93)

1 . Is the individual, family, or population
aware of its needs and the services
available in the

community?

2 . Can the individual, family, or pop-
ulation gain access to the services it
needs?

3 . Are services available and convenient
for the individual, family, or popu-
lation in terms of time, location, and
place for use?

4 . How affordable are the services for
the individual, family, or population?

5 . Are the services acceptable to the
individual, family, or population in
terms of choice, satisfaction, and
congruency with cultural values and
beliefs?

6 . How appropriate are the services for
the individual, family, or population?

7 . Are the services adequate in terms of
quantity or degree for the individual,
family, or population?

Part IV: Analysis of Population Health Data

n Summarize the population demographics and health status
n Summarize the physical and social environmental factors
n Identify the major protective factors for population health
n Identify the major risk factors for population health
n Identify the key health disparities within the population as a whole and between sub-groups

TABLE 3.6 Community-Assessment Guide (continued)

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63CHAPTER 3 n Competency #1

Windshield Survey
The windshield survey is a first look at a community through
a car’s windshield . Observers are asked to use their senses
(sight, hearing, and smell) to learn about a community as
they drive, walk, or use public transportation to get around
the community . They then make observations about the
physical and social environments and the natural and built
environments . The windshield survey is sometimes referred
to as a familiarization survey because it helps establish the
community context of care for PHNs . It can also be an initial

step to a more comprehensive community assessment by
raising awareness of issues for further exploration . Table 3 .7
includes a list of questions you might ask yourself to help
guide your windshield survey and analyze your findings .

Other types of windshield surveys may also be carried
out, such as environmental hazard surveys (see Chapter 5)
and walkability surveys to assess areas not accessible by car
such as sidewalks, paths, parks, playgrounds, campuses,
and malls .

TABLE 3.7 Windshield Survey—Snapshot of Community Assessment

Windshield Survey

The first steps of a windshield survey require identifying the community boundaries and determining whether you will conduct the
survey by car, by public transportation, or partially on foot to determine feasibility of your possible travel routes . It is best to con-
duct the survey in pairs or as a group . As you drive or ride through the community, pay careful attention to as many characteristics
of the community as possible . You may wish to take photos or videotape your windshield survey . Make sure that you are only taking
photos of people in public places . Be sensitive to the privacy of others; avoid taking pictures of people where they could be identified .

n Which resources/assets do you see available in the community? Resources may include libraries, clinics, thriving local
businesses, and other features that may provide support to community members .

n Which types of services for families do you see in the community?
n Are there other organizations, such as youth centers, churches, or Head Start programs that might provide activities for

children/families?
n Where do people live in the community? Is the housing primarily single-family housing or apartments? What is the condition

of the housing?
n What types of jobs are available in the community? Would these jobs likely be held by people in the area?
n Where do people shop? Which types of stores are available: locally owned or chain stores?
n How do people get around in the community? Is public transportation available?
n What do you notice about ethnic diversity in the community? Which age range seems predominant?
n What is the geographic environment? Which types of opportunities are available for exercise? Are parks available? Is there

green space?
n Which options are available for eating out?
n What did you learn about the health status of population groups in the community that augments published population

health data?
n Where can people go for healthcare services?
n Based on your observations, what would you identify as assets in this community?
n Overall, how did you feel about being in the community (e .g ., safe, comfortable, uneasy)?

Reflection and Analysis Questions
n What is the story of each photo you have taken? What do the photos tell you about the life and health of the community?
n What are the community’s outstanding assets? Is there a relationship between these assets and the health of the community?
n What appear to be the community’s major challenges? Is there a relationship between these challenges and the health of

the community?
n What do you see as the most striking characteristic about the community? Would this characteristic influence your approach

to providing care to the community?
n What did you find to be the most unexpected? Would the unexpected be an asset or a challenge to providing care to the

community?

Source: Modified from Hargate, 2013

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64 PART II n Entry-Level Population-Based Public Health Nursing Competencies

‘‘

’’

PHN Assessment at the
Systems Level of Practice
Systems are part of the social environmental category of
health determinants . Systems can be assessed to determine
their ability to respond to public health priorities in the
community . Systems that PHNs interact with on an ongo-
ing basis include healthcare systems; public and govern-
mental agencies; schools and school systems; community
health and social service agencies; local and state govern-
ments, including elected and appointed officials; insurance
companies; and faith-based organizations . PHNs assess
systems to identify the extent to which they can meet com-
munity health needs and, if gaps exist, to identify the addi-
tional resources that are needed . Kristi’s discussion about
the local Catholic church, the Salvation Army, and county
public health nurses working together demonstrates how
public-private partnerships can often fill the gap when one
organization cannot meet the need alone .

Kristi and her fellow students find that two organizations
in the community are interested in developing some out-
reach services to pregnant and parenting teens: a local
Catholic church and the Salvation Army. She asks her PHN
preceptor if two such different organizations might be able
to work together.

Beth advises, “You might want to divide your group of
four students into two and ask each pair to assess one of
the organizations. You would want to look at their values,
goals, resources, and willingness to work with each other.

If you find common ground based on an interest in help-
ing pregnant and parenting teens, then you can arrange a
meeting of the two organizations. You could let them know
that the PHNs in our agency would be willing to help them.”

Kristi responds, “Wow! We might be able to do some-
thing valuable for the community while we are carrying out
our clinical assignment. I am going to call my classmates
and set up a meeting to get started. Thanks.”

Identifying Community Health Priorities
PHNs employed in governmental public health agencies
are accountable to the public for the health priorities they
select, the populations they serve, and the services they pro-
vide (see Chapter 7) . PHNs consciously make the connec-
tion between the health needs of the community as a whole
and the health needs of individuals and families within the
community . The priority health needs identified through
the community-assessment process help PHNs determine
the most vulnerable and underserved populations in their
communities and target those with greatest need for services .

PHNs also identify health priorities in the community
by determining health and illness patterns among their
individual clients and families by aggregating data on all
the families whom their agency serves . PHNs look at mul-
tiple interacting health determinants, including the social
determinants of health, to identify population health pat-
terns and causes when working with individual clients
and community partners (Monsen, Swenson, & Kerr, 2016;
Monsen, Brandt et al ., 2017; Monsen, Swenson, Klotzbach,
Mathiason, & Johnson, 2017) . PHNs also conduct research
to identify health concerns in known vulnerable popula-
tions . For example, a study of early care and education pro-
grams identified the following health needs of the centers
and enrolled children: hygiene and hand-washing; sanita-
tion and disinfection; supervision; and safety of indoor and
outdoor equipment (Alkon, Rose, Wolff, Kotch, & Aronson,
2016) . PHNs can determine community health priorities by
reviewing the community-assessment data to determine
which health problems have the greatest potential for harm
and have effective interventions . Questions to consider
when establishing health priorities are listed in Table 3 .8 .

PHNs are ever-vigilant community watchers who are
often the first to notice when a new health concern emerges
or when a service gaps exists in the community . An exam-
ple of a health concern identified by a PHN intake nurse,
explored by agency staff, and taken to a group of commu-
nity partners for a systems-level intervention is found in
Evidence Example 3 .5 .

EVIDENCE EXAMPLE 3.4
Windshield Survey

A total of 284 windshield surveys were carried out by
nursing students in Mexico, New Zealand, Norway,
Turkey, and the United States. The Omaha System Prob-
lem Classification Scheme was used to evaluate the wind-
shield survey data. The students were able to input the
community-assessment data into electronic records using
an online checklist of 11 Omaha System problems. This
framework for collecting and analyzing community data
was found to be an effective teaching-learning tool for
students.

Source: Kerr et al ., 2016

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65CHAPTER 3 n Competency #1

TABLE 3.8 Determining Community
Health Priorities

1 . What is the incidence and prevalence of major diseases,
health risk behaviors, and health concerns in the com-
munity (e .g ., heart disease, teen pregnancy, drinking
and driving, smoking, depression, influenza)?

2 . What are the major causes of death and disability in the
community (e .g ., heart attacks, stroke, cancer, demen-
tia, car accidents, and homicide)?

3 . Which populations in the community are most affected
by these health problems (health disparities)?

4 . What are the major health risks in the community
(e .g ., obesity, air pollution, homes with lead-based
paint, seasonal flooding, homelessness, lack of health
insurance)? Consider level of risk and proportion of
population affected . What are the key social determi-
nants of health affecting vulnerable populations in the
community?

5 . Which health needs are met by community resources?

6 . Which health needs are not met?

7 . Are affordable and effective interventions available for
these health needs?

8 . Who is responsible for meeting these health needs?

9 . Rank order priorities by level of risk or hazard to
community population or sub-populations .

Decline in Child Mortality

GOAL 3 Significant progress has been made in reducing child mortality. In 2015, the mortality rate for
children under age 5 worldwide was 43 deaths per 1,000 live births—a 44% reduction since 2000. This
translates to 5.9 million under-5 deaths in 2015, down from 9.8 million in 2000. But despite progress in
every region, wide disparities persist. Sub-Saharan Africa continues to have the highest under-5 mortal-
ity rate, with 84 deaths per 1,000 live births in 2015—about twice the global average.
Children are most vulnerable in the first 28 days of life (the neonatal period). To reduce child deaths
even further, greater attention must be focused on this crucial period, where progress has not been as
rapid. In 2015, the global neonatal mortality rate was 19 deaths per 1,000 live births, a 37% reduction

since 2000. This means that, in 2015, about 2.7 million children died in the first month of life. Neonatal mortality remains highest
in Central and Southern Asia and in sub-Saharan Africa: 29 deaths per 1,000 live births in 2015 in both regions.
The share of newborn deaths in all under-5 deaths grew from 40% in 2000 to 45% in 2015, due to the slower pace of progress
among newborns. It is estimated that 40% of neonatal deaths could be prevented by providing high-quality care for both mother
and baby around the time of birth (United Nations, n.d.).

EVIDENCE EXAMPLE 3.5
Determining Population Needs in a
Rural/Suburban County

The intake nurse at the public health agency was respon-
sible for logging referrals and conversations of significant
public health concern. The agency she worked at was small
and lacked an on-site physician or walk-in clinic services.
It was a 50-mile drive to the larger metropolitan commu-
nity where low-cost clinics were available. An analysis of
the monthly logs included calls from uninsured adults with
a variety of acute and chronic healthcare conditions. The
intake nurse found a trend of increasing numbers of working
adults lacking access to care. She compiled a brief report
summarizing two months of log entries and presented it to
her public health director. At the next community partner
committee meeting with local medical clinics and hospi-
tals, the director shared the intake nurse’s report. After
consulting with other community partners, the committee
proposed establishing a nursing center. The hospital agreed
to fund the part-time center staffed by a PHN for one after-
noon a week for two years. Services focused on screening,
referrals, and health promotion. A review of client data after
several months identified a need for limited physician ser-
vices. A local medical clinic offered to see patients referred
by the nursing center free of charge. Another healthcare
provider purchased a mobile health unit to do mammog-
raphy outreach. The committee worked with this provider
to use the mobile unit to visit several community sites on
a monthly basis. These services were the direct result of
systems-level collaboration and advocacy for those lacking
access to healthcare.

Source: Kleinfehn-Wald, 2010

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66 PART II n Entry-Level Population-Based Public Health Nursing Competencies

Public health diagnoses for populations are often written
as population risk diagnoses . The traditional risk diagno-
ses have four components: health risk, population at-risk,
modifiable risk factors, and bio-statistical data . This tradi-
tional population risk diagnosis has been modified to create
an asset-based risk diagnosis by adding the component of
modifiable protective factors (see Table 3 .9) . This approach
helps to build on existing community resources and involve
community members when creating an intervention plan .

If you wish to write an asset-based public health risk
diagnosis using the Omaha System taxonomy, you would
include Domain, Problem, and Signs/Symptoms in the
health risk area and could use the KBS ratings as a way to
measure outcomes . The category of Problem as discussed in
Chapter 2 may also be used to identify strengths .

Public Health Nursing Community Action Plan
When the PHN is working with the community, the plan-
ning process and intervention process involves an interpro-
fessional team and key community members . After the team

has established priorities and formulated clear statements
of the health priorities to be addressed, it is time to deter-
mine goals . Community goals are based on community
values, beliefs, and the willingness of community members
and elected and appointed officials to make changes; the
resources available; and a consensus of what is achievable
in the given time frame . Specific outcomes are then estab-
lished . An example of a goal and an outcome for a commu-
nity follow (sometimes the words goal and outcome are used
interchangeably):
n Goal: Reduce obesity in our community
n Outcome: Reduce obesity in adults in our community

by 10% by 2020

Population Health Goals
The United States has established population health goals
each decade since 1990 . The purpose of the goals is to
encourage communities to work together to improve the
health of their citizens and to empower individuals to make
better health decisions (U .S . Department of Health and
Human Services [U .S . DHHS], 2010) . These measurable out-
comes, called health status indicators, are determined by
reviewing existing population health outcomes, comparing
specific population outcomes with outcomes from other
populations, and analyzing evidence from the literature on
acceptable outcomes . They are time-specific and stated as a
percent . For example, scientific evidence suggests that obe-
sity is a risk factor for many diseases, so reduction of obesity
in adults within the U .S . population by 2020 would be a pos-
itive health outcome . Healthy People 2020 was based in part
on the level of achievement of Healthy People 2010 goals
(Reinberg, 2010; U .S . Department of Health and Human
Services [U .S . DHHS], 2010) . Healthy People 2030 will be
based on the population progress toward achievement of
Healthy People 2020 goals . Evidence Example 3 .6 illustrates
the ongoing monitoring of level of achievement of Healthy
People 2020 goals .

TABLE 3.9 Asset-Based Public Health
Population Risk Diagnosis

Components Example

Health risk Increased risk of infection (pertussis)

Population at risk Among nonimmunized or partially
immunized infants and children in
(specify geographic area, community,
or county)

Modifiable risk
factors

Related to contact with non-
immunized children and adults who
may have pertussis, health beliefs
opposing childhood immunizations,
knowledge deficit about benefits of
immunization, lack of access to health
resources

Modifiable
Protective Factors

Related to increased funding for
outreach and immunizations to at-risk
populations through the public health
department, coalition with local
religious organizations and safety net
organizations to immunize children .

Bio-statistical data
(for geographic
area, community,
city, county, state,
national)

As evidenced by lack of herd immu-
nity (80–90% immunization) in
preschool population (state immuni-
zation rate) in (geographic area or city,
county, state, country) with (insert
number of cases) reported cases of
pertussis in the last month in infants
and children ages (insert age range) .

EVIDENCE EXAMPLE 3.6
Healthy People 2020 Goals

A mid-decade review of progress toward Healthy People
2020 goals identified that Healthy People 2020 goals
would be more modest than the 2010 goals. Only 19% of
Healthy People 2010 goals were met, and progress was
made on only 52% of them. Some, like obesity, had become
worse since 2000. U.S. obesity rates increased from 25%
to 34% between 2000 and 2010 (Reinberg, 2010), and the
prevalence of obesity in the U.S. was 35.6% between 2011
and 2014 (CDC, 2015).

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67CHAPTER 3 n Competency #1

n Systems Level: Consult with schools to increase the
physical activities of students within the curriculum .

n Individual/family Level: Provide health education and
counseling to children and families to empower them to
develop healthier lifestyles .

The Public Health Nursing
Community Intervention Plan
PHNs work collaboratively with multiple community part-
ners to establish population health goals and to develop
intervention plans . These plans need to be consistent with
the demography, culture, and health status of the target
population and be in language that is clear to interprofes-
sional partners and the community . It may be more appro-
priate to label the plan a population health plan rather than
a nursing care plan . However, the framework of the public
health nursing process can be used effectively with interpro-
fessional as well as lay groups . Public health interventions
for population health:
n Modify the health determinant risk factors that are

causing the population health problems or disparities by
weakening or eliminating the risk factors

n Modify health determinant protective factors that will
improve the ability of at-risk and vulnerable populations
to better manage their own healthcare

Online Activity
Go to Healthy People 2020 and study a goal of interest
to you.

n Identify an objective and then click “National Snapshots”
to see how progress has been made on that goal.

n Go to the “Interventions & Resources” tab to find evidence
of interventions that have been effective in working to
achieve this goal.

Public health nurses and other public health profession-
als use Healthy People goals as well as their community-
assessment data to establish organizational and program
goals for their communities and the clients they serve . The
focus in Public Health is primary prevention; however,
PHNs will include secondary and tertiary prevention goals
when appropriate to meet unmet community needs . PHNs
often work at more than one level of practice simultane-
ously . For example, if there is a primary prevention goal to
reduce childhood obesity, the PHNs might do the following .
n Community Level: Collaborate with local television

stations to have a media campaign to increase commu-
nity level of awareness for the need to increase children’s
activity levels and to develop more afterschool sports
and activity programs for children .

THEORY APPLICATION
Population-Based Models for PHN Interventions and Outcomes

Twelve conceptual models of population-based PHN interven-
tions and outcomes published between 1981 and 2003 were
identified and compared (Bigbee & Issel, 2012). Four of the
twelve models are very consistent with the PHN community

assessment and intervention model presented in this chapter.
The following table demonstrates how these models reflect
essential components of this book’s population-based PHN
intervention plan.

Model Major Components PHN Concepts

PHN Conceptual Model (White, 1982) Determinants of health impacted by
nursing process at individual/family,
and population levels

PHN process, levels of practice, deter-
minants of health, PHN interventions,
outcomes

Community as Partner Model
(Anderson & McFarlane, 1988, 2011)

Based on Neuman’s systems model and
includes assessment wheel and inter-
ventions based on Intervention Wheel

PHN process, levels of prevention,
PH interventions from the Intervention
Wheel, outcomes

Public Health Intervention Model
(Keller-Olson et al ., 1998)

Population-based model including 17
interventions at individual, commu-
nity, and systems levels

Population focus, levels of practice,
interventions, interprofessional aspects

LA Public Health Nursing Practice
Model–LA Model (Smith &
Bazini-Barakat, 2003)

Population-based model using nursing
process to address health indicators
using Intervention Wheel

PHN process, population focus,
levels of practice, interventions
from Intervention Wheel, outcomes,
interprofessional aspects, client
participation

Source: Abstracted from Bigbee & Issel, 2012

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68 PART II n Entry-Level Population-Based Public Health Nursing Competencies

‘‘

’’

The Public Health Nursing Community Intervention
Plan includes the following components:
n Public health asset-based population risk diagnosis
n Population health goal and level of prevention focus
n Client focus: individual/family, community, system
n SMART behavioral outcomes that are measurable and

attainable and understandable to the family . SMART
outcomes are:

l Specific: What needs to be accomplished?
l Measurable: How will the nurse, client, and family

know the goal has been met?
l Attainable: Can the goal be met with the resources

available?
l Realistic: Does the client (and family) have the physi-

cal, emotional, and mental capacity to meet the goal?
l Time-Bound: When will the goal be achieved?
n Evidence-Based Public Health Interventions: Pub-

lic Health Intervention Wheel (Keller, Strohschein,
Lia-Hoagberg, & Schaffer, 2004; refer to Chapter 2) or
Omaha System (Omaha System, 2017) interventions may
be used . Include the intervention, the strategy or process
to be used, and the provider(s) of the intervention

n Evidence-Based Rationale for each intervention:
Include the scientific rationale with citations as well as
population preferences

n Evaluation of Outcomes: Use quantitative measures to
determine the progress made toward achievement of the
outcome . These measures to be used should be selected
during the planning process .

EVIDENCE EXAMPLE 3.7
Evaluation of a Home Visiting Program for Pregnant and Parenting Teens

After interventions are implemented, it is necessary to assess
the effectiveness of the program and the progress of the target
population toward goal and outcome achievement.
Four commonly used public health evaluation methods
identified by Spiegelman (2016) are:

n Feasibility evaluation: Assess whether something will
work and be effective in the “real world”

n Impact evaluation: Assess the efficacy and effectiveness
of an intervention on health outcomes

n Program evaluation: Assess a program’s processes to
improve them (quality improvement approach)

n Comparative effectiveness: Assess and compare
interventions to see which work best for whom, in what
situations, and from a cost-effectiveness perspective

The Pregnant and Parenting Teen program, discussed in
Evidence Example 3.8, demonstrates the effectiveness of
using all four of these evaluation methods.

Implementing population-based interventions in a com-
munity often includes collaborative efforts of many provid-
ers, organizations, and community members . Usually, a core
team develops the implementation plan timeline and selects
or designs public health intervention strategies . For exam-
ple, if social marketing is selected for a program to encour-
age parents to have their children immunized, potential
strategies could be billboards, development of online and
printed media, and radio and television adds or other forms
of media . It would be important to know when the best time
(i .e ., window of opportunity) would be to start a social mar-
keting campaign and where (before school starts in the fall,
during spring preschool enrollment, etc .) .

Kristi and her classmates complete an assessment of the
sub-population of pregnant and parenting teens in their
community and identify an unmet need for a pregnant
and parenting peer support group. They work with a
group of local churches and the Salvation Army to plan
a community-wide outreach effort with the Salvation
Army for the meeting site. The church groups and local
high school are ready to start recruiting teen participants.
They work with Kristi’s preceptor, Beth, to identify the best
time to recruit teens and start the program. They decide to
recruit teens at the time the pregnancy is confirmed, and
decide that the beginning of the next school year is a good
time to launch the program.

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69CHAPTER 3 n Competency #1

‘‘

’’

‘‘

’’

Kristi asks her neighbor, a county commissioner, if she
would help to find funds for the pregnant and parenting
teen peer support group that will be held at the Salvation
Army. The group needs funding for transportation for the
teens and their babies to attend a support group meeting
once a week for 6 months. The commissioner asked Kristi
if she has data to support the need for transportation ser-
vices. Kristi assures her that she does. There are 20 teens
interested in joining such a group, and only two of them
have transportation. Although the local bus service has a
stop only a block away from the Salvation Army, only five
of the girls are on a bus line. That leaves 13 teens without
transportation. In addition, the PHNs have assessed all the
teens and have data that support the need for socialization
and peer group support for these pregnant and parenting
teens. The commissioner is not sure if these teens can make
a commitment to attend the group or if attending the group
would really make a difference. Kristi tells the commis-
sioner that PHNs from the county are going to be group
facilitators and would be using the Problem Rating Scale
for Outcomes to determine if the outreach and counseling
efforts are effective. Of course, she has to explain to the
commissioner what the Problem Rating Scale for Outcomes
is! The commissioner asks Kristi and her classmates to
come to a council meeting to present their proposal. Kristi
says they can do that and she will also ask her PHN precep-
tor to come to the meeting.

EVIDENCE EXAMPLE 3.8
PHN Home Visiting Program for Pregnant and Parenting Teens

A visiting nurse association created and implemented a Preg-
nant and Parenting Teen Program to promote family and child
health and family self-sufficiency for teen moms 19 years
of age or younger. The pillars of the program are: a trusting
relationship between the PHN and the teen; outreach and
coordination with schools, clinics, and human service agen-
cies; a comprehensive and intensive maternal mental health
curriculum; and community support and caring by provision
of needed resources. A comprehensive evaluation of the pro-
gram’s effectiveness and client outcomes’s success was com-
pleted after two years (Schaffer, Goodhue, Stennes, & Lanigan,
2012). Key outcomes presented by four public health evalua-
tion methods follow.

n Feasibility evaluation: 78% of the teens referred to the
program accepted the services.

n Impact evaluation: 76% of teens with 10 or more visits
continued or graduated high school compared to 56% of
teens who received 9 visits or less; 97% were up-to-date
on well-child check-ups; 95% were up-to-date on immuni-
zations; and 96% had healthy birth weight babies.

n Program evaluation: 69% referred to community
resources; 47% received needed resources.

n Comparative effectiveness: Teens with 10 or more visits
were more successful in achieving expected outcomes
than teens who had 9 or fewer visits.

Ethical Application
Community assessment and program evaluation involves
collecting data on individuals . These data are then aggre-
gated to provide for confidentiality and anonymity . How-
ever, when the group size is small or the members of the
group are easily identified, ethical issues related to privacy
rights can arise .

Kristi is concerned because there are only 20 teens who will
be participating in the initial pregnant and parenting teen
peer support program. Most of these teens are well known
in the community. She is worried that when the program
evaluation occurs, the teens will be evaluated as individu-
als. Even though their outcome data will be aggregated, it
will be difficult to provide for anonymity if there is a need
to present program outcomes to the county commissioners.

Use the ethical framework in Table 3 .10 to determine how
you would use ethical principles to make decisions about
this ethical problem .

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70 PART II n Entry-Level Population-Based Public Health Nursing Competencies

TABLE 3.10 Ethical Application of the Nursing Process in Public Health Nursing

Ethical Perspective Application

Rule Ethics
(principles)

n Respect the rights of individuals related to privacy, autonomy, and self-determination .
n Critique selected actions and interventions for possible unintended harmful consequences that might

occur for diverse populations in a community .
n Select interventions that promote justice through reducing health disparities .

Virtue Ethics
(character)

n Maintain the dignity and confidentiality of individuals, families, populations, and communities when
assessing their health needs .

n Be honest in communicating the purpose of selected interventions to individuals, families,
populations, and communities .

n Be an advocate for assessing the public health needs of vulnerable populations .

Feminist Ethics
(reducing oppression)

n Include voices of vulnerable populations in community assessments and in setting priorities for action .
n Emphasize the contribution of the assets that communities and diverse populations bring to resolving

public health concerns .

Table based on work by Volbrecht (2002) and Racher (2007)

n PHNs use public health nursing interventions to provide
nursing services to individuals, families, communities,
and systems .

n PHNs use EHRs and HIS to assist them in assessing and
monitoring their clients’ health status, evaluating their
clients’ progress, and determining the effectiveness of
interventions and programs . The Omaha System is the
only ANA-recognized standardized terminology that
has integrated those components .

KEY POINTS

n PHNs are accountable to the individuals and families
they serve, and the communities in which they live
and work, to take action to maintain or improve their
health status .

n PHNs work in partnership with individuals, families,
communities, and systems .

n The public health nursing process is used to assess and
intervene with individuals, families, communities, and
systems .

n PHNs collect demographic and health determinant data
when carrying out family and community assessments .

REFLECTIVE PRACTICE

It is difficult for public health nursing students to adapt to
providing nursing care in the unstructured environment
of the home and community . When students are in family
homes, they are visitors in someone else’s personal space .
Visits often do not go as planned . It takes time to develop
trust with family members who may initially be uncom-
fortable with a nurse in their home . Think about Kristi’s co-
visits with her PHN preceptor Beth to Sara, the pregnant
teen, and her mother and then the individual visit Kristi
made to complete the home environmental assessment . If
you were making that visit alone as Kristi was, consider how
you would carry out the home environmental assessment
with Sara and her mother .
n How would you prepare for the visit? What would you

wear? Do you think you should phone Patricia or Sara
to confirm the visit?

n How would you introduce yourself to Sara and her
mother and review the purpose of the visit?

n This is your first visit alone with Sara and her mother .
Think about what makes a good first visit . What would
you want to do to make your visit a good one?

n When you carry out the home environmental assess-
ment, you will probably be going into some private areas
of the home . What can you do to make Sara, her mother,
and yourself comfortable in these private spaces?

n What will you do if you are told you cannot go into
certain rooms?

n Will you share your assessment of the family home
environment as you conduct the assessment, or will you
wait until the end of the visit?

n How will you end the visit with Sara and her mother?

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71CHAPTER 3 n Competency #1

Centers for Disease Control and Prevention . (n .d .-a) . MAP-IT:
A guide to using Healthy People 2020 in your community.
Retrieved from http://www .healthypeople .gov/2020/
implement/MapIt .aspx

Centers for Disease Control and Prevention . (n .d .-b) . Public health
101 series: Introduction to public health informatics. Retrieved
from https://www .cdc .gov/publichealth101/documents/
introduction-to-public-health-informatics

Centers for Disease Control and Prevention . (2015) . Prevalence of
obesity among adults and youth: US 2011–2014. Retrieved from
https://www .cdc .gov/nchs/data/databriefs/db219

Clark, M . J . (2008) . Community health nursing. Upper Saddle
River, NJ: Pearson/Prentice Hall .

Eriksson, I ., & Nilsson, K . (2008) . Preconditions needed for estab-
lishing a trusting relationship during health counseling—An
interview study . Journal of Clinical Nursing, 17(17), 2352–2359 .

Friedman, M . M ., Bowden, V . R ., & Jones, E . (2003) . Family
nursing: Research, theory, and practice (5th ed .) . Hoboken, NJ:
Pearson Education, Inc .

Gardner, A . (2010) . Therapeutic friendliness and the development
of therapeutic leverage by mental health nurses in community
rehabilitation settings . Contemporary Nurse, 34(2), 140–148 .

Hargate, C . (2013) . Survey. Unpublished manuscript, Bethel
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APPLICATION OF EVIDENCE

Think about the community assessment you and your class-
mates are going to complete . You are interested in deter-
mining the need for and the resources for a teen pregnant
and parenting peer support group . Your assessment is going
to be assessing a sub-group of the community (i .e ., aggre-
gate), so you need to think about whom you will want to
work with and what data you need to collect .

Review Figure 3 .4 (Community Planning Process:
MAP-IT):

1. How would you use this tool to plan a community
assessment?

2. How would you carry out the community assessment?
3. When you develop your intervention plan, you need

to consider your “window of opportunity” for imple-
mentation . How would you find your “window of
opportunity”?

4. The implementation phase requires a detailed work
plan . What would you include in your work plan?

5. The tracking phase includes measuring the effective-
ness of your intervention plan . How would you mea-
sure the effectiveness of your plan?

6. Review Evidence Example 3 .7 . What type of evaluation
would you want to include? What measures might
you use?

Review the Community-Assessment Guide . This is an
aggregate assessment . You do not have to collect all of the
community data . Think about what you need:

1. What community demographic data would you want
to collect?

2. What biological and genetic health determinant data
would you want to collect?

3. What physical environmental health determinant data
would you need?

4. What social environmental health determinant data
would be most important?

5. How would you collect information about healthcare
access?

6. Once you have all of your data collected, how would
you analyze it?

7. What would be effective methods to communicate
your community-assessment data to others?

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72 PART II n Entry-Level Population-Based Public Health Nursing Competencies

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Racher, F . (2007) . The evolution of ethics for community practice .
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healthy people. Indianapolis, IN: Sigma Theta Tau International .

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delphia, PA: Wolters Kluwer Health/Lippincott Williams and
Williams .

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73CHAPTER 3 n Competency #1

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‘‘

’’

CHAPTER

4
COMPETENCY #2
Utilizes Basic Epidemiological (The
Incidence, Distribution, and Control of
Disease in a Population) Principles in
Public Health Nursing Practice

n Carolyn M. Porta
with Noreen Kleinfehn-Wald, Linda J. W. Anderson, and Madeleine Kerr

Elizabeth has worked as a public health nurse (PHN) doing home visits on the maternal child health
team for approximately a year. One day as she is having lunch with her co-workers, someone mentions
that an outbreak of pertussis had occurred in an adjacent county. In fact, there are 42 cases! Two days
later, Elizabeth’s supervisor asks whether she can help the Disease Prevention & Control (DP & C) team
investigate 10 probable cases of pertussis.

DP & C nurses operate the immunization clinic and work with infectious disease issues, such as tuber-
culosis. Other than these activities, Elizabeth knows very little of what their day-to-day work is like.
Her supervisor explains that disease investigation is case management work. She will most likely not be
required to do any additional home visits. (Sometimes follow-up visits are necessary when it is difficult to
locate people.) She will need to plan on a limited amount of time to place phone calls, review records, and
work with community partners, such as school nurses. Elizabeth agrees to take the additional assignment
and arranges to receive orientation from the lead nurse. During this briefing, the lead nurse explains
the state’s data-privacy laws, the state health department’s infectious disease reporting requirements for
pertussis, and the report form that needs to be completed by the healthcare provider or the lab associated
with the clinic for each suspect or confirmed case. This is a lot of new information!

ELIZABETH’S NOTEBOOK
COMPETENCY #2 Utilizes Basic Epidemiological (The Incidence, Distribution,
and Control of Disease in a Population) Principles in Public Health Nursing Practice

A. Understands the relationship between community assessment and health promotion/disease prevention
programs, especially the populations and programs with which the PHN works

B. Understands the relationships between risk/protective factors and health issues

C. Obtains and interprets information regarding risks and benefits to the community

D. Applies an epidemiological framework when assessing and intervening with communities, systems,
individuals, and families

Source: Henry Street Consortium, 2017
(continues)

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76 PART II n Entry-Level Population-Based Public Health Nursing Competencies

USEFUL DEFINITIONS

Agent: The primary cause of the health-related condition. Agents are most often classified into six main types:
physical agents, chemical agents, nutritive agents, infectious agents, genetic agents, and psychological agents
(Valanis, 1999). [Note that the term infectious agent has been replaced with causative factors (Merrill,
2017, p. 11).]

Communicability: The ability of a disease to be transmitted from one person to the next; communicability is
determined by how likely a pathogen or agent is to be transmitted from a diseased or infected person who is not
immune and is susceptible (Merrill, 2017, p. 43).

Environment: Reflects the aggregate of those external conditions and influences affecting the life and develop-
ment of an organism . . . physical, chemical, biological, and social factors that affect the health status of people
(Merrill, 2017, p. 214); factors external to the human or animal that cause or allow transmission (p. 8).

Epidemic: Occurrence of cases of an illness, specific health-related behavior, or other health-related events
clearly in excess of normal expectancy in a community or region (Merrill, 2017, p. 5).

Epidemiological Triangle: Shows the interaction and interdependence of the agent, host, environment, and time
(Merrill, 2017, p. 8).

Epidemiology: The study of the distribution and determinants of health-related states or events in human
populations and the application of this study to the prevention and control of health problems (Stedman’s
Medical Dictionary for the Health Professions and Nursing (5th ed.) in Merrill, 2017, p. 2).

Herd Immunity: Resistance a population has to the invasion and spread of an infectious disease. Herd immunity
is accomplished when the number of susceptible people is reduced and the number of protected or non-
susceptible people dominates the herd (population); provides barriers to direct transmission of the disease;
occurs when 85% level of immunity exists (Merrill, 2017, p. 53).

Host: The human being affected by the particular condition under investigation. Factors that the host brings
to the triangle include intrinsic factors (age, gender, race, etc.), physical and psychological factors, and the
presence or absence of immunity (Clark, 2008). Host can be a human or animal that is susceptible to disease
(Merrill, 2017, p. 8).

Immunity: The state of nonsusceptibility to a disease or condition. Types include (a) active immunity, where the
host is exposed to the antigen through having the disease or via immunization; and (b) passive immunity, where
antibodies are provided to the host via immune globulin or mother-to-fetus transfer across the placenta—
passive immunity is short-lived (Merrill, 2017, p. 52).

Incidence: The number of individuals who develop the disease over a defined period of time (Le, 2001) or the
number of new cases of a particular health-related state or event reported over a specific period of time
(Merrill, 2017, p. 74).

Life Course Epidemiology: The study of long-term effects on later health or the risk of disease due to physi-
cal or social exposures during gestation, childhood, adolescence, young adulthood, and later adult life (Kuh,
Ben-Shlomo, Lynch, Hallqvist, & Power, 2003, p. 778).

Prevalence: The presence of a disease or health condition in a given population at a given point in time divided
by the number of persons in that population (Friis, 2018, p. 64).

Protective Factor: Health determinants that protect one from illness or assist in improving health
(see Chapter 1).

Risk Factor: A condition that is associated with the increased probability of a health-related state or event
(Merrill, 2017, p. 3). Risk factors are also health determinants (see Chapter 1).

Surveillance: The ongoing systematic collection, analysis, interpretation, and dissemination of health-related
data to improve the health of populations (Centers for Disease Control and Prevention [CDC], 2001). Public
health surveillance is the systematic ongoing collection, analysis, interpretation, and dissemination of health
data (Merrill, 2017, p. 112).

ELIZABETH’S NOTEBOOK (continued)

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77CHAPTER 4 n Competency #2

n Which interventions can reduce the spread of this
occurrence/disease?

n Will I be working at the individual/family, community,
or systems level?

n Do I need to consider any ethical issues?
n How will I know whether the interventions are effective?
n What could have prevented this outcome?

At its core, epidemiology is the study of solving
mysteries—of understanding where and to what extent
diseases, events, and behaviors are influencing the health
of populations. Epidemiology is more than simply under-
standing what is going on. It also involves acting on what
you learn to prevent or control problems. Similarly, a PHN
should be committed not only to understanding what is con-
tributing to a problem and the extent of the problem but also
to identifying and implementing disease prevention and
health promotion strategies. In fact, this use of core epide-
miological tools—namely, mathematics and data analysis—
contributed to advancing the role and view of nursing in
the 19th century (Earl, 2009). See Evidence Example 4.1 to
examine how Lillian Wald and Florence Nightingale used
data gathering and analysis to understand and address key
health problems. By doing so, they advanced the profession
of nursing beyond what had, up until that time, been a fairly
ill-considered occupation.

Using Data to Solve Health
and Disease Mysteries
Nurses often want to know why something happens or does
not happen. This inquisitive nature is useful when nurses
are working to prevent something from happening or to
intervene before something gets worse. In some situations,
if questions are not asked, credible solutions might be over-
looked, and health outcomes might not be optimal. In a
worst-case scenario, lives might be lost or seriously harmed
if the status quo is maintained and curious questions are
not asked and acted upon. At the foundation of effective
population-based public health nursing is the science of epi-
demiology. Epidemiology guides the questions that PHNs
ask and the steps that they take to find answers and solu-
tions. Following is a list of questions nurses ask or should
ask regularly:
n When did the problem start (end, worsen, improve)?
n What has contributed to the change? Triggered a

response?
n Why have x, y, z not improved?
n How did this occur?
n Who should be involved to contribute to the solution?
n Where are available resources to aid in addressing this

situation?

EVIDENCE EXAMPLE 4.1
Origins of Epidemiology and Nursing

Catherine Earl (2009) has written a fascinating and thorough
historical article that describes the influence of epidemiol-
ogy in the developing role of public health nursing. Beginning
in the early 19th century, Earl presents a summary of history
that reminds the reader of how far nursing and science have
come in the past 200 years. Not that long ago, diseases were
addressed solely within the individual, with little appreciation
given for trends among the group or population. Advances
in mathematical theories caused a shift, notably when Pierre
Charles Alexandre Louis, a leading 19th-century physician,
declared that the practice of bloodletting (often with the help
of leeches) was ineffective and used statistics to support his
claims. It is intriguing that, according to Earl, the use of quan-
titative methods was not well supported at that time and was
poorly understood. In the 21st century, quantitative analyses
are core to randomized controlled trials (RCTs), which are con-
sidered the gold standard for establishing evidence.
Lillian Wald used this advance in health and science to sup-
port her work with families in New York. She advocated for
nurses to live and work near and among those they were also
serving. She used numbers to support her need for resources,
including the number of nurses. Her successes are many, and
they are in part based on her foresight and wisdom in rec-
ognizing the need for data to accomplish goals and meet the

health and social needs of society. Earl summarizes well the
contribution PHNs—led by Lillian Wald—made in addressing
tuberculosis, because they collected and reported critical data:
“Nurses’ involvement in the care of TB [tuberculosis] patients
in 1914 was considered a major advancement in the use of sta-
tistical methods, because nurses became involved in improv-
ing health through their role as data collectors” (p. 262).
Florence Nightingale, considered by many to be the first
biostatistician and the first epidemiologist, also used data to
support her efforts to address health and sanitation. In her era,
it was not common for women to be educated, yet her father
encouraged her to learn varied subjects, including mathe-
matics. As a result, Nightingale had skills that enabled her to
identify causes of problems and to intervene not only to heal
or cure but also to prevent. As Earl states, “With an epidemi-
ological perspective and further discussions of mortality and
morbidity rates and the importance of sanitary conditions as
described by Florence Nightingale, the first preventorium, a
program established to save children, was designed for the
prevention, not the treatment, of TB” (p. 263). Both Lillian
Wald and Florence Nightingale contributed to a significant
shift from solely focusing on treatment to also concentrating
on prevention, which today is also a primary focus of PHNs all
over the world.

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78 PART II n Entry-Level Population-Based Public Health Nursing Competencies

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‘‘

Although most PHNs are not epidemiologists, many
activities that PHNs engage in parallel the work of epide-
miologists. Often, epidemiologists work at the systems level
of a healthcare facility or state health department and are
responsible for the data collection, analysis, and program
development related to a particular health/medical issue.
Conversely, PHNs are frequently found in the grassroots
level of healthcare, working with local vulnerable popula-
tions and community partners, interpreting and promot-
ing the recommendations, protocols, and policies that have
been developed by an authoritative body. See Table 4.1 for a
sample list of activities that an epidemiologist often engages
in, and note the similarities to many public health nursing
activities and interventions.

Elizabeth realizes she needs to have a better understand-
ing of terms that she is reading as she investigates state
and county reports about infectious disease threats in her
community. She is getting confused by the different labels
for cases and isn’t exactly clear on the difference between
quarantine and isolation. She finds the following defini-
tions that provide clarity and adds them to her notebook:

✔ Case: Person or population identified as having a particular
disease, disorder, injury, or condition (Merrill, 2017, p. 7)

l Primary case: The first disease case in the population (p. 7)

l Index case: The first disease case brought to the attention
of the epidemiologist (p. 7)

l Secondary case: Persons who have become infected and ill
after contact with a primary case (p. 7)

✔ Incubation period: Time interval between the invasion by
an infectious agent and the appearance of the first signs or
symptoms (Friis, 2018, p. 284)

✔ Isolation: Persons who have a communicable disease are kept
away from other persons for a period of time that corre-
sponds generally to the interval when the disease is commu-
nicable (Friis, 2018, p. 284)

✔ Quarantine: Persons, animals, or objects that have been
exposed to a contagious disease are kept away from other
persons for a specified period of time (adapted from Merrill,
2017, p. 57)

Historically, nurses participated in epidemiological inves-
tigations to determine the cause of a recurring problem, such
as cholera outbreaks. As part of that process, nurses realized
very early on that numerous risk factors often contributed to
the spread of disease. This realization led to creative inter-
ventions that had multiple components to aid those already
sick or affected and to prevent others from becoming sick.
Quarantine (i.e., separation of an exposed individual from
the rest of the community) laws are a good example of a spe-
cific effort to contain the spread of disease in the absence
of other strategies. Interestingly, quarantine strategies are
still used today, because some infectious viruses can spread

TABLE 4.1 Alignment of Epidemiologist
Activities With PHN Intervention Wheel

Epidemiologist
Activities

Public Health Nursing
Activities and
Interventions

Identifying risk factors for
disease, injury, and death

Disease and Health Event
Investigation

Describing the natural
history of disease

Health Teaching

Identifying individuals and
populations at greatest risk
for disease

Outreach

Screening

Referral and Follow-Up

Advocacy

Case Management

Identifying where the public
health problem is greatest

Surveillance

Disease and Health Event
Investigation

Monitoring diseases and
other health-related events
over time

Surveillance

Evaluating the efficacy and
effectiveness of prevention
and treatment programs

A key part of the nursing
process, but not a specific
component of the interven-
tion wheel

Providing information useful
in health planning and
decision-making for estab-
lishing health programs with
appropriate boundaries

Consultation

Collaboration

Community Organizing

Policy Development and
Enforcement

Assisting in carrying out
public health programs

Most interventions on the
Public Health Intervention
Wheel

Serving as a resource Consultation

Communicating health
information

Outreach

Health Teaching

Social Marketing

Consultation

Source: Adapted from Merrill, 2017

during an incubation period before symptoms are present.
Examples of such illnesses in the 21st century include per-
tussis, chicken pox, measles, Ebola, avian influenza, and
seasonal flu. When an individual is diagnosed with pertus-
sis and other family members have been exposed, the per-
tussis case is strongly encouraged to stay isolated from the

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79CHAPTER 4 n Competency #2

home environment remains unchanged, the child’s recov-
ery might not be maintained. In this case, the nurse might
link the family to resources such as financial heat assistance,
food banks, food stamps, etc. The nurse might begin to cre-
ate long-term solutions by helping adult family members to
explore financial management strategies as well as possi-
bilities for higher-paying employment or more affordable,
reliable housing. Finally, the nurse might advocate for leg-
islation that prohibits companies or landlords from turning
off heat sources during cold winter months. Nurses encoun-
ter numerous possible mechanisms for influence when they
face a problem that might appear to have a simple solution
but often requires complex intervention approaches to keep
that problem from recurring.

Understands the Relationship Between
Community Assessment and Health
Promotion and Disease Prevention
Programs, Especially the Populations and
Programs With Which the PHN Works
Many public health agencies and community organizations
use community assessments to prioritize their resources
and subsequent programs and services. Fundamental to the
community assessment is the understanding of the inci-
dence and distribution of disease in the community. The
PHN might begin by reviewing the birth and death (mor-
tality) data available through the state department of health.
Morbidity (illness/disease/injury not resulting in death)
data can also be reviewed to determine trends in reportable
diseases (such as tuberculosis or sexually transmitted infec-
tions) or conditions such as cancers or motor vehicle fatali-
ties. A comprehensive review of data sources generally leads
and directs the community assessment process.

A variety of other strategies (e.g., needs assessment via
focus groups or key-informant interviews, windshield
survey) can be used to expand the community assess-
ment. (See Chapter 3 for more information on community
assessment.) PHNs work collaboratively in conducting
assessments and using the resulting data for informing pri-
orities and actions. Although it might be natural to focus on
needs because the nurse is trying to address a problem, it is
extremely valuable to take an asset-based approach toward
the issue (Lind & Smith, 2008). An asset-based approach
ensures that the assessment includes documentation of
existing or potential strengths. In this way, the possible
problem-solving strategies will ideally build on identified
strengths and assets. If nurses focus only on problems, they
might reach a solution that consists of outside resources
rather than builds on what is available. Asset-based per-
spectives inherently encourage capacity building as well as
self-care among individuals and families, communities, and
populations. (See Chapter 8 for discussion of incorporating
community assets.)

broader community until five days of antibiotic treatment
have been completed. During the Sudden Acute Respira-
tory Syndrome (SARS) event in 2002 and 2003, quarantine
of exposed individuals was key to containing the epidemic.
Individuals placed under quarantine were monitored twice
daily by public health workers until the SARS incubation
period was completed. Although quarantines are not always
enforced as they were years ago and in the SARS event, they
can be effective when they are followed and when individu-
als and families adhere to the restrictions.

More broadly, Lillian Wald offers a great example of a
PHN using a variety of intervention tools to address uncon-
trolled disease and unnecessary deaths in New York City
tenements, as shown in Figure 4.1. At the individual level,
she provided direct care for sick individuals in crowded
apartments. At the community level, she organized com-
munity care for neighborhood children in need of a place
to engage in physical activity. At the systems level, she advo-
cated for programs that would meet the needs of many (e.g.,
welfare, food accessibility, child labor laws).

Today’s PHN needs a repertoire of intervention strat-
egies so that when health improves, it can be maintained
over time—which is sometimes hard to do, especially in
the presence of poor health determinants. For example, if
a child recovers from an illness that worsened as a result
of malnourishment and lack of warmth, but the family

FIGURE 4.1 How Lillian Wald Practiced the
Individual/Community/System Approach to Healthcare

Individual/Family
Provided direct care
for sick individuals

Community
Organized community
care for neighborhood
children

System
Advocated for programs to
meet the needs of many
(welfare, food accessibility,
child labor laws)

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80 PART II n Entry-Level Population-Based Public Health Nursing Competencies

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‘‘ because of fear, and without a known cause, they had little
confidence that the disease could be stopped or prevented.
John Snow created a map that began to identify where the
deaths from cholera were occurring across London. This
now-famous map (see Figure 4.2) yielded some clues for
Snow, because he managed to visualize the areas where
the deaths were most heavily concentrated. He suspected
a water source, so to prohibit people from accessing this
source of “risk,” he removed the water pump handle:

1854: Physician John Snow convinces a London local
council to remove the handle from a pump in Soho. A
deadly cholera epidemic in the neighborhood comes to
an end immediately, though perhaps serendipitously.
Snow maps the outbreak to prove his point… and
launches modern epidemiology (Alfred, 2009, p. 1).

In the 21st century, PHNs continue to solve mysteries in
identifying and eliminating health risks, and although con-
ditions have improved in many parts of the world, reducing
the risks from unsanitary conditions, these improvements
are not universal. Consider the following observation:

The 2010 cholera epidemic in Haiti (and the 2017 chol-
era outbreak that persists in Yemen) reminds us that
cholera remains a deadly disease, not all that differ-
ent from the time of John Snow. While Snow debated
the appropriateness of the germ theory versus the
miasmatic theory for the cause of the disease, cur-
rent scientists are focusing on different, but related,
hypotheses (University of California, Los Angeles
[UCLA], 2010, p. 1).

Elizabeth looks at the faxed pertussis report she has been
given on 11-year-old Billy Johnson. Information includes
Billy’s birth date, address, phone number, and laboratory
results, which are positive for pertussis. Next, Elizabeth
looks up Billy in the computerized state immunization
registry. She sees that he was vaccinated with five doses of
DTaP vaccine, the last of which was administered at 5 years
of age. Elizabeth recognizes that the immunity provided by
the vaccine has possibly waned.

Activity
Reflect on the following questions:

n What has Elizabeth discovered so far?

n What are her next steps?

Understands the Relationships
Between Risk and Protective Factors,
and Health Issues
No better classic example of understanding the relation-
ship between a risk factor and a health issue exists than
that of John Snow in mid-1800s London (Alfred, 2009). For
unknown reasons, many people in London began to suffer
and die as a result of cholera. People were fleeing the city

FIGURE 4.2 A Map Detailing Cholera Deaths in 1800s London; the Beginning of Epidemiology
Source: Alfred, 2009

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81CHAPTER 4 n Competency #2

‘‘

Indeed, it is true that more than a century since Snow’s
solved mystery, PHNs continue to seek clear answers and
solutions regarding the risks and diseases that are present in
public health settings across the globe. In the United States,
PHNs face complex challenges in meeting the needs of indi-
viduals, families, communities, and populations. Nurses
need to identify risk and protective factors at multiple influ-
encing levels. For example, a nurse might be working with
a child recently diagnosed with asthma. The nurse needs to
identify risk factors in the family environment that might
be triggers for asthma episodes. Similarly, the nurse needs
to assess for protective factors in the family, such as parental
commitment to preventing episodes, which is an import-
ant asset the nurse can support with education and related
tools. The nurse might want to go further and explore the
neighborhood environment, including collaborating with
school personnel, for possible risks or protections influenc-
ing the child.

It can take time to carefully and thoroughly assess risk
and protective factors using a strengths-based approach.
Usually, the time is well spent because the PHN will have
a very clear picture of available assets as well as deficits
to address when intervening on a particular health issue.
Doing this proactively is a critical part of health promotion.
Conducting assessments of risk and protective factors after
a health issue has become apparent is important to mini-
mize the effect of the health problem and to encourage pos-
itive intervention results. PHNs continually reassess for risk
and protective factors, because these factors can be tempo-
ral; one day a risk might exist (e.g., lack of health insurance
coverage), but the following week the family might have new
health insurance coverage. PHNs commit to efforts that
routinely assess, intervene, evaluate, and reassess.

A PHN also stays informed about emerging diseases and
pandemic threats. For example, during 2015 pertussis cases
decreased by 37% compared with 2014. See Table 4.2 for
states that had the highest reported rates of pertussis in 2015.
The majority of deaths continue to occur among infants
younger than 3 months of age, and the incidence rate of per-
tussis among infants exceeds that of all other age groups.
The Centers for Disease Control again observed increased

TABLE 4.2 States With Incidence of Pertussis the Same or Higher Than the National Incidence
During 2015, Which Is 6.5/100,000 Persons

Nebraska 27.2 Oregon 14.6 Minnesota 10.9

Montana 22.3 Kansas 14.5 California 9.2

Maine 21.1 Alaska 14.2 Arizona 8.5

Washington 19.3 Wisconsin 13.1 Vermont 7.8

Colorado 16.7 Idaho 11.7 Pennsylvania 6.9

Utah 16.6 New Mexico 11.6

Source: 2015 Final Pertussis Surveillance Report, Centers for Disease Control and Prevention [CDC], 2015

rates in adolescents ages 13–15 as well as in 16-year-olds.
In the case of pertussis, the PHN would recognize pertus-
sis vaccination as a protective factor. Lack of vaccination,
waning immunity from vaccination, and posing immune-
compromising conditions would be risk factors.

Elizabeth prepares to call Billy’s parents. She places the pro-
tocol nearby and has her report form ready. Billy’s mother
answers the phone, and Elizabeth introduces herself as a
PHN who works with infectious diseases. She explains how
she has obtained a pertussis report on Billy and inquires
whether his mother has about 15 minutes to speak with her.
Billy’s mother states that she operates an in-home daycare,
but most of the children have not yet arrived.

Elizabeth mentally notes this information about the
daycare and then explains that the purpose of the call is
to identify what can be done to prevent the spread of the
disease. Elizabeth starts with what she thinks is the most
logical question—when did this cough start? Billy’s mother
recalls that he started coughing on September 17 and had
a paroxysmal cough without a whooping sound. He occa-
sionally coughed so hard that he vomited. About 1 week
before his cough started, he had a low-grade fever and a
runny nose.

Because his cough was not getting any better, his mother
brought Billy to the clinic on September 26. Billy did not
have pneumonia or any other complications of pertussis. He
was given azithromycin antibiotic and is now on his third
day of a 5-day course of treatment. Elizabeth jots down a
note that states the period of infectivity started about Sep-
tember 10, or about a week before the cough started.

Next Elizabeth asks how many other family members
are in the home. Billy lives with his parents and has no
siblings. Neither parent has been coughing. Elizabeth dis-
cusses with his mother the public health recommendation
that other household members take a preventive course of
antibiotics. She agrees to call the clinic for prescriptions.

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82 PART II n Entry-Level Population-Based Public Health Nursing Competencies

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a PHN might be interested in exploring trends related to
tuberculosis cases in the community over the past 5 years—
that is, the nurse is doing surveillance of TB in the juris-
diction (see Figure 4.3). The data in a graph form provide
a snapshot of how the number of cases is increasing, main-
taining, or decreasing. In the tuberculosis example, it is
apparent that active TB cases are progressively increasing,
whereas latent TB cases can dramatically decrease, increase,
and then stabilize. This information might lead the PHN to
ask questions about pulmonary versus nonpulmonary TB
or population changes in the community and explore spe-
cific intervention strategies to reduce the number of active
TB cases over the next few years.

healthypeople.gov

Healthy
People

The Healthy People 2020 website offers
opportunities to explore the uses of data in
public health. On the website, click “Data
Search.” From here, you can do a data search on a public health
topic of interest to you. Select the health topic and then limit
your search by a variety of factors, such as sex, age, race/
ethnicity, and geographic location. The results are presented
using the Healthy People 2020 indicators (goals/markers) and
show trends over the past few years. What do you observe in
the data you explore? How might these data be useful to a PHN
engaged in health promotion?

Data Trend per 100,000 in a Graph
Similarly, a PHN might examine the trend of chlamydia
cases over a period of five years. Rather than looking at
the raw number of cases (as in the tuberculosis example),
the PHN might prefer to examine the rate of cases, which
is always based on a ratio or number of cases per 100,000
persons. The raw case number in the tuberculosis exam-
ple does not give a picture of how serious the problem is,

To further assess for close contacts, Elizabeth asks
questions about Billy’s school. Billy told his mother “a lot
of kids” were coughing in his classroom. Elizabeth states
that she will talk to the school nurse about sending a noti-
fication letter to the parents of the students in Billy’s class-
room; Elizabeth is careful to inform the mother that Billy
will not be identified in the letter. Elizabeth explains that
she will also be working with the school to identify children
who sit adjacent to Billy, as they might also need preventive
antibiotics.

Obtains and Interprets Information
Regarding Risks and Benefits to
the Community
PHNs need to know how to find and use data. Data drive
so much of what PHNs do. In fact, PHNs determine health
priorities by using data to identify key problem areas or con-
cerns. PHNs also use data to evaluate whether interventions
or programs are successful in reducing the risks or health
problems in a local community. Unfortunately, data are not
always easy to interpret or understand; data are often pre-
sented in such formats as tables, figures or graphs, or raw
numbers. They might be posed as percentages or risk ratios.
Although in-depth knowledge of data, formulas, and calcu-
lations is not necessary for entry-level PHNs, some aware-
ness of how to read data and data types is useful.

Data Trend in a Graph
Often, data are presented over time by using graphs to show
what is happening in a community with respect to a par-
ticular health problem or population trend. For example,

FIGURE 4.3 Sample Trend of Active and Latent Tuberculosis Cases in a Community

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83CHAPTER 4 n Competency #2

because the graph does not indicate how many people are
in the community. For example, if the community popu-
lation count were 100 and there were 50 cases of latent TB,
the PHN would be much more concerned than if there were
50 cases in a community population of 100,000. In the chla-
mydia example, the rate of cases appears to be increasing,
from around 340 per 100,000 in year 1 to nearly 428 per
100,000 in year 5 (see Figure 4.4). This increase is concerning
by itself, but the PHN might want to compare the rate in one
community with the rate in another community. Compar-
ing rates in different communities or populations provides
the PHN with perspective about the relative severity of the
disease incidence or prevalence and helps determine how to
prioritize efforts to prevent the spread of chlamydia.

Evidence Example 4.2 discusses using data regard-
ing incidence rates to identify a problem and evaluate the
impact of a system-wide intervention—in this case the rate
of tuberculosis among correctional system inmates.

Data Comparison Between State
and National Sources
Comparing health and disease trends across communities
can be challenging and create turmoil if it is not done care-
fully. No community wants to appear worse than another
when it comes to a health problem or condition. On the other
hand, if resources are scarce, a community might want to
justify acquiring greater access to available resources. Care-
ful comparison of data within and across communities is
vital to ensure that public health priorities are appropriate
and that the chosen resource allocation is warranted. Com-
parison is useful because it can bring understanding of the
severity or scope of a problem, especially if policymakers
are unaware of the problem or not convinced that it requires
attention.

EVIDENCE EXAMPLE 4.2
Use of Epidemiological Tuberculosis Data to Inform
a New York State Corrections Intervention

In a study addressing tuberculosis, data were used to inform
strategies to prevent increases of tuberculosis among
inmates in the New York State Corrections system (Klopf,
1998). Data indicated that the incidence of tuberculosis
had increased over a 6-year period from 43 per 100,000
to 225 per 100,000, a serious problem that warranted
intervention. Collaboratively, people from corrections, the
local department of health, and the parole division devel-
oped a comprehensive TB control program that focused on
the prevention and containment of disease. Importantly,
they implemented a nurse-led case management program,
using infection control nurses to carefully monitor and
intervene on active and suspected TB cases. The program
was truly comprehensive, including policies, development
of a TB registry, surveillance, detection, and case man-
agement involving preventive and directly observed ther-
apy among the inmates. The staff and inmates received
education regarding testing, diagnoses, disease process,
and treatment. It is believed that this comprehensive pro-
gram contributed to the reduced incidence of TB. Six years
later, the rate decreased from 225 per 100,000 to 61 per
100,000—a 73% reduction! The data informed the need
for an intervention that relied heavily on nurses. The data
also demonstrated, in part, the impact of the intervention
program, showing a significant reduction in the new cases
of TB among New York’s inmates.

FIGURE 4.4 Chlamydia Example of Case Rate per 100,000 Over 5 Years

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84 PART II n Entry-Level Population-Based Public Health Nursing Competencies

different timeframes, and it’s good to note when discrepan-
cies exist. In Figures 4.5 and 4.6, both MDH and CDC data
are reported for 2015, which offers a useful comparison. An
effective PHN tries to find the most comparable data possi-
ble but does point out discrepancies when comparisons are
made between incomparable data. Using data that are not
a perfect match is not wrong, but these differences must be
identified so that people can make informed decisions based
on the existing data. It might not be true that people can
make data say exactly what they want them to say, but it
certainly is possible to inadvertently or purposefully present
data in ways that might not be entirely accurate. Therefore,
PHNs need to spend time practicing how to present data in
meaningful, representative ways, and, equally vital, they
need to have the ability to interpret and critique any data
that are presented to them.

Data Comparison Between National
and Global Sources
To understand the context from which a client originates, a
PHN may be interested in disease incidence in other parts
of the world. The earlier PHN who graphed active TB cases
against latent TB cases may have found increasing numbers
of families from several parts of the world now living in her
community. Reviewing information from the World Health
Organization (WHO) will inform her of the distribution
of TB elsewhere. This information can then be applied to
determine communicable disease risk related to immigra-
tion patterns in her community.

Data as Population Trends
Equally valuable are data that demonstrate population
trends. These are most commonly presented in the form of
a population pyramid, which at a glance provides a picture
of population growth (see Figure 4.7). In this figure, the age
distribution of people in the U.S. is portrayed. Compared
with other years, one can visually see changing trends in
population age distribution. This could be valuable to
determining priorities for PHN interventions, particularly

A good example of this scenario is Lyme disease, which
is contracted through exposure to ticks. Lyme disease cases
between 1996 and 2016 have varied from 252 to 1,431 cases
in Minnesota and have steadily increased since 2002 (see
Figure 4.5). However, without being able to compare these
numbers to those of another state, it is difficult to determine
whether the problem is serious or relatively consistent with
national trends. The PHN investigating this issue might
look beyond state-level data to what is occurring nationally.
Review of national data provided by the CDC demonstrates
that Minnesota has one of the highest density areas of Lyme
disease, second only to states along the East Coast (see
Figure 4.6). The data in Figure 4.6 are from a Geographic
Information System (GIS) wherein a dot is placed within the
county of residence for each confirmed case of Lyme disease.
GIS is an example of a mapping tool that PHNs may use for
surveillance. (See “Innovative Data Collection: Maps and
Apps,” for more GIS information.) These data would sup-
port efforts by PHNs to bring attention to the problem and
to invest in preventive messages for Minnesotans regarding
the spread of Lyme disease.

Often data are not easily and perfectly comparable
between sources due to different years of reported data or

EVIDENCE EXAMPLE 4.3
Comparing Virtual and Outpatient Tuberculosis
Clinic Models of Care

In a recent study, the use of a virtual public health clinic was
compared with a traditional outpatient clinic for managing
tuberculosis in a Canadian province (Long, Heffernan, Gao,
Egedahl, & Talbot, 2015). The TB prevention and care model
was delivered through one virtual and two outpatient clin-
ics, which were subsequently assessed on 28 performance
indicators. Overall, one clinic type did not demonstrate
superiority to the other, which is promising for virtual or
tele-health models of healthcare delivery and management
for challenging public health concerns such as TB.

Addressing Asthma to Improve Health in Cities

GOAL 11 Nurses are on the front line globally for addressing asthma, which is the most common
chronic condition among children that can have long-term consequences when left undiagnosed and
undertreated. Nurses in Iceland and the United States developed an International School Nurse Care
Coordination Model that informs strategies addressing asthma at both the student and the school
levels, including symptom management, care coordination within and outside the school setting, and
broader educational strategies (Garwick et al., 2015). Collaborative efforts such as this offer promise of
achieving this SDG by recognizing where global challenges might be met with similar strategic models.

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85CHAPTER 4 n Competency #2

FIGURE 4.6 Reported Cases of Lyme Disease—United States, 2016
Source: Centers for Disease Control and Prevention [CDC], 2016

FIGURE 4.5 Reported Cases of Lyme Disease in Minnesota, 1996–2016 (n = 17,744)
Source: Minnesota Department of Health [MDH], 2016

Reported Cases of Lyme Disease
in Minnesota by Year, 1996–2016 (n = 17,744)

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86 PART II n Entry-Level Population-Based Public Health Nursing Competencies

be interested in more in-depth statistical comparisons and
analysis, such as chi-square analysis. PHNs might not rou-
tinely calculate these numbers, but they often read and ana-
lyze research that includes reported rates, risk ratios, odds
ratios, chi-squares, and levels of significance (i.e., p < .001 or p < .05). It is beyond the scope of this book to completely explain how to calculate each of these, but it is useful for PHNs to have an awareness of what the numbers mean and how to appropriately interpret them.

Table 4.3 shows an example of data used to calculate odds
and an OR. This ratio is useful in identifying the odds of con-
tracting the disease, given the presence or absence of a risk
factor. The formula for calculating the OR is (a/c) / (b/d) =
ad/bc. Specifically, the odds of contracting the disease in the
presence of the risk factor is calculated by dividing the num-
ber of people with the disease and the risk by the number of
people without the disease but with the risk (i.e., 75/25, or 3).
Similarly, the odds of contracting the disease but not having
the risk factor can be calculated 2/98, or 0.0204. The OR is
calculated by dividing the odds with the risk factor by the
odds without the risk factor (3/0.0204), or 147. In this exam-
ple, someone with the risk factor is 147 times more likely to
contract the disease than someone without the risk factor. A
PHN with this information needs to make decisions on how
to act based on many factors. For example, even though the
OR is so high, the disease might not be life threatening, or

when resources are limited. Population data are important
because they offer a glimpse into the big picture of how peo-
ple are distributed, but the data by themselves might not be
sufficient to guide intervention decisions or justify program
budget priorities.

Data as Risk Ratios and Odds Ratios
Another very common tool used to examine the data regard-
ing risks and health outcomes is a 2×2 table (see Table 4.3).
This table aids in understanding how a disease is distributed
in a population based on the presence or absence of a risk fac-
tor. From this table, a PHN can calculate the rate of disease
in each group; the risk ratio (RR: the rate of disease for those
with the risk behavior divided by the rate of disease for those
without the risk behavior); and the odds ratio (OR), which
is regularly used to describe the likelihood of contracting a
disease for someone with the risk factor compared to some-
one without. In the example shown in Table 4.3, the rate of
disease for the “Yes” risk behavior group is 0.75 (75/100),
and the rate of disease for the “No” risk behavior group is
0.02 (2/100). Already a relationship between the risk behav-
ior and the disease seems obvious given the raw rates (0.75
versus 0.02). Taking this a step further, you can calculate
the RR (0.75/0.02 = 37.5). PHNs do not often use the RR by
itself, but it is an important calculation for those who might

FIGURE 4.7 Population Pyramid of United States—2016
Source: Central Intelligence Agency: The World Factbook, 2016

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87CHAPTER 4 n Competency #2

Innovative Data Collection:
Examples of Maps and Apps
Data are typically collected through surveillance systems
at the local, state, or national levels. Sometimes healthcare
professionals provide the data, and other times individuals,
families, or communities are surveyed. PHNs need to be
aware of the variety of tools used to collect epidemiologi-
cal data, because they might participate in data collection,
interpretation, or dissemination. A Geographic Informa-
tion System (GIS) is an example of a tool growing in pop-
ularity in the field of public health. Technological advances
make it possible for local PHNs (and the general public) to
access GIS data and contribute to mapping efforts readily
via smartphones, tablets, and laptops.

GIS tools can yield data useful to a neighborhood, com-
munity, state, or country in advancing public health pri-
orities. The County Health Rankings & Roadmaps provide
an annual check-up of the health of each county in the U.S.
(County Health Rankings & Roadmaps, 2012). This publica-
tion shows that some places are doing very well, while oth-
ers have room for improvement. Figure 4.8 shows maps that
provide insights about health outcomes and health factors
in Minnesota, with healthier counties depicted in lighter
colors. See Figure 4.8, County Health Rankings & Road-
maps; and Figure 4.9, a sample interactive GIS map from
the California Department of Public Health that addresses
nutrition, from www.cnngis.org.

TABLE 4.3 Association Between
Risk Factor and Disease

Disease

Risk Factor Yes No Total

Yes a c a + c

No b d b + d

Total a + b c + d a + b + c + d

Disease

Risk Factor Yes No Total

Yes 75 25 100

No 2 98 100

Total 77 123 200

the risk factor might not be common. The risk factor might
easily be eliminated with an intervention, or the risk factor
might not be easily identified, making it difficult to inter-
vene. PHNs need to consider numerous factors when data
are interpreted and then acted upon. PHNs have an import-
ant role in helping interpret data so that they are not used
inappropriately to justify action or inaction.

FIGURE 4.8 County Health Rankings & Roadmaps: Minnesota
Source: County Health Rankings & Roadmaps, 2018

2018 Health Factors: Minnesota2018 Health Outcomes: Minnesota

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88 PART II n Entry-Level Population-Based Public Health Nursing Competencies

n Federal Emergency Management Agency (FEMA)
Geoplatform (at http://fema.maps.arcgis.com/
home/index.html) provides geospatial data and
analytics for emergency management (see also
www.geoplatform.gov)

n FEMA Geospatial Coordination Mapping
and Data (see https://data.femadata.com/
NationalDisasters/HurricaneHarvey/Documents/
Geospatial%20Coordination%20Call%20Notes/
for Hurricane Harvey examples)

n American Red Cross Online Mapping provides infor-
mation about open shelters and ongoing storm data (see
http://arc-nhq-gis.maps.arcgis.com/home/index.html)

n National Oceanic and Atmospheric Administration
NowCOAST provides real-time coastal observations,
warnings, and forecasts (see https://nowcoast.noaa.gov/)

n Ushahidi crowdsource mapping was used to aid
in response and recovery efforts (see https://
irmamiami.ushahidi.io/views/map) including oil
spill tracking after Hurricane Harvey (see https://
skytruth.ushahidi.io/views/map)

GIS data are also being used to carefully examine
community-level assets and risks related to public health
problems such as obesity prevention. For example, GIS data
can aid in understanding how communities compare in
terms of access to full-scale grocery stores, corner supermar-
kets, gas stations, and liquor stores. Additionally, GIS data
can indicate the location of parks and transpose (e.g., over-
lay) violent crime data, which might provide insights into
why youth in certain neighborhoods are reporting higher
levels of physical activity than youth in other neighborhoods.

In emergency situations, GIS programs are playing a cru-
cial role. In Haiti in 2010, a GIS program was used within
the first few hours after the earthquake to update a base-
line map of Haiti. People on the ground used OpenStreet-
Map, a GIS crowdsourced mapping program, to modify the
existing map in real time, thereby facilitating rescue efforts.
The pre-earthquake terrain maps that existed were not very
helpful, but the real-time maps provided valuable support to
search-and-rescue teams. Since then, the use of GIS to map
disaster events and response has dramatically increased.
Consider just a few of the following GIS resources that were
available and used in 2017 to aid in addressing hurricanes
(Harvey, Irma, Matthew, and others):

FIGURE 4.9 Sample GIS Map Viewer: Network for a Healthy California

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http://fema.maps.arcgis.com/home/index.html

https://data.femadata.com/NationalDisasters/HurricaneHarvey/Documents/Geospatial%20Coordination%20Call%20Notes/

http://arc-nhq-gis.maps.arcgis.com/home/index.html

https://nowcoast.noaa.gov/

https://irmamiami.ushahidi.io/views/map

https://skytruth.ushahidi.io/views/map

89CHAPTER 4 n Competency #2

Mapping is also being used to monitor and visualize
outbreaks across the globe (see http://www.healthmap.org/
en/) and can be valuable historically to review an outbreak,
such as the 2014 Ebola outbreak (see https://www.cdc.gov/
vhf/ebola/outbreaks/2014-west-africa/distribution-map.
html). The data behind the mapping are useful not only in
the real-time incidents that require response and interven-
tion, but also in the future, as scientists use data to develop
algorithms that could help to predict future outbreaks. With
public health professionals questioning when, not if, the
next worldwide outbreak or pandemic threat might occur,
the ability to see and process a large amount of real-time
data, and historic data, is very important.

Consider learning about the Global Health Security
Agenda (see https://www.ghsagenda.org/) to “advance a
world safe and secure from infectious disease threats, to
bring together nations from all over the world to make new,
concrete commitments, and to elevate global health security
as a national leaders-level priority” (Global Health Secu-
rity Agenda [GHSA], 2017, para. 1). This initiative is exten-
sive, promoting efforts that engage global partners, local
government, universities, those already in the workforce,
and those who are about to graduate and enter the public
health workforce as public health nurses, veterinarians, and
environmental health professionals. Examples of these ini-
tiatives are found online: One Health Workforce at https://
medium.com/one-health-workforce and PREDICT at http://
www.vetmed.ucdavis.edu/ohi/predict/.

In addition to broad use of mapping data in public health,
there are real-time data collection strategies being used
to more quickly and more thoroughly understand public
health problems and to more efficiently deliver public health
interventions. Consider the extensive and overwhelming
availability of smartphone apps designed to help individu-
als manage their health, quit an unhealthy behavior, begin a

healthy one, and track every step along the way. Visit an app
store and do a search for a common public health challenge
you might address as a PHN working with individuals or
families. You will find dozens, if not hundreds, of possible
tools. Of value are articles that summarize the benefits and
challenges of these apps, as well as websites that offer rank-
ings and scores to help potential users consider the right app
for them. An example is provided for mental health apps
at https://adaa.org/finding-help/mobile-apps. Not every sit-
uation warrants use of an app (or a map), and it is really
important for PHNs to understand this. Just because a tech-
nological tool exists does not inherently mean it should be
used. PHNs need to consider the challenge being addressed,
the stakeholders, the benefits or challenges associated with
the technological solution, and then make an informed
decision about using it.

Applies an Epidemiological Framework
When Assessing and Intervening With
Communities, Systems, Individuals,
and Families
How a PHN comes to understand a problem and its possible
causes and solutions is somewhat dependent on the frame-
work that the PHN uses. The epidemiological triangle has
traditionally been used to understand disease transmission.
This triangle consists of identifying a host system affected
by the condition, an agent that causes the condition, and the

EVIDENCE EXAMPLE 4.4
Using Big Data to Inform PHN
Home Visiting Interventions

There is so much data generated in every home visit, and
over time and across visits, the data repository grows and
becomes a valuable source of broad information. PHNs
have traditionally provided the data, offering rich chart-
ing and thorough details for each home visit, but now
PHNs are using these data to understand patterns and
inform interventions to a much greater extent. Monsen
et al. (2017) analyzed data from 4,263 women who had
received home visits, examining social and behavioral
determinants of health as well as outcomes following the
home visits. Analyses demonstrated that minority women
showed greater improvements following the interventions
and revealed the value of using big data to begin to unravel
intervention elements and intervention outcomes.

EVIDENCE EXAMPLE 4.5
Screening for Neurodevelopmental Delays in
Four Communities in Mexico and Cuba

Cuban and Mexican PHNs used a newly developed com-
puterized evaluation instrument to assess and compare
the prevalence of neurodevelopmental problems in three
areas: language/communication, psychomotor, and hear-
ing/vision (Guadarrama-Celaya et al., 2012). Four hun-
dred children ages 1 to 5 years were screened using the
Neuropediatric Development (NPED) screening tool in
urban and suburban cities in Cuba and Mexico. Results
demonstrated failures in all communities (e.g., 2.3% vision,
16.5% language) and differences by country (e.g., higher
failures rate for hearing in Cuban communities). Results
also demonstrated successful use of this computerized
Spanish-language tool for broad community assessment
of key neurodevelopmental problems among children at
important stages of development. This tool can facilitate
earlier identification and intervention so that long-term
neurodevelopmental problems can be avoided as children
develop.

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http://www.healthmap.org/en/

https://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/distribution-map.html

https://www.ghsagenda.org/

https://medium.com/one-health-workforce

http://www.vetmed.ucdavis.edu/ohi/predict/

https://adaa.org/finding-help/mobile-apps

90 PART II n Entry-Level Population-Based Public Health Nursing Competencies

the web design to identify all the factors influencing the cen-
ter of the web (i.e., the disease, such as cardiovascular disease
or asthma, or the social health problem, such as teen preg-
nancy). After you have drawn the web, you are faced with a
dilemma—specifically, which related thread to address first.
How do you decide whether to prioritize a biological-related
factor or a social-based factor? The web might help identify
numerous potential causes, contributors, and influences,
yet the model by itself does not yield readily apparent strat-
egies or solutions. More than 10 years ago, Nancy Krieger
(1997) identified these criticisms of the web framework and
proposed an ecosocial framework for developing epidemio-
logical theories about public health problems and possible
solutions. The central question answered using an ecosocial
framework is, “Who and what is responsible for population
patterns of health, disease, and well-being, as manifested in
present, past, and changing social inequalities in health?”
(Krieger, 2001a, p. 694).

A shift in thinking about traditional epidemiology mod-
els has occurred, with growing recognition of the impor-
tance of social epidemiology, the field that acknowledges
and seeks to address the complex combination of biological
and social factors influencing health and well-being. Social
epidemiology was initially defined in the 1950s but has in
more recent decades grown in popularity and use among
public health professionals (Krieger, 2001b, 2012). PHNs
need to be aware of the trends in public health as well as
the theories that guide understanding of the “risk-asset-
problem-intervention” relationships in public health.

environment that contributes to the condition. Host consid-
erations include genetics; inherent characteristics, such as
age and gender; acquired characteristics, such as immune
status; and lifestyle factors. Agents are typically categorized
as infectious, chemical, or physical agents. Environmental
factors might include a variety of physical, social, and eco-
nomic factors. Interactions between these three elements
of the triangle are examined to determine how diseases are
transmitted and how intervention strategies can be targeted
to stop or prevent transmission of the health conditions.
Using influenza as an example of the three triangle compo-
nents, the host would be the individual susceptible to the flu,
the agent is the influenza virus, and the environment might
be the physical apartment that is overcrowded and under-
heated (Clark, 2008).

This model has been adapted to consider more complex
scenarios that might be contributing to disease or illness
(see Figure 4.10). It is an important adaptation, because for
most health problems that PHNs address, the contributing
factors are complex and multifaceted. Illnesses result not
merely from a simple transmission in the right time and
place but also because of factors not easily controlled or
resolved (e.g., poverty, inadequate housing, food shortages).

For many in public health, complex contributing factors
to poor health or well-being have been informed by such
models as the web of causation. The name itself implies
greater complexity than the epidemiological triangle, yet
this model is also not perfect. For example, imagine a spider
web (where the name is drawn from) and how you might use

FIGURE 4.10 Epidemiological Triangle in the 21st Century
Source: Merrill, 2017, p. 11

Environment
Behavior and culture,
physiological factors,

ecological factors

Causative Factors
Biological (infectious agents),
chemical (drugs, acids, alkali,
heavy metals, poisons, some

enzymes), physical (excessive
heat, cold, noise, radiation,

collisions, injuries, etc.)

Group or Population
Age, gender, ethnicity, religion, customs,

occupation, heredity, marital status,
family background, previous diseases

Time

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91CHAPTER 4 n Competency #2

’’

‘‘

Permanente (see https://www.cdc.gov/violenceprevention/
acestudy/index.html) have been done, showing the strong—
and in some cases, predictive—relationship between expo-
sure to these risks in childhood and poor outcomes in
young adulthood and adulthood (Holman et al., 2016; Wolff,
Baglivio, & Piquero, 2015).

The life course perspective views health not in stages
separate from each other (infancy, early childhood, adoles-
cence, adulthood) but as a continuum. As Krieger (2001a,
p. 695) describes, “Life course perspective refers to how
health status at any given age, for a given birth cohort,
reflects not only contemporary conditions but embod-
iment of prior living circumstances.” A classic life course
study was the research on the effects of the 1944–1945 Dutch
famine that linked malnutrition with subsequent effects on
human development and mental performance (Stein, Susser,
Saenger, & Marolla, 1975). Throughout the life course con-
tinuum, biological, behavioral, environmental, psycholog-
ical, and social factors dynamically interact, contributing
to one’s health. As Matthias Richter (2010, p. 458) summa-
rizes, “This perspective was truly helpful to contribute to a
better understanding of biological, behavioural and social
influences—from gestation to death—for health as well as
health inequalities.”

The next area for Elizabeth to assess for close contacts is
the in-home daycare. Billy’s mother states that they have a
split-entry home and that the lower level is for the licensed
daycare. On a normal day, she has five children who stay
until 5:30 p.m. In addition, a set of 1-year-old twin girls
stay until approximately 11:00 p.m. Billy’s mother indicates
that since Billy has been ill, he has stayed only on the upper
level, away from most of the lower-level childcare children.
However, the situation with the twins is different: Billy eats
supper with them and plays with them until bedtime. The
twins have been exposed to pertussis and, according to
the definition in the protocol, are considered face-to-face
contacts.

Elizabeth asks whether the twins’ parents have been told
about Billy’s pertussis. The mother states that she has not
told them because she is concerned about losing her clients
and income. Elizabeth explains that the public health rec-
ommendation is that the twins receive preventive antibiot-
ics because of their close contact with Billy. Billy’s mother
agrees to notify the twins’ parents by passing out to all par-
ents a standardized notification letter from the PHN.

Public health nursing is grounded in the science of
epidemiology. On numerous levels, epidemiological data
help describe the scope of a problem, prioritize interven-
tion strategies, and evaluate outcomes or trends over time.
Data are presented and collected using many different for-
mats; nurses need the skills to interpret and critique these
data, regardless of how they are presented. PHNs also use

Nursing practice should always be informed by theory.
It is relatively easy in nursing practice to get caught up in
the tasks one has to do and to forget, at times, to take a step
back, reflect, and consider why something is being done a
certain way or why certain events are occurring. Theories
are always advancing, and an effective PHN strives not only
to use theory but also to keep up with theoretical ideas that
guide and inform practice and the care of individuals, fam-
ilies, communities, and populations. Epidemiology is an
ideal example of the value and importance of theory as a
guide for understanding and intervening in extremely com-
plex societal health problems and conditions.

Another important theoretical framework in public
health that PHNs should be aware of is referred to as life
course epidemiology. Historically, as the focus of epidemiol-
ogy shifted from infectious disease to chronic illness in the
mid–20th century, new and expanded paradigms emerged
to better recognize and understand the antecedents and
causes of chronic diseases. Consider adverse childhood
experiences (ACEs); these are now commonly understood
as important life events that can have physical and men-
tal health effects that persist into adulthood (Felitti et al.,
1998). ACEs include a range of experiences, but most com-
mon are those that children experience directly (e.g., sex-
ual abuse, emotional abuse, physical abuse), and through
exposure in the home (e.g., parental substance use or incar-
ceration, parental mental health problems, parental abuse,
parental divorce or separation). Numerous studies since
the original ACEs Study conducted by the CDC and Kaiser

THEORY APPLICATION
Ecosocial Theory

Krieger’s ecosocial theory offers an integrated framework
that considers pathways of public health problems in the
context of life course (e.g., from infancy to older adulthood),
and ecological layers (e.g., individual, family, community,
system, etc.). Critical to the theory is the explanatory man-
ner in which complex, intersectional risks and protections
can be considered when examining a public health or social
problem (see Krieger, 2012, p. 938, for a modeling of the
framework applied to racism, for example). Krieger states
that the ecosocial theory is a tool that:

fosters analysis of current and changing population
patterns of health, disease, and well-being in rela-
tion to each level of biological, ecological and social
organization (e.g., cell, organ, organism/individual,
family, community, population, society, ecosystem)
as manifested at each and every scale, whether rel-
atively small and fast (e.g., enzyme catalysis) or rel-
atively large and slow (e.g., infection and renewal
of the pool of susceptible for a specified infectious
disease) (Krieger, 2001b, p. 671).

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https://www.cdc.gov/violenceprevention/acestudy/index.html

92 PART II n Entry-Level Population-Based Public Health Nursing Competencies

epidemiological theories to inform actions and priorities for
addressing public health problems. PHNs need to use and
contribute to the development of theories that recognize the
social complexities influencing public health problems in
the 21st century.

Ethical Considerations
As seen in the narrative woven throughout this chapter, the
daycare provider was concerned about a loss of income and
her reputation as a provider. Many times, PHNs confront
challenging situations in their practice. For example, report-
ing a nuisance house situation to the city building inspector
might prompt the eviction of a renter or harassment from
a landlord. Although they are trying to protect children
living in less than desirable circumstances, PHNs’ actions

TABLE 4.4 Ethical Action in Using Epidemiological Principles in Public Health Nursing

Ethical Perspective Application

Rule Ethics (principles) n PHNs should use epidemiology to assess and develop interventions that promote beneficence.
n PHNs can support the autonomy of those they are working with, even when uncomfortable

changes are needed to minimize the spread of disease.

Virtue Ethics (character) n PHNs need to demonstrate respect for individuals, families, and communities when suggesting
promotion or prevention strategies; this can be challenging but necessary, especially when some
might refuse to adhere to the actions being recommended.

n PHNs should be persistent in understanding the complexity of factors contributing to a problem
so that potential solutions are comprehensive and yield lasting changes.

Feminist Ethics
(reducing oppression)

n PHNs can advocate for system-level changes that promote the well-being of those who often feel
they have no voice (e.g., tenants who are unable to ask a landlord to maintain heat levels during
the winter).

n PHNs should explore societal changes that can improve the underlying environment for people,
such as increasing the minimum-wage law so that families have additional resources to sustain
and promote health.

might have unintended consequences for entire families.
Similarly, interventions focused on reducing the expo-

sure to lead paint in older homes might be embarrassing
or financially difficult. Although the health department
might offer a free home/environmental inspection for the
detection of lead paint, this activity might force families
to temporarily leave their homes, which some may per-
ceive as an invasion of privacy. Moving in with relatives for
a day might be embarrassing for some; for others, staying
in a hotel might be beyond the family budget. Some health
departments offer a free service to abate lead in a home if the
family has not done so. Although this solution is helpful in
covering up a lead source, the repainting services are often
spotty and unsightly in appearance. The benefits of reduc-
ing lead exposure to children must be weighed against the
other consequences for the family. See Table 4.4 for ethical
perspectives and applications relevant to epidemiological
principles in public health nursing.

n Epidemiological data, including prevalence and inci-
dence data, help set national and local public health
priorities.

n PHNs can and should use epidemiological data to
advocate for health promotion priorities in their areas
of influence.

KEY POINTS

n Epidemiology is an important foundation to the work
of PHNs.

n There is a growing shift from traditional epidemiologi-
cal models toward more complex models that consider
social influences on health, such as a social epidemio-
logical model.

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93CHAPTER 4 n Competency #2

Clark, M. (2008). Community health nursing: Advocacy for popula-
tion health (5th ed.). Upper Saddle River, NJ: Pearson Education.

County Health Rankings & Roadmaps. (2012). Minnesota. Univer-
sity of Wisconsin Population Health Institute. Retrieved from
http://www.countyhealthrankings.org/app/minnesota/2018/
overview

Earl, C. (2009). Medical history and epidemiology: Their contri-
bution to the development of public health nursing. Nursing
Outlook, 57(5), 257–265.

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz,
A. M., Edwards, V., & Koss, M. P. (1998). Relationship of child-
hood abuse and household dysfunction to many of the leading
causes of death in adults: The Adverse Childhood Experiences
(ACE) study. American Journal of Preventive Medicine, 14(4),
245–258.

Friis, R. H. (2018). Epidemiology 101 (2nd ed.). Burlington, MA:
Jones & Bartlett

References
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cholera outbreak. Retrieved from http://www.wired.com/
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Centers for Disease Control and Prevention. (2001). Updated
guidelines for evaluating public health surveillance systems:
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mmwr/preview/mmwrhtml/rr5013a1.htm

Centers for Disease Control and Prevention. (2015). 2015 Final
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Centers for Disease Control and Prevention. (2016). Lyme dis-
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library/publications/resources/the-world-factbook/geos/us.html

REFLECTIVE PRACTICE

Investigating outbreak possibilities can be challenging, but
it can also present opportunities to practice great commu-
nication skills. Elizabeth handled a situation that could have
been extremely difficult in a professional, thoughtful man-
ner. She asked the right questions and managed to express
concern rather than judgment. By building a good relation-
ship right away, Elizabeth received honest responses from
the childcare provider, and together they determined who
had been exposed and an appropriate course of action.

1. What do you imagine will be some follow-up steps that
Elizabeth will take in this situation?

2. How can Elizabeth be a resource for the childcare pro-
vider if her clients grow angry when they are informed
about the possible exposure?

3. Who might be additional partners to Elizabeth within
the health department as she follows this case until it
is resolved?

4. How might Elizabeth address an ethical issue, such
as whether some of the exposed refuse preventive
treatment?

5. How will Elizabeth know whether this case investiga-
tion has been successful? What will be important for
Elizabeth to document?

6. How will the numbers that Elizabeth has collected
as part of this investigation be useful to others at her
local health department? At the state level? At the
national level?

7. How might Elizabeth use each of the Cornerstones
of Public Health Nursing (see Chapter 1) in this case
investigation?

APPLICATION OF EVIDENCE

1. What are some ways you can use the ecosocial theory
to examine contributing and influencing factors on
complex public health problems in the United States in
the 21st century, such as obesity or the opioid epidemic?

2. Examine the different types of data presented in this
chapter (e.g., rates, maps) and identify when you might
use one type of data more than another type.

3. As a PHN working in a community, identify three to
five sources of state- or federal-level data you would
want to use in demonstrating how your community
issues compare to others.

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http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5013a1.htm

https://www.cdc.gov/pertussis/downloads/pertuss-surv-report-2015

94 PART II n Entry-Level Population-Based Public Health Nursing Competencies

Lind, C., & Smith, D. (2008). Analyzing the state of community
health nursing: Advancing from deficit to strengths-based
practice using appreciative inquiry. Advances in Nursing Science,
31(1), 28–41.

Long, R., Heffernan, C., Gao, Z., Egedahl, M. L., & Talbot, J. (2015).
Do “virtual” and “outpatient” public health tuberculosis clinics
perform equally well? A program-wide evaluation in Alberta,
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pone.0144784

Merrill, R. M. (2017). Introduction to epidemiology (7th ed.).
Sudbury, MA: Jones and Bartlett.

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http://www.health.state.mn.us/divs/idepc/diseases/lyme/casesyear

http://www.ph.ucla.edu/epi/snow.html

CHAPTER

5
COMPETENCY #3
Utilizes the Principles and Science of
Environmental Health to Promote Safe and
Sustainable Environments for Individuals/
Families, Systems, and Communities

n Patricia M. Schoon
with Noreen Kleinfehn-Wald, Carolyn M. Porta, and Stacie O’Leary

‘‘

’’

Jeff, Gena, Max, and Dana are working with Candace, the school nurse, at an environmental mag-
net elementary school. Candace tells them that she has documented an increase in asthma attacks and
asthma-related absences since the beginning of the flu season a month ago. She asks the students to do
an assessment, kind of like a modified community assessment, to identify the potential causes of the
increased incidence. The students are having a meeting to discuss how to organize their assessment.

Jeff states, “I think we need to research all of the causes of asthma and asthma attacks and what might
place these students at risk for increased attacks.”

Gena responds, “This is going to be complicated. My niece has asthma and my sister is always looking
for asthma triggers. My sister also recently met with the school nurse to develop an asthma action plan to
use at school. There are so many risk factors.”

Dana comments, “I don’t know much about environmental health. I think I want to do some reading
about what it is and what environmental health has to do with nursing.”

Max responds, “I agree with Dana. When I think of environmental health and nursing I think of how
we dispose of hazardous waste materials in the hospital. There is also the climate change issue, but I don’t
know what this has to do with nursing. I need to figure out where asthma triggers fit in all of this.”

Gena reflects, “Besides this community assessment, we are all making home visits with a public health
nurse [PHN]. Maybe some of what we learn will help us with our assessment of the families we are visiting
and with the interventions we do with our PHN preceptors.”

The students review the environmental health PHN competencies they will be developing as they com-
plete this project. Jeff starts a to-do list and writes a list of definitions the group will need as they research
their topic from an environmental perspective.

JEFF’S NOTEBOOK
COMPETENCY #3 Utilizes the Principles and Science of Environmental Health to Promote Safe
and Sustainable Environments for Individuals/Families, Systems, and Communities

A. Promotes environments that facilitate holistic well-being and health, healing, and healthy lifestyles for
individuals/families, systems, and communities

1) Assesses environmental risk factors and protective factors for individuals/families, systems, and
communities

2) Engages in actions to reduce environmental risk factors and strengthen protective factors for
individuals/families, systems, and communities

3) Takes actions to reduce and manage harmful waste products from individuals/families, systems,
and communities

4) Evaluates the outcomes of actions to promote healthy environments
(continues)

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96 PART II n Entry-Level Population-Based Public Health Nursing Competencies

B. Seeks to protect individuals/families, systems, and communities from environmental hazards

1) Educates individuals, families, systems, and communities about environmental hazards and harmful
lifestyle factors

2) Recommends modifications in home, neighborhood, workplace, and community environments to
increase safety for individuals and families across the life span

3) Supports right-to-know legislation and regulations that protect and inform the public about hazardous
products

C. Considers the diverse values, beliefs, cultures, and circumstances of individuals/families and populations
when recommending and implementing healthy environmental interventions

1) Is attentive to diverse lifestyle factors and assesses potential health and safety risks related to them

2) Accepts and supports diversity in environmental lifestyle factors

3) Makes referrals when appropriate to governmental agencies when harmful environmental lifestyle
factors place children and vulnerable adults at risk

D. Promotes stewardship of the environment at local, national, and international levels

1) Advocates for sustainable natural and built environments

2) Advocates for environmental justice for vulnerable and under-represented populations

3) Supports policies that promote safe and sustainable natural and built environments and water and
food systems

Source: Henry Street Consortium, 2017

USEFUL DEFINITIONS

Built Environment: Includes products, structures, buildings, or transportation created or modified by
human beings.

Environment: “Reflects the aggregate of those external conditions and influences affecting the life and develop-
ment of an organism… physical, chemical, biological, and social factors that affect the health status of people”
(Merrill, 2017, p. 214); “factors external to the human or animal that cause or allow transmission” (p. 8).

Environmental Health: “Environmental health comprises those aspects of human health, including quality of
life, that are determined by physical, chemical, biological, social, and psychosocial factors in the environment.
It also refers to the theory and practice of assessing, correcting, controlling, and preventing those factors in the
environment that can potentially affect adversely the health of present and future generations.”—draft defini-
tion developed at a WHO consultation in Sofia, Bulgaria, 1993 (U.S. Department of Health and Human Services
[U.S. DHHS] Environmental Health Policy Committee, Risk Communication and Education Subcommittee, 1998).

Environmental Stewardship: The responsibility for environmental quality shared by all those whose actions
affect the environment (Environmental Protection Agency Environmental Action Council, 2005).

Exposure: A three-phase process: “1) contact is between a target and one or more agents in the same
environment; 2) agent accesses target by one or more routes of entry; and 3) the agent enters the target by
crossing a barrier or boundary” (Thompson & Schwartz Barcott, 2017, p. 1315).

Hazard: Ability of an environmental agent to do harm.

Natural Environment: Includes the physical environment (e.g., air, water, land, soil, plants, weather, climate)
and biological and chemical entities that exist in the environment.

Planetary Health: The achievement of the highest attainable standard of health, well-being, and equity world-
wide through judicious attention to the human systems—political, economic, and social—that shape the future
of humanity, and the Earth’s natural systems that define the safe environmental limits within which humanity
can flourish. Planetary health is the health of human civilization and the state of the natural systems on which it
depends (Lancet Commission, 2015; Whitmee et al., 2015).

JEFF’S NOTEBOOK
COMPETENCY #3 (continued)

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97CHAPTER 5 n Competency #3

and morbidity is referred to as the global disease burden, as
illustrated in the following quotation:

Twenty-three percent of global deaths and 22% of
global disability adjusted life years were attributable
to environmental risks in 2012… The global disease
burden attributable to the environment is now domi-
nated by noncommunicable diseases. Susceptible ages
are children under five and adults between 50 and 75
years (Prüss-Ustün et al., 2017).

Responses to environmental health challenges involve
efforts to eliminate or weaken the hazard, reduce the poten-
tial for exposure to the hazard, and mitigate the effects of
the exposure.

History of U.S. Environmental Health Movement
The contemporary environmental health movement in the
United States began with the 1962 publication of the book
Silent Spring, written by Rachel Carson, a marine biologist.
She published her research on chemical pesticides, which
resulted in the government banning the agricultural pesti-
cide DDT, a synthetic aromatic hydrocarbon (U.S. Fish and
Wildlife Service, 2012).

From 1942 to 1953, a chemical company dumped chem-
ical hazardous waste into Love Canal, an aborted Niagara
River canal project that ran through a 15-acre working-class
neighborhood (Kleiman, 2017). In the 1970s, investigative
reporters revealed a cluster of illnesses including epilepsy,
asthma, migraines, and nephrosis, as well as abnormally
high rates of birth defects and miscarriages occurring in
families that lived near Love Canal. Contaminated water
was found in the basements and yards of residents as well
as in the school playground built over the canal. Activist
women, mostly mothers in the Love Canal neighborhood,
tried to get the New York State government to take action,
but it did not. Between 1978 and 1981, 939 families were
relocated by the federal government. This tragedy mobi-
lized concerned citizens nationwide to lobby Congress
to act to make businesses responsible for cleanup of toxic

What Is Environmental Health?
When you think of the environment, what comes to your
mind? The first things that probably come to mind are the
physical locations in which you spend your daily life, such
as your home, neighborhood, parks, and open green spaces.
When you consider the health of the environment, you
must pay attention to both the seen (e.g., air, water, land)
and the unseen (e.g., microscopic pollutants) as well as the
social factors, including individual and societal behaviors,
that shape the world. A holistic definition of environmental
health would include physical, chemical, biological, social,
and behavioral factors that influence the environment. A
thorough understanding of environmental health requires
looking beyond the factors that compose “environment”
and determining whether it is healthy or unhealthy. You
need to also carefully consider the interactive effects, and
you need to further analyze the role of human behavior and
response to the environment that is consequently shaping
the world and impacting health.

Challenges of Environmental Health
In this chapter, you will read about both the immediate and
the long-term challenges of environmental health, ranging
from the hazards and exposures that you encounter on a
daily basis to the broader encompassing global challenges
of climate change. Public health nurses (PHNs) give atten-
tion to the immediate environmental risks faced by individ-
uals, families, and communities, such as the availability of
clean water, healthy food, and safe home and community
environments. In many parts of the world there are threats
to health related to the presence and disposal of biological
and chemical hazards. These environmental challenges to
health are substantial and necessitate action to mitigate
them and promote health and well-being. Exposure to envi-
ronmental hazards poses significant threats to health that
include acute illness, infectious and chronic diseases, and
premature deaths (i.e., those occurring before expected life
span). The impact of environmental hazards on mortality

Precautionary Principle: When an activity raises threats of harm to human health or the environment, precau-
tionary measures should be taken even if some cause and effect relationships are not fully established scien-
tifically. In this context, the proponent of an activity, rather than the public, should bear the burden of proof
(Chaudry, 2008).

Risk: The likelihood of harm occurring once an individual is exposed to a hazard (United Nations [UN], 2015).

Social Environment: Social interactions, behaviors, norms, institutions, and access to healthcare.

Sustainable Community: A sustainable community is one that is economically, environmentally, and
socially healthy and resilient. It meets challenges through integrated solutions, rather than through frag-
mented approaches that meet one of those goals at the expense of the others (Institute for Sustainable
Communities, n.d.).

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98 PART II n Entry-Level Population-Based Public Health Nursing Competencies

environmental health as a core function of nursing practice
in all clinical practice areas and not just the province of
nurses who specialize in environmental health (IOM, 1995).
The IOM also identified the importance of using the pop-
ulation-based public health nursing approach for environ-
mental health issues and the need to prepare more nurses at
the baccalaureate level so that the nursing profession would
have greater capacity to address the environmental health
concerns of populations as well as individuals. In 2007,
the American Nurses Association (ANA), recognizing the
importance of environmental health as a core component of
the scope of practice of professional nursing, published the
ANA’s Principles of Environmental Health for Nursing Prac-
tice with Implementation Strategies (see Table 5.1).

A coalition of U.S.-based nurses created the Alliance of
Nurses for Healthy Environments (ANHE) in 2008 (ANHE,
2017). This alliance has published standards for environ-
mental health nursing, developed an online free eBook,
Environmental Health in Nursing (2016), maintains a listing
of environmental hazards (see https://envirn.org/) and has

waste dumps that they created. In 1980, Congress passed
The Superfund Bill (i.e., Comprehensive Environmental
Response, Compensation, and Liability Act). These citizen
actions were the beginning of a grassroots environmental
movement that continues to the present day.

Environmental Health—
At the Core of Nursing Practice
PHNs are concerned about how the environment affects
individuals, families, and the community/society at large.
They consider the ongoing interactions between their clients
and the environment and the cumulative effects of envi-
ronmental hazards on health status. PHNs assess both the
protective and the risk factors of the natural and the built
physical environment and take actions to reduce environ-
mental risk factors to improve the health status of individu-
als, families, and communities.

Since the time of Florence Nightingale, nurses have iden-
tified the relationship between the environment and health
outcomes. In Notes on Nursing, Nightingale lists five things
that must be present to have a healthy home; although gen-
erated in the 19th century, they remain relevant to the 21st
century: pure air, pure water, efficient drainage, cleanliness,
and light (Nightingale, 1860). Nightingale was responsi-
ble for applying principles of cleanliness in the care of the
injured during war, which likely resulted in numerous
saved lives.

Clara Barton, trained as a teacher and not a nurse, pro-
vided nursing care to Union soldiers during the Civil War
and was officially named head nurse for one of General Ben-
jamin Butler’s units in 1864. Her experience in the Civil War
began her long history of helping those in need in times of
conflict and disaster. Barton was instrumental in starting
the American Red Cross in 1881 and was president of the
Red Cross until 1904. She then started National First Aid
Association of America; the organization’s priority was
emergency preparedness (Michaels, 2015).

Years later, Lillian Wald, recognized as the first public
health nurse in the U.S., worked to improve horrifically
overcrowded and infested housing conditions in New York
City. She believed that the crowded and dismal living con-
ditions of immigrants and children on the Lower East Side
of New York resulted in poor health outcomes and began
providing nursing services in peoples’ homes. She used her
societal position to lobby for safe spaces for children to play
in New York City, and helped to establish the first parks and
playgrounds for children in the 20th century (Filiaci, n.d.).
Wald founded the Henry Street Settlement in 1893 and led
that organization until 1933, providing health and social
services to people who suffered health consequences for the
environmental health condition of their place of residence
(Henry Street Settlement, 2017).

The Institute of Medicine’s (IOM) 1995 landmark pub-
lication, Nursing, Health, and the Environment, addressed

TABLE 5.1 ANA’s Principles of
Environmental Health for Nursing Practice

1. Knowledge of environmental health concepts is essential
to nursing practice.

2. The Precautionary Principle guides nurses in their practice
to use products and practices that do not harm human
health or the environment and to take preventive action in
the face of uncertainty.

3. Nurses have a right to work in an environment that is safe
and healthy.

4. Healthy environments are sustained through multi-
disciplinary collaboration.

5. Choices of materials, products, technology, and practices
in the environment that impact nursing practice are based
on the best evidence available.

6. Approaches to promoting a healthy environment respect
the diverse values, beliefs, cultures, and circumstances of
patients and their families.

7. Nurses participate in assessing the quality of the environ-
ment in which they practice and live.

8. Nurses, other health care workers, patients, and commu-
nities have the right to know relevant and timely informa-
tion about the potentially harmful products, chemicals,
pollutants, and hazards to which they are exposed.

9. Nurses participate in research of best practices that
promote a safe and healthy environment.

10. Nurses must be supported in advocating for and imple-
menting environmental health principles in nursing
practice.

Source: ANA, 2007, p. 16

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99CHAPTER 5 n Competency #3

decisions about actions you should take. For example, long
before the causal relationship between the ultraviolet rays of
the sun and skin cancer was known, people took precautions
about time spent in the sun to avoid sunburn. The acronym
ACT serves as a critical-thinking approach to known and
potential environmental hazards, including those that pose
both immediate and long-term actual and potential risks:

A. Assessment: Assess environmental hazards and
health risks.

C. Critical thinking: Reflect on the consequences of
these risks and how best to mitigate or eliminate
them in the short and long term. Consider the sus-
tainability of interventions and the evidence base for
their likely success.

T. Take Actions: Know best practices to reduce envi-
ronmental hazards and risks, and apply them.
Consider PHN interventions at the individual/family,
community, and systems levels of PHN practice.

Environmental Health—
The Role of the PHN
The role of the PHN in environmental health is dependent in
part on the employment location of the PHN, the structure
of the public health agency, and existing laws and regula-
tions. Some agencies include an environment health section,
and some employ a single environmental health special-
ist or a sanitarian. Agencies provide services for building
code compliance, solid waste disposal, and hazardous waste
removal. If there is a sanitarian on staff, the PHN may serve
as a consultant to the sanitarian or work with those cases
that need long-term follow-up due to a medical or health
impact. In agencies where there is not a sanitarian, PHNs
may do the environmental risk assessment themselves.

PHNs often collaborate with human service providers
working in child protection or with vulnerable adults. The
PHN might accompany a social worker to a home to assess
safety conditions or might request a social worker to inter-
vene after doing an initial home visit. Family lifestyle pat-
terns are diverse, so it is important to consider whether the
differences in conditions are benign or harmful to family
members. The PHN might need to make a determination as
to whether the conditions are significant enough to warrant
removal or temporary relocation of an individual. The PHN
may also be involved in a plan to improve the livability of
a dwelling. Some environmental situations, such as hoard-
ing, can be very complex and could involve social workers,
mental health professionals, law enforcement, and others to
address the situation.

Existing laws and ordinances greatly shape the role of
the PHN in addressing environmental hazards or risks. For
example, a state law or local ordinance may designate a pub-
lic health inspection. If such is the case, then there is usu-
ally a process to give legal orders to abate a situation, and a

workgroups for education, research, practice, and policy/
advocacy. ANHE has identified ten reasons why it is import-
ant and appropriate for nurses to be involved in environ-
mental health (see Table 5.2).

The Precautionary Principle
PHNs take actions to prevent harm to their clients. How-
ever, the cause-effect relationship between some environ-
mental hazards or potential hazards is not always clear.
PHNs use the Precautionary Principle to guide their actions
in protecting themselves and their families, clients, and
community. The following definition provides guidelines
for applying the Precautionary Principle to nursing actions.

When an activity raises threats of harm to human
health or the environment, precautionary measures
should be taken even if some cause and effect rela-
tionships are not fully established scientifically. In
this context the proponent of an activity, rather than
the public, should bear the burden of proof. The pro-
cess of applying the Precautionary Principle must be
open, informed, and democratic and must include
potentially affected parties. It must also involve an
examination of the full range of alternatives, includ-
ing no action (Science and Environmental Health
Network, 1998).

Using the Precautionary Principle makes good sense.
Start by considering what you can do in your home, neigh-
borhood, and workplace to reduce exposure to hazards.
You can also look at correlation and make common sense

TABLE 5.2 Top Ten Reasons That Nurses
and Environmental Health Go Together

n Nurses provide healing and safe environments for people.
n Nurses are trusted sources of information.
n Nurses are the largest healthcare occupation.
n Nurses work with persons from a variety of cultures.
n Nurses effect decisions in their own homes, work settings,

and communities.
n Nurses are good sources of information for policymakers.
n Nurses translate scientific health literature to make it

understandable.
n Nurses with advanced degrees are engaged in research

about the environment and health.
n Health organizations recognize nurses’ roles in

environmental health.
n Nursing education and standards of nursing practice

require that nurses know how to reduce exposures to
environmental health hazards.

Source: ANHE, 2016, p. 2

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100 PART II n Entry-Level Population-Based Public Health Nursing Competencies

‘‘

’’

Online Activity
Help Max and Jeff research environmental asthma
triggers. Here are a few online resources for you to use. Refer
to the information on the following websites and make a list of
environmental asthma triggers.

n Environmental Health in Nursing, an open-source text-
book, written by members of the Alliance of Nurses for
Healthy Environments at https://envirn.org/wp-content/
uploads/2017/03/Environmental-Health-in-Nursing

n Environmental Triggers of Asthma at https://
www.atsdr.cdc.gov/csem/csem.asp?csem=32&po=6

n Asthma and Allergies and Their Environmental Triggers
at https://kids.niehs.nih.gov/topics/pollution/
asthma-and-allergies/index.htm

n Childhood Asthma at http://asthmaandallergies.org/
asthma-allergies/childhood-asthma/

Individual/Family Level of Practice
This section focuses on identifying key environmental haz-
ards that have a direct effect on individuals and families and
strategies for how to prevent or mitigate the exposures and
their effects. A few hazards often encountered by PHNs in
their personal lives and daily work are discussed. Five com-
mon types of environmental hazards are found in the home,
in the workplace, and in schools:
n Chemical: Medications; illegal drugs; pesticides; form-

aldehyde (found in almost all new products containing
glue); volatile organic compounds (VOCs) found in
household products such as paints, varnishes, wax,
mothballs, many cleaning and disinfecting products,
personal hygiene products, and cosmetics; and indus-
trial chemicals used in cars and in the workplace

n Physical: Radon, radiation, weather, sound, vibration,
impact

n Mechanical: Pressure, ergonomics, confined space,
repetitive motion

n Biological: Bacteria, viruses, parasites, mold, allergens,
pet dander

n Sociocultural: Violence and war, interpersonal abuse,
institutionalized racism

The impact of the exposure to human beings and ani-
mals is often multifaceted and might have immediate, short-
term, or long-term influence. The three-phase process of
exposure includes: 1) exposure of the target host with one
or more environmental agents; 2) ability of the agent to
access one or more routes of entry in the target host; and,
3) entry of the agent into the target host by crossing a barrier
or boundary (Thompson & Schwartz Barcott, 2017, p. 1315).

process to follow in the event the property owner does not
comply. The PHN may be involved in tracking the progress
made or consulting with the local court system if there is
noncompliance. Some states legally designate local public
health to be the final authority on cleanup of methamphet-
amine houses (homes that have been contaminated because
of the presence of a meth lab). Often public health nurses
need to be fluent on issues related to lease agreements,
tenant rights, and accessing low-cost legal assistance as they
provide counsel to vulnerable clients.

Nurses also need to advocate with medical providers and
insurance companies to provide equipment that reduces the
risks of those with chronic disease who are exposed to envi-
ronmental hazards in the home. For example, home care
nurses who have clients with respiratory conditions may
need to advocate for air purifiers to improve the quality of
indoor air. PHNs may also be the advocate for those living
in sub-standard housing or in areas where there are sig-
nificant outdoor environmental hazards. There is a known
disparity in the availability of healthy homes and healthy
living environments, which has a disparate impact on the
poor and minorities (U.S. DHHS, 2009). PHNs may need
to advocate with policymakers to improve the opportuni-
ties for disadvantaged populations to have access to healthy
homes and neighborhoods.

Jeff and Max have been thinking about the role of the nurse
in environmental health. They feel overwhelmed. They
talk with Gena and Dana, who have just made their first
home visit with a public health nurse. Dana made a home
visit to a young woman who is pregnant and was worried
about environmental exposures she might have had that
could harm her baby. During a visit to a young family with
a child with asthma, Gena found out that the family has
bedbugs.

Dana reflects, “What we are learning in our home vis-
iting experiences about environmental health can help us
determine what environmental factors we need to consider
when looking for the causes of increased asthma attacks. I
think we need to look at the physical environment both at
home and at school to see what the risks are. Let’s focus on
the students’ homes and their families. We need to look for
the asthma triggers.”

Gena reminds them, “We also need to think about the
school environment—both the physical and the social
aspects. We need to find out what the school staff know
about asthma triggers and what they are doing that pro-
tects the children with asthma.”

Max states, “I am going to research environmental
asthma triggers.”

Jeff responds, “We need to find more resources.”

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https://kids.niehs.nih.gov/topics/pollution/asthma-and-allergies/index.htm

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CARING FOR POPULATIONS

SECOND EDITION

Christine L. Savage, PhD, RN, FAAN
Professor Emerita

Johns Hopkins University School of Nursing
Baltimore, Maryland

7711_FM_i-xviii 21/08/19 11:08 AM Page iii

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Library of Congress Cataloging-in-Publication Data

Names: Savage, Christine L., author.
Title: Public/community health and nursing practice : caring for populations

/ Christine L. Savage.
Other titles: Public health science and nursing practice
Description: 2nd edition. | Philadelphia : F.A. Davis Company, [2020] |

Preceded by: Public health science and nursing practice / Christine L.
Savage, Joan E. Kub, Sara L. Groves, 2016. | Includes bibliographical
references and index.

Identifiers: LCCN 2019007149 (print) | LCCN 2019008721 (ebook) | ISBN
9780803699878 (ebook) | ISBN 9780803677111 (pbk.)

Subjects: | MESH: Public Health Nursing | Community Health Nursing | Health
Planning | Population Characteristics

Classification: LCC RT97 (ebook) | LCC RT97 (print) | NLM WY 108 | DDC
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7711_FM_i-xviii 21/08/19 11:08 AM Page iv

To my husband, Joe, for all his love and support.

7711_FM_i-xviii 21/08/19 11:08 AM Page v

Preface

The World Health Organization (WHO) partnered with
the International Council of Nursing and began the
Nursing Now campaign that “… aims to improve health
by raising the profile and status of nursing worldwide”
(WHO, 2018). They recognized that nurses provide care
essential to the optimizing of health for individuals, fam-
ilies and communities. Health occurs from the cellular
to the global level; thus nurses must have knowledge re-
lated to health across this continuum. Nursing education
often begins with understanding health at the cellular
level through courses related to pathophysiology and
physical assessment. Building on this knowledge, this
text covers health, disease, and injury within the context
of the world we live in. No matter what settings nurses
work in, they apply public health science on a daily basis
to prevent disease, reduce mortality and morbidity in
those who are ill, and contribute to the health of the com-
munities we serve. Our goal with this book is to lead you
on the journey of discovering how the public health sci-
ences are an integral part of nursing practice and how
nurses implement effective public health interventions.

About This Book
This book presents public health in a way that captures
the adventure of tackling health from a community- and
population-based perspective. Public health helps us to
answer the question, “Why is this happening?” and to im-
plement interventions that improve the health of popu-
lations. Public health issues are usually messy real-world
problems that do not always have obvious solutions. You
will learn through the examples provided how to gather
the needed information to understand important health
issues, especially those included in Healthy People. You
will have an opportunity to explore population-level,
evidence-based interventions and learn how to evaluate
the effectiveness of those interventions. We aim to pro-
vide you with the knowledge to achieve the competencies
in public health you increasingly need as a professional
nurse across multiple settings. You will be provided with
numerous examples of how public health nurses integrate
nursing and public health, with a focus on promoting the
health of populations.

The application of public health knowledge in the
provision of care and the prevention of disease is not
new to the nursing profession. Florence Nightingale is
often viewed as the first nurse epidemiologist because of
her work in the Crimean War. She applied public health
science to nursing practice in a way that saved lives and
improved outcomes, both in the context of war and back
in England, with the development of professional nurs-
ing in hospital and home settings. As nurses practicing
in the 21st century, we follow in her footsteps. Consider
nurses working in primary care with mothers and chil-
dren or those working in low-income countries facing
epidemics of tuberculosis and HIV/AIDS. How does
knowledge of public health science enhance our ability
to address these complex health issues? Before we can
improve health outcomes, we must understand the nat-
ural history of disease, the social context in which these
health issues arise, and the resources critical to address-
ing all of the barriers to care. Knowledge of public health
and how it applies to nursing practice has taken on in-
creased importance as we move from a fee-for-service
model of care to a health-care system that rewards pre-
vention of disease.

Nurses must know how to apply the basics of the pub-
lic health sciences such as epidemiology, social and be-
havioral sciences, and environmental health. They must
also meet the Quad Council generalist core competencies
such as community assessment, health planning, and
health policy. To help you to do that, we have employed
a problem-based learning approach to the presentation
of the material in this book so that you can apply the
principles of public health to real-life nursing settings.

Throughout the book, case studies demonstrate how
the application of the public health sciences and public
health practice to nursing practice is essential to the pro-
motion of health and the prevention of disease. At times,
the focus will be on solving health-related mysteries and
how that leads to the implementation of interventions to
address the health problems at the population level. At
other times, the focus will be on the application of the
public health sciences to the development and imple-
mentation of evidence-based, population-level interven-
tions aimed at addressing the health issue.

vii

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Although there have been significant improvements
in health during the past 100 years, achieving our
stated health goals, whether it be Healthy People goals
and objectives or global goals, continues to be a chal-
lenge. The ability of each individual, family, and com-
munity to lead a healthy and productive life involves
an interaction among ourselves, our environment, and
the communities in which we live. Understanding
the multiple determinants of health, including social
determinants that significantly influence health dispar-
ities and health inequities, is an essential skill for
nurses. The public health sciences help us understand
the complexity of the interaction of external and inter-
nal forces that shape our health. The premise of this
book is that all nurses require adequate knowledge of
the public health sciences and how to apply it to nurs-
ing practice across all settings and populations. With
this knowledge, we can truly contribute to the building
of a healthy world.

Organization of the Text
The philosophical approach to this text is that all profes-
sional nurses incorporate population-level interventions
no matter what the setting. We include not only chapters
on the traditional public health settings such as the public
health department and school health, but also chapters
on acute and primary care settings. The book uses a con-
structivist learning approach by which the learner con-
structs her or his own knowledge. Thus, the content is
delivered by applying the information within the context
of the real world.

This text uses a problem-based learning approach so
that the student can apply the content to nursing prac-
tice. It is organized into three units. Unit I, Basis for
Public Health Nursing Knowledge and Skills, covers the
essential knowledge based in the public health sciences
and core public health nursing competencies needed to
solve health problems and implement evidenced-based
interventions at the population level. This unit provides
the basic public health knowledge needed by all gener-
alist nurses. The content covered in these chapters is
applied across the next two units of the book. Unit II,
Community Health Across Populations: Public Health
Issues, covers health issues that span populations and
settings including communicable and noncommunica-
ble disease, health disparity, behavioral health, and
global health. Unit III, Public Health Planning, covers
the settings in which nurses practice, public health
policy, and disaster management.

Understanding health within the context of commu-
nity includes understanding the role of culture. To help
underscore the importance of culture, it has been inte-
grated across each of the chapters rather than have a
stand-alone chapter dedicated to culture. In each chapter
there is a callout box related to the role of culture specific
to the subject of that chapter.

Global health is the other concept now integrated
across all of the chapters. In earlier public health textbooks,
the term most often used was ‘international health’. As it
became clearer that the health of one nation does not
occur in a vacuum, but rather contributes to the health of
the globe, global health became the accepted term. To truly
adhere to the concept that health is global across all set-
tings, we have included a cellular to global box in every
chapter relevant to the content in that chapter. As nurses
dedicated to optimizing health for all, visualizing health
within a global context will help us join with the WHO in
promoting nursing as a true force in health.

Key Features
t CASE STUDIES
Throughout the book, the student will find case studies
embedded in the chapters that provide essential content
within the context of actual nursing practice. This ap-
proach begins with the issue and walks the reader through
the process of deciding how best to address the problem
presented. In some of the cases presented, the object is to
solve the mystery (Solving the Mystery), such as the case
in Chapter 8 that walks through how to solve the mystery
of why people are presenting at the emergency depart-
ment with severe gastrointestinal symptoms. Other cases
(Applying Public Health Science) describe how nurses
apply the public health sciences, such as epidemiology, to
help develop and implement evidence-based interven-
tions at the population level. There is a standard case
study at the end of selected chapters. For instructors, there
is online access on the DavisPlus website for the book to
a problem-based learning exercise that can be used to fur-
ther apply the content presented in the chapter.

n HEALTHY PEOPLE
Healthy People is referenced throughout, including
Healthy People 2020 and information on Healthy People
2030 available prior to publication. Boxes are included
that present the Healthy People 2020 objectives and the
midcourse reviews on progress towards meeting those
objectives.

viii Preface

7711_FM_i-xviii 21/08/19 11:08 AM Page viii

n EVIDENCE-BASED PRACTICE
BOXES

Evidence-Based Practice (EBP) boxes illustrate how re-
search and its resulting evidence can support and inform
public health nursing practice. Cutting-edge EBP is a
strong underpinning of the book as a whole.

LEARNING OUTCOMES AND KEY TERMS

Each chapter begins with Learning Outcomes and a list
of Key Terms that appear in boldface and color at first
mention in a chapter.

Teaching/Learning Package
Instructor Resources
Instructor Resources on DavisPlus include the following:

• NCLEX-Style Test Bank
• PowerPoint Presentations
• Instructor’s Guide with PBL exercises

• Problem-Based Learning PowerPoint Presentation
• Case Study Instructor’s Guides for end-of-chapter

case studies
• QSEN Crosswalk
• Quad Council Competencies
• Simulation Experiences

Student Resources
Student Resources on DavisPlus include the following:

• Student Quiz Bank
• Student Guide to Problem-Based Learning
• List of Web Resources
• QSEN Crosswalk
• Quad Council Competencies

We hope you will enjoy this book and, most of all,
we hope as nurses you will always care for the health
of populations no matter the setting, thus increasing
the contribution of nursing to the goal of optimal
health for all.

Preface ix

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Contributors

Laurie Abbott, PhD, RN, PHNA-BC
Assistant Professor

Florida State University College of Nursing
Tallahassee, Florida

Chapter 13

Kathleen Ballman, DNP, APRN, ACNP-BC, CEN
Associate Professor of Clinical Nursing, Coordinator,
Coordinator of Adult-Gerontology Acute Care
Programs

University of Cincinnati, College of Nursing
Cincinnati, Ohio

Chapter 14

Derryl E. Block, PhD, MPH, MSN, RN
Dean, College of Health and Human Sciences

Northern Illinois University
DeKalb, Illinois

Chapter 21

Susan Bulecza, DNP, RN, PHCNS-BC
State Public Health Nursing Director

Florida Department of Health
Tallahassee, Florida

Chapter 13

Deborah Busch, DNP, RN, CPNP-PC, IBCLC
Assistant Professor

Johns Hopkins School of Nursing
Baltimore, Maryland

Chapter 17

Amanda Choflet, DNP, RN, OCN
Director of Nursing, Johns Hopkins Medicine
Department of Radiation Oncology & Molecular
Radiation Sciences

Baltimore, Maryland
Chapter 11

Christine Colella, DNP, APRN-CNP, FAANP
Professor, Executive Director of Graduate Programs

University of Cincinnati, College of Nursing
Cincinnati, Ohio

Chapter 15

Joanne Flagg, DNP, CRNP, IBCLC, FAAN
Assistant Professor, Director MSN Programs

Johns Hopkins School of Nursing
Baltimore, Maryland

Chapter 17

Gordon Gillespie, PhD, DNP, RN, PHCNS-BC, CEN,
CPEN, FAEN, FAAN
Professor, Associate Dean for Research, Deputy
Director Occupational Health Nursing Program

University of Cincinnati
Cincinnati, Ohio

Chapters 5, 20, & 22

Bryan R. Hansen, PhD, RN, APRN-CNS, ACNS-BC
Assistant Professor

Johns Hopkins School of Nursing
Baltimore, Maryland

Chapter 10

Barbara B. Little, DNP, MPH, RN, PHNA-BC, CNE
Senior Teaching Faculty

Florida State University
Tallahassee, Florida

Chapter 13

Minhui Liu, RN, PhD
Post-doctoral

Johns Hopkins University School of Nursing
Baltimore, Maryland

Chapter 19

Donna Mazyck, MS, RN, NCSN, CAE
Executive Director

National Association of School Nurse
Silver Spring, Maryland

Chapter 18

Paula V. Nersesian, RN, MPH, PhD
Assistant Professor

Johns Hopkins University School of Nursing
Baltimore, Maryland

Chapter 16

7711_FM_i-xviii 21/08/19 11:08 AM Page xi

Michael Sanchez, DNP, ARNP, NP-C, FNP-BC,
AAHIVS
Assistant Professor

Johns Hopkins School of Nursing
Baltimore, Maryland

Chapters 8 & 11

Phyllis Sharps, RN, PhD, FAAN
Professor
Associate Dean for Community Programs
and Initiatives

Johns Hopkins University School of Nursing
Baltimore, Maryland

Chapter 17

Christine Vandenhouten, PhD, RN, APHN-BC
Associate Professor (Nursing & MSHWM Programs
Chair of Nursing and Health Studies, Director
of BSN-LINC

University of Wisconsin, Green Bay Professional
Program in Nursing
Green Bay, Wisconsin

Chapter 21

Erin Rachel Whitehouse, RN, MPH, PhD
Epidemic Intelligence Service Officer at Centers
for Disease Control and Prevention

Atlanta, Georgia
Chapter 3

Erin M. Wright, DNP, CNM, APHN-BC
Assistant Professor

Johns Hopkins School of Nursing
Baltimore, Maryland

Chapter 17

Contributors to Previous Edition

Sheila Fitzgerald, PhD

Sara Groves, RN, MPH, MSN, PhD

Joan Kub, PhD, MA, PHCNS-BC, FAAN

William A. Mase, Dr.PH, MPH, MA

Mary R. Nicholson, RN, BSN, MSN CIC

xii Contributors

7711_FM_i-xviii 21/08/19 11:08 AM Page xii

Reviewers

Kathleen Keough Adee, MSN, DNP, RN
Associate Professor

Salem State University
Salem, Massachusetts

Lynn P. Blanchette, RN, PhD, PHNA-BC
Associate Dean, Assistant Professor

Rhode Island College School of Nursing
Providence, Rhode Island

Dia Campbell-Detrixhe, PhD, RN, FNGNA, CNE,
FCN
Associate Professor of Nursing

Oklahoma City University Kramer School of Nursing
Oklahoma City, Oklahoma

Kathie DeMuth, MSN, RN
Assistant Professor

Bellin College
Green Bay, Wisconsin

Bonnie Jerome-D’Emilia, RN, MPH, PhD
Associate Professor

Rutgers University School of Nursing-Camden
Camden, New Jersey

Vicky P. Kent, PhD, RN, CNE
Clinical Associate Professor

Towson University
Towson, Maryland

Kimberly Lacey, DNSc, RN, MSN, CNE
Assistant Professor

Southern Connecticut State University
New Haven, Connecticut

Charlene Niemi, PhD, RN, PHN, CNE
Assistant Professor

California State University Channel Islands
Camarillo, California

Phoebe Ann Pollitt, PhD, RN, MA
Associate Professor of Nursing

Appalachian State University
Boone, North Carolina

Lisa Quinn, PhD, CRNP, MSN
Associate Professor of Nursing

Gannon University
Erie, Pennsylvania

Delbert Martin Raymond III, BSN, MS, PhD
Professor

Eastern Michigan University
Ypsilanti, Michigan

Meredith Scannell, PhD, MSN, MPH, CNM,
SANE, CEN
Nursing Faculty

Institute of Health Professions
Charlestown, Massachusetts

Elizabeth Stallings, RN, BSN, MA, DmH
Assistant Professor

Felician University
Lodi, New Jersey

xiii

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Acknowledgments

This book exists because of the wonderful students I have had over the years and their
dedication to improving the health of individuals, families, and communities. Their
thirst for knowledge fed my own. I am grateful to my colleagues who I have had the
privilege to work with over my nursing career, with a very special thanks to those who
contributed to the writing of this book. I would also like to thank Jeannine Carrado,
Elizabeth Hart, and Terri Allen at F. A. Davis for their support and guidance throughout
the writing of this book. Improving the health of communities thrives on respectful and
thoughtful collaboration between many different people, and so does the writing of a
text book.

7711_FM_i-xviii 21/08/19 11:08 AM Page xv

Table of Contents

Unit I n Basis for Public Health Nursing Knowledge and Skills 1

Chapter 1 Public Health and Nursing Practice 1
Chapter 2 Optimizing Population Health 23
Chapter 3 Epidemiology and Nursing Practice 55
Chapter 4 Introduction to Community Assessment 77
Chapter 5 Health Program Planning 107
Chapter 6 Environmental Health 128

Unit II n Community Health Across Populations: Public Health Issues 157

Chapter 7 Health Disparities and Vulnerable Populations 157
Chapter 8 Communicable Diseases 191
Chapter 9 Noncommunicable Diseases 218
Chapter 10 Mental Health 239
Chapter 11 Substance Use and the Health of Communities 256
Chapter 12 Injury and Violence 283

Unit III n Public Health Planning 313

Chapter 13 Health Planning for Local Public Health Departments 313
Chapter 14 Health Planning for Acute Care Settings 343
Chapter 15 Health Planning for Primary Care Settings 372
Chapter 16 Health Planning with Rural and Urban Communities 398
Chapter 17 Health Planning for Maternal-Infant and Child Health Settings 420
Chapter 18 Health Planning for School Settings 447
Chapter 19 Health Planning for Older Adults 479
Chapter 20 Health Planning for Occupational and Environmental Health 509
Chapter 21 Health Planning, Public Health Policy, and Finance 537
Chapter 22 Health Planning for Emergency Preparedness and Disaster Management 569

Index 607

xvii

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Basis for Public Health Nursing
Knowledge and Skills

Chapter 1

Public Health and Nursing Practice
Christine Savage, Joan Kub, and Sara Groves

LEARNING OUTCOMES

After reading the chapter, the student will be able to:

KEY TERMS

1. Identify how public health plays a central role in the
practice of nursing across settings and specialties.

2. Describe public health in terms of current frameworks,
community partnerships, and the concept of population
health.

3. Investigate determinants of health within the context of
culture.

4. Explore the connection between environment, resource
availability, and health.

5. Identify the key roles and responsibilities of public health
nurses (PHNs).

6. Identify the formal organization of public health services
from a global to local level.

Aggregate
Assessment
Assurance
Community
Core functions
Cultural competency
Cultural humility
Cultural lenses
Culture

Determinants of
health

Diversity
Ethnicity
Global health
Globalization
Health
High-income countries

(HICs)

Life expectancy
Low-income countries

(LICs)
Lower middle-income

countries (LMICs)
Policy development
Population health
Population-focused

care

Public health
Public health nursing
Public health science
Race
Upper middle-income

countries (UMICs)

n Introduction
Every day the media presents us with riveting stories: “The
flu season—the worst in a decade,” “Flint’s water supply
contaminated with high levels of lead,” “School shooting
leaves 17 dead,” “Hurricane Maria leaves 80% of Puerto
Rico without power and water,” “Zika virus results in con-
genital brain damage,” “The homicide rate in Chicago rises,”
“More than 80 dead from the Camp Fire in California.” All
of these stories reflect the connections among the health of
individuals and families, the communities they live in, the

quality of the public health infrastructure, and population-
level events such as disasters (natural and manmade), com-
municable diseases (CDs), and violence. As nurses, we
provide care directly to individuals and families within
the context of the communities we serve. That context
encompasses diverse and unifying cultures, demographics,
geography, infrastructure, resources, and the vulnerability
of certain members of the community. That is why under-
standing health from a cellular to global level requires
a sound grounding in public health science, a central
component of nursing science and practice.

U N I T I

7711_Ch01_001-022 23/08/19 10:19 AM Page 1

As nurses, we apply public health science daily. Ob-
vious examples include infection control nurses, school
nurses, and nurses in the public health department.
Nurses working in an acute care setting also apply public
health science when using protective equipment and
caring for a patient in isolation to prevent transmission
of a CD. Public health science applies to every setting
where nurses work; understanding public health and the
science behind it is a core competency of professional

nursing. It is expected that upon graduation an entry-
level nurse will be able to integrate knowledge from pub-
lic health into their nursing practice. Nurses must apply
the nursing process and incorporate knowledge of the
ecological and social determinants of health as they care
for individuals and families, and by extension commu-
nities and populations. Finally, they are expected to be
able to evaluate health within a global context and
demonstrate cultural humility in the care of individuals,
families, communities, and populations.1 According to
the American Nurses Association’s (ANA) Scope and
Standards, the importance of public health is clear.2
Other competencies grounded in public health include
infection control (Chapter 8), emergency preparedness
and disaster management (Chapter 22), environmental
health (Chapter 6), and a basic understanding of epi-
demiology (Chapter 3).

Public Health Science and Practice
What exactly is public health science? Public health sci-
ence is the scientific foundation of public health practice
and brings together other sciences including environ-
mental science, epidemiology, biostatistics, biomedical
sciences, and the social and behavioral sciences.3,4

Thus, public health science, as a combination of sev-
eral other sciences, allows us to tackle health problems
using a wide range of knowledge. We apply the results of
public health science to deal with health problems on a
regular basis. For example, the evidence that underlies
the reliability and validity of screening and diagnostic
test results comes from the analysis of population-level
data using the science of epidemiology. Public health sci-
ence also provides the tools needed to try and solve a
problem in the community or in a geographical area.

When confronted with a health problem, health care
providers begin with the question “What can we do
about it?” This requires an examination of the underlying
risks and protective factors related to the health problem,
both individual and population based. Based on this type
of examination, lead experts in nursing used a population
health framework to develop a conceptual model of nurs-
ing that reflects the shift from a concentration on indi-
vidual health alone to an understanding that health
occurs within the context of a population and factors that
support or undermine the health of the population as a
whole.5 Understanding the factors that contribute to
health, both negative and positive, from both a popula-
tion and an individual/family perspective allows us to de-
velop nursing interventions that incorporate the full
continuum of health from individuals to populations,

2 U N I T I n Basis for Public Health Nursing Knowledge and Skills

n CELLULAR TO GLOBAL
Health Across the Continuum

The health of individuals occurs across a continuum
from the cellular level to the global level. When we
care for individuals and their families, understanding
the context of their health is vital to the promotion of
optimum health. For example, a person with type 2 dia-
betes who is seeking care may or may not have access
to the needed resources depending on what exists in
their community as well as their own financial status.
Providing care to that person requires use of pre-
scribed medication, encouragement to exercise, and
encouragement to maintain a healthy diet. As you
learned in pathophysiology, type 2 diabetes occurs at
the cellular-level, but external factors may increase the
risk for being diagnosed with the disease. In addition,
the community in which a person lives, both locally
and at the state level, has an impact on their ability to
pay for medications, to have access to safe areas for
exercise, and to obtain affordable fresh food.

Likewise, individual health at the cellular level de-
pends on the health of the Earth from a global level.
Optimal health requires access to basic resources
such as potable water, a secure food supply, sanitation,
and adequate shelter. Events at the global level such
as climate change can result in the inability to obtain
these needed resources. For example, following the
2018 Camp Fire in California, which was associated
with climate change, many people lost their homes.
Outbreaks of communicable diseases (see Chapter 8)
in one part of the world can spread and affect many
other parts of the world, such as the Zika virus
outbreak in the summer of 2016. Natural disasters
often have far-reaching effects such as the tsunami
of 2004 that resulted in deaths and injury across
multiple countries including Indonesia, India, Malaysia,
Myanmar, Thailand, Sri Lanka, and the Maldives. Thus,
all disease and injury occur within the context of the
health of the community and the globe.

7711_Ch01_001-022 23/08/19 10:19 AM Page 2

and, it is hoped, to contribute with each intervention to
the goal of the World Health Organization (WHO), the
public health arm of the United Nations (UN): “… to
build a better, healthier future for people all over the
world.”6

According to Issel,7 individuals do not achieve health
through uninformed, individualistic actions. Instead, in-
dividual health occurs within the surrounding context of
the population and the environment. Therefore, all
nurses need skills and knowledge related to their pa-
tients’ informed actions within the context of the health
of their community. During the last century and into the
21st century, public health science has been the backbone
of the nursing interventions we provide to individuals,
families, and communities. Standard care, such as flu
vaccinations, lead poisoning screening, and prevention
programs, comes from work done using the principles
of public health science. As nurses, we must be suffi-
ciently competent to understand the basics of this science
and apply it daily in our care. After all, it is our heritage.
The modern founder of our profession, Florence
Nightingale, was an early pioneer in epidemiology and
public health science.

Although public health has contributed significantly
to the health of the nation over the past century, it is
often difficult to define. In 1920, a respected public health
figure, C.E.A. Winslow, defined public health as:

… the science and art of preventing disease, prolonging life
and promoting health and efficiency through organized
community effort for the sanitation of the environment,
the control of communicable infections, the education of
the individual in personal hygiene, the organization of
medical and nursing services for the early diagnosis and
preventive treatment of disease, and for the development
of the social machinery to insure everyone a standard of
living adequate for the maintenance of health, so organiz-
ing these benefits as to enable every citizen to realize his
birth right of health and longevity.3

Winslow’s definition reflects what public health is, the
scientific basis of public health, and what it does, and it
remains relevant to this day.4

In 1988, the Institute of Medicine (IOM), now known
as the Health and Medicine Division (HMD) of the
National Academies of Sciences, Engineering, and Med-
icine, in its report The Future of Public Health, added
clarity to the term by defining public health as what so-
ciety does collectively to assure the conditions for people
to be healthy.8 It identified three core functions that en-
compass the purpose of public health: (1) assessment,
(2) policy development, and (3) assurance. Assessment

focuses on the systematic collection, analysis, and mon-
itoring of health problems and needs. Policy develop-
ment refers to using scientific knowledge to develop
comprehensive public health policies. Assurance relates
to assuring constituents that public health agencies pro-
vide services necessary to achieve agreed-upon goals.

In 1994, the Public Health Functions Steering Com-
mittee, a group of public and private partners, added fur-
ther clarification to the definition by establishing a list of
essential services (Chapter 13). The committee developed
the list of essential services through a consensus process
with federal agencies and major national public health
agencies (see Box 1-1). 9

Although the government is likely to play a leadership
role in ensuring that essential services are provided, pub-
lic, private, and voluntary organizations are also needed
to provide a healthy environment and are a part of
the public health system. In a 2012 report by the IOM,
experts concluded that “… funding for governmental

C H A P T E R 1 n Public Health and Nursing Practice 3

The 10 essential public health services provide the
framework for the National Public Health Performance
Standards Program (NPHPSP). Because the strength
of a public health system rests on its capacity to effec-
tively deliver the 10 Essential Public Health Services,
the NPHPSP instruments for health systems assess how
well they perform the following:

1. Monitor health status to identify community health
problems.

2. Diagnose and investigate health problems and health
hazards in the community.

3. Inform, educate, and empower people about health
issues.

4. Mobilize community partnerships to identify and
solve health problems.

5. Develop policies and plans that support individual
and community health efforts.

6. Enforce laws and regulations that protect health and
ensure safety.

7. Link people to needed personal health services and
assure the provision of health care when otherwise
unavailable.

8. Assure a competent public health and personal
health-care workforce.

9. Evaluate effectiveness, accessibility, and quality of
personal and population-based health services.

10. Research for new insights and innovative solutions to
health problems.

BOX 1–1 n Ten Essential Public Health Services

Source: (9)

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public health is inadequate, unstable, and unsustain-
able.”10 Thus the promotion of population level health
requires a comprehensive public health infrastructure.
According to Healthy People 2020 (HP 2020) the three
essential infrastructure components include a capable
and qualified workforce, up-to-date data and informa-
tion systems, and public health agencies capable of
assessing and responding to public health needs (see
Box 1-2). 11

Public Health Frameworks: Challenges
and Trends
Public health in the 21st century is facing new challenges
and trends that are likely to demand different frameworks
for its practice. Over the past 2 decades, numerous events
both here in the U.S, and globally have brought this fact
to the forefront including the attacks of September 11,
2001; numerous hurricanes; mass shootings; emerging
CDs such as Ebola and the Zika virus; and massive
migrations of populations due to war. These events have
brought recognition to alarming public health concerns
related to both manmade and natural disasters. These
events result in disease, death, displacement of commu-
nities, and serious damage to essential public health
infrastructures.

To better understand the impact of both natural and
manmade disasters, it is helpful to revisit Hurricane

Katrina, which savaged the Gulf Coast of the United
States in the summer of 2005. A horrified TV audience
watched news stories detailing the collapse of the emer-
gency systems in New Orleans. This collapse left people
to suffer and die, not only from the destruction of the
hurricane, but also from a lack of water, food, sanitation,
and medical attention. The aftermath of Katrina and
the attacks of September 11, 2001, highlighted the need
to strengthen the public health infrastructure, with an
increasing emphasis on disaster preparedness and emer-
gency response. Unfortunately, responses to natural
disasters continue to challenge the United States as
exemplified by Hurricane Maria and the devastation
to Puerto Rico, and Hurricane Harvey in Houston,
Texas, both in 2017. Full restoration of power and access
to food and potable water remained a challenge in
Puerto Rico long after the hurricane was over. Individ-
ual health requires essential services at the population
level including adequate sanitation, potable water, and
power. Understanding the interaction among cultural
considerations, the economy of a country, and public
health infrastructure is essential to promotion of health
and adequate response to disasters and subsequent
threats to health.

Any disaster can quickly escalate from direct injuries
and deaths to indirect illness and risk of mortality be-
cause of the destruction of the public health infrastruc-
ture and the lack of public health resources especially for
vulnerable populations. CD outbreaks challenge com-
munities to respond in a way that provides care for those
with the disease as well as protection for those who are
in danger of getting the disease. Care for those with long
term noncommunicable disease (NCD) requires access
to care and to environments that support healthy living.
Across the continuum from cellular to global, public
health systems are a key component in the promotion of
health and adequate care for those with disease. How-
ever, much of the emerging threats to population health
are tied to increasing globalization.

Globalization is “the process of increasing economic,
political, and social independence and integration as cap-
ital, goods, persons, concepts, images, ideas, and values
cross state boundaries.”12 It is associated with increased
travel, trade, economic growth, and diffusion of technol-
ogy, resulting sometimes in greater disparities between
rich and poor, environmental degradation, and food
security issues. It has also resulted in greater distribution
of products such as tobacco or alcohol. With globaliza-
tion, there is also an emergence and re-emergence of
CDs, including Zika, human immunodeficiency virus
(HIV), acquired immunodeficiency syndrome (AIDS),

4 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Public health infrastructure is fundamental to the provi-
sion and execution of public health services at all levels.
A strong infrastructure provides the capacity to prepare
for and respond to both acute (emergency) and chronic
(ongoing) threats to the nation’s health. Infrastructure is
the foundation for planning, delivering, and evaluating
public health. Public health infrastructure includes three
key components that enable a public health organization
at the federal, tribal, state, or local level to deliver public
health services. These components are:

A capable and qualified workforce
Up-to-date data and information systems
Public health agencies capable of assessing and respond-

ing to public health needs

These components are necessary to fulfill the previ-
ously discussed 10 Essential Public Health Services.

BOX 1–2 n Healthy People 2020: Public Health
Infrastructure

Source: (11)

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severe acute respiratory syndrome (SARS), hepatitis,
malaria, diphtheria, cholera, measles, and Ebola virus.
Planning for CD outbreaks, including pandemics, may
require new ethical frameworks to guide decision making
regarding appropriate action with limited resources.13

Despite climate change, wars, terrorism, and other
challenges, population health at the global level is
improving. Infrastructure, educational opportunities,
and a growing global economy are some of the factors
that contribute to this improvement. According to global
data made available through the “Our World in Data”
Web site, run by Oxford University economist Max
Weber, fewer people are experiencing poverty, life ex-
pectancy is up, and more people have access to electricity
and drinking water.14 Some interesting statistics using
these data demonstrate the positive news related to global
improvements in indicators of a healthy life. In the 1950s,
more than 60% of the world’s population was illiterate;
today, only 14.7% are illiterate.15 In 1980, 44% of the
world’s population lived in extreme poverty, which is
living with less than $1.90 USD per day. The 2015 pro-
jections bring that down to just 9.6%.16 Another common
indicator of the health of a community is access to
potable water. According to Richie and Roser, access to
potable water also rose from 76% in 1990 to 91% in
2015.17 A key measure of the health of populations is life
expectancy, which is the average number of years a per-
son born in a given country would live if mortality rates
at each age were to remain constant in the future. The
WHO reported a 5-year rise in the global average life
expectancy to 71.4 years (73.8 years for females and
69.1 years for males) between 2000 and 2015. According
to the WHO this was the fastest increase since the 1960s.18

Another challenge facing public health is the advance-
ment of scientific and medical technologies that pose
ethical questions.13 The increasing use of genomics, for
example, raises questions of how to protect against
discrimination. Another challenge is aging and increas-
ing diversity within populations. With aging, comes an
increase in persons living with NCDs and CDs that re-
quire long-term care. Examples of disease that require
long-term care include diabetes and HIV. In addition,
some long-term diseases and health concerns relate to
lifestyle choices such as smoking and poor nutrition. In
1926, Winslow discussed the need for new methods to
address heart disease, respiratory diseases, and cancer.19

We still need frameworks to help improve NCD and
CD outcomes and, from a global perspective, to address
how international collective action becomes essential
to combating preventable risk factors associated with
development of disease such as the tobacco epidemic.20,21

Emerging Public Health Frameworks
In 2003, the IOM (now HMD) produced The Future of
the Public’s Health in the Twenty-First Century as an
update of the 1988 IOM report.22 The new report pre-
sented the ecological model as the basis not only for un-
derstanding health in populations but also for assuring
conditions in which populations can be healthy. The
committee built on an ecological model created by
Dahlgren and Whitehead,23 and based its model on the
assumption that health is influenced at several levels:
individuals, families, communities, organizations, and
social systems (Fig. 1-1). The model is also based on the
assumptions that:

• There are multiple determinants of health.
• A population and environmental approach is critical.
• Linkages and relationships among the levels are

important.
• Multiple strategies by multiple sectors are needed to

achieve desired outcomes.24

Conventional public health models such as the epi-
demiological model of the agent, host, and environment
(Chapter 3) are grounded in the ecological model. How-
ever, the ecological model reflects a deeper understand-
ing of the role not only of the physical environment but
also of the conditions in the social environment creating
poor health, referred to as an “upstream” approach.10,21,24

C H A P T E R 1 n Public Health and Nursing Practice 5

Individual

Relationship

Community

Societal

Figure 1-1 The Social-Ecological Model. (Adapted by
CTLT by Dahlgren and Whitehead, 1991; Worthman, 1999)

7711_Ch01_001-022 23/08/19 10:19 AM Page 5

Upstream refers to determinants of health that are some-
what removed from the more “downstream” biological
and behavioral bases for disease. These upstream deter-
minants include social relations, neighborhoods and
communities, institutions, and social and economic poli-
cies (see Chapter 2).24

Community Partnerships
One of the recommendations of the 2003 IOM report
was to increase multisectored engagement in partner-
ships with the community. In 2016, the National Acad-
emy of Sciences published a detailed report Communities
in Action: Pathways to Health Equity that addresses the
importance of community-level efforts aimed at improv-
ing health.25 In the past, the community’s role in health
programs had often been that of a passive recipient, ben-
eficiary, or research subject, with the active work carried
out by public health experts. There is now a growing
commitment to collaboration in promoting the health of
communities and populations. Evidence shows that such
efforts increase effectiveness and productivity, empower
the participants, strengthen social engagement, and
ensure accountability.25, 26

Population Health and Population-
Focused Care
According to Caldwell,27 a population is a mass of peo-
ple that make up a definable unit to which measurements
pertain. The WHO defined health as “the state of com-
plete physical, mental, and social well-being, and not
merely the absence of disease or infirmity.”28 However,
population health is more than just a combination of
these two terms, because it requires an understanding of
all the factors listed in the ecological model that con-
tribute to the health of a population.

Much of the curricular content in nursing programs
pertains to acquiring the knowledge and skill the nurse
needs to deliver nursing care to individuals. When nurses
deliver care to an individual, the outcomes of interest are
at the individual level. The goal is to implement nursing
interventions that contribute to the individual’s ability
to achieve a maximum health state. However, achieving
a complete state of health and well-being usually extends
beyond the interventions that nurses and other health-
care professionals provide on an individual level during
a single episode of care. A state of health and well-being
requires meeting an individual’s mental, social, and eco-
nomic needs as well as their immediate health needs. To
take in this wider scope of influences on the person’s
health, the nurse must consider the individual as a part

of a greater whole, which includes the individual’s inter-
actions with other individuals and groups. This requires
placing the individual within his or her socioecological
context.

With individuals, nurses always start their care with
an assessment. This requires knowledge of the biomed-
ical, social, and psychological sciences. When providing
population-focused care, nurses need a basic knowledge
of the different scientific disciplines that make up public
health science. When nurses assess a community and/or
a population, they use their knowledge of epidemiology
and biostatistics to help identify priority health issues
at the population level. Some terms relevant to a discus-
sion of public health—aggregate, population, and
community—are sometimes used interchangeably, but
there are differences among them (see Box 1-3 for

6 U N I T I n Basis for Public Health Nursing Knowledge and Skills

For this book, these terms are defined within the context
of public health building on standard dictionary defini-
tions and definitions used in the literature.

Aggregate: In public health, this term represents individual
units brought together into a whole or a sum of those
individuals. In public health science, the term aggregate
often refers to the unit of analysis, that is, at what level
the health-care provider analyzes and reports data.

Population: Refers to a larger group whose members
may or may not interact with one another but who
share at least one characteristic such as age, gender,
ethnicity, residence, or a shared health issue such as
HIV/AIDS or breast cancer. The common denomina-
tor or shared characteristic may or may not be a
shared geography or other link recognized by the
individuals within that population. For example, peo-
ple with type 2 diabetes admitted to a hospital form a
population but do not share a specific culture or place
of residence and may not recognize themselves as
part of this population. In many situations, the terms
aggregate and population are used interchangeably.

Community: Refers to a group of individuals living within
the same geographical area, such as a town or a
neighborhood, or a group of individuals who share
some other common denominator, such as ethnicity
or religious orientation. In contrast to aggregates and
population, individuals within the community recog-
nize their membership in the community based on
social interaction and establishment of ties to other
members in the community, and often join collective
decision making.

BOX 1–3 n Definitions for Aggregate, Population,
and Community

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detailed definitions).29,30 All of these interventions,
grounded in public health science, when framed beyond
the individual ultimately improve the health of aggre-
gates, populations, and communities.

Determinants of Health and Cultural
Context
Determinants of health include a range of personal, so-
cial, economic, and environmental factors.31 Before de-
veloping an intervention to improve health outcomes in
a population, a nurse must first identify these determi-
nants of health. MacDonald explained that earlier models
related to population health were built on the assump-
tion that patterns of disease and health occur through a
complex interrelationship between risk and protective
factors.32 This resulted in a focus on biological and be-
havioral risk factors that require changes at the individ-
ual level. Multiple examples exist of health promotion
activities that focus on changing individual behavior to
reduce risk, such as smoking cessation, healthy eating,
and increased exercise. Some success has occurred with
this approach. However, there have also been successful
efforts at the macrosocioecological level. These interven-
tions focus on population behavioral change that then
trickles down to the individual. Population behavioral
change addresses risk factors that affect the whole popu-
lation, such as provision of potable water to prevent
cholera. The underlying assumption is that the popula-
tion level of risk affects health outcomes independent of
individual/family-level risk factors.

Take, for example, lung cancer. One of the well-
documented determinants of this disease is the use of to-
bacco. Efforts to reduce this risk factor focus on changing
individual behavior. Theories have emerged that help to
explain behavior, such as the Transtheoretical Model of
Change.33 This model theory helps a health-care provider
determine in what stage of change a person is and helps
the provider put together a plan of care that fits the indi-
vidual’s readiness to quit smoking. Many of the inroads
made in tobacco use cessation in this country began with
a broader population health approach, including media
campaigns related to smoking cessation and governmen-
tal nonsmoking policies that resulted in a cultural shift
within our society. Once researchers made the case for
the hazards of secondary smoke, tolerance of smoking
within the community dramatically decreased. The pop-
ulation’s exposure to tobacco smoke has decreased be-
cause the cultural view of tobacco use has changed. An
increasingly negative perception of smoking has also in-
creased the willingness of communities to implement

policies that reduce the community’s risk. A cultural shift
reducing tolerance of smoking in public places and
increasing the ostracism experienced by smokers has
reduced the prevalence of smoking. Healthy behaviors
remain a key issue in the health of populations. Taking a
population approach allows for elevation of behavioral
changes from the individual/family level to the popula-
tion level.

Serious disparities in health exist at the global level,
which can be seen by comparing life expectancies between
high-income countries and low-income countries. For ex-
ample, the estimated life expectancy in 2017 in Monaco
was 89.4 years, whereas in Chad it was 50.6 years. The U.S.
was ranked 43 with a life expectancy of 80.0 years.34 To
address these disparities, public health as a science has
shifted from focusing on dramatic cases to focusing on
existing disparities and addressing the underlying social
determinants of health, such as poverty.35

Cultural Context, Diversity, and Health
Understanding the determinants of health begins with
the cultural context and the diversity of populations
across the globe. Diversity reflects the fact that groups
and individuals are not all the same but differ in relation
to culture, ethnicity, and race. Culture as defined in the
Merriam Webster Dictionary as “… the customary be-
liefs, social forms, and material traits of a racial, religious,
or social group; also: the characteristic features of every-
day existence (such as diversions or a way of life) shared
by people in a place or time.”36

C H A P T E R 1 n Public Health and Nursing Practice 7

n CULTURAL CONTEXT
AND NURSING CARE

Knowledge and understanding of the cultural context
of persons constitutes a key aspect in the development
of effective nursing interventions. This context includes
many aspects of life that affect the health of individuals,
such as food preferences, gender roles, birthing prac-
tices, language, and spiritual beliefs to name a few.
Spector equated culture to a set of luggage that a
person carries that contains such things as beliefs,
habits, norms, customs, and rituals that are handed
down from one generation to the next through both
verbal and nonverbal communication. Spector goes on
to state, “All facets of human behavior can be inter-
preted through the lens of culture.”37 Thus, nurses
must have an appreciation for cultures represented
within the population they are caring for while ac-
knowledging and understanding their own cultural
views of the world, also known as cultural lenses.

7711_Ch01_001-022 23/08/19 10:19 AM Page 7

Ethnicity, Race, and Culture
Having clear definitions of race and ethnicity helps in the
understanding of what is meant by cultural context. Race
and ethnicity are often used interchangeably but are
actually different constructs. Multiple definitions exist
for ethnicity. Commonalities across definitions include
shared geographical origin, language or dialect, religious
faith, folklore, food preferences, and culture. O’Neill38

included physical characteristics as well and suggested
that we use ethnicity in two distinct ways: to classify peo-
ple who may have no specific cultural traditions in com-
mon into a loose group, and to classify groups that have
a shared language and cultural traditions. For example,
to classify an ethnic group under the name Native Amer-
ican results in grouping together people who are actually
diverse in both culture and language. However, if the eth-
nic group is a specific Native American tribe, such as the
Navajo, then the group does share specific cultural tra-
ditions, beliefs, and language that may not be shared with
other Native American tribes such as the Inuit. There-
fore, care is required when using the term ethnicity be-
cause of the variation in its use. Identifying the ethnicity
of a group of people, which only considers broad shared
characteristics, may miss key cultural differences within
the group.

Geographical differences also play a part in diversity
across groups and can result in shared cultural traditions
that extend across ethnic groups within that geograph-
ical region. In the United States, cultural differences
exist among specific regions, such as New England, the
South, and the West Coast. These three regions differ in
dialect, accepted protocol for social interactions, and
food preferences.

Race categorizes groups of people based on superficial
criteria such as skin color, physical characteristics, and
parentage. In the United States, we continue to use racial
categories; these are increasingly less accurate as ethnic
groups become less defined. The U.S. Census Bureau
acknowledges that the use of racial categories is limited,
especially because some people may classify themselves
as belonging to more than one category.39,40 As the field
of genetics grows, so does the evidence that there is no
scientific basis for placing an individual into one racial
group. In a classic article in Newsweek, “What Color Is
Black?” Morganthau challenged the myth of race and
concluded that it is not a legitimate method for classify-
ing groups of people. Scientists found that people with
very dissimilar racial characteristics such as skin color
and facial features were in some cases more closely
related genetically than groups with similar skin color.41

However, race continues to be used to identify groups.

Traditionally, scientists report epidemiological data
using racial categories as a means of identifying disparity
between racial groups, especially in relation to health
outcomes and access to care. The U.S. 2010 Census
shows that the ability to group people using racial cate-
gories is increasingly difficult as these categories expand
to include individuals who identify themselves as biracial
and multiracial.

Understanding diversity in a population enhances the
process of partnering with communities and improves
the likelihood of the potential success of an intervention.
By contrast, if a nurse plans an intervention without tak-
ing into account the cultural and ethnic diversity within
the population, violation of ethnic and cultural values or
beliefs can lead to failure to achieve the goals of the
intervention. If the nurse only views an intervention
through his or her cultural lens, and if that lens differs
from those who will receive the intervention, then a key
piece is missing. Does the population view the interven-
tion as culturally relevant? Is the desired health outcome
valued? For example, if a nurse develops an intervention
aimed at increasing the number of women who breast-
feed their infants, the first step is to evaluate the cultural
view of breastfeeding. If the target population includes
all the women giving birth at a large urban hospital, the
population is probably diverse and may include cultures
with different practices related to breastfeeding. If
the nurse fails to acknowledge this fact and incorporate
possible cultural differences into the assessment and
planning stage (Chapters 4 and 5), the intervention may
not succeed with women who have specific cultural
beliefs surrounding breastfeeding.

Respecting culture and diversity when planning
population level interventions requires the inclusion of
the community members as partners in the process.
Interventions planned for communities rather than with
communities ignore the point made by Murphy that
communities interpret their own health. In addition,
Murphy stated that communities themselves can come
up with ways to improve their health. From a population
health perspective, collaboration and community partic-
ipation are essential when developing interventions.42

Engagement with the community can occur only within
the context of culture and ethnic heritage and the com-
munity’s own perception of what constitutes optimal
health.

Cultural Competency and Cultural Humility
Cultural competency is a core aspect of care for health-
care providers. It is traditionally defined as the attitudes,
knowledge, and skills the health-care provider uses to

8 U N I T I n Basis for Public Health Nursing Knowledge and Skills

7711_Ch01_001-022 23/08/19 10:19 AM Page 8

provide quality care to culturally diverse populations. It
requires an understanding and capacity to provide care
in a diverse environment. This implies an endpoint of
acquired knowledge related to the culture of others.
Cultural humility, conversely, acknowledges that the
understanding of the multitude of diverse cultures in the
world today may be too big a task. Cultural humility is
an understanding that self-awareness about one’s own
culture is an ongoing process, and an acknowledgment
that we must approach others as equals, with respect
for their prevailing beliefs and cultural norms.43 One is
not exclusive of the other. Cultural competence is the
standard to help guide the delivery of health care to in-
dividuals and to populations, whereas cultural humility
is the underlying quality needed to truly implement
interventions to improve health in partnership with
communities and populations.

Developing cultural humility takes self-reflection. This
provides an essential beginning point for nurses to de-
velop the insight and knowledge needed to provide care
to those who differ culturally from themselves. How do
nurses create health-care environments that are safe and
welcoming for clients and patients from all backgrounds?
The first step in this process for individual nurses should
be a cultural self-assessment. Cultural self-assessment
involves a critical reflection of one’s own viewpoints,
experiences, attitudes, values, and beliefs. When one can
honestly identify learned stereotypes and ethnocentric
attitudes, enlightenment can occur. Nurses cannot begin
to effectively consider the cultural context while provid-
ing care without first exploring their own cultures using
basic questions (Box 1-4).

Creating a culturally welcoming health-care environ-
ment requires purposeful action by health-care providers.
This necessitates commitment to principles and practices
on all levels that support inclusion. These principles and
practices should be a part of the systemic workings of
health-care organizations. There should be visible and tan-
gible signs of culturally welcoming health-care environ-
ments. However, more important are nurses who provide
care that is inclusionary and culturally appropriate.

Environment and Resource Availability
The environment is another factor that affects health
(see Chapter 6). Availability of clean air, abundant
and potable water, and adequate food supplies all affect
the health of an environment. For much of humankind’s
existence, the health of a population was concerned
with the short-term survival of that population and cen-
tered on food sources, predators, and pestilence. This
changed dramatically during the industrial revolution

as populations moved from rural communities to urban
areas. As large groups of people congregated in these
urban areas, new issues arose related to sanitation, food
supplies, and water. Communities with fewer resources
and inadequate infrastructure to provide these essential
components of a healthy life are at greater risk for
disease. Poor sanitation and lack of potable water sig-
nificantly increase the possibility of the spread of CDs.
For example, in April of 2015, Uganda experienced a
typhoid epidemic. As you can see in Figure 1-2, there
are serious environmental risks to children and an
increased risk for contaminated water sources.

Epidemiology, the study of the occurrence of disease
in humans, identifies environment as a key factor con-
tributing to morbidity and mortality (see Chapter 3).
Epidemiology emerged in the 19th century in response
to these new challenges brought by the industrial revo-
lution. Though early epidemiologists did not understand
that microscopic pathogens caused disease (the germ
theory), they firmly established the role that environment
plays in the health of humans. Efforts during the last half
of the 19th century and into the 20th century focused
on the introduction of sanitary measures, including
management of sewage and providing clean water and
adequate ventilation.32

John Snow was an epidemiologist who first studied as-
pects of the environment related to sanitation (see Chap-
ter 3). He conducted a classic investigation of a cholera

C H A P T E R 1 n Public Health and Nursing Practice 9

The following questions can be used to guide cultural
self-reflection:

• Where did I grow up? How did this environment influ-
ence my worldview (country, region, rural, urban)?

• What values were emphasized in my family of origin?
• Who were the people most influential to me in

shaping my worldview?
• Who were the people within my circle of friends and

acquaintances during my years of growing up? How did
they differ from me?

• What privileges did I enjoy while growing up?
• What are some of the key experiences that have

shaped my view of the world and the people in it?
• What are my religious beliefs, if any?
• What are the values and morals that I adhere to?
• What does “good health” mean to me? How do I

obtain and maintain good health?
• How do I view those individuals whose values differ

from my own?

BOX 1–4 n Personal Cultural Assessment

7711_Ch01_001-022 23/08/19 10:19 AM Page 9

outbreak in the Soho area of London in 1854.44 Snow
mapped out cholera deaths block by block and found
that they clustered around the Broad Street pump, lead-
ing him to conclude that the pump was the source of the
contamination. He even examined the water under a
microscope and identified “white, flocculent particles”
that he thought were the causative agents. Though other
authorities dismissed his evidence of a microscopic
agent, he convinced others of the link between the
disease and the water pump. He was successful in getting
the water company to change the pump handle.55

Snow’s work brought attention to the importance of safe
water. The measures taken did not require a change in
individual behavior but rather a change in how the water
company delivered water to the populace.

Initial public health efforts focused on the develop-
ment of a public health infrastructure related to sanita-
tion and delivery of safe water supplies. In the late 19th
and early 20th centuries, large metropolitan municipal-
ities initiated the development of underground sewerage
systems and water pipes that are still in service today. The
implementation of similar systems in smaller towns and
rural areas occurred later, with outhouses still in use in
the 1950s. In the United States, long before antibiotics
were available, addressing these sanitation and safe water
issues directly reduced the spread of CDs such as infan-
tile diarrhea and cholera. In undeveloped countries with-
out this public health infrastructure, these two diseases
continue to contribute to the morbidity and mortality of
their populations.

To survive, humans need adequate water and food
supplies, shelter from the elements, and protection from

pestilence and disease. In modern developed societies,
geopolitical groups come together to supply adequate
potable water and sewerage. Agricultural businesses pro-
vide food. In most developed societies, most individuals
and families have the means to purchase adequate shelter
and the health care needed to protect them from both
CDs and NCDs. In some societies, government-based
programs provide the means for obtaining health-care
resources aimed at protection from pestilence and dis-
ease, and in other societies individuals purchase the
health care either directly or indirectly through health
insurance. Governments and individuals need adequate
money to provide these resources; thus, obtaining
adequate resources to promote the health of a population
depends on that population’s economic health. When
the economy is healthy, the majority of the population
generally has access to adequate water, food, and shelter.
However, an economy in jeopardy may result in a
reduced ability to meet these basic needs. In all societies,
nurses must be aware of the environment in which the
patient resides. Does the patient live in a community
with a healthful environment? Is there adequate, safe,
and usable water? Is food available, affordable, and
nutritionally beneficial? Is the economy strong enough
to provide access to health-care resources? Environment
is one of the main determinants of health for individuals,
populations, and the communities they live in.

Public Health as a Component of Nursing
Practice Across Settings and Specialties
Nursing practice requires the application of knowledge
from multiple sciences, including public health. Health
is not just a result of individual factors such as biology,
genetics, and behavior; it is also a product of an indi-
vidual’s social, cultural, and ecological environment.
To meet our obligation to maximize health on all levels,
we must incorporate public health science into our
nursing care.

Public Health Science and Nursing Practice
In 2010, the IOM (now HMD) published a report on the
future of nursing.45 The stated goal was to have 80% of
all registered nurses prepared at the baccalaureate of
science in nursing (BSN) level or higher. The rationale
for this goal was that BSN programs emphasize liberal
arts, advanced sciences, and nursing coursework across
a wide range of settings, along with leadership develop-
ment and exposure to community and public health
competencies. In addition, the authors emphasized that

10 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Figure 1-2 Children in Uganda during typhoid out-
break. (Courtesy of the CDC/Jennifer Murphy)

7711_Ch01_001-022 23/08/19 10:19 AM Page 10

entry-level nurses need to be able to transition smoothly
from their academic preparation to a range of practice
environments, with an increased emphasis on commu-
nity and public health settings.45

Population-Focused Care Across Settings
and Nursing Specialties
Nurses provide population-focused care every day, in
every setting. For a staff nurse working in an urban hos-
pital, the population of interest is the patients who come
to that hospital for care. The population may include var-
ious subpopulations based on shared geographical resi-
dence, age group, primary diagnosis, culture, and ethnic
group. Staff nurses in an acute or community-based set-
ting take care of patients on an individual level, often
serving as the member of the health-care team that de-
livers the interventions and evaluates the effectiveness of
those interventions. Nurses actively participate in re-
viewing how well the team is delivering care to the pa-
tient population as a whole. Over time, the health-care
team begins to group patients based on diagnosis or
other identifying characteristics to provide better care.
This may occur when nurses are engaged in performance
improvement activities, the development of a care map,
or in response to changes in the population.

Across settings and specialties, nurses work to success-
fully answer the “who, what, when, where, why, and how”
of health problems within the context of populations.
Providing individual care alone after disease has occurred
is an essential part of what nurses do. In a sense, all nurses
are Public Health Nurses (PHN) because our mandate is
not only to provide state-of-the-art care to individuals but
also to safeguard the public’s health and actively partici-
pate in optimizing health for all populations.

Public Health Nursing as a Specialty
Public health nursing is the practice of promoting and
protecting the health of populations using knowledge
from nursing, social, and public health sciences. Public
health nursing is a specialty practice within nursing and
public health. It focuses on improving population health
by emphasizing prevention and attending to multiple de-
terminants of health. Often used interchangeably with
community health nursing, this nursing practice includes
advocacy, policy development, and planning, which ad-
dresses issues of social justice. With a multi-level view of
health, public health nursing action occurs through com-
munity applications of theory, evidence, and a commit-
ment to health equity. In addition to what is put forward
in this definition, public health nursing practice is guided

by the ANA Public Health Nursing: Scope and Standards
of Practice and the Quad Council of Public Health Nurs-
ing Organizations’ Core Competencies for Public Health
Nurses.46

Public health nursing is different from other nursing
specialties because of its focus on eight principles
outlined in an unpublished white paper by the Quad
Council in 199747 and cited in the Public Health Nursing:
Scope and Standards of Practice.48 (See Box 1-5.) These
principles define the client of public health nursing as the
population and further delineate processes and strategies
used by PHNs.

Public Health Nursing as a Core Component
of Nursing History
The roots of public health nursing lie in the work of
women who provided comfort, care, and healing to indi-
viduals during the Middle Ages. During that time, nuns,
deaconesses, and women of religious orders provided
comfort and care to the sick in their homes.49 The imme-
diate precursor to public health nursing was district
nursing, which began in England. William Rathbone
employed a nurse to care for his wife during her terminal
illness and after this experience realized that home visiting
to the sick poor could benefit society. This resulted in the

C H A P T E R 1 n Public Health and Nursing Practice 11

1. The client or unit of care is the population.
2. The primary obligation is to achieve the greatest good

for the greatest number of people or population as a
whole.

3. The processes used by PHNs include working with
the client as an equal partner.

4. PRIMARY prevention is the priority in selecting appro-
priate activities.

5. Public health nursing focuses on strategies that create
healthy environmental, social, and economic condi-
tions in which populations may thrive.

6. A PHN is obligated to actively identify and reach out
to all who might benefit from a specific activity or
service.

7. Use of available resources must be optimal to assure
the best overall improvement in the health of the
population.

8. Collaboration with a variety of other professions,
populations, organizations, and other stakeholder
groups is the most effective way to promote and
protect the health of the people.

BOX 1–5 n The Eight Principles of Public Health
Nursing

Source: (1)

7711_Ch01_001-022 23/08/19 10:19 AM Page 11

development of district nursing, under which towns were
divided into districts, and health visitors provided nursing
care and education to the sick poor within those districts.
In 1861, Rathbone wrote Florence Nightingale to request
the development of a training school for both infirmary
and district nursing, which eventually resulted in trained
nurses in 18 districts of Liverpool.53 Public health nursing
owes much of its early development to Florence Nightin-
gale. She was concerned about the care of the sick poor
and the quality of their homes and workhouses. She is also
widely known for her work during the Crimean War,
during which she kept impeccable statistical records on
the living conditions of the soldiers and on the presence
of disease. She is also known for her promotion of health
reform.50,51

Beginnings of Public Health Nursing
in the United States
Public health nursing in the United States evolved from
district nursing in England. In 1877, the New York City
Mission hired Francis Root to make home visits to the
sick. Other sites followed suit, and visiting nurse associ-
ations were set up in Buffalo (1885), Boston (1886), and
Philadelphia (1886). Trained nurses cared for the sick
poor and provided instruction on improving the clean-
liness of their homes. Originally these associations bore
the name District Nursing Services, with the Boston
association referred to as the Boston Instructive District
Nursing Association. Eventually they all changed their
names to Visiting Nurse Associations.52

In 1893, Lillian Wald and Mary Brewster established
a district nursing service called the Henry Street Settle-
ment on the Lower East Side of New York and coined the
term public health nurse.53 In her work, Wald emphasized
the role that social and economic problems played in
illness and developed unique programs to address the
health needs of the immigrant population. During the
early part of the 20th century, poverty was increasingly
seen as a cause of social problems and poor health in com-
munities. Wald believed that environmental and social
conditions were the causes of ill health and poverty.54,55

For Lillian Wald and her colleagues, efforts of social re-
form were focused on civil rights for minorities, voting
rights for women, the prevention of war, child labor laws,
and improving unsafe working conditions.55

Public Health Nursing in the 20th Century
Wald’s accomplishments were the background for the
development of the public health nursing specialty. Pub-
lic health efforts in the early part of the 20th century
made great strides in reducing disease, especially due to

advances related to the provision of potable water, regu-
lations around food and milk supply, removal of garbage,
and disposal of sewage. However, authorities realized
that they needed to implement other programs to work
on improving health education among those most at risk,
especially the poor. PHNs filled this need and provided
care to the sick while educating families on personal
hygiene and healthy practices.55 The visiting nurse move-
ment, with a focus on caring for the sick poor, joined
forces with public health to focus on prevention. Accord-
ing to Buhler-Wilkerson, “By 1910, the majority of
the large urban visiting nurse associations had initiated
preventive programs for school children, infants, moth-
ers, and patients with tuberculosis.”56

Public health nursing continued to grow with the
expansion of the federal government. The Social Security
Act of 1935 provided funding for expanded opportuni-
ties in health protection and promotion, resulting in the
employment of PHNs, increased education for nurses in
public health, the establishment of health services, and
research. World War II increased the need for nurses
both for the war effort and at home. PHNs also played
a role in surveillance and treatment of CDs such as
tuberculosis and Hanson’s disease, also known as lep-
rosy. As seen in the photo in Figure 1-3, taken in 1950,
PHNs worked with other nurses caring for the patients
receiving care for CDs.

The 1960s and 1970s saw the implementation of neigh-
borhood health centers, maternal-child health programs,
and Head Start programs. By the 1980s, however, there
was another shift in funding to more acute services, med-
ical procedures, and long-term care. The use of health
maintenance organizations (HMOs) was encouraged. By

12 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Figure 1-3 Public Health Nurses in the 1950s. (Courtesy
of the CDC/Elizabeth Schexnyder, National Hansen’s Disease
Museum, Curator)

7711_Ch01_001-022 23/08/19 10:19 AM Page 12

the latter part of the 1980s, public health as a focus had
declined and the percentage of PHNs working as govern-
ment employees had dropped.

Public Health Nursing in the 21st Century
In this century, the move toward population health and
the need for more services to communities outside of
traditional hospital settings has the potential to increase
the demand for PHNs. Currently, PHNs work in a wide
variety of settings. Some are based in schools, commu-
nity clinics, local health departments, and visiting nurse
associations. PHNs also work at the national level in the
United States Public Health Service, a branch of the
armed services in the U.S. (Fig. 1-4).

Based on a report completed by the Health Resources
and Services Administration on the registered nurse pop-
ulation in the United States, in 2017, 61% of nurses work
in hospital settings, 18% work in primary care, 5% work
in government, 7% in extended care facilities, and 3% in
education.57 If the predictions of Ezekiel J. Emanuel, vice
provost of the University of Pennsylvania Hospital, are
correct, hospitals will continue to downsize as health care

moves out into the community and individual homes.58

This may require an increase in the number of practicing
PHNs. This will also increase the need for all nurses to
have sufficient knowledge and skills to provide care
across the continuum from individuals to populations
within the context of community.

Public Health Nursing Scope and Standards
of Practice
The Public Health Nursing: Scope and Standards of
Practice outlines the expectations of the professional
role of the PHN and sets the framework for public
health nursing practice in the 21st century.1 As with the
other nursing specialties’ scope and standards, these are
based on the nursing scope and standards established
by the ANA.1,2

Public Health Nursing Standards
Included in the 11 Standards of Professional Performance
for Public Health Nursing (see Box 1-6)1 are six standards
of practice that describe a competent level of care using
the nursing process: (1) Assessment, (2) Population
Diagnosis and Priorities, (3) Outcomes Identification,
(4) Planning, (5) Implementation, and (6) Evaluation.
Specific standards related to implementation include the
coordination of care, health teaching, and health promo-
tion, consultation, and regulatory activities. These stan-
dards of practice are differentiated for the PHN and the
advanced PHN.

Public Health Nursing Competencies
The Scope and Standards of Practice delineates compe-
tencies for practice based on the ANA nursing frame-
work assuring that public health nursing fits as a
recognized nursing specialty. In addition, the Council of
Linkages Between Academia and Public Health Practice,
a coalition of organizations concerned with the public
health workforce, produced a document in 2001 that has
been used as a framework for the development of addi-
tional public health nursing competencies. The 2018 re-
vised version of the PHN Core Competencies includes
eight domains (Box 1-7) and incorporates three tiers of
practice: Basic or generalist (Tier 1); Specialist or mid-
level (Tier 2); and Executive and/or multisystem level
(Tier 3).59 These tiers reflect the different levels of respon-
sibility for those working in public health.60

Public Health Nursing Roles
and Responsibilities
There are roles and responsibilities specific to public
health nursing practice built on nursing practice for all

C H A P T E R 1 n Public Health and Nursing Practice 13

Figure 1-4 United States Public Health Service Nurse at
a blood pressure clinic. (Courtesy of the CDC/Nasheka Powell)

7711_Ch01_001-022 23/08/19 10:19 AM Page 13

14 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Standard 1. ASSESSMENT

The PHN collects comprehensive data pertinent to the
health status of populations.

Standard 2. DIAGNOSIS

The PHN analyzes the assessment data to determine the
diagnoses or issues.

Standard 3. OUTCOMES IDENTIFICATION

The PHN identifies expected outcomes for a plan specific
to the population or situation.

Standard 4. PLANNING

The PHN develops a plan that prescribes strategies and
alternatives to attain expected outcomes.

Standard 5. IMPLEMENTATION

The PHN implements the identified plan.

Standard 5A. COORDINATION OF CARE

The PHN coordinates care delivery.

Standard 5B. HEALTH TEACHING AND HEALTH
PROMOTION

The PHN employs multiple strategies to promote health
and a safe environment.

Standard 5C. CONSULTATION

The PHN provides consultation to influence the identi-
fied plan, enhance the abilities of others, and effect
change.

Standard 5D. PRESCRIPTIVE AUTHORITY

The advanced practice registered nurse practicing in the
public health setting uses prescriptive authority, proce-
dures, referrals, treatments, and therapies in accordance
with state and federal laws and regulations.

Standard 5E. REGULATORY ACTIVITIES

The PHN participates in applications of public health laws,
regulations, and policies.

Standard 6. EVALUATION

The PHN evaluates progress toward attainment of
outcomes.

Standard 7. ETHICS

The PHN practices ethically.

Standard 8. EDUCATION

The PHN attains knowledge and competence that reflect
current nursing practice.

Standard 9. EVIDENCE-BASED PRACTICE AND
RESEARCH

The PHN integrates evidence and research findings into
practice.

Standard 10. QUALITY OF PRACTICE

The PHN contributes to quality nursing practice.

Standard 11. COMMUNICATION

The PHN communicates effectively in a variety of formats
in all areas of practice.

Standard 12. LEADERSHIP

The PHN demonstrates leadership in the professional
practice setting and the profession.

Standard 13. COLLABORATION

The PHN collaborates with the population, and others in
the conduct of nursing practice.

Standard 14. PROFESSIONAL PRACTICE
EVALUATION

The PHN evaluates her or his own nursing practice in
relation to professional practice standards and guide-
lines, relevant statutes, rules, and regulations.

Standard 15. RESOURCE UTILIZATION

The PHN utilizes appropriate resources to plan and
provide nursing and public health services that are safe,
effective, and financially responsible.

Standard 16. ENVIRONMENTAL HEALTH

The PHN practices in an environmentally safe, fair, and just
manner.

Standard 17. ADVOCACY

The PHN advocates for the protection of the health,
safety, and rights of the population.

BOX 1–6 n Standards of Public Health Nursing Practice

Source: (1)

7711_Ch01_001-022 23/08/19 10:19 AM Page 14

specialties. They are in alignment with the Scope and
Standards of Nursing Practice in general and build in the
care of communities and populations.

Coordination, Consultation, and Leadership: A PHN
is responsible for coordinating programs, services, and
other activities to implement an identified plan.46 A PHN
acts as a consultant when he or she works with commu-
nity organizations or groups to develop a local health fair
or provide the latest information about a CD outbreak
to the community. At a more complex level, Advanced
Public Health Nurses (APHN) act as consultants when
providing expert testimony to the federal or state gov-
ernments about a health promotion program. As leaders,
PHNs can serve in coalition-building efforts around a
health issue such as teen smoking prevention or opioid
overdose prevention.

Advocacy: Advocacy refers to the responsibility of
PHNs to speak for populations and communities that
lack the resources to be heard.1 Assisting families living
in poverty to access appropriate services is one example
of an important role of PHNs. Another example of ad-
vocacy is engaging in strategies to affect policy at the
local, state, or national level.

Health Education and Health Promotion: The
PHN selects teaching and learning methods to help com-
munities address health issues, presenting the informa-
tion in a culturally competent manner, implementing the
health education program in partnership with the com-
munity, and evaluating the effectiveness of the program
by collecting feedback from participants.

Regulatory Activities: Since the beginning of public
health nursing, health policy has been an important
aspect of practice. Responsibilities include identifying,
interpreting, and implementing public health laws, reg-
ulations, and policies.1 Activities include monitoring and
inspecting regulated entities such as nursing homes. It

also includes educating the public on relevant laws, reg-
ulations, and policies.

Ongoing Education and Practice Evaluation:
PHNs are responsible for maintaining and enhancing
their knowledge and skills necessary to promote popu-
lation health. This requires PHNs to take the initiative to
seek experiences that develop and maintain their com-
petence as PHNs. Thus, as with nurses in other settings,
PHNs must engage in self-evaluation, seek feedback
about performance, and implement plans for accom-
plishing their own goals and work plans.

Professional Relationships and Collaboration:
Effective partnerships with communities and stakehold-
ers provide the mechanism for moving the public
health agenda forward.1 For example, nurses working in
health departments often join with other human service
providers to develop effective programs aimed at ad-
dressing a health issue of mutual concern such as the
opioid epidemic. PHNs seek collegial partnerships with
peers, students, and colleagues as a means of enhancing
public health interventions.

Public Health Nursing Ethics
The principles guiding any ethical discourse in nursing
include autonomy, dignity, and rights of individuals.
The same is true for public health nursing. Assuring
confidentiality and applying ethical standards are critical
in advocating for health and social policy.60,61 Equally
important to any discussion of public health ethics is the
fact that public health is concerned with the public good,
which can override individual rights.62 This is evident in
the enforcement of laws that are aimed at the whole
population (e.g., immunizations, disease reporting, or
quarantines). Underlying public health ethics is the con-
cept of social justice defined as: “… acting in accordance
with fair treatment regardless of economic status, race,
ethnicity, citizenship, disability, or sexual orientation.”1

This includes the eradication of poverty and illiteracy,
the establishment of sound environmental policy, and
equality of opportunity for healthy personal and social
development.1

Global Health
Global health is “the collaborative transnational research
and action for promoting health for all.”63 This definition
aligns with the WHO classic definition of health: “a state
of complete physical, mental, and social well-being
and not merely the absence of disease or infirmity.”64

The constitution of the WHO further recognizes “the

C H A P T E R 1 n Public Health and Nursing Practice 15

1. Assessment and analytical skills
2. Policy development/program planning skills
3. Communication skills
4. Cultural competency skills
5. Community dimensions of practice skills
6. Public health science skills
7. Financial planning, evaluation and management skills
8. Leadership and systems thinking skills

BOX 1–7 n PHN Core Competencies includes
Eight Domains

Source: (60)

7711_Ch01_001-022 23/08/19 10:19 AM Page 15

enjoyment of the highest attainable standard of health …
as one of the fundamental rights of every human
being.”65 The WHO recognizes that nurses play a large
role in the promotion of global health. In February of
2018, the WHO launched a new global campaign, called
Nursing Now, to “… empower and support nurses in
meeting 21st century health challenges.”66

One of the variables associated with differences
among countries is their economic well-being. The terms
most often used to differentiate countries based on
country-level income data are high-income countries
(HICs), upper middle-income countries (UMICs),
lower middle income countries (LMICs), and low-
income countries (LICs). These terms replace the earlier
terms of developed and developing countries. The World
Bank classifies countries based on current economic
ranges of the annual per capita gross national income
(GNI). In 2016, a LIC was a country with a per capita
GNI equal to or less than U.S. $1,005; LMIC’s per capita
GNI ranged from U.S. $1,006 to $3,955; UMIC’s per
capita GNI ranged from $3,956 to $12,235; and an
HIC’s per capita GNI was equal to or greater than U.S.
$12,236.67 From a global health perspective, a major con-
cern is the growing disparity between the two lower
groups (LIC and LMIC) and the two higher groups
(HIC and UMIC). Previously, international health-care
workers in LICs and LMICs looked for solutions to
health care within the country or collaborated with
one other country. The key conceptual change in global
health over the past 2 decades is the recognition of
the interdependence of countries; the interdependence
of the health of people in all countries; and the interde-
pendence of the policies, economics, and values that arise
related to health.68 The 2018 WHO launch of “Nursing
Now” with the stated purpose “… to empower and sup-
port nurses in meeting 21st century health challenges”
showcases this conceptual change.66

An example of global efforts to assist countries
with fewer resources to improve health is the effort to
improve access to vaccines for common childhood
illnesses. For example, in 2008 the Cairo M/R Catch-Up
Campaign was initiated (Fig. 1-5), a national supple-
mental immunization activity in Egypt. Another exam-
ple, in 2018, is the plan by the Bill and Melinda Gates
Foundation to pay off the $76 million debt that Nigeria
owes Japan for their program to eradicate polio. These
efforts demonstrate the importance of health of children
as a primary focus of health at the global level. World-
wide in 2016, the number of children under the age
of 5 who died was 5.6 million, down from 6.6 million
children in 2012 and a sharp decrease from 1990 when

the total number of deaths was 12.4 million.69 Despite
these gains, efforts continue to help lower the number
as most of the deaths are preventable.

Public Health Organizations and Management:
Global to Local
Public health organizations constitute an essential
part of improving health from the cellular to the global
level. These organizations provide essential public health
services such as conducting surveillance, responding to
CD outbreaks and disasters, and evaluating the evidence
to make recommendations for action. In addition, these
organizations set goals related to the improvement of
health such as the UN’s Sustainable Development Goals
(SDGs).70

World Health Organization
The WHO, established in 1948, is the world health
authority under the auspices of the UN. Their “… primary
role is to direct and coordinate international health

16 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Figure 1-5 Vaccinating children for measles and rubella
in Egypt. (Courtesy of the CDC/Carlos Alonso)

7711_Ch01_001-022 23/08/19 10:19 AM Page 16

within the United Nations’ system.”64 Their stated areas
of work include health systems, promoting health
through the life-course, NCD, CD, and corporate serv-
ices.76 Based in Geneva, the WHO employs 7,000 people
working in 150 country offices, 6 regional offices, and at
the central headquarters.64

In 1978, the WHO held a conference in Alma-Ata
(now Almaty), Kazakhstan, that supported the resolu-
tion that primary health care was the means for attaining
health for all. At the beginning of the first decade in
the 21st century, a new model emerged of integrated
services that respond to multiple threats to health. The
WHO has expanded to include emergency response and
disaster preparedness initiatives (see Chapter 22). An-
other key initiative was the institution of International
Health Regulations (IHRs) that countries must follow
in response to disease outbreaks and to increase the abil-
ity of the WHO to respond to public health emergencies
brought on by natural or manmade disasters.64 The
WHO continues to set global population heath goals
and tracks the attainment of these goals. The current
SDGs built on the Millennial Development Goals
(MDGs) that ended in 2015. There are 17 goals with a
target date of 2030 and, unlike the MDGs, the goals
apply to all countries, and there is no distinction be-
tween LIC and other countries (Box 1-8). The stated
purpose of the SDGs is to “… end poverty, protect the
planet, and ensure prosperity for all.”70

National Health Organizations
Individual countries have their own national organiza-
tions dedicated to the promotion of health and the pro-
tection of their populations. They coordinate with the
WHO and, as evidenced by the new interdependency
framework mentioned earlier, often work together to ad-
dress threats to heath. Some countries, including the
U.S., have public health departments, also known as
boards of public health. Even though these governmental
bodies do not encompass the entirety of the field of pub-
lic health, they are key to providing infrastructure as well
as oversight of the health of populations.

The U.S. Constitution provides for a two-layer pub-
lic health system composed of the federal level and the
state level. However, the Constitution did not make any
specific provisions for the management of public health
issues at the federal level, therefore, public health man-
agement now comes under state authority.30 After rat-
ification of the 14th Amendment, states were required
to provide protections to their own citizens, which
helped to legalize activities of local health departments
to take such actions as imposing quarantines.

Centers for Disease Control and Prevention
The CDC, founded in 1946, grew out of the wartime
effort related to malaria control. In the beginning, the
CDC employed approximately 400 people, including en-
gineers and entomologists (scientists who study insects).
Only seven employees functioned as medical officers.71

The work of the CDC contributed to the 10 great public
health achievements over the past century (Box 1-9).72

These included immunizations, fluoridation of water,
and workplace safety. The implementation of childhood
vaccination programs resulted in the eradication of
smallpox and the banishment of mumps and chickenpox
from schools in the United States.79 Without an active
public health infrastructure, the marked increases in life
expectancy in the 20th century would not have occurred.

Activities of the CDC: From this humble beginning,
the CDC has grown into one of the major operating
components of the Department of Health and Human

C H A P T E R 1 n Public Health and Nursing Practice 17

According to the United Nations, “The SDGs build
on the success of the Millennium Development Goals
(MDGs) and aim to go further to end all forms of
poverty. The new Goals are unique in that they call for
action by all countries, poor, rich and middle-income to
promote prosperity while protecting the planet. They
recognize that ending poverty must go hand-in-hand with
strategies that build economic growth and addresses a
range of social needs including education, health, social
protection, and job opportunities, while tackling climate
change and environmental protection.”70

The 17 sustainable goals include:

1. No poverty
2. Zero hunger
3. Good health and well-being
4. Quality education
5. Gender equality
6. Clean water and sanitation
7. Affordable and clean energy
8. Decent work and economic growth
9. Industry, innovation, and infrastructure

10. Reduced inequalities
11. Sustainable cities and communities
12. Responsible production and consumption
13. Climate action
14. Life below water
15. Life on land
16. Peace, justice, and strong institutions
17. Partnerships for the goals

BOX 1–8 n United Nations’ Sustainable
Development Goals

Source: (70)

7711_Ch01_001-022 23/08/19 10:19 AM Page 17

Services (DHHS). The scope of the agency’s efforts includes
the prevention and control of CDs and NCDs, injuries,
workplace hazards, disabilities, and environmental health
threats. In addition to health promotion and protection,
the agency also conducts research and maintains a national
surveillance system. It also responds to health emergencies
and provides support for outbreak investigations.73 Ac-
cording to the CDC, it is distinguished from its peer agen-
cies for two reasons: the application of research findings to
people’s daily lives and its response to health emergencies.74

The CDC collaborates with state and local health de-
partments in relation to disease and injury surveillance
and outbreak investigations, including bioterrorism. It
sets standards for the implementation of disease preven-
tion strategies and is the repository for health statistics.
Health statistics are available to health providers, health
departments, and the public.74 Web sites of interest to
nurses needing population level information include
CDC WONDER, FASTSTATS, and VITALSTATS (see
Box 1-10 for details).

Healthy People: Every decade Healthy People releases
a set of goals and health topics with specific objectives
aimed at improving health across the life span. As the tar-
get date of 2020 approached, the CDC and the USDHHS
worked on the development of the next iteration of
Healthy People, HP 2030 (see Box 1-11).73

18 U N I T I n Basis for Public Health Nursing Knowledge and Skills

1. Immunizations
2. Motor vehicle safety
3. Workplace safety
4. Control of communicable diseases
5. Declines in deaths from health disease and stroke
6. Safer and healthier foods
7. Healthier mothers and babies
8. Family planning
9. Fluoridation of drinking water

10. Tobacco as a health hazard

BOX 1–9 n Top 10 Public Health Achievements

Source: (79)

CDC WONDER provides online data sources (AIDS
public use data, births, cancer statistics); environment
(daily air temperature, land service temperatures,
fine particulate matter, sunlight, and precipitation);
mortality (detailed mortality, infant deaths, online
tuberculosis information systems); population (bridged
population, census); sexually transmitted morbidity;
and vaccine adverse event reporting.

Source: http://wonder.cdc.gov/.
FASTSTATS provides statistics on topics of public health

importance.
Source: http://www.cdc.gov/nchs/fastats/.
VITAL STATISTICS ONLINE DATA PORTAL is a

Web site that provides users with the ability to access
vital statistics, specifically birth and mortality data.
Source: https://www.cdc.gov/nchs/data_access/
vitalstatsonline.htm.

BOX 1–10 n Centers for Disease Control
and Prevention Web Resources

n HEALTHY PEOPLE 2030
Proposed Framework

For 2030, there are five overreaching goals and a plan
of action for reaching those goals.

Vision: “Where we are headed”

A society in which all people achieve their full potential
for health and well-being across the life span.

Mission: “Why we are here”

To promote and evaluate the Nation’s efforts to im-
prove the health and well-being of its people.

Overarching Goals: “What we plan to achieve”

• Attain healthy, purposeful lives and well-being.
• Attain health literacy, achieve health equity, eliminate

disparities, and improve the health and well-being of
all populations.

• Create social and physical environments that pro-
mote attaining full potential for health and well-being
for all.

• Promote healthy development, healthy behaviors,
and well-being across all life stages.

• Engage with stakeholders and key constituents across
multiple sectors to act and design policies that im-
prove the health and well-being of all populations.65

Public health systems are commonly defined as “all
public, private, and voluntary entities that contribute to
the delivery of essential public health services within a
jurisdiction.” This means that all entities’ contributions
to the health and well-being of the community or state
are recognized in assessing the provision of public health
services.72 As noted earlier, the CDC laid out 10 essential
public health services (see Box 1-1) that help guide all
public health organizations in the United States.9 These

7711_Ch01_001-022 23/08/19 10:19 AM Page 18

functions and services directly relate to the ability of
a public health department to address CDs, eliminate
environmental hazards, prevent injuries, promote
healthy behaviors, respond to disasters, and assure qual-
ity and accessibility of health services.72 The CDC col-
laborates with state and local health departments, as well
as public health entities across the world, especially the
WHO. Globally it has personnel stationed in 25 foreign
countries.

State Public Health Departments
States independently decide how they will structure their
local and state health departments (see Chapter 13). Vari-
ations exist across states in relation to the organization
and management of formal public health systems. The
variation stems, in part, from how the state government
has directed the establishment of public health boards or
departments and from the variation in state jurisdictional
structure. For example, some states such as Pennsylvania
use a town/city (municipality), township, or county sys-
tem, and other states such as Massachusetts divide their
entire state into municipalities. Finally, some states such
as Alaska have territories as well as municipalities because
they have smaller populations spread across a larger land

mass. States with sovereign Native American nations
within their borders add an additional layer to the struc-
turing of their state level public health department.

Local Public Health Departments
The basic mandate of the local public health department
is to protect the health of the citizens residing in their
county, municipality, township, or territory. However,
how public health departments implement this protec-
tion varies across states (see Chapter 13). This results in
variability in the services offered and the public health
activities of the local health departments. As a result of
federal mandates, public health departments uniformly
perform certain activities. These include surveillance,
outbreak investigation, and quarantine as well as man-
dated reporting of specific diseases and cause of death to
state health departments and the CDC. This allows the
federal government to track the incidence and prevalence
of disease from a national perspective. Local health de-
partments are essential to the health of communities and
provide the day-to-day services required to assure safe
environments and the provision of essential public health
services (see Chapter 13) with state departments and fed-
eral health organizations.

C H A P T E R 1 n Public Health and Nursing Practice 19

Overarching Goals
• Attain healthy, thriving lives and well-being, free of pre-

ventable 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 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.

Plan of Action
• Set national goals and measurable objectives to guide

evidence-based policies, programs, and other actions to
improve health and well-being.

• Provide data that is accurate, timely, accessible, and
can drive targeted actions to address regions and

populations with poor health or at high risk for poor
health in the future.

• Foster impact through public and private efforts to im-
prove health and well-being for people of all ages and
the communities in which they live.

• Provide tools for the public, programs, policy makers,
and others to evaluate progress toward improving health
and well-being.

• Share and support the implementation of evidence-
based programs and policies that are replicable, scalable,
and sustainable.

• Report biennially on progress throughout the decade
from 2020 to 2030.

• Stimulate research and innovation toward meeting
Healthy People 2030 goals and highlight critical research,
data, and evaluation needs.

• Facilitate development and availability of affordable
means of health promotion, disease prevention, and
treatment.

BOX 1–11 n Healthy People 2030 Goals and Action Plan

7711_Ch01_001-022 23/08/19 10:19 AM Page 19

n Summary Points
• Public health is a core component of nursing knowl-

edge and competency across settings and specialties.
• The goal of nursing is to help people achieve optimal

health, which ultimately requires understanding the
health of populations and communities due to the
intricate interplay between individuals, families, and
the communities in which they live.

• Public health science encompasses efforts to improve
the health of populations from the cellular to the
global level.

• Public health provides us with the means to build a
healthy environment and respond to threats to our
health from nature and from humans.

• Public Health Nursing is a recognized specialty at the
generalist and advanced level with specific scope and
standards of practice.

• Formal structures from the global to local level exist
to promote health, reduce risk, and protect popula-
tions from threats to health.

REFERENCES

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3. Winslow, C.E.A. (1920). The untilled field of public health.
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20 U N I T I n Basis for Public Health Nursing Knowledge and Skills

t THE CASE OF THE PARASITE ON
THE PLAYGROUND

In 2018, the New York Times published an article
related to roundworms, genus Toxocara, found in the
intestines of cats and dogs that are shed in the feces.1
The CDC estimated that about 5% of the U.S. popula-
tion has been exposed based on positive blood tests
for Toxocara antibodies. The rate is higher in those
who live below the poverty line (10%) and for African
Americans (7%).1,2 The difference in prevalence appears
to be based on economic status due to the higher num-
ber of strays in poorer neighborhoods versus pets with
regular veterinary care. Based on a recent survey of
pediatricians conducted by the CDC, a little less than
half of the doctors correctly diagnosed it.3 Cognitive
development is one of the long-term consequences
associated with exposure to the worm.4

Suggested prompts for discussion:

1. Review the CDC Web site on Toxocara. What
interventions are needed at the individual level
versus the community level?

2. What knowledge does a nurse need to set up
interventions to prevent this disease?

3. What is the role of individual health care providers,
health care organizations, and public health depart-
ments. Who else might play a role?

4. How does this issue depict the role of the social
determinants of health in the spread of disease?

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3. Woodhal, D.M., Garcia, A.P., Shapiro, C.A., Wray,
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4. Walsh, M.G., & Haseeb, M.A. (2012). Reduced
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39. Humes, K.R., Jones, N.R., & Ramirez, R.R. (2011). Overview
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41. Morganthau, T. (1995, February 13). What color is black?
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42. Murphy, N. (2008). An agenda for health promotion.
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44. Sommers, J. (1989). Soho—a history of London’s most
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46. American Public Health Association, Public Health Nursing
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nursing: Leadership, policy, and practice (pp. 2-26). Clifton
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22 U N I T I n Basis for Public Health Nursing Knowledge and Skills

7711_Ch01_001-022 23/08/19 10:19 AM Page 22

KEY TERMS

Attributable risk
Behavioral prevention
Clinical prevention
Downstream approach
Ecological determinants of

health
Environmental prevention
Health education
Health literacy

Health prevention
Health promotion
Health protection
Indicated prevention
Intervention Wheel
Multiphasic screening
Natural history of disease
Population attributable

risk (PAR)

Prevalence
Prevalence pot
Prevented fraction
Prevention
Primary prevention
Reliability
Risk reduction
Secondary prevention
Selective prevention

Sensitivity
Social determinants of

health
Specificity
Tertiary prevention
Universal prevention
Upstream approach
Validity
Yield

n Introduction
The proposed vision of Healthy People 2030 (HP 2030)
is that of “A society in which all people achieve their
full potential for health and well-being across the life
span.” The mission is “To promote and evaluate the
nation’s efforts to improve the health and well-being of
its people.”1 Thus, the health of populations takes center
stage in the effort to achieve the vision of reaching the
full health potential for all. The major objective of nurs-
ing practice is to provide interventions to individuals,
families, communities, and populations aimed at ad-
dressing disease and optimizing health. This requires
implementing multiple levels of prevention along the
entire spectrum of health and disease. To provide the
best possible care requires not only an understanding of
the pathophysiology of disease but also of the concepts
of health promotion, risk reduction, and the underlying

frameworks of prevention that help guide nursing inter-
ventions. These frameworks are not unique to nursing
and, for the most part, come from the public health
sciences.

In 2018, the New York Times published an op-ed
article by Pagan Kennedy who explained that, although
there are things individuals can do to improve their
health, there are things that remain outside of our control
such as bad genes, unintentional injuries, and environ-
mental risk factors. She stated that, “It’s the decisions that
we make as a collective that matter more than any choice
we make on our own.”2 In other words, the effects of
the environment and genes can override what we do at
the individual behavioral level. Making our collective de-
cisions as a society about our environment is perhaps
more important than our individual decisions about our
behavior. Kennedy uses examples of experts in healthy
living who nevertheless died early despite adherence to

Chapter 2

Optimizing Population Health
Christine Savage and Sara Groves

LEARNING OUTCOMES

After reading the chapter, the student will be able to:
1. Apply the concept of population health to nursing

practice.
2. Describe current public health frameworks that guide

prevention efforts from a local to a global perspective.
3. Apply public health prevention frameworks to specific

diseases.
4. Compare and contrast different levels of health

promotion, protection, and risk reduction interventions.

5. Identify health education strategies and chronic disease
self-management within the context of prevention
frameworks.

6. Describe components of screening from a population
and individual perspective.

7. Identify public health methods used to evaluate the
outcome and impact of population-based prevention
interventions.

7711_Ch02_023-054 23/08/19 10:21 AM Page 23

a healthy diet and exercise. It is often factors outside our
individual control that contribute to early death.

To be effective as nurses, with the understanding that
our collective decisions as a society impact our health, we
need basic knowledge and skills at the population health
level as well as at the individual level to provide expert
care to individuals and their families. As evidenced by the
launch of the Nursing Now campaign in February of
2018, nurses are key to reaching the goals set by the World
Health Organization (WHO) as well as the proposed
HP 2030 goals. Nursing Now represents a collaborative
effort by the WHO and the International Council of
Nurses “… to improve health globally by raising the pro-
file and status of nurses worldwide – influencing policy-
makers and supporting nurses themselves to lead, learn,
and build a global movement.”3

As a profession, nursing contributes substantially to
the health of populations. In turn, healthier populations
lead to more robust communities and societies. To achieve
the proposed HP 2030 overarching goals (see Chapter 1),
HP published the proposed framework for these goals
that includes foundational principles that clearly link the
health of populations to a well-functioning society.

The proposed goals and foundational framework for
HP 2030 align well with those of the United Nations’
(UN) Sustainable Development Goals (SDGs) (Box 2-1)
that focus on sustaining and developing healthy
environments. In particular, goal three of the SDGs is
to “… ensure healthy lives and promote well-being
for all at all ages.”4 All of this requires a population
level perspective and encompasses more than treating
or preventing disease. It requires promotion of a healthy

24 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Goal 1. End poverty in all its forms everywhere.
Goal 2. End hunger, achieve food security and improved

nutrition, and promote sustainable agriculture.
Goal 3. Ensure healthy lives and promote well-being for

all at all ages.
Goal 4. Ensure inclusive and equitable quality education

and promote lifelong learning opportunities for all.
Goal 5. Achieve gender equality and empower all

women and girls.
Goal 6. Ensure availability and sustainable management of

water and sanitation for all.
Goal 7. Ensure access to affordable, reliable, sustainable,

and modern energy for all.
Goal 8. Promote sustained, inclusive, and sustainable

economic growth, full and productive employment,
and decent work for all.

Goal 9. Build resilient infrastructure, promote inclusive
and sustainable industrialization, and foster innovation.

Goal 10. Reduce inequality within and among countries.
Goal 11. Make cities and human settlements inclusive,

safe, resilient, and sustainable.
Goal 12. Ensure sustainable consumption and production

patterns.
Goal 13. Take urgent action to combat climate change

and its impacts.*
Goal 14. Conserve and sustainably use the oceans, seas,

and marine resources for sustainable development.
Goal 15. Protect, restore and promote sustainable use

of terrestrial ecosystems, sustainably manage forests,
combat desertification, and halt and reverse land
degradation and biodiversity loss.

Goal 16. Promote peaceful and inclusive societies for
sustainable development, provide access to justice
for all, and build effective, accountable, and inclusive
institutions at all levels.

Goal 17. Strengthen the means of implementation and
revitalize the Global Partnership for Sustainable
Development.

BOX 2–1 n Sustainable Developmental Goals

Source: (4)
*Acknowledging that the UN’s Framework Convention on Climate Change is

the primary international, intergovernmental forum for negotiating the global
response to climate change.

n HEALTHY PEOPLE 2030
Foundational Principles: “What Guides
Our Actions”

Note: Foundational Principles explain the thinking that
guides decisions about Healthy People 2030.

• Health and well-being of the population and communi-
ties are essential to a fully functioning, equitable society.

• Achieving the full potential for health and well-being
for all provides valuable benefits to society, including
lower health-care costs and more prosperous and
engaged individuals and communities.

• Achieving health and well-being requires eliminating
health disparities, achieving health equity, and
attaining health literacy.

• Healthy physical, social, and economic environments
strengthen the potential to achieve health and
well-being.

• Promoting and achieving the nation’s health and well-
being is a shared responsibility distributed among all
stakeholders at the national, state, and local levels,
including the public, profit, and not-for-profit sectors.

• Working to attain the full potential for health and well-
being of the population is a component of decision
making and policy formulation across all sectors.

• Investing to maximize health and well-being for the
nation is a critical and efficient use of resources.1

7711_Ch02_023-054 23/08/19 10:21 AM Page 24

access to healthier foods in 2014.6 Although this initiative
is not currently active, the framework provides a way to
visualize the interaction between the elements that con-
tribute to the health of populations.

Increasing the number of healthy persons at all stages
of their life across the globe requires purposeful and well-
planned prevention on the part of nurses across the con-
tinuum of prevention. The full scope of interventions
includes those aimed at health promotion, risk reduc-
tion, and disease prevention. Specific population health
interventions done routinely by nurses include screen-
ing, health education, and evaluation of the effectiveness
of disease and injury prevention programs.

Population Health Promotion, Health
Protection, and Risk Reduction
The social ecological model of health has been used in
the public health field for the last 3 decades and clearly
demonstrates that health occurs from the cellular to
global level (Chapter 1, Fig. 1-1). It provides a basis for
understanding health promotion and prevention efforts
key to the achievement of the HP Goals and the SDGs
through an inclusion of both the physical and social
environments as key components of health.7,8 More
recently some authors have suggested turning the model
inside out, “… placing health-related and other social
policies and environments at the center.”9 Turning it
inside out places the focus on community context as
a means for fostering health policy and environmental
development.9 Either way, the model emphasizes the
interaction among communities, policy, and environ-
ment and their role in the health of individuals and their
families.

The social environmental determinants of health are
different from the individual-level biological and behav-
ioral determinants of health that are the usual focus of
health prevention interventions. The use of the ecological
model within the context of health promotion, health
protection, and risk reduction requires the inclusion
of social relations, neighborhoods and communities, in-
stitutions, and social and economic policies in the devel-
opment of prevention strategies.

Health Promotion, Risk Reduction,
and Health Protection
Health promotion-related interventions are an essential
component of nursing practice and occur from the in-
dividual to the population level. Authors use various
terms in relation to reducing the occurrence or severity
of disease in a population and enhancing the capacity of

environment, ending poverty and hunger, and increas-
ing access to education.4 It also requires development
of partnerships within nations and across the globe to
promote a healthy world.

In the U.S., over the past 2 decades, health care has
taken on a central role at the federal policy level. Follow-
ing the passage of the Affordable Care Act (ACA), the
National Prevention Council released a comprehensive
plan, the purpose of which was to increase the number
of Americans who are healthy at every stage of life.5 It in-
cluded four broad strategic directions fundamental to
this prevention strategy: (1) building healthy and safe
community efforts; (2) expanding quality preventive
services in both clinical and community settings; (3) em-
powering people to make healthy choices; and (4) elim-
inating health disparities (Fig. 2-1). There were seven
priorities: (1) tobacco-free living, (2) preventing drug
abuse and excessive alcohol abuse, (3) healthy eating,
(4) active living, (5) injury- and violence-free living,
(6) reproductive and sexual health, and (7) mental and
emotional well-being.5 The National Prevention Council,
per the ACA, was required to provide the president with
an annual report until 2015. The last report covered ad-
vances made including increasing the number of colleges
with tobacco-free campuses, improving school nutrition,
increasing supports for breast feeding, and increasing

C H A P T E R 2 n Optimizing Population Health 25

Figure 2-1 National Prevention Strategy Priorities.
(From National Prevention Council, 2012.)

7711_Ch02_023-054 23/08/19 10:21 AM Page 25

a population to achieve optimal health. These terms
include health promotion, risk reduction, and health
protection. The WHO’s definition of health promotion
is: “… the process of enabling people to increase control
over, and to improve, their health. It moves beyond a
focus on individual behaviour towards a wide range of
social and environmental interventions.”10 Risk reduc-
tion refers to actions taken to reduce adverse outcomes
such as the use of a condom to reduce the risk of trans-
mission of a communicable disease (CD). Another term
used in conjunction with risk reduction is health pro-
tection, which puts the emphasis on increasing the per-
son’s ability to protect against disease. An example of a
health promotion intervention is the institution of an
exercise program in an elementary school; an example
of a health protection, risk reduction program is a
vaccination outreach program. The first intervention
promotes a healthy behavior and the second increases
the ability of the immune system to protect against a
communicable agent, thus reducing risk.

Health promotion often focuses on interventions
aimed at helping patients increase healthy behaviors,
such as a healthy diet and exercise, and reduce unhealthy
behaviors, such as tobacco use or at-risk alcohol use.
In 2008, Michael O’Donnell, editor-in-chief emeritus of
the Journal of Health Promotion, stated that health pro-
motion is both a science and an art that helps people
change their lifestyles to achieve optimal health.11 From
O’Donnell’s perspective, health promotion remains
rooted in individual behavioral change. However, exam-
ined from a broader perspective and following the
WHO definition, health promotion encompasses
activities taken to promote health that require changes
other than behavioral changes, such as facilitating the
individuals’ ability to improve the health of their envi-
ronment and increase their access to resources needed
to promote health, such as good nutrition or a safe place
to exercise.

The socioecological model provides the basis of eco-
logical health promotion that expands on O’Donnell’s
individual approach to health promotion by taking into
account social and ecological determinants of health
using an upstream approach. Ecological determinants
of health include “… potable water and sanitation, af-
fordable and clean energy, climate action, life below
water, and life on land.”12 Social determinants of health,
according to the WHO “… are the conditions in which
people are born, grow, live, work, and age. These circum-
stances are shaped by the distribution of money, power,
and resources at global, national, and local levels. The
social determinants of health are mostly responsible for

health inequities—the unfair and avoidable differences
in health status seen within and between countries.”13 To
achieve optimal health for all, educational, policy, eco-
nomic, and environmental strategies are used to increase
access to needed resources as well as interventions aimed
at health promotion and protection.14 Nurses support
this goal of achieving optimal health for all not only
through the delivery of care to individuals, families, and
communities but also through advocacy and active in-
volvement in policy development, implementation, and
evaluation (see Chapter 21).

Health Promotion
Health promotion at the individual and family level
helps people make lifestyle changes aimed at achieving
optimal health. These prevention interventions are
implemented in various ways and often focus on behav-
ioral change. In relation to obesity, health promotion ac-
tivities focus on diet and exercise. Health-care providers
deliver these interventions to individuals in their care.
These interventions are also delivered to populations via
health education programs, media campaigns, or in the
workplace. The goal of these health promotion programs
is to achieve change at the individual level based on the
biological and behavioral issues related to developing
disease due to obesity. The assumption is that the pro-
motion of healthy behaviors will reduce risk and thereby
reduce the prevalence of morbidity and mortality related
to obesity.

The ecological model allows us to expand on this
approach to health promotion by incorporating what is
referred to as an upstream approach in contrast to a
downstream approach to these efforts.14 An upstream
approach focuses on eliminating the factors that increase
risk to a population’s health. In contrast, a downstream
approach represents actions taken after disease or injury
has occurred. These two terms are important in under-
standing health promotion efforts today. Upstream rep-
resents a macro approach to addressing health whereas
downstream takes a more micro approach with a focus
on illness care. Both are needed to adequately address
health issues in the population.15 Take obesity as an ex-
ample. With a downstream approach, a health-care
provider may focus primarily on nutritional health
teaching based on nutritional patterns, portions, and
choices without taking into consideration the environ-
mental factors influencing choices within a community.
If there are no supermarkets within a community, it is
difficult to make healthy choices. In contrast to a down-
stream approach, an upstream approach to obesity might
include interventions focused on agriculture subsidies,

26 U N I T I n Basis for Public Health Nursing Knowledge and Skills

7711_Ch02_023-054 23/08/19 10:21 AM Page 26

transportation policies, and urban zoning. It might also
involve interventions restricting television advertising of
food to children, creating national nutrition standards
for meals served in childcare settings, or working with
the private sector to introduce healthier options in
restaurants and local markets

An upstream approach to health promotion related to
the obesity epidemic examines the environmental factors
that contribute to the epidemic and institutes prevention
interventions that target environmental change. Using
the first and third strategic directions of the National
Prevention Strategy as examples, this can occur through
empowering community members to initiate and imple-
ment the changes to create a healthy community. For
example, to promote healthy eating behaviors in chil-
dren, a school system in Kentucky took action and elim-
inated all fried foods that had been offered on the school
menu. Other communities have eliminated all vending
machines in schools that offer unhealthy beverages and
food. The National School Lunch Program supports in-
cluding larger portions of fruits and vegetables, less
sodium, and no trans fats. It also places a cap on the num-
ber of calories for the school lunch at 650 for grades K
through 5, 700 calories for grades 6 through 8, and
850 calories for grades 9 through 12. Milk can be at most
1% fat, and flavored milk must be fat-free although there
are flexibilities allowed to help provide more local con-
trol.16,17 Such an approach to health promotion requires
that the planners for the health promotion intervention
take into account the context of the healthy behavior they
hope the population will adopt. If the focus is only on
having the schoolchildren change their eating habits
without taking into account the food available to them
in their total environment, then that kind of health
promotion program will likely fail.

Health Protection and Risk Reduction
In contrast to health promotion, which focuses on the
promotion of a healthy lifestyle and environment,
health protection/risk reduction interventions protect
the individual from disease by reducing risk. These
terms are often used interchangeably, but are in actu-
ality distinct. A good example of health protection is
the use of vaccines. When an individual is vaccinated,
the body develops immunity to the infectious agent and
is therefore protected from the disease. The use of a
vaccine has reduced the risk of developing disease. Risk
reduction, conversely, encompasses more than biolog-
ical protection. It can involve removing risk from the
environment or reducing the level of risk, for example,
by reducing hazardous chemical emissions produced at

industrial plants. Health protection and risk reduction
activities are an important component of our national
effort to prevent disease.

Much of the health protection and risk reduction
activities currently used in our health-care system focus
on influencing behavioral change at the individual level.
The focus is to have individuals adopt protective health
activities, even if the prevention program is offered to
groups or populations. For example, policies related to
the recommended childhood vaccines are population
based and aimed at reducing risk for the development
of childhood CDs. However, the actual delivery of the
vaccine requires an individual response.

Risk reduction and health promotion must take into
account the broader concept of risk for development of
disease by incorporating environmental and social risk
factors associated with the development of disease that
may not be amenable through individual-level interven-
tions. For example, protection from lead poisoning re-
quires an environmental approach aimed at eradicating
lead paint in the environment. The risk factor, lead paint,
cannot be eliminated solely at the individual level and
often requires a system or community approach related
to allocation of funds, development of public policy, and
follow-through with the removal of lead paint from older
buildings in the community.

Prevention Frameworks
Prevention is a word used often in health care, but what
does it mean and how does it work? From a simplistic
standpoint, prevention refers to stopping something from
happening. From a health perspective, health prevention
refers to the prevention not only of disease and injury
but also to the slowing of the progression of the disease.
It also refers to the prevention of the sequelae of diseases
and injury, such as the prevention of blindness related
to type 1 diabetes. Health prevention is accomplished
through the institution of public health policies, health
programs, and practices with the goal of improving the
health of populations, thus reducing the risk for disease,
injury, and subsequent disability and/or premature death.

Health promotion and protection are fundamental
concepts for nursing practice and are based on preven-
tion frameworks in use in the public health field.18,19 Pre-
vention frameworks help nurses shape prevention
interventions within a particular context. In the summer
of 2016, a major public health issue was the Zika virus
epidemic. Preventing the spread of the disease was the
main focus of the public health interventions taken by
the Centers for Disease Control and Prevention (CDC)

C H A P T E R 2 n Optimizing Population Health 27

7711_Ch02_023-054 23/08/19 10:21 AM Page 27

and the WHO. These activities included behavioral,
environmental, and clinical interventions. People were
asked to modify their behavior by utilizing insect repellent
and avoiding unprotected sexual intercourse with a
person who had been exposed. Governments worked to
reduce the mosquito population through sprays, and
travel alerts were put in place. How do these interventions
relate to the natural history of disease, and how do they
fit into current public health prevention frameworks?

Natural History of Disease
An understanding of the natural history of disease is an
essential basis for the discussion of current prevention
frameworks that follows. The natural history of disease
provides the foundation for the public health frameworks
currently in use, especially the most widely used frame-
work of primary, secondary, and tertiary prevention.
The natural history of disease depicts the continuum of
disease from the disease-free state to resolution. The four
stages are (1) susceptibility; (2) the subclinical phase after
exposure when pathological changes are occurring with-
out the person being aware of them; (3) clinical disease
with the development of symptoms; and (4) the resolu-
tion phase in which the final outcomes are cure, disability,
or death.20,21 The subclinical phase is also sometimes
referred to as the incubation period for CDs and latency
period for noncommunicable illness (Fig. 2-2).

This traditional presentation of the natural history of
disease with four stages initially appears linear. For some
diseases such as influenza, this linear model works well.
In some disease processes, an individual may go from a
subclinical stage to a clinical stage and then back to a sub-
clinical stage. For example, in human immunodeficiency
virus (HIV) infection, during the initial subclinical stage
an infected individual has no clinical symptoms that meet
the criteria for a diagnosis of acquired immunodeficiency

syndrome (AIDS). As the infection progresses, the person
may develop one or more clinical diagnoses, thus placing
the individual in the clinical stage of the disease. However,
with the treatments now available for treating AIDS, an
individual may recover from a clinical episode and return
to being asymptomatic, but there has been no resolution
of the disease; instead, that individual has reverted to a
subclinical stage.

Figure 2-2 also depicts the outcome of a particular
disease. Following the development of clinical disease, an
individual recovers completely (cure), is disabled by the
disease (disability), or dies. Some diseases, both commu-
nicable and noncommunicable, have no endpoint except
death. HIV/AIDS is an example of a CD with no cure.
Those who become infected will remain infected for the
rest of their lives. An example of a noncommunicable
disease (NCD) without a cure is type 1 diabetes. A person
diagnosed with this type of diabetes does not at some point
in time revert to producing insulin at normal levels.

To further illustrate, examine the prevalence of a
disease and the prevalence pot. Prevalence is basically
the number of total cases of disease (numerator) divided
by the total number of people in the population (denom-
inator) and reflects the total number of cases of a disease
in a given population. A prevalence pot is a way of
depicting the total number of cases of the disease in
the population that takes into account issues related to
duration of the disease and the incidence of the disease
(Fig. 2-3). For some CDs with a short incubation period
such as influenza, cases rapidly move in and out of the
prevalence pot, but for long-term chronic diseases with
no known cure, the prevalence pot can grow over time
(e.g., HIV infection). If the definition of a case is infection
with the HIV virus, then individuals who are subclinical
and those who have evidence of clinical illness that meets
the criteria for an AIDS diagnosis would all be in the

28 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Stage of Recovery,
Disability, or Death

Stage of
Clinical Disease

Stage of
Subclinical Disease

Stage of
Susceptibility

Pathological
ChangesExposure

Onset of
Symptoms

Usual Time
of Diagnosis

Figure 2-2 The natural
history of disease timeline.
(From Centers for Disease
Control and Prevention. (1992).
Principles of epidemiology (2nd ed.).
Atlanta, GA: U.S. Department
of Health and Human Services.
Retrieved from http://www.cdc.
gov/osels/scientific_edu/ss1978/
lesson1/Section9.html.)

7711_Ch02_023-054 23/08/19 10:21 AM Page 28

prevalence pot. During the early years of the AIDS epi-
demic, there were few treatment options. Once diag-
nosed, an individual often died within a short period of
time. As treatment has improved and the survival rate
for those infected with HIV has greatly increased, the
number of AIDS-associated deaths has declined. How-
ever, the HIV/AIDS prevalence pot has grown, because
the only way out of the prevalence pot is through death.
In developing countries where treatment for HIV/AIDS
is less available, the prevalence pot has not grown as rap-
idly, even with a higher number of cases, because the life
span of those with HIV/AIDS remains short.

Mapping out a disease using the natural history of dis-
ease model helps to identify where on the continuum
prevention efforts are needed. The prevalence pot helps
identify those health conditions that may have an in-
creasing number of cases over time if the development
of new cases is not prevented. In the case of seasonal flu,
laying out the natural history of the strain of flu appear-
ing in a given year helps to determine where the primary
focus should be. In the beginning of the fall in most years,
the majority of the U.S. population does not have in-
fluenza. As the next few months progress, more and
more people usually become infected, and some die.
Based on the severity of the flu epidemic nationwide,
large-scale prevention efforts may be instituted. In 2009,
during the H1N1 flu outbreak, efforts focused on vacci-
nating populations at greatest risk, in that case pregnant
women, children, and older adults, resulting in a focus
on those without disease at highest risk for mortality.22

This was important due to the shortage of vaccines avail-
able. Those who were most vulnerable got priority for
receiving the vaccine. The H1N1 virus is now a regular

human flu virus. Based on the 2009 pandemic and data
from subsequent years, the CDC updated its warnings
related to populations that were most vulnerable.
The most vulnerable populations now include children
under the age of 5, pregnant women, older adults, Native
Americans, and Native Alaskans. 23

How does the natural history of the disease and the
prevalence pot help public health officials focus on inter-
ventions? In the case of flu epidemics, the incubation
period, that is, the time interval between infection and
the first clinical signs of disease (Chapter 8), is short, with
those infected rapidly developing symptoms. In addition,
the course of the disease is also short. People with in-
fluenza are able to infect others from 1 day before getting
sick to 5 to 7 days after getting sick. Those who become
infected with a flu virus rapidly develop clinical symp-
toms including fever, cough, and in some cases gastroin-
testinal symptoms. New cases that enter the prevalence
pot usually leave the pot within 7 days. Most recover
completely, some experience long-term effects such as
coma and/or respiratory problems, and some die.

Using the natural history of disease model, the nurse
can lay out the progression of influenza (see Fig. 2-2).
The preclinical phase is very short (1 to 2 days), and there
are no interventions available that would prevent the
progression from this phase to clinical disease. Once the
patient is in the clinical phase, there are limited options
for intervention because the causative agent, the flu virus,
does not respond to antibiotics. However, early recogni-
tion in vulnerable patients, such as older adults, and
treatment with antiviral medication may help to reduce
the risk of complications and adverse consequences.

Because of the limited ability of antiviral medication
to prevent adverse consequences in at-risk populations
and the short period of time between phases, the best
approach is to focus on preventing disease from occur-
ring in the first place. The natural history of influenza
provides the basis for the nationwide public focus on pri-
mary prevention through the development, distribution,
and administration of flu vaccines with the hope of keep-
ing the majority of the population disease-free because
of the limited ability to provide effective secondary or
tertiary prevention interventions.

The natural history of a disease also allows the nurse
to identify who is at greatest risk for developing the
disease. For influenza, early evaluation of the prevalence
of the disease by age groups helps to establish who is
most likely to become ill. In the case of the 2009 H1N1
flu pandemic, the CDC concluded that there was a
greater disease burden on those under the age of 25.22

Unlike in other flu outbreaks, those who were younger,

C H A P T E R 2 n Optimizing Population Health 29

Figure 2-3 The prevalence pot.

Death

Leaving the pot

New Cases
People newly

diagnosed

The
Prevalence Pot:

Total Current
Cases

All people with
the disease

Entering the pot

Disability

Cure

7711_Ch02_023-054 23/08/19 10:21 AM Page 29

immune compromised, or pregnant were at increased
risk of death. This led to the speculation that the virus
was related to earlier strains, and those in late adulthood
had immunity due to earlier exposure. Thus, the older
members of the population had natural biological pro-
tection, whereas those under the age of 60 did not. With
limited vaccine available in the fall of 2009, decisions
were made to provide the vaccine to those at highest
risk. This included pregnant women, household and
caregiver contacts of children younger than 6 months of
age, health-care and emergency medical services person-
nel, people from 6 months through 24 years of age,
and people aged 25 through 64 years who had medical
conditions associated with a higher risk of influenza
complications.

The natural history of disease for type 1 diabetes is quite
different from H1N1 flu. The etiology, or cause, of type 1
diabetes is genetic rather than infectious. Although there
is no known prevention for type 1 diabetes, early detection
during stage one can lead to early diagnosis and treatment.
However, identifying the disease early will not prevent the
development of clinical disease, which lasts for a lifetime
because the body is unable to produce insulin. There is no
cure. This puts the majority of the focus on treatment of
the patient in the clinical stage to prevent premature death
and disability. Another key distinction between the natural
history of these two diseases is that influenza is population
based, that is, the disease spreads from one person to
another. Interventions are required to protect the entire
population at risk. By contrast, a disease such as type 1
diabetes is individual based, and the risk is usually tied to
a genetic trait passed down in families.

Public Health Prevention Frameworks
The natural history of a disease and the difference be-
tween population-based risks and individual-based risks
form the basis for two main prevention frameworks used
in public health science. The first framework is the tra-
ditional public health prevention model of primary, sec-
ondary, and tertiary prevention.21 The second is the
framework of universal, selected, and indicated preven-
tion based on work done by Gordon and put forth by the
Health and Medicine Division (HMD) of the National
Academies of Sciences, Engineering, and Medicine (for-
merly known as the IOM). 24 Both use a health promotion
and health protection approach, and employ the three
types of interventions—clinical, behavioral, and environ-
mental. The best place to start is with the traditional pri-
mary, secondary, and tertiary prevention model, because
it has been in use since the 1950s, and the newer IOM
framework was not used widely until it was mandated by

the Centers for Substance Abuse Prevention (CSAP), a
branch of the U.S. Federal Substance Abuse and Mental
Health Service Administration (SAMHSA), in 2004.25

Levels of Prevention
The traditional public health approach to prevention
focuses on health prevention based on the natural his-
tory of disease and includes three levels of prevention—
primary, secondary, and tertiary. Primary prevention
interventions are conducted to prevent development of
disease or injury in those who are currently healthy.21

The focus is usually on people at risk for developing the
disease or injury but may take a population approach
such as recommendations that all persons be vaccinated
against the flu. Activities include promoting healthy
behaviors and building the ability of populations and
individuals within that population to protect themselves
against disease. Many health policies are aimed at
primary prevention such as banning smoking in public
places, which is aimed at reducing the development of
diseases secondary to exposure to second-hand smoke.
The goal is to reduce risk factors for a health problem.
If the risk for developing disease or sustaining an injury
can be reduced, then the incidence (occurrence of new
cases) of a disease will be reduced. Secondary preven-
tion interventions include those aimed at early detection
and initiation of treatment for disease, thus reducing
disease-associated morbidity and mortality.21 If early
intervention results in cure from the disease, with or
without disability, screening can contribute to the reduc-
tion of the prevalence of a disease (total number of new
and old cases), thereby reducing the size of the preva-
lence pot. Secondary prevention can include screening
or case finding in CD outbreaks by seeking contacts of
people already ill. The focus of tertiary prevention is the
prevention of disability and premature death and, when
indicated, the initiation of rehabilitation for those diag-
nosed with disease.21 It includes interventions aimed at
preventing secondary complications related to disease
such as the prevention of bedsores.

Primary Prevention: Primary prevention is a central
part of nursing practice. Nurses engage in the delivery of
primary prevention across settings, including the acute
care setting where, on first glance, it looks as though the
nurse is only providing tertiary prevention interventions.
Because this approach is based on the natural history of
disease, what types of primary prevention does a nurse
provide in an acute care setting when every patient ad-
mitted has a diagnosis of clinical disease? A prime exam-
ple is the activities nurses do to prevent hospital-acquired
infections. All nurses must follow hospital policy related

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to the use of personal protective equipment, isolation
precautions, and personal hygiene. These activities pre-
vent the spread of infection from a patient with disease
to patients or health-care workers without disease.
Nurses also participate in primary prevention from a
health protection perspective. All nurses must comply
with hospital policy related to vaccinations. In this way
the members of the health-care workforce who are free
of disease take steps to build their immunity to disease,
thus preventing the spread of disease to patients and
fellow workers who are free of disease. All these activities
are population based.

Nurses also apply the principles of primary prevention
on an individual level through health education, vacci-
nation, and other activities aimed at promoting and
protecting the health of their patients and increasing
the patients’ ability to protect themselves from disease.
Patients receiving nursing care in acute care settings
who are receiving care for one clinical disease may be at
increased risk for other disease or injury. Nurses often
include primary prevention in their plan of care, such as
altering the environment to prevent falls and teaching
basic fall prevention strategies to patients and their
families that can be implemented on discharge. Health
education begins with primary prevention, teaching
patients to reduce risk for disease (e.g., teaching patients
to increase exercise, reduce caloric intake, and perform
proper hand hygiene). Nurses working in the community
provide primary prevention by providing health educa-
tion, promoting breastfeeding, and working with com-
munities to reduce hazards such as lead paint.

During epidemics and pandemics, countries depend
on nurses as frontline workers in nationwide primary
prevention efforts to reduce the incidence of the disease
and prevent premature death. Public health departments
across the country often mobilize nurses and student
nurses to administer the vaccines at schools, health clin-
ics, and other community settings. Because of the need
for nurses to deliver the vaccine to large groups of at-risk
individuals, nurses and other health-care providers are
often the first to receive the vaccine when it becomes
available. Primary prevention is an essential part of pro-
viding nursing care to individuals and populations across
all settings.

Secondary Prevention: Nurses also regularly partic-
ipate in secondary prevention interventions in all set-
tings. Screening is one aspect of secondary prevention
and is an essential component of the nursing assessment
focused on early detection of problems in asymptomatic
individuals who already have certain risk factors. Screen-
ing also targets conditions that are not yet clinically

apparent for purposes of earlier detection. Early treat-
ment reduces risk for further morbidity and for mortal-
ity. In acute, community, and long-term care settings,
nurses regularly screen patients of all ages for the possible
existence of a number of conditions. Screening for
developmental delays is an example of secondary pre-
vention in children, whereas encouraging mammograms
is an example of a secondary prevention intervention for
adults. The goal of mammograms is to detect early stage
breast cancer. Some activities done by nurses can serve
as both secondary prevention and tertiary prevention.
For example, the simple taking of blood pressures at a
blood pressure clinic held in a local senior center is a type
of screening when conducted with older adults who have
not been identified previously as having hypertension.
At the same clinic, taking an individual’s blood pressure
reading may function as a method for monitoring the
health status of an older person who has already been
diagnosed with hypertension.

Through early detection, nurses can implement
interventions that will alter the natural history of the
disease. For example, on admission to long-term care
facilities, elderly patients are routinely screened for skin
integrity. If there is any evidence of skin breakdown,
nursing interventions are immediately put in place to
halt the progression of a stage 1 pressure ulcer (bed sore)
to a stage 2. In stage 1, the skin is reddened, but there is
no break in the skin. Without intervention, the patient
is at greatly increased risk for skin breakdown and rapid
development of a stage 2 to a stage 3 pressure ulcer.

There are many circumstances when early detection
and initiation of treatment prior to the development
of clinical disease can improve outcomes. Public health
efforts to prevent premature death due to cancer include
media campaigns for mammography screening, colono-
scopies, and prostate screening. Screening is also con-
ducted for behavioral health issues such as at-risk alcohol
use (see Chapter 11). Screening for syphilis and early
treatment can prevent serious disability, reduce the in-
cidence of syphilis infection in newborns, and prevent
premature death. Nurses participate in these efforts
by conducting screenings and by educating patients to
encourage their participation in screening.

Health education is done with a secondary prevention
focus. For example, a nurse participating in a blood pres-
sure screening health fair will include secondary preven-
tion health education for adults with a blood pressure
reading greater than or equal to 130/80. Adults with a
blood pressure reading between 130/80 and 139/89 are
considered to have stage 1 hypertension, and those with
a blood pressure reading greater than 140/90 have stage

C H A P T E R 2 n Optimizing Population Health 31

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2 hypertension. It is recommended that the diagnosis of
hypertension be based on the average of ≥2 readings ob-
tained on ≥2 occasions.26 Thus, it is important to refer
persons with blood pressures greater than 130/80 to a
primary care physician for follow-up. Early intervention
through lifestyle changes and medical intervention can
reduce the development of life-threatening conditions
such as stroke or myocardial infarction.

Tertiary Prevention: The primary focus of nursing
interventions in most acute care settings is tertiary pre-
vention. Once an individual has been diagnosed with
clinical disease, prevention aims at reducing disability,
promoting the possibility of cure when possible, and pre-
venting death. Efforts are made to interrupt the natural
progression of the disease or to reduce the impact of the
injury through multiple strategies including medical, en-
vironmental, and psychosocial.

Health education is a key tertiary prevention activity
for the nurse. For those with chronic diseases, a disease
self-management approach is often used. This approach
puts the individual in charge of managing his or her
disease with the goal of reducing disability and prevent-
ing premature death. The nurse serves as the teacher/
facilitator by helping the individual to identify the key
strategies needed to manage disease, such as regular foot
care and blood sugar monitoring in patients with
diabetes. The use of chronic disease self-management is
effective in reducing health-care utilization in general
populations, improving perceived self-efficacy, and
improving perception of health status for various non-
communicable chronic diseases.27,28,29

Universal, Selected, and Indicated Prevention
Models
The traditional public health framework consisting of
levels of prevention was introduced in the 1950s and

still has utility today, especially for diseases in which the
natural history and causal pathways for development of
the disease are well understood. It is also useful when
the early clinical and subclinical signs of the disease
are known and the disease is actually preventable. On the
flip side, the framework has limitations because of the
underlying linear approach to diseases with a clear etiol-
ogy. The framework is difficult to adapt to diseases or
disorders (see Chapters 10 and 11) with complex risk
factors; a curvilinear progression; and broad health
outcomes that encompass not only physical outcomes
but also psychological, social, and economic outcomes.
It also limits the majority of the prevention efforts to in-
terventions conducted by health-care providers and is
not as readily applicable to the broader interdisciplinary
field of public health.

An alternate approach using a continuum-of-health
framework was proposed by the IOM in the 1990s and
has been adopted by the Substance Abuse and Mental
Health Services Administration (SAMHSA).25 This model
divides the continuum of care into three parts: preven-
tion, treatment, and maintenance (Fig. 2-4). Under pre-
vention there are three categories: universal, selected, and
indicated. This model was first adopted by the behavioral
health field because there is less distinction in mental
disorders and substance use disorders between the tradi-
tional levels of prevention that were developed based
on the natural history of disease—primary (stage of sus-
ceptibility), secondary (subclinical stage), and tertiary
(clinical stage).24

A universal prevention intervention is one that is
applicable to the whole population and is not based on
individual risk. The intervention is aimed at the general
population. The purpose is to deter the onset of a health
issue within the population. Public health media cam-
paigns use a universal approach by targeting everyone

32 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Compliance
With Long-term

Treatment
(Goal: Reduction
in Relapse and

Recurrence)

Standard
Treatment
for Known
Disorders

Case
Identification

Indicated

Selective

Universal

Aftercare
(Including

Rehabilitation)

Maintenance

Treatment

P
re

ve
nt

Figure 2-4 Continuum-of-Care
Prevention Model. (From the Substance
Abuse and Mental Health Services Admin-
istration. [2004]. Clinical preventive
services in substance abuse and mental
health update: From science to services
[DHHS Publication No. (SMA) 04-3906].)

7711_Ch02_023-054 23/08/19 10:21 AM Page 32

in the population with such things as a billboard anti-
smoking campaign or TV ads aimed at preventing
drunk driving. All individuals in the population are
provided with the information and/or skills necessary
to prevent disease regardless of risk. Often the interven-
tion is passive, as in media campaigns, in that nearly all
of the population is exposed to the intervention. The
intervention often does not include participation on an
individual level. However, universal vaccination pro-
grams are not passive and require active participation
by individuals. This is an appropriate approach when
the entire population is at risk and would benefit from
prevention programs.

Selective prevention interventions are aimed at a
subset of the population that has an increased level of
risk for developing disease. This can be based on demo-
graphic variables such as age, gender, or race, or it can be
based on other risk factors such as genetic, environmen-
tal, or socioeconomic risk factors. Examples of selective
prevention interventions include: efforts to screen
women for breast cancer who have a known family
history of breast cancer, or providing community edu-
cation programs to prevent lead poisoning in older
urban neighborhoods. This level of prevention targets
everyone in the subgroup regardless of risk. For exam-
ple, everyone in a neighborhood with older buildings is
included in the selective lead poisoning intervention
whether or not they have already removed the lead
from their own residence. Once again, a selective inter-
vention can be passive or have an active component on
the individual level.

Indicated prevention interventions are provided to
populations with a high probability of developing
disease. Like secondary prevention, the purpose of indi-
cated interventions is to intervene with individuals with
early signs of disease or subclinical disease to prevent the
development of a more severe disease. The difference is
that the individuals included in the intervention have
already been identified as being at greater risk for the
disease whereas in secondary prevention the effort is to
identify those with the disease among an apparently
healthy population. The indicated prevention approach is
used in the substance abuse field to develop programs for
individuals with early warning signs of increased potential
for developing a substance use disorder, such as falling
grades or at-risk alcohol use. Only those individuals with
specific risk factors for developing the disease but who do
not yet meet the diagnostic criteria for the disease are
included in the intervention. The purpose is to reduce
behavioral risk factors that contribute to the develop-
ment of disease and to delay onset of disease or severity

of disease. The level of intervention provided is more
intensive and often multilevel. It always requires individ-
ual participation. An example of an indicated prevention
program is that of a weight-loss program for adolescents
who are obese and are showing signs of hyperglycemia
but who have not been diagnosed with type 2 diabetes.
Such an intervention would probably include case man-
agement, health education, nutritional counseling, and
an individualized exercise plan. If the program is effec-
tive, participants may not only delay the onset of type 2
diabetes but may also reverse the hyperglycemia and not
develop the disease.

Delivery of Public Health Prevention Strategies
The delivery of prevention services includes the use of
three basic strategies—clinical, behavioral, and environ-
mental. Clinical prevention strategies are those that
use a one-to-one delivery method between the health-
care provider and the patient, and usually occur in tra-
ditional health-care settings. These can include health
protection activities such as vaccinations, as well as
screening, and early detection of disease. Behavioral
prevention, often focused on health promotion strate-
gies, is aimed at changing individual behavior such
as exercise promotion, smoking cessation, or responsi-
ble drinking. Environmental prevention focuses on
health protection by improving the safety of the envi-
ronment such as fluoridating water, banning smoking
in public places, enacting laws against drunk driving,
enforcing clean air acts, and building green spaces for
recreation.21

In an effort to standardize clinical prevention strate-
gies through the application of evidence-based preven-
tion practices, the Agency for Healthcare Research and
Quality (AHRQ) created the U.S. Preventive Services
Task Force.30 This task force is made up of a panel of
experts in primary care and prevention. These experts
systematically review the evidence found in published
research related to the effectiveness of prevention strate-
gies and then develop recommendations for clinical
interventions. These recommendations are helpful in the
development of a clinical prevention program.

The earlier example of type 2 diabetes illustrates how
to apply both frameworks to a serious national health
issue. Globally, many health issues contribute to prema-
ture death. The CDC provides yearly updates on the
top 10 causes of death in the United States (Box 2-2).31,32

This is based on the classification of the death or injury
using accepted codes entered in the death registry for
each death. This information is sent to the U.S. Depart-
ment of Health and Human Services, which then sends

C H A P T E R 2 n Optimizing Population Health 33

7711_Ch02_023-054 23/08/19 10:21 AM Page 33

the information to the CDC. The cause of death listed on
the death certificates at the local level is the basis for the
aggregate statistics related to mortality rates at the state
and national levels. Though this provides important in-
formation, the underlying risk factors provide the infor-
mation needed to build health promotion, protection,
and risk-reduction interventions.

Not only is cause of death classified by disease or
injury, it is also further classified by risk factor, that
is, the underlying cause of death. Four health at-risk
behaviors—lack of exercise or physical activity, poor
nutrition, tobacco use, and drinking too much alcohol—
are underlying causes for illness and premature death.33

In other words, it is important not only to track the
causes of actual deaths but also to track the occurrence
of preventable risk factors to help predict whether efforts
to prevent these deaths are working. This information
helps to guide major prevention efforts aimed at reduc-
ing both morbidity and mortality in populations.

Each death can also be classified in quantitative terms
using attributable risk and prevented fraction. Attribut-
able risk is the measure of the proportion of the cases or
injuries that would be eliminated if a risk factor was not
present. Epidemiologists begin by determining the the-
oretical limit of the impact of prevention aimed at re-
moving the risk factor. That is, if the risk factor did not
exist, how many cases would be eliminated? For example,
if no one smoked, how many cases of lung cancer would
be eliminated, or if no one drove while intoxicated, how
many motor vehicle crashes (MVCs) would not occur?
It is calculated using the population attributable risk
(PAR), which is based on the strength of the risk factor
and the prevalence of the risk factor in the population.
To determine the strength of the risk factor, epidemiol-
ogists calculate what is referred to as the relative risk (RR)
(Chapter 3). If these pieces of the equation are known,

that is, the RR and the prevalence, then the PAR can be
calculated.21

Those who wish to implement a prevention program
can use the PAR to calculate the cost benefit and cost effec-
tiveness of the prevention program. However, the PAR is
population based and operates on the assumption that the
risk factor is removed from the entire population being
targeted. The prevented fraction provides the information
on what can be accomplished based on the intervention
actually being delivered at the community level. The
prevented fraction is defined as a measure of what can
actually be achieved in a community setting. It includes
the proportion of the population at risk that actually
participates and the number of cases prevented. This
approach takes into account the number of participants in
a program who will actually succeed in eliminating the risk
factor. For example, how many obese children participat-
ing in an after-school activity program will actually reduce
their weight to a normal body mass index?

Prior to implementing an intervention aimed at
prevention, it is important to understand the underly-
ing risk factors. The top four risk factors for preventable
death in the United States—tobacco use, improper
diet, physical inactivity, and alcohol use—relate to
behaviors.33 At first glance, it appears that a behavioral
intervention is the best approach. However, other in-
terventions are also helpful, including environmental
and policy-based interventions. For example, alcohol-
related MVCs can occur with just one episode of heavy
episodic drinking. The teenage driver who has con-
sumed alcohol for the first time at high levels and then
drives home may become involved in an MVC that
results in the death of people who are not consuming
alcohol. The teen did not have an alcohol use disorder
but instead had engaged in at-risk alcohol use. The nat-
ural history of disease does not fit this health-related
issue, yet prevention of alcohol-related MVCs is an
important issue. The questions become:

• What types of interventions will work to prevent dis-
ease or injuries?

• Is it primary, secondary, or tertiary prevention?
• Can it occur using a clinical, behavioral, or environ-

mental approach?
• In designing this approach, should it be addressed

as a universal, selected, or indicated preventive
intervention?

In answering these questions, it is important to have
a better understanding of some potential public health
nursing interventions and a framework that guides
public health nursing practice.

34 U N I T I n Basis for Public Health Nursing Knowledge and Skills

• Heart disease: 635,260
• Cancer: 598,038
• Accidents (unintentional injuries): 161,374
• Chronic lower respiratory diseases: 154,596
• Stroke (cerebrovascular diseases): 142,142
• Alzheimer’s disease: 116,103
• Diabetes: 80,058
• Influenza and pneumonia: 51,537
• Nephritis, nephrotic syndrome, and nephrosis: 50,046
• Intentional self-harm (suicide): 44,965

BOX 2–2 n Number of Deaths for Top 10 Leading
Causes of Death, 2017

Source: (31)

7711_Ch02_023-054 23/08/19 10:21 AM Page 34

A Public Health Nursing Framework
Conceptual frameworks and models guide the practice
of public health nurses (PHNs). One of the models im-
plemented by the Minnesota State Department of Health
in 2001 is the Intervention Wheel, which illustrates how
PHNs can improve the health of the individuals, families,
communities, and systems34,35 (Fig. 2-5). The model
evolved from the practice of PHNs in Minnesota and

consists of several components. The first component is
the population basis of all interventions. This component
illustrates that the focus of all interventions is population
health. The second component consists of the three levels
of care: individual/family, community, and systems. Care
can be provided at all three levels of working with indi-
viduals, the community as a whole, or with systems. In-
dividual level practice focuses on knowledge, attitudes,
practices, beliefs, and behaviors of individuals. A PHN’s

C H A P T E R 2 n Optimizing Population Health 35

Public Health Interventions
Applications for Public Health Nursing Practice

March 2001

Minnesota Department of Health
Division of Community Health Services
Public Health Nursing Section

Figure 2-5 Components of
the Intervention Wheel. (From
Minnesota Department of Health,
Division of Community Health
Services, Public Health Section.
[2001]. Public health interventions:
Applications for public health
nursing practice.)

7711_Ch02_023-054 23/08/19 10:21 AM Page 35

home visit to a new mother is an example of individual-
level practice. During the visit, the PHN provides antic-
ipatory guidance about the value of breastfeeding.

Community-level practice is focused on changing
norms, attitudes, practices, awareness, and behaviors. An
example of community-level practice is the development
of a faith-based program focused on smoking cessation.
Systems-level practice is concerned with policies, laws,
organization, and power structures within communities.
For example, a coalition of several senior housing sites
could be formed to address pest control and improve-
ment of overall environmental conditions, or a group of
parents could come together to build a safe playground
for the children.

The third component consists of 17 public health
interventions (Box 2-3). Three of these interventions—
health education, screening, and case management—are
discussed in this chapter as they relate to levels of pre-
vention, and the other interventions are discussed in
other chapters.

A Primary Prevention Approach:
Health Education
The purpose of health education is to positively change be-
havior by increasing knowledge about health and disease.
Health education is an important nursing intervention,

36 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Advocacy pleads someone’s cause or act on someone’s
behalf, with a focus on developing the community,
system, individual, or family’s capacity to plead their
own cause or act on their own behalf.

Case finding locates individuals and families with identified
risk factors and connects them with resources.

Case management optimizes self-care capabilities of indi-
viduals and families and the capacity of systems and
communities to coordinate and provide services.

Coalition building promotes and develops alliances among
organizations or constituencies for a common purpose.
It builds linkages, solves problems, and/or enhances
local leadership to address health concerns.

Collaboration commits two or more people or organiza-
tions to achieve a common goal through enhancing the
capacity of one or more of the members to promote
and protect health. (Henneman, Lee, & Cohen. [1995].
Collaboration: A concept analysis. Journal of Advanced
Nursing, 21, 103-109.)

Community organizing helps community groups to iden-
tify common problems or goals, mobilize resources, and
develop and implement strategies for reaching the goals
they collectively have set. (Minkler, M. [Ed.]. [1997].
Community organizing and community building for health
[p 30]. New Brunswick, NJ: Rutgers University Press.)
Delegated functions are direct care tasks that a regis-
tered professional nurse carries out under the authority
of a health-care practitioner as allowed by law. Dele-
gated functions also include any direct care tasks that a
professional registered nurse entrusts to other appro-
priate personnel to perform.

Consultation seeks information and generates optional
solutions to perceived problems or issues through in-
teractive problem-solving with a community, system,
family, or an individual. The community, system, family,

or individual selects and acts on the option best meet-
ing the circumstances.

Counseling establishes an interpersonal relationship with
the community, a system, the family, or an individual
intended to increase or enhance their capacity for self-
care and coping. Counseling engages the community, a
system, family, or an individual at an emotional level.

Disease and other health event investigation systemati-
cally 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.

Health teaching communicates facts, ideas, and skills that
change knowledge, attitudes, values, beliefs, behaviors,
and practices of individuals, families, systems, and/or
communities. (Adapted from American Nurses Associa-
tion [2010]. Nursing’s social policy statement: The essence
of the profession. [2010]. Silver Springs, MD; American
Nurses Publishing.)

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.

Policy development places health issues on decision mak-
ers’ agendas, acquires a plan of resolution, and deter-
mines needed resources. Policy development results in
laws, rules and regulations, ordinances, and policies.

Policy enforcement compels others to comply with the
laws, rules, regulations, ordinances, and policies created
in conjunction with policy development. (Minnesota
Department of Health, Division of Community Health
Services, Public Health Section. [2001]. Public health in-
terventions: Applications for public health nursing practice.
Retrieved from http://www.health.state.mn.us/
divs/opi/cd/phn/docs/0301wheel_manual .).

BOX 2–3 n Public Health Interventions

7711_Ch02_023-054 23/08/19 10:21 AM Page 36

and it is important in changing behavior at all levels of
prevention. The Joint Committee on Health Education
and Promotion Terminology defined health education
as learning aimed at acquiring information and skills
related to making health decisions.36 The WHO defines
health education as “… any combination of learning
experiences designed to help individuals and communi-
ties improve their health, by increasing their knowledge
or influencing their attitudes…”37 Health education in-
volves not just teaching but also encouraging and giving
confidence to people to take the necessary action to im-
prove health, which includes making changes in social,
economic, and environmental determinants of health.

Theories of Education
Because health education involves teaching, understand-
ing how people learn is essential to effective teaching.
There are a number of learning theories that help us
understand how learning occurs from both a physiolog-
ical and social basis. The main theories come under four
categories: behaviorism, cognitivism, constructivism,
and humanism.

Behaviorism is the theory of classical conditioning. In
this framework, the behavior change is what is impor-
tant, and it is achieved with an environmental stimulus
that results in a response. The focus is only on the
observed behavior change and not on the mental activity.
Learning is based on reward and punishment by condi-
tioning (e.g., when a monkey learns to push a button for
a reward of food).38

The cognitive framework focuses more strongly on
inner mental activity. It is more rational than it is on re-
flexively responding to an external stimulus. There is be-
havior change as a result of knowledge that has changed
thought patterns. It frequently occurs as a result of varied
sensory inputs with repetition. The social learning theory

of Bandura is rooted in both the behavior and cognitive
frameworks, emphasizing that understanding, in addition
to behavior and environment, are all interrelated. He
stresses imitation of a behavior and reinforcement in
learning.39 An example of Bandura’s theory of social
learning is television commercials. An action is portrayed,
eating a certain food or using a certain cleaning product,
and the audience, seeing it as desirable, is encouraged to
model or imitate that behavior.

Constructivism is a learning theory that reflects on
our own experiences.40 We actively construct our own
world as we increase our experience and knowledge. It
is a process that builds knowledge within our own
unique framework. A good example is problem-solving
learning. To learn, students are actively involved in in-
tegrating new knowledge in their own frameworks with
guidance from the teacher. For example, children can
learn about what happens to their heart rate with exercise
by experimenting with different types of exercise and
counting pulse rates. They experience the concept of a
heart rate rather than merely having it verbally explained
to them.

Humanism learning uses feelings and relationships,
encouraging the development of personal actions to
fulfill one’s potential and achieve self-actualization.38

It is self-directed learning, examining personal motiva-
tion and goals. This is also a theory of adult learning.40

As an example, an individual diagnosed with elevated
cholesterol purchases books, seeks out articles, talks with
knowledgeable people, and in general informs him- or
herself about the problem and actions to take to solve the
problem then self-initiates these activities to improve
health.

All learning theories influence how we teach. The
identified teaching methods based on these theories
are varied but include the need to be developmentally

C H A P T E R 2 n Optimizing Population Health 37

Source: (34)

Referral and follow-up assist individuals, families, groups,
organizations, and/or communities to identify and
access necessary resources to prevent or resolve
problems or concerns.

Screening identifies individuals with unrecognized health
risk factors or asymptomatic disease conditions in
populations.

Social marketing uses commercial marketing principles and
technologies for programs designed to influence the
knowledge, attitudes, values, beliefs, behaviors, and
practices of the population-of-interest.

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 (Centers for Disease Control and
Prevention. [2012]. CDC’s vision for public health
surveillance in the 21st century. Morbidity and Mortality
Weekly Report, S61).

BOX 2–3 n Public Health Interventions—cont’d

7711_Ch02_023-054 23/08/19 10:21 AM Page 37

appropriate with children and with adults with varying
levels of education. Many of the more recent theories
provide a more balanced learning; encourage experien-
tial learning; and solve real problems in real places
by using role playing, visual stimuli, service learning,
interpersonal learning, and the promotion of complex
higher-order thinking.

Adult Learning
Pedagogy (pedagogical learning) is the correct use of
teaching strategies to provide the best learning. Andra-
gogy is similar but is specifically the art and science of
helping adults learn using the correct strategies.40 In
nursing, we are often teaching adults, as it is adults who
generally develop chronic diseases, are in a position to
promote health, and care for children. In the 1950s
Malcolm Knowles, using humanism learning theory,
suggested that adults learn differently from children and
that the role of the instructor is quite different. Adults
bring a great deal of experience to the learning situation,
and this experience influences what education they
receive and how they receive it.41 They are active learners
and need to see applications for the new learning.
Knowles identified six suppositions for adult learning:

1. The adult needs to know why he or she is learning
something.

2. The adult’s own experiences are an important part
of the learning process.

3. Adults need to participate in the planning and eval-
uation of their learning.

4. Adults learn better if the information has immediate
relevance.

5. Adults like problem-centered approaches to learning.
6. Adults respond better to internal rather than to

external motivation.

The role of the teacher in this situation is to direct the
learner.41

To be an effective educator the nurse needs to be flex-
ible. Nurses organize the learning experience by first as-
sessing the individual’s or population’s learning needs.
They then select the best learning format, create the best
possible learning environment, and send a clear message.
The learning should be participatory and include evalu-
ation and feedback.

Health Literacy
One of the first considerations before planning health
education is to consider the health literacy of the indi-
vidual client, the group, or the population. In conjunc-
tion with literacy, culture and language should also be

included. Health literacy is defined as “the degree to
which individuals have the capacity to obtain, process,
and understand basic health information and services
needed to make appropriate health decisions.”42 The
HMD division of the National Academies of Sciences,
Engineering, and Medicine built on this definition and
added key issues related to the individual receiving in-
formation. They stated that health literacy is something
that “emerges when the expectations, preferences, and
skills of individuals seeking health information and serv-
ices meet the expectations, preferences, and skills of those
providing information and services. Health literacy arises
from a convergence of education, health services, and
social and cultural factors.”42

Assessing literacy levels is currently done based on
levels, with levels 4 and 5 representing the top level and
level 1 and below representing the lowest literacy level.
According to the National Center for Education Statis-
tics, 18% of U.S. adults scored at or below level 1.43

They reported an association between age and literacy
with a greater percentage of those between the ages
of 25 and 44 scoring at the top level. For those who
were unemployed, 75% had 12 years of education or
less and approximately a third scored at level 1 or
below.44 There is evidence of a causal relationship
between health literacy and health outcomes. Those in-
dividuals with basic health literacy had a higher level
of health-care utilization and higher expenditures for
prescriptions.45 To address the problem of health liter-
acy the CDC put together five talking points about
health literacy that can be adapted to a specific organ-
ization as a means to advocate for promotion of heath
literacy (Box 2-4).46

Shame and stigma of having low health literacy have
been found to be major barriers to seeking care. The IOM
committee found that health education occurred in most
primary and secondary schools, but there was no univer-
sal sequencing, and only about 10% of teachers were qual-
ified health educators. One of the most telling of the IOM
findings was that health professionals had limited training
in patient/population education and had few opportuni-
ties to develop skills to improve a patient’s health literacy.
The IOM gave multiple suggestions on how to improve
health literacy, and points of intervention (Fig. 2-6). Some
of the most relevant to nursing included:

• Improve K through 12 basic health education.
• Help individuals learn how to assess the credibility of

what they see and read about health.
• Provide clear communication, allow ample time to

give this information, and encourage questions from
the patient.42

38 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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In the past few years, considerable research has been
done that brings better understanding to the magnitude
and consequences of the health literacy problem. One of
the issues is how to assess correctly and rapidly the level
of health literacy in a patient/population. Though there
are tools to screen for health literacy, they were developed
primarily for research purposes and are not currently rec-
ommended for routine use. Instead the recommendation
is to use universal health literacy precautions, which
translates into providing patients with information both
oral and written that is understandable and easily acces-
sible to persons across all education levels.47 The AHRQ
recommends use of universal health literacy precautions
and lays out what needs to be done (Box 2-5). The AHRQ
developed an evidenced-based toolkit for health-care

providers to help implement universal health literacy
precautions within a health-care setting. The goal is to
increase the health literacy of all patients, not just those
that appear to need assistance.48

Develop a Teaching Plan
Writing a teaching plan for individuals or populations
provides a means to lay out what will be taught, using
what methods, as well as a method for evaluating the
effectiveness of the teaching plan (Box 2-6). The teaching
begins with the assessment of the health education need.
What does this individual or population need to learn, or
what would they benefit from learning, to promote
health, prevent disease, or help manage an identified
health problem? Next, the nurse assesses the type of
learner or learners who will receive the education. For
example, what is their level of health literacy? Also, what
is the cultural context for the population? What is their

C H A P T E R 2 n Optimizing Population Health 39

Potential Intervention Points

Health
System

Culture
and

Society

Health
Outcomes
and Costs

Education
System

Health
Literacy

Figure 2-6 Potential points for intervention in the
health literacy framework. (From Nielsen-Bohlman, L.,
Panzer, A., Kindig, D. [2004]. Health literacy: A prescription to
end confusion [IOM Report].)

You are a health literacy ambassador. It is up to you to
make sure your colleagues, staff, leadership, and commu-
nity are aware of the issues. Whether to review for
yourself, present to others, or convince your leadership,
the following resources may help you talk about health
literacy.

Five Talking Points on Health Literacy: These brief
talking points may be helpful if you need to tell someone
quickly what health literacy is and why it is important.
Add in talking points relevant to your organization.

1. Nine out of 10 adults struggle to understand and use
health information when it is unfamiliar, complex, or
jargon-filled.

2. Limited health literacy costs the health-care system
money and results in higher than necessary morbidity
and mortality.

3. Health literacy can be improved if we practice clear
communication strategies and techniques.

4. Clear communication means using familiar concepts,
words, numbers, and images presented in ways that
make sense to the people who need the information.

5. Testing information with the audience before it is
released and asking for feedback are the best ways
to know if we are communicating clearly. We need
to test and ask for feedback every time information is
released to the general public.

BOX 2–4 n The CDC’s Five Talking Points on Health Literacy

Source: (45)

Health literacy universal precautions are the steps that
practices take when they assume that all patients may
have difficulty comprehending health information and
accessing health services. Health literacy universal precau-
tions are aimed at:

• Simplifying communication with and confirming
comprehension for all patients, so that the risk of
miscommunication is minimized.

• Making the office environment and health-care system
easier to navigate.

• Supporting patients’ efforts to improve their health.

BOX 2–5 n Health Literacy Universal Precautions

Source: (47)

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age, gender, and level of vulnerability? All of this infor-
mation will help drive how the information is provided.
Inclusion of the recipients in the planning process can be
an important strategy as can be the use of peer teachers.

Once the assessment has been completed, the next
step is to identify the goal(s) of the health education

program. Again, inclusion of the recipients in the pro-
gram will result in shared goals and greater engagement
of those receiving the program. For example, if from the
nurse’s perspective the goal of a proposed health educa-
tion program is to reduce premature births, including
women in the community who are pregnant or who may
become pregnant in the development of the program
may help shape the articulation of goals. What are the
immediate benefits to them for having a full-term baby?
What other issues are they concerned about related to
pregnancy and birth? This way specific objectives can be
written that truly meet the goals of the community.

To help frame learning objectives, Bloom identified
three learning domains: cognitive, affective, and psy-
chomotor.50 Identifying which learning domain is being
targeted is important when developing the plan. Within
the cognitive domain, Bloom identified six levels of cog-
nitive learning, from simple knowledge recall to more
abstract and higher-level synthesis and evaluation. Each
level, especially the first three, builds on the next. This is
referred to as Bloom’s Taxonomy, and this classification
is useful in looking at levels of learning, outcomes, and
the correct action verbs to be used when writing specific-
level learning objectives (Box 2-7). The first level of
learning is knowledge, which refers to remembering or
recalling specific information that has been taught. Com-
prehension is the second level and requires some demon-
stration of really understanding what was learned.
Application, the third level, requires using the knowledge
in real situations such as problem-solving. The next level
is analysis, wherein the acquired knowledge is broken
down by its organization and things such as making
inferences and looking for motives or causes. The last
two are synthesis and evaluation. In synthesis, the ac-
quired knowledge is used creatively to produce some-
thing new. Evaluation provides a way to judge the end
product. In addition to cognitive learning, Bloom also
identified affective and psychomotor learning. The affec-
tive domain looks at a growth in feelings, values, and at-
titudes. Psychomotor learning is the development of
manual or physical skills, a domain frequently taught by
nurses.

Once the plan is developed, the next step requires
identifying materials and resources needed for effective
teaching. Factors include the length of the lesson, where
it will be taught, what activities will promote the best
learning, and how much time will be needed to prepare
the lesson. It is helpful to write out a description of the
lesson including the key concepts and the learning do-
main of knowledge, attitude, and/or practice. The final
two steps are to write out the detailed procedure for the

40 U N I T I n Basis for Public Health Nursing Knowledge and Skills

1. Identify the health education need in the selected
population (individual/family/community).

2. Assess the learner; include health literacy, culture,
language, age, and learning style.

3. Write a goal for the teaching intervention.
4. Write specific, measurable objectives for the teaching

intervention (consider Bloom’s Taxonomy).
5. Identify materials and resources needed for the

teaching plan; include the appropriate teaching
environment and the length of the lesson.

6. Describe the lesson; include key concepts.
7. Write out the procedure step by step for teaching

the lesson using a variety of teaching methods.
8. Have a plan for the evaluation.

BOX 2–6 n Steps in Developing a Health Education
Teaching Plan

n CULTURAL CONTEXT
National Institutes of Health: Clear
Communication
The NIH Office of Communications and Public Liaison
(OCPL) established a “Clear Communication” initiative
related to health literacy with cultural respect as one of
the two foci of the initiative. Specifically:

• Cultural respect is a strategy that enables organizations
to work effectively in cross-cultural situations. Developing
and implementing a framework of cultural competence
in health systems is an extended process that ultimately
serves to reduce health disparities and improve access to
high-quality health care.

• Cultural respect benefits consumers, stakeholders, and
communities. Because a number of elements can influence
health communication—including behaviors, language,
customs, beliefs, and perspectives—cultural respect is also
critical for achieving accuracy in medical research. NIH
funds and works with researchers nationwide for the
development and dissemination of resources designed to
enhance cultural respect in health-care systems.49

Further resources are available through their Web site.

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teaching plan, carefully outlining each activity, and, if ap-
propriate, the follow-up for these activities. The final
component is to determine how an evaluation will meas-
ure whether or not the intended learning took place. The
evaluation plan should reflect the learning objectives and
be in place before teaching begins to anticipate how to
measure the outcomes.

Methods of Instruction
There are many ways to learn the same information, and
each of us has a preference for how we like to learn. There
are lists of different teaching methods that include formal
presentations, small-group work, field trips, role playing,
written assignments, and Internet activities, to identify a
few. Usually, experiential learning is most effective for
adults. Lecture format rarely appeals to an adult who
wants guided interactive learning. If people can feel it,
handle it, see it, taste it, smell it, and discuss it, they can
better integrate it into their own life experiences. A group
concerned with nutrition and being overweight may be
told that Ritz crackers, potato chips, corn chips, and
cheeseburgers are high in fat and also high in calories.
The group can be given numbers of calories and grams,
but it is not easily integrated into their life experiences.
However, if the portion size of four Ritz crackers, 10 po-
tato chips, and 1 ounce of corn chips, all having 8 to
9 grams of fat, are demonstrated, it is easier for people to
put it into the context of their own lives.

Using real-life scenarios to teach how to solve health
problems has also been quite effective. Giving new moth-
ers a vignette in which a family is having difficulty getting
adequate sleep at night because their 4-month-old
infant is awake all night allows for group discussion and
problem-solving that can be relevant at the moment. This
is information these women can take home and apply
immediately. Teaching children the importance of exer-
cise by using videos, Internet, and PowerPoint slides
can be entertaining and provide basic knowledge. Help-
ing children form walking groups and joining them for
their walks can help them apply this knowledge and start
to change behavior. Written material can help encourage
discussion, but the material must be appropriate for
literacy, content, culture, and language.

Regardless of the teaching method, it is always impor-
tant to emphasize the benefits of the proposed behavior
change and to personalize the message. A good strategy
is to apply the intended new behavior within the context
of the individual’s lifestyle and needs. Help clients weigh
the cost and benefit of the new health behavior. Key
points should be emphasized during teaching and new
information provided in small increments. Most people
can absorb only one or two new pieces of information in
an encounter. Learners are the best source of information
about what they want to learn and if the teaching method
is meeting their needs. Feedback should be frequently
sought from learners.

C H A P T E R 2 n Optimizing Population Health 41

Knowledge Comprehension Application Analysis Synthesis Evaluation
Define Discuss Interpret Distinguish Plan Judge
Repeat Recognize Apply Calculate Design Appraise
List Explain Use Test Assemble Value
Name Interpret Practice Compare Invent Assess
Tell Outline Demonstrate Question Compose Estimate
Describe Distinguish Solve Analyze Predict Select
Relate Predict Show Examine Construct Choose
Locate Restate Illustrate Compare Imagine Decide
Write Translate Construct Contrast Propose Justify
Find Compare Complete Investigate Devise Debate
State Describe Examine Categorize Formulate Verify
Arrange Classify Classify Identify Create Argue
Duplicate Express Choose Explain Organize Recommend
Memorize Identify Dramatize Separate Arrange Discuss
Order Indicate Employ Advertise Prepare Rate

Locate Practice Appraise Propose Prioritize
Determine

BOX 2–7 n Bloom’s Taxonomy of Learning*

Source: (49)
*Active verbs represent each level.

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The environment should not be neglected in a teach-
ing plan. The physical environment is important and
should be maximized as much as possible even when
many things in a community setting may be outside of
one’s control. A space should be the right size, have a
comfortable temperature, adequate places to sit, the nec-
essary resources for the planned lesson, and a place
where, as appropriate, the learners can receive and share
confidential information. However, one also needs to
create an environment conducive to learning in which
the learner has space to be an active learner and to learn
from real situations with someone to assist with guidance
and direction to master the material. It should be a place
in which individuals feel free to voice opinions, experi-
ment with new ideas, and identify what they do not
know; a place in which there is enthusiasm for learning
in a nonthreatening environment.

Evaluation
Successful learning changes behavior. Deciding how to
evaluate whether this learning has occurred requires re-
ferring back to the specific objectives for the level of
learning that was to take place and the specific outcomes
expected. If the first stage of teaching was to increase
knowledge, an appropriate method is needed to measure
whether the knowledge did increase. If the objective was
for the mother to explain how the different childhood
immunizations will keep her child healthy and prevent
disease, the mothers should be asked to repeat back the
information they have just received or play a game in
which they have to know the answers to specific factual
questions. If the objective was to help individuals apply
knowledge, the applied learning should be evaluated
in a different way. For application, one can provide a sce-
nario at the end of the teaching session and then note
how students solve the problems utilizing the informa-
tion just taught. A follow-up discussion with the group
may be held after they have had time to apply their new
knowledge. If the objective was for the mother to practice
primary prevention by having her child fully immunized
by 2 years of age, the mother’s behavior may be observed
after the teaching to determine whether the knowledge
has been applied and the child has been fully immunized.

There are several tools that can be used to evaluate
health education. It is always a good idea to ask for verbal
reaction to the teaching at the end of a teaching session.
This is useful in planning for future health education
sessions. To measure an increase in knowledge, a classic
pre- and post-test should be used, or a pre- and post-
interview/observation. Using a formal testing method is
frequently not well liked by adult learners, especially

those who have limited literacy skills. They respond
better to the oral interview, but this is more difficult to
carry out. To assess change, one can observe and inter-
view over a specific time period, especially to note the
sustainability of the change. These tools need to be
thoughtfully developed to provide objective, reliable
data. Likewise, long-term effects of the teaching may be
evaluated using objective predesigned tools (for more
complete discussion of evaluation, see Chapter 5).

Health education forms the basis for many health pre-
vention programs aimed at improving the health of in-
dividuals as well as of families. Nurses learn this skill first
with individuals, then families, and finally with popula-
tions and communities. Health education operates under
the assumption that improving health literacy is central
to improving health. In addition to health education,
other activities regularly performed by nurses, such as
screening, contribute to building the health of commu-
nities. Often these activities require the use of health
education as a strategy to improve full participation in
the prevention activity.

A Secondary Prevention Approach:
Screening and Early Identification
Just as health education is the basis of many primary
prevention programs, screening is central to secondary
prevention. The classic definition of screening is the
presumptive identification of unrecognized disease or
defect by the application of tests, examinations, or other
procedures that can be applied rapidly to sort out those
with a high probability of having the disease from a
large group of apparently well people.51 Screening is not
diagnostic and only indicates who may or may not have
a disease or a risk factor for disease.

Nurses routinely screen for health risks and disease
across health-care settings. This type of intervention
clearly fits within the secondary prevention phase of the
traditional public health prevention model. This allows
for early identification and treatment of disease as well
as the reduction of risk for those who are at greatest
risk for developing disease or sustaining injury. A good
example is blood pressure screening. If those with hyper-
tension are identified prior to development of clinical
symptoms, the institution of behavioral and clinical
interventions such as diet modification and the use of a
diuretic can bring the individual’s blood pressure back
to within the normal range and prevent adverse health
consequences associated with hypertension, such as
stroke. Screening conducted to detect risk factors in

42 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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people without disease includes screening for at-risk
drinking or fall risk. This type of screening is aimed at
distinguishing those with a higher risk for developing
disease or injury from those with low risk. For example,
screening for at-risk drinking not only identifies those
who may have an alcohol use disorder but also identifies
those with a current drinking pattern that puts them at
risk for developing an alcohol use disorder, developing
alcohol-related adverse consequences, or experiencing
alcohol-related injury (see Chapter 11).

When using the traditional public health model,
screening clearly falls into the category of secondary
prevention. The purpose is to identify within a group
of apparently well people those who probably have the
disease. For those with complex risk factors and a less
clear natural history of disease, the traditional model
has less utility. This is true with mental health, sub-
stance use disorders, and injury. In these cases, screen-
ing is done for the purpose of detecting risk for disease
or injury prior to the occurrence of disease as well as
the detection of disease in those who are apparently
well. It can be classified as both primary and secondary
prevention.

Using a continuum of health approach to prevention
provides a broader context for understanding the role of
screening as a prevention intervention. Screening in-
cludes identification of those with risk factors for disease
or injury as well as those with subclinical disease. In the
first case the assumption is that early detection of risk
and delivery of risk reduction interventions will reduce
disease or injury from occurring. In the second case,
the assumption is that early identification and treatment
of those with disease will result in reduction of the mor-
bidity and mortality associated with the disease. This
allows for screening to prevent disease or injury from
occurring in the first place (primary prevention) as well
as to prevent adverse health consequences that can be
avoided with early detection and treatment of disease
(secondary).

Most diseases are associated with a complex set of risk
factors and often do not progress in a linear fashion. In
addition, the broader continuum health model takes into
account not only adverse physical outcomes, but also
psychological, social, and economic outcomes. An exam-
ple of screening that reflects primary prevention is the
approach being used to prevent childhood obesity.
Screening for risk factors such as inactivity and high
caloric intake can help identify children without disease
who would most benefit from an intervention. Thus, the
screening process is conducted in a population without
disease to separate those with a high probability for

developing disease or sustaining an injury from those
with low or no risk factors for the disease or injury.

Diagnosis, Screening, and Monitoring
The difference between diagnosis, screening, and monitor-
ing is often blurred. For example, taking blood pressure
readings at a blood pressure screening event that only
includes people who have not been diagnosed with hyper-
tension is clearly screening, detecting probable disease in a
population of apparently well people. Taking a blood pres-
sure reading for a patient every 4 hours on a medical-surgi-
cal unit in the hospital is done to monitor the patient’s vital
signs and detect possible changes in the patient’s status,
and it is not a screening activity. Taking blood pressure
readings at a booth at a health fair where many of the par-
ticipants come to the booth and state that they have
hypertension and need to know how they are doing is a
combination of screening and monitoring, because many
of the participants have already been diagnosed. The nurse
practitioner or physician takes a blood pressure reading
during a physical work-up to assist in establishing a differ-
ential diagnosis for hypertension. The same activity is done
to screen, monitor, or assist in obtaining a diagnosis.

For each of these activities, there are set parameters
for the measure. In the case of monitoring the patient,
the nurse compares the most recent blood pressure read-
ing with the patient’s baseline reading and the readings
over the admission to determine whether there has been
a change in the patient’s status. The blood pressure read-
ing is part of a larger nursing assessment and, if the read-
ing reflects a change in the patient’s status, the nurse may
change the plan of care for either a positive or negative
change. When using the blood pressure reading from a
diagnostic standpoint, there are specific guidelines for
the clinician, and the blood pressure levels are based
on the average of two or more readings. These readings
are taken during the course of two or more visits.26 Using
the guidelines, the clinician can make a diagnosis of
stage 1 or stage 2 hypertension, or classify the patients as
prehypertensive. The guidelines have been revised based
on growing evidence related to both hypertension and
the development of a new category of risk, prehyperten-
sion, and are evidence based.26

The guidelines state that the process for diagnosing
hypertension occurs after an initial screening. So how
does the screening differ from the diagnostic stage be-
cause the same measurement is taken—a blood pressure
reading using standard equipment? In this case, the main
difference is that the screening is based on one reading
rather than two or more blood pressure readings over a
number of visits, and the purpose of taking the blood

C H A P T E R 2 n Optimizing Population Health 43

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pressure reading is to identify those who may be hyper-
tensive and are in need of further assessment and possi-
ble treatment. The clinician conducting the screening
will refer the individual whose blood pressure meets the
cutoff for probable hypertension to a clinician who is
qualified to conduct the needed assessment and is able
to make a differential diagnosis.

Sensitivity and Specificity
For all of these activities—screening, monitoring, and
diagnosis—the clinician must have a clear understanding
of the reliability and validity of the measure chosen to
screen for risk and/or probability of disease. Understand-
ing the reliability and validity of a screening tool provides
the clinician conducting the screening with the guide-
lines for deciding what is a positive screen and what is a
negative screen, that is, who most probably has the dis-
ease and who most probably does not. Or in the case of
screening for risk, it provides the guidelines for deciding
what is considered high risk and what is considered
low risk. In the case of blood pressure screening, the
screening is done for the most part using the same basic
instrument used to diagnose disease and monitor phys-
ical status, but for other health issues, the screening tool
is different from the diagnostic tool. Determining the
validity of the instrument for screening uses different
criteria than for diagnosis or for monitoring status.

In screening, the reliability and validity of the instru-
ment is crucial. Reliability is defined as the ability of the
instrument to give consistent results on repeated trials.
Validity is defined as the degree to which the instrument
measures what it is supposed to measure. For screening
instruments, the two aspects of validity that are the main
concerns are the sensitivity and the specificity of the in-
strument. Sensitivity is defined as the ability of the
screening test to give a positive finding when the person
truly has the disease, or true positive. Specificity is de-
fined as the ability of the screening test to give a negative
finding when the person truly does not have the disease,
or true negative.

44 U N I T I n Basis for Public Health Nursing Knowledge and Skills

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Silent Killer
Public Health Science Topics Covered:

• Screening
• Population assessment
• Health planning

Choosing a screening instrument requires under-
standing the importance of both sensitivity and

specificity. For example, in a hypothetical case a
team of nurses at a large urban hospital noticed that
there had been an increase in admissions of African
American men with a diagnosis of cardiovascular dis-
ease secondary to hypertension. They wanted to put
a large-scale blood pressure screening program in
place for the African American men in their city to
improve early detection of hypertension and poten-
tially reduce the need for hospitalization. Prior to
implementing the program, they wanted to make sure
that the method they used to screen for hypertension
was valid. This was important for two reasons. First,
they did not want to have too many false negatives. In
other words, they wanted to identify as many men as
possible with hypertension because there was such a
high morbidity and mortality rate for untreated hy-
pertension in the male African American population.
Second, they did not want too many false positives,
because this population had limited resources to pay
for care. Unnecessary visits to the physician could
result in reduced participation in the program, espe-
cially because an accurate diagnosis requires more
than one visit to a health-care provider. Too many
false positives could result in unnecessary utilization
of health-care resources.

Prior to initiating a full-scale screening program,
the nurses conducted a pilot with 250 African Ameri-
can men who had not been diagnosed with hyperten-
sion, who were not taking antihypertensive (blood
pressure–lowering) drugs, and who were not acutely
ill. To do the screening, they used a standard blood
pressure cuff and stethoscope and measured the
blood pressure in millimeters of mercury (mm Hg).
The nurses debated over the cutoff point. The 2017
guidelines for a diagnosis of stage one hypertension
is a blood pressure reading greater than or equal to
130 systolic (mm Hg) or greater than or equal to
80 diastolic was not yet released.26 Thus, they chose
the then-current diagnostic criteria of a blood pressure
reading greater than or equal to 140 systolic (mm Hg)
or greater than or equal to 90 diastolic. To evaluate the
sensitivity and specificity of the screening, all the partici-
pants were asked to complete three follow-up visits
with a primary care physician to establish whether or
not the participants had hypertension. Because this was
a pilot study, the nurses obtained written consent from
the participants and followed the Internal Review Board
process required by their institution.

Once they had obtained approval, the nurses con-
ducted the pilot study with 250 participants. First, the

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C H A P T E R 2 n Optimizing Population Health 45

A = True positives (screened positive and had the disease)

Screening for stage 1 or 2 hypertension with 250 persons

B = False positives (screened positive and did not have the disease)

C = False negatives (screened negative and had the disease)

D = True negatives (screened negative and did not have the disease)

Screening
Results Yes No Total

Yes 15 55

Disease (+ = BP �140/90)

C D

15No 180 195

55Total 195 250

Figure 2-7 Sensitivity and specificity matrix.

nurses screened the participants for possible hyperten-
sion by obtaining a blood pressure reading. They then
obtained follow-up data on all 250 in relation to
whether or not they were diagnosed with stage one or
stage two hypertension based on the current classifica-
tion of hypertension for adults age 18 years and older.
A diagnosis of hypertension is based on the average
of two readings greater than or equal to 130 systolic
(mm Hg) or greater than or equal to 80 diastolic.26 The
nurses then calculated basic frequencies on their data
and found that 55 of the participants screened positive
for hypertension and, on follow-up, 55 were diagnosed
with hypertension. On the surface, it looked as though
their screening instrument was 100% sensitive as they
correctly identified all who had the disease, but that
was not the case.

To determine the sensitivity and specificity of the
method they used to screen for hypertension, the
nurses constructed a two-by-two matrix using screen-
ing and diagnostic data (Fig. 2-7). They determined the
number of participants that belonged in each box of
the matrix. Each box of the matrix corresponds to four
different categories of participants: (1) those who were
true positives, that is, they screened positive and the
physician diagnosed them with hypertension, box A;

(2) those who were false negatives, that is, they
screened negative but the physician diagnosed them
with hypertension, box C; (3) those who were false
positives, that is, they screened positive and the physi-
cian did not diagnose them with hypertension, box B;
and (4) those who were true negatives, that is, they
screened negative and the physician did not diagnose
them with hypertension, box D.

Using these numbers, the nurses examined the sen-
sitivity of their instrument. They took the total of all
the persons who had positive screens and were subse-
quently diagnosed with either stage one or stage two
hypertension and divided it by the total number of peo-
ple diagnosed with the hypertension and multiplied this
by 100. Another way to express this formula is to use
the letters in the lower right-hand corner of two of the
boxes in the matrix, boxes A and C. The total number
of true positives, or A, is 40, and the total number
with disease (true positives plus false negatives)
equals 55, or A + C. Thus, the formula for sensitivity
is (A/(A + C)) × 100. In this example, the sensitivity is:
(40/55) × 100, or 72.7%

They then determined the specificity of their instru-
ment. To do this, they repeated what they had done
with sensitivity, but now they were concerned with
the relationship between those who were true nega-
tives and the total number who screened negative.
Again, the letters in the lower right-hand corner of
the boxes are used to construct the formula, but this
time the boxes of interest are boxes B and D. The
total number of participants who are true negatives,
or D, is 180, and the total number without disease
equals 195, or D + B. The formula for specificity is
(D/(B + D)) × 100. In this example, the specificity is:
(180/(15 + 180)) × 100 = 92.3%

In this example, the specificity of the screening
test was higher at 92.3% than the sensitivity that is
72.7%. More than 25% of the participants who had hy-
pertension would have been missed if the participants
relied on screening alone, but less than 10% of those
without disease were incorrectly identified as possibly
having hypertension when they actually did not have
the disease (see Fig. 2-5). The nurses had met one of
their requirements for the program (high specificity)
but not the other requirement of high sensitivity.
How could they address these issues?

First, they could look at the reliability of the instru-
ment they were using to obtain the blood pressure
reading. Because the method of measurement for
screening and diagnosis in this case is the same, the

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46 U N I T I n Basis for Public Health Nursing Knowledge and Skills

120/80

True negatives

False positive
and negative
screening

True positives

100/70 130/85 140/90 160/10 180/11 200/12

Figure 2-8 Distribution of blood pressure readings in
those with and without hypertension.

reliability could be a concern. There are two possible
issues: variation in the method and observer variation.
Observer variation has been known to happen when
taking blood pressures using the standard method
owing to observer variation in hearing acuity and expe-
rience in taking blood pressures. The nurses actually
addressed this issue prior to conducting the pilot
study. They did both inter-rater and intra-rater reliabil-
ity, testing at baseline for the nurses who would con-
duct the screening. For the inter-rater reliability, they
had different nurses take the blood pressure on the
same individual to determine the variation between
each rater’s blood pressure reading. For intra-rater
reliability, they compared one nurse or rater’s measure
of repeated blood pressures on the same person.
They initially found low inter- and intra-rater reliability
between the nurses. They then conducted a blood
pressure training workshop for all the nurses who
participated in the screening. Following training, the
reliability of the measure was high.

Because the nurses felt confident that they had
been using a reliable instrument, they considered ad-
justing their cutoff point. As they were working on the
project the 2017 Guideline for the Prevention, Detection,
Evaluation, and Management of High Blood Pressure in
Adults was released. They decided to reexamine the
sensitivity and reliability of their screening using the
new criteria for stage one hypertension of a blood
pressure reading greater than or equal to 130 systolic
(mm Hg) or greater than or equal to 80 diastolic.
Adjusting the cutoff point to a lower value could im-
prove the sensitivity of the screening process, but
would it result in reducing the specificity as they first
feared? Making this decision was done not only based
on the new guidelines, but also by comparing the con-
sequences of a false negative with the consequences
of a false positive. In this case, a false positive would
result in extra visits to the physician, whereas a false
negative would result in untreated disease. Missing
more than a quarter of the population being screened
was a serious problem. Hypertension is known as the
silent killer, that is, the disease has few if any clinical
symptoms until damage has occurred. A person with
the disease often does not know he or she has it until
damage has already occurred.

The nurses plotted the blood pressure readings on
a chart to help determine the cutoff point for 100%
sensitivity and 100% specificity to help decide whether
a lower cutoff point would increase sensitivity while
still maintaining adequate specificity. Plotting out the

normal distribution of the blood pressure values in
those with hypertension and those without hyperten-
sion helped to illustrate what would happen if they
changed the cutoff value (Fig. 2-8). If they changed
the value to 130/80, they would have 100% sensitivity,
but their specificity would drop to nearly 50%. If they
shifted the cutoff point to 145/95, they would achieve
100% specificity but decrease their sensitivity to less
than 70%. Choosing a cutoff value is always a compro-
mise. In this case, the nurses decided to use the diag-
nostic criteria for stage one hypertension as their
cutoff point. This increased their sensitivity to over
80% whereas the specificity decreased only a small
amount to a little less than 90%.

Armed with the information on the reliability and
validity of their screening method, the nurses were
ready to present a proposal to their hospital for
conducting the hypertension screening program as
a citywide outreach program for the hospital. They
approached the director of the community outreach
department with their information, sure that they
would be able to proceed. The director asked them
questions to which they could not respond, so they
went back to obtain more information.

The first question the director posed was, “What
is the expected yield of the screening program?” The
nurses were not sure what this meant. They found
that the yield is defined as the number of previously
undiagnosed cases of disease that result in treatment
following screening. They already had a crucial piece
of information, the sensitivity of the screening program
they proposed. The higher the sensitivity is, the greater
the potential yield will be. The next issue related to

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C H A P T E R 2 n Optimizing Population Health 47

yield is the prevalence of undetected disease. This
depends on the duration of the disease, the duration
of the subclinical phase of the disease, and the level
of available care. The natural history of disease (see
Fig. 2-2) was a helpful guide for the nurses. They went
back to their original literature review related to hy-
pertension and once again found clear evidence that
the duration of the subclinical phase (stage 1) can be
long, and early treatment can have significant effects on
reducing morbidity and mortality. They also reviewed
the statistics on access to care for the low-income
African American population with high levels of
poverty in their city. Owing to changes in the cutoff
for Medicaid eligibility in their state, access to care
was limited and African American males in the immedi-
ate area were less likely to have regular physical
checkups. The nurses also charted out the current
national estimates on the prevalence of undiagnosed
hypertension in African American males. They found
that more than 40% of African Americans have
hypertension, and hypertension was often not diag-
nosed in this population until individuals became
symptomatic.52,53

The nurses concluded that, because of the high
sensitivity of their screening method and the high
prevalence in the target population, the potential yield
was high. However, they had not reviewed the avail-
ability of medical care. Because they needed to deter-
mine whether treatment was available for those who
screened positive, they did a review of all the primary
care clinics in the area. They also reviewed their pilot
data on the resources used by the participants to iden-
tify which primary care clinics were most frequently
used. They then contacted these clinics to determine
whether the clinics would be able to handle a large
influx of potentially new clients following the screening.
The nurses were able to establish that the existing
primary care system was sufficient and that the major-
ity of clinics and primary care offices were willing to
put in writing their support for the project.

The second question the director asked had to do
with multiphasic screening, defined as administering
multiple tests to detect multiple conditions during the
same screening program. The nurses had not consid-
ered this idea, but felt it had merit and reviewed the
current information on health and African American
males. They found that colorectal cancer (CRC) and
high cholesterol were two other serious health prob-
lems for African American males. However, conducting
CRC screening would require a different approach

owing to the complexity of the screening procedure.
Although combining blood pressure screening with
screening for high cholesterol was promising, it was
more invasive and would require purchasing more
supplies, possibly using more personnel. The nurses
also did not have pilot data to provide information on
the sensitivity and specificity of screening with a sample
from the target population, so they would have to rely
on national data.

The director had also asked about the cost benefit
of the program. Because they were asking the hospital
to fund this program, the director wanted to know
the possible benefits of the program related to cost,
simplicity of administration, safety, and acceptability
of the population. The nurses mapped out the actual
budget of the proposed program. Because no new
equipment was needed, the majority of the cost was in
staff time. To reduce costs, the nurses collected a pool
of nurse volunteers willing to participate in the pro-
gram. The taking of blood pressures is safe and nonin-
vasive, and takes little time to complete. This helps
reduce cost because the time needed to conduct the
screening per individual is short.

When reviewing the acceptability of the program,
they were careful not to make the assumption that, be-
cause blood pressure clinics are common, the popula-
tion they wished to engage would come to theirs.
They had asked the participants in their pilot study for
feedback on the best site for conducting the screening
and they also enlisted the help of members of the
community in identifying the right sites and means of
advertising the program. They also reviewed the litera-
ture for evidence of other successful screening pro-
grams with African American males. Though some of
the participants had mentioned schools or churches as
good sites, the site that was mentioned most and also
supported in the literature was the local barbershop.

The nurses shared their data with the director
and reported that the blood pressure screening
program they proposed had a potentially high yield
and the cost would be low given the availability of vol-
unteers. They suggested that the screening program be
conducted in the local barbershops but recommended
that further work be done to develop a partnership
with the owners of these shops prior to implementing
the program. They then discussed the possibility of de-
veloping a multiphasic screening program by combining
blood pressure screening with other screenings such
as cholesterol but cautioned that this would require
additional funding and time investment.

7711_Ch02_023-054 23/08/19 10:21 AM Page 47

Criteria for Screening Programs and Ethical
Dilemmas
Screening is performed on a regular basis across popu-
lations and settings, and is often taken for granted as a
worthwhile endeavor. Prior to implementing a screening
program, it is important to determine whether the
screening program meets certain criteria. There are
serious ethical considerations that must be addressed.
For the majority of screening, the core assumption is that
the screening program will reduce disease-associated
morbidity and mortality due to early identification and
engagement in treatment. The other major assumption
is that all those who screen positive for probable disease
have access to appropriate assessment and treatment
services. These assumptions form the basis of the criteria
used to determine whether a screening program should
be implemented.

Criteria for Screening Programs
The first criterion is to be certain that the screening test
has high specificity and sensitivity. This is complex as
demonstrated in the previous case study. There is always
a trade-off between specificity and sensitivity. When
planning a screening program, it helps to review the im-
pact of missing true cases versus falsely identifying a per-
son with the disease as having the disease. For example,
if the disease being screened has a high mortality rate, it
may be more important to identify as many individuals
with the disease as possible; that is, it should have a high
sensitivity. That way there is a good chance of detecting
disease, even if the specificity is low and the percentage
without disease that ends up going through diagnostic
testing is high. However, those who screen positive and
do not have disease may unnecessarily experience a high
level of stress while waiting to find out whether they
do indeed have the disease. On the opposite end, if the
mortality for the disease is lower and the cost and incon-
venience of diagnostic testing is high, high specificity
may be more important than high sensitivity. The best-
case scenario is to have a test with both high specificity
and high sensitivity. There is always a trade-off.

The next important criterion is that the test needs to
be simple to administer, inexpensive, safe, rapid, and ac-
ceptable to patients. Screening that can be done quickly
with minimal time and effort has a higher likelihood
of success. It also needs to be safe. Some screening tests
are invasive and may carry some risk. For example, a
colonoscopy requires some anesthesia with its associ-
ated risk. A paper-and-pencil questionnaire is noninva-
sive and carries minimal risk. Also, a simple one-page

48 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Figure 2-9 Blood pressure screening. (From Centers for
Disease Control and Prevention, James Gathany, 2005.)

The director then challenged them to describe how
they would evaluate the success of the program. In
response they shared with him the hospital discharge
data that had initially sparked their interest in doing
the screening. They felt that this would provide suffi-
cient baseline data to help evaluate the outcome of
the screening program. The director asked them to
clarify what their programmatic outcome would be.
They were not sure, so the director asked them to
come back when they had a clear idea of how they
would evaluate the success of the program (for more
on evaluation, see Chapter 5). After reviewing basic
models for program evaluation, they decided on a
short time span for their evaluation and chose simple
measures to evaluate the impact of the program. They
chose to measure the number of people who attended
the program, the number of positive screens, and the
number of positive screens who accepted information
related to referral for treatment. They went back to
the director and stated that, owing to the limited re-
sources for the targeted population, there were three
clinics that were most often used by residents in the
targeted community. The nurses felt it would be practi-
cal to track individuals postscreening. To do this, they
proposed to first keep a record of how many men
attended the screening. They then would contact each
of the clinics and ask them to track the number of men
who said they had been referred by the screening
program. Based on all the information provided, the
director finally approved their request, and the nurses
were able to institute the screening program (Fig. 2-9).

7711_Ch02_023-054 23/08/19 10:21 AM Page 48

paper-and-pencil screening tool is rapidly administered,
whereas a colonoscopy requires a minimum of 24 hours
including preparation for the test, the administration of
the test, and recovery from the test. Acceptability of the
screening test is often dependent on cost, time, safety,
and ease of administration, which are reasons that it is
harder to get individuals to have the recommended
colonoscopy screening than it is other screening tests.

Even paper-and-pencil tests should be reviewed for
simplicity. Many screening tests take too long to admin-
ister, decreasing the chance that a person will complete
a test. Consider the difference between screening for pos-
sible depression using a 10-item questionnaire that can
be inserted into a regular health assessment versus a
32-item questionnaire. A 10-item test is simpler. It is also
easier to learn and perform, and can be delivered by non-
medical personnel. A good example of a measurement
tool for depression with high sensitivity, specificity, and
reliability is the 10-item Center for Epidemiologic Stud-
ies Short Depression Scale (CES-D 10).54,55 The original
screening tool was 20 items long and took longer to learn
and administer. The shorter form is easier to administer
and more acceptable to patients.

The next criterion is that the disease be sufficiently se-
rious to warrant screening. The purpose is to prevent the
adverse consequences associated with the disease. In the
case of colonoscopy, the screening test does not meet the
rapid, simple, inexpensive, and acceptable criteria. How-
ever, the severity of the disease outweighs the inconven-
ience and cost of the screening test. CRC is the third
leading cause of cancer-related deaths in the United
States.54 Screening and early detection of CRC increase the
chance of a cure in a disease with a high mortality rate
when treated in its late stages. Screening often leads to the
identification of precancerous lesions (i.e., adenomas),
which can be removed, thus preventing CRC.56

The next criterion addresses the issue of whether the
treatment for disease is easier and more effective when
the disease is detected early. This is not the case for all
diseases and is the reason that there is ongoing scientific
inquiry into the utility of screening tests. If screening is
done, will it reduce the disease-associated morbidity and
mortality through initiation of early treatment and to
what extent? If there was a screening test for Parkinson’s
disease, what type of early treatment exists? Because
there is no known cure and treatment is confined to
reducing symptoms, early detection does not serve to
reduce the disability associated with the disease. Con-
versely, mammography has the potential of identifying
breast cancer in the early stages, thus increasing the
potential survival rate.

This then raises the issue of the acceptability of the
available diagnostic services and treatment. If screening is
done, will those who screen positive seek further assess-
ment? Will those with a positive diagnosis engage in treat-
ment? This issue was raised over the use of a reliable
instrument to screen for at-risk drug use. There is no evi-
dence that screening resulted in subsequent assessment
and treatment. Those who screened positive were not
likely to follow up with the next steps related to the screen-
ing. Based on this, the National Quality Forum’s (NQF)
publication on evidence-based treatment for substance use
disorders does not recommend that health-care providers
screen for at-risk drug use as a standard practice in general
populations.54 When screening will not result in the
needed follow-up, the screening program will not result
in reduced disease-related morbidity and mortality.

Another criterion for implementing a screening pro-
gram is to determine whether the prevalence of a disease
is high in the population to be screened. Despite the
NQF’s recommendation that screening for at-risk drug
abuse not be conducted in the general population, it is
applicable in a population in which the prevalence of
at-risk drug use is high, such as an inner-city program for
adolescent males with failing grades. The prevalence is
higher, and the program staff can be trained to provide
health education along with the screening, thus improving
the acceptability of subsequent referral and possible treat-
ment by the boys in the program who screen positive.

This criterion is also helpful when deciding whom to
target when putting together a screening program. The
IOM continuum health prevention model referenced
earlier30 provides a framework for deciding whom to in-
clude in the screening program. A universal approach
would include everyone in the population regardless of
age, gender, or other characteristic. A screening program
that uses a selected approach would focus on those at
higher risk. Making these decisions is based on preva-
lence and risk for disease. For example, breast cancer
screening through mammography is not done using a
universal approach. Instead, age, gender, and risk factors
are used to determine who should get a mammogram
and how often.

The final and ethically the most important criterion is
that resources are available for referral for diagnostic
evaluation and possible treatment. In our example of
putting together a screening program for hypertension
in African American men, the team first ascertained
whether there were available resources to handle those
with a positive screen. The main issues to address are
economic access, physical access, and capacity to treat.
Economic access refers to the ability to pay for care. Will

C H A P T E R 2 n Optimizing Population Health 49

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all those who attend the screening program be able to re-
ceive follow-up diagnostic services and possible treat-
ment? If the answer is yes, will they have physical access
to the clinics providing the care? For example, what type
of transportation is available to get to the clinics provid-
ing services, and will everyone who attends the screening
have adequate transportation in terms of time, utility,
and cost? Finally, if a large-scale screening program
is done, does the existing health-care system have the
capacity to provide diagnostic and treatment services for
the anticipated increase in individuals needing these
services? This last criterion is rarely addressed and can
result in serious consequences.

Ethical Considerations
The criteria discussed raise serious ethical questions
related to screening. It is unethical to conduct screening
if treatment is not available. Screening programs are
often done without thinking through the consequences.
A serious ethical question is, what will be done with the
positive screens? Availability of treatment is not just
related to the existence of health-care resources that pro-
vide the treatment but also to the ability of those partic-
ipating in the screening to access those resources. What
if nurses conducted blood pressure screening with a
homeless population in a neighborhood where the near-
est hospital was three bus rides away; the nearby clinics
required a minimal co-pay of $50.00; there were no
pharmacies in the area that provided medications to
those without the ability to pay; the soup kitchens in the
area served donated food that was high in salt, fat, and
sugar; and there were limited public toilets? What would
they do with the homeless persons who had a positive
screen? Even if they managed to see a physician who
then prescribed a salt-free diet and a powerful diuretic,
how would they be able to fill the prescription and fol-
low the diet? If they were able to fill the prescription,
how would they handle the frequent need to urinate
without getting arrested for urinating in public? The pri-
mary question is, did the screening program result in re-
duced morbidity and mortality in this population? Was
it ethical to conduct the screening without ensuring first
that a system was in place to provide the needed health-
care services?

Another example involves the American Cancer
Society’s eagerness to provide free breast exams and
mammography to low-income Hispanic and African
American women in a midwestern city. The organization
engaged several partners to provide the service (at a time
before most states provided free screening to low-income

women). The director of one of those clinics agreed to
see a specific number per week for free (one criterion was
no health insurance). However, the director insisted that
the clinic would do this only if the American Cancer
Society had a plan in place for diagnosing and treating
any woman who screened positive for the cancer. The
ethical and moral question that the planners then ad-
dressed was what to do if they told a participant in the
screening program that she had cancer and then had no
way for her to receive treatment. The planners were able
to contract with three physicians and two hospitals that
agreed to provide care. The screening program began and
the first woman screened was positive for breast cancer,
requiring major surgery. She had no insurance and no
resources to pay for the surgery. To be eligible for Med-
icaid, she would have had to give up her home, a resource
for which she had spent a lifetime saving. Because of the
preplanning, this woman and the four other women
participating in the program who were diagnosed with
cancer all received the needed surgery. Without the gen-
erosity of the physicians and hospitals, they would not
have been able to have the surgery, and the planners
of the screening program would have been left with a
serious ethical dilemma.

Another ethical issue has been raised by the possible
use of genetic screening as a means of identifying those
who are genetically at risk for developing disease. For ex-
ample, with our increased knowledge related to geneti-
cally linked disease, genetic screening can help determine
whether a well person without disease is at risk for de-
veloping disease. A woman’s risk of developing breast
and/or ovarian cancer is greatly increased if she inherits
a deleterious (harmful) BRCA1 or BRCA2 mutation.
Men with these mutations also have an increased risk of
breast cancer. Both men and women who have harmful
BRCA1 or BRCA2 mutations may be at increased risk of
other cancers. Should genetic screening be done and, if
so, what interventions should occur related to positive
results? There are no easy answers. Consider the woman
who screens positive for a BRCA1 or BRCA2 mutation.
Should she consider removing her healthy breasts prior
to the development of disease?

Tertiary Prevention and
Noncommunicable Disease
Secondary prevention attempts to reduce morbidity and
mortality through early detection and treatment. Tertiary
prevention is another powerful prevention approach that

50 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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can also reduce the burden of disease. During the past
100 years, as the life span of populations has increased,
the prevalence of NCD (Chapter 9), also referred to as
chronic diseases, increased, creating a growing burden
of noncommunicable chronic disease in the United
States and across the world.57 According to the WHO, in
contrast to CDs, NCDs are defined as disease that are not
passed from person to person, they have a long duration
and usually a slow progression. There are four main
categories of NCDs: cardiovascular diseases, cancers,
chronic respiratory diseases, and diabetes.55 Almost half
of the population in the United States has been diagnosed
with at least one noncommunicable chronic disease, and
four in every five health-care dollars are spent on the care
of NCD. Although the U.S. health system is built on an
acute care model, the vast majority of the care provided
is for the management of noncommunicable chronic
diseases.56

Once it has been identified, how do NCDs fit into
the prevention frameworks previously presented? Using
the traditional public health model, tertiary prevention
is the logical choice. The goal of tertiary prevention in-
terventions is to prevent premature mortality and ad-
verse health consequences related to an NCD. For some
diseases, such as hypertension, tertiary prevention efforts
can result in the person returning to a normal state; that
is, a combination of behavioral changes and pharmaceu-
tical interventions can result in the patient’s blood pres-
sure returning to normal limits. In other diseases, the
prevention strategies are aimed at slowing the progres-
sion of the disease and reducing the likelihood of adverse
consequences related to the disease. With pharmaceuti-
cal interventions, patients with Parkinson’s disease can
improve their gait and reduce the tremors. This reduces
their risk of falls and other injuries while improving their
ability to perform ADLs, but they are not returned to a
normal state.

Tertiary prevention appears at first glance to be indi-
vidual based rather than population based. However, the
burden of NCDs affects the whole population, and move-
ment toward more population-level interventions is gain-
ing momentum. In 2009, the WHO released a report
calling for “urgent action to halt and turn back the growing
threat of chronic diseases.”56 In that report, the WHO
stressed that population interventions can be done related
to reducing the burden of already diagnosed chronic dis-
eases. In the 2014 WHO report on NCDs, the Director
General released a statement that: “WHO Member States
have agreed on a time-bound set of nine voluntary global
targets to be attained by 2025. There are targets to reduce

harmful use of alcohol, increase physical activity, reduce
salt/sodium intake, reduce tobacco use and hypertension,
halt the rise in diabetes and of obesity, and to improve cov-
erage of treatment for prevention of heart attacks and
strokes. There is also a target to improve availability and
affordability of technologies and essential medicines to
manage NCDs. Countries need to make progress on all
these targets to attain the overarching target of a 25%
reduction of premature mortality from the four major
NCDs by 2025.”57

Tertiary care also occurs with CDs during both the
acute and recovery stages of infection. For many CDs,
tertiary care focuses on provision of acute care, that is,
treatment of the disease to prevent further morbidity
and mortality, such is the case of treatment for influenza
or measles. For some CDs such as HIV, there is no cure
and the infection requires long term care to prevent
and/or treat AIDS. Other CDs require long-term care to
bring about a disease-free state such as tuberculosis. Due
to the long-term duration of AIDS and other CDs, the
preferred term NCD helps to distinguish between dis-
eases based on the ability of a disease to be transmitted
from one human to another. In addition, with CDs part
of tertiary prevention becomes primary prevention, that
is, the prevention of transmission to other persons (see
Chapter 8).

n Summary Points
• Health promotion and protection are major

emphases of national and global health
organizations.

• The socioecological model of health promotion
uses an upstream approach that includes the social,
environmental, and economic contexts of healthy
populations.

• The health of a population is greater than the
sum of the health of each individual in the
population.

• Health prevention frameworks provide
guidance for the development of prevention
interventions.

• Health education and health literacy are keys
to improving the health of populations.

• Screening for possible disease has the potential
to reduce disease-related morbidity and mortality
but has serious ethical issues that must be
addressed.

• Tertiary prevention can help to reduce the burden
of chronic diseases.

C H A P T E R 2 n Optimizing Population Health 51

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23. Centers for Disease Control and Prevention. (2018). People
at high risk of developing flu complications. Retrieved from
https://www.cdc.gov/flu/about/disease/high_risk.htm.

52 U N I T I n Basis for Public Health Nursing Knowledge and Skills

t CASE STUDY
The Centers for Disease
Control and Prevention Asks
the Question: “Should I Get
Screened for Prostate Cancer?”

The CDC follows the U.S. Preventive Services Task
Force recommendations that the prostate specific anti-
gen (PSA)-based screening should not be done for men
who do not have symptoms.58 Other organizations
have made different recommendations. Based on your
review, answer the following questions:

1. What is the sensitivity and specificity of PSA tests?
2. The CDC states that one of the reasons is “… the

PSA test may have false positive or false negative
results. This can mean that men without cancer
may have abnormal results and get tests that are
not necessary.” What is the biggest issue?

3. How well does a PSA differentiate between
non-aggressive and aggressive prostate cancer?

4. Review the information on PSA screening and the
criteria and ethical guidelines for conducting a
screening program on pages 48-50. Of the list of
criteria and ethical issues listed in this chapter,
which ones are a concern related to PSA
screening?

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6. U.S. Department of Health and Human Services, Office of
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24. Gordon, R. (1987). An operational classification of disease
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27. Havas, K., Bonner, A., & Douglas, C. (2016). Self-manage-
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28. Enworom, C.D., & Tabi, M. (2015). Evaluation of kidney
disease education on clinical outcomes and knowledge of
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29. Salvatore, A. L., SangNam, A., Luohua, J., Lorig, K.,
Ory, M. G., Ahn, S., & Jiang, L. (2015). National study of
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30. U.S. Preventive Health Services Task Force. (2017). Home. Re-
trieved from https://www.uspreventiveservicestaskforce.org/
Page/Name/about-the-uspstf.

31. Centers for Disease Control and Prevention. (2017).
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www.cdc.gov/nchs/fastats/leading-causes-of-death.htm.

32. National Center for Health Statistics. (2017). Health,
United States, 2016: With chartbook on long-term trends
in health. Hyattsville, MD: National Center for Health
Statistics.

33. Institute of Medicine and National Research Council.
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34. Keller, L.O., Strohschien, S., Lia-Hoagberg, B., & Schaffer, M.
(2004). Population-based public health interventions:
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35. Minnesota Department of Health, Division of Community
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36. Joint Committee on Health Education and Promotion
Terminology. (2014). Report of the 2011 Joint Committee
on Health Education and Promotion Terminology.
American Journal of Health Education, 43(sup 2), 1-19.
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37. World Health Organization. (2018). Health education.
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education/en/.

38. Shunk, D.H. (2012). Learning theories: An educational per-
spective (6th ed.). Boston: Pearson.

39. Bandura, A. (1977). Social learning theory. New York:
General Learning Press.

40. Hughes, N., & Schwab, I. (2010). Teaching adult health
literacy: principles and practice. Berkshire, England:
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41. Knowles, M.S. (1990). The adult learner: A neglected species
(4th ed.). Houston, TX: Gulf.

42. The Institute of Medicine, Committee on Health Literacy,
Board on Neuroscience and Behavioral Health. (2004).
Health literacy: A prescription to end confusion. Washington,
DC: The National Academies Press.

43. U.S .Department of Education, National Center for
Education Statistics. (2016). Skills of U.S. unemployed,
young, and older adults in sharper focus: results from the
program for the international assessment of adult competen-
cies (PIAAC) 2012/2014. Retrieved from https://nces.ed.gov/
pubs2016/2016039rev .

44. Rasu, R.S., Bawa, W.A., Suminski, R., Snella, K., & Warady,
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ijhpm.2015.151.

45. Centers for Disease Control and Prevention. (2016).
Talking points about health literacy. Retrieved from
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TellOthers.html.

46. Hersh, L., Salzman, B., & Snyderman, D. (2015). Health
literacy in primary care practice. American Family Physician,
92(2), 118-124.

47. Agency for Health Care Research and Quality. (2015). AHRQ
Health Literacy Universal Precautions Toolkit (2nd ed.).
Rockville, MD: Author.

48. National Institutes of Health. (2017). Clear communica-
tion: cultural respect. Retrieved from https://www.
nih.gov/institutes-nih/nih-office-director/office-
communications-public-liaison/clear-communication/
cultural-respect.

49. Bloom, B.S. (1956). Taxonomy of educational objectives:
Handbook 1. The cognitive domain. New York, NY: David
McKay.

50. Commission on Chronic Illness. (1951). Chronic illness
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University Press, Commonwealth Fund.

51. American Heart Association. (2016). High blood pressure
and African Americans. Retrieved from http://www.heart.
org/HEARTORG/Conditions/HighBloodPressure/
UnderstandSymptomsRisks/High-Blood-Pressure-
and-African-Americans_UCM_301832_Article.jsp#.
Wxly1fZFw2w.

52. Centers for Disease Control and Prevention. (2016). High
blood pressure facts. Retrieved from https://www.cdc.gov/
bloodpressure/facts.htm.

53. Radloff, L.S. (1977). The CES-D scale: A self-report depres-
sion scale for research in the general population. Applied
Psychological Measurement, 1, 385-401.

54. Andresen, E.M., Malmgren, J.A., Carter, W.B., & Patrick,
D.L. (1994). Screening for depression in well older

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adults: Evaluation of a short form of the CES-D (Center for
Epidemiologic Studies Depression Scale). American Journal
of Preventive Medicine, 10, 77-84.

55. Centers for Disease Control and Prevention. (2017). Colorec-
tal cancer statistics. Retrieved from https://www.cdc.gov/
cancer/colorectal/statistics/index.htm.

56. Centers for Disease Control and Prevention. (2017). Chronic
disease prevention and health promotion: National Center for

Chronic Disease Prevention and Health Promotion. Retrieved
from https://www.cdc.gov/chronicdisease/resources/
publications/aag/NCCDPHP.htm.

57. World Health Organization. (2009). Preventing chronic
diseases: A vital investment. Retrieved from http://www.
who.int/chp/chronic_disease_report/en/.

58. World Health Organization. (2014). Global status report
on noncommunicable diseases 2014. Geneva: Author.

54 U N I T I n Basis for Public Health Nursing Knowledge and Skills

7711_Ch02_023-054 23/08/19 10:21 AM Page 54

KEY TERMS

Active surveillance
Agent
Analytical epidemiology
Attack rate
Biostatistics
Causality

Demography
Descriptive epidemiology
Environment
Epidemiology
Host
Incidence

Infectivity
Life expectancy
Morbidity
Mortality
Passive surveillance
Percent change

Prevalence
Prospective
Rate
Retrospective
Secondary attack rate
Web of causation

n Introduction
In 2017, a National Public Radio headline reported “U.S.
has the worst rate of maternal deaths in the developed
world,” based on a recent study of global levels of maternal
mortality.1 Information from the Centers for Disease Con-
trol and Prevention (CDC) also confirms that pregnancy-
related deaths, defined as the death of a woman during or
within 1 year of the end of pregnancy, have been increas-
ing in the United States since 1987 when this information
was collected.2 A headline like this inspires many ques-
tions: Why is the mortality rate increasing? What factors
are influencing this disparity between the U.S. and other
developed countries? Is a particular population affected
more by high rates of maternal mortality? How was this
information collected? Is this an accurate headline based
on the information?

As nurses, if we were to investigate these data
further we would discover that there are great disparities
in the pregnancy-related mortality within the U.S.
According to the CDC, for example, black women have a
much higher rate of pregnancy-related deaths compared

with white women (12.7 deaths per 100,000 live births for
white women vs. 43.5 deaths per 100,000 live births for
black women).2 However, for a public health nurse, this
suggests the need for further inquiry into what factors
might be driving this difference: poverty, urban/rural
differences, racial stigma, or differing access to care. See
Chapter 17 for more details specific to maternal child
health, and maternal mortality and public health.

Collecting, analyzing, and synthesizing data to under-
stand public health questions such as disparities in mater-
nal mortality is the heart of epidemiology. Epidemiology,
the combination of three Greek words: epi, translated
as “upon”; demos, translated as “people”; and logy, or
“the study of something”, is broadly defined as the study
of factors that influence health and disease in populations.3
Epidemiology is a natural fit for the nursing profession
because nursing, unlike many of the health-related pro-
fessions, extends well beyond one-on-one patient-clinician
interactions to engaging groups of people where they live,
work, and play. Public health nursing has traditionally
blended health promotion, disease prevention, health
education, and population-based initiatives in an effort to

Chapter 3

Epidemiology and Nursing Practice
Erin Rachel Whitehouse and William A. Mase

LEARNING OUTCOMES

After reading the chapter, the student will be able to:
1. Describe aspects of person, place, and time as they

relate to epidemiological investigation.
2. Explain the epidemiological triangle.
3. Apply the epidemiological constants to an investigation.
4. Identify sources of epidemiological data.
5. Apply basic biostatistical methods to analyze

epidemiological data.

6. Differentiate cohort and case-control study design and
select appropriate measures of effect.

7. Explain surveillance and the difference between active
and passive surveillance.

7711_Ch03_055-076 21/08/19 11:06 AM Page 55

maximize the health and wellness of individuals through
population-level strategies. As 21st-century health profes-
sionals, nurses are now more than ever required to
demonstrate both competency and proficiency in the prin-
ciples of epidemiology.

Today the curriculum in accredited colleges of nurs-
ing is shifting toward the inclusion of epidemiology as
core content. The historical development of epidemiol-
ogy is replete with references to the same women who
carved out the nursing profession. Public health nursing
and population-based health and wellness are evident in
the pioneering efforts of Florence Nightingale, Lillian
Wald, Clara Barton, Mary Breckinridge, and Dorothea
Dix. Each of these legendary women initiated public
health efforts from a population health perspective
toward the reduction of disease and promotion of health
within populations.

What Is Epidemiology?
Epidemiology has been defined many ways. Tradition-
ally, it is the study of the distribution of disease and
injury in human populations. More recently, broader

56 U N I T I n Basis for Public Health Nursing Knowledge and Skills

n CELLULAR TO GLOBAL
Epidemiology and biostatistics are critical fields to
understand health outcomes from a cellular to global
level. Mycobacterium tuberculosis (TB), the leading
cause of communicable disease deaths globally, is an
example of a disease that affects health on a cellular,
individual, community, and global level.4 Diabetes, smok-
ing, and HIV infection are leading risk factors both for
the development of TB and for poorer treatment
outcomes through mechanisms such as increased
inflammation, decreased immunity, and structural lung
damage. TB is also related to community factors such
as poverty because risk factors like overcrowded
housing increase the risk of exposure and subsequent
development of TB. Drug-resistant TB, which is resist-
ant to the first-line TB antibiotics, is an increasing
challenge in part due to insufficient health systems
that do not have the appropriate resources to treat it.
Finally, preventing and treating TB is a global challenge
given the movement of populations due to migration,
war, famine, natural disasters, and even tourism.
Epidemiological principles are one tool to understand
how risk factors on cellular, local, national, and global
levels impact population health outcomes like mortality
from TB.

definitions of the term move beyond the study of disease
and include the examination of factors that affect the
health and illness of populations, thus providing the basis
for interventions aimed at improving the health and
well-being of populations. The focus of epidemiology is
on populations rather than on individuals. Epidemiology
takes an analytical investigative approach to this study of
health and disease, and is built on three central elements:

• Person: Which groups of individuals are affected?
• Place: Where does the health issue occur, i.e., what

geographically defined region?
• Time: Over what specified period of time does the

health issue occur?

These three elements of person, place, and time are
the bricks of epidemiology. The mortar cementing these
bricks is made up of the methods of quantitative com-
parison used by epidemiologists when studying patterns
of disease and health. The tools used by epidemiologists
are best described as comparative, numeric, and analyt-
ical. To effectively quantify illness and disease, accurate
data are required. Epidemiological data sources vary
widely. Some of the more frequently used data sources
include hospitals, community-based clinical practices,
health departments, workplaces, schools, and health
insurance reimbursement claims. The capacity for an
epidemiologist to effectively analyze and present data is
inextricably linked to the network of health-care–related
workers throughout an array of health and human
service–related industries. Nurses are pivotal to the ac-
curate assessment and timely reporting of health-related
data upon which epidemiology is grounded.

Historical Beginnings
John Snow is celebrated as the founder of modern epi-
demiology just as Florence Nightingale is recognized
as the founder of modern nursing (see Chapter 1). John
Snow’s watershed work, Snow on Cholera, introduced
methods of epidemiological investigation and methods
upon which contemporary epidemiological methods are
founded.5 His use of the epidemiological strategy, now
defined as disease mapping, to study the incidence of
cholera deaths reported in London, England, laid the
foundation for investigation of disease in populations.
The Lambeth Company provided residents of London
with drinking water collected from the Thames River.6
Snow’s enumeration and subsequent investigation of
cholera deaths reported for residents living near the
Lambert Company’s Broad Street water pump is her-
alded as the defining event upon which all future
epidemiological methods are based. Snow developed a

7711_Ch03_055-076 21/08/19 11:06 AM Page 56

timely measures for disease investigation using contem-
porary 21st-century methods. The three elements of per-
son, place, and time are as central to an epidemiological
investigation now as they were in the time of Snow, and
they form the building blocks for modern-day epidemi-
ological investigations.

Since the time of Snow’s work, epidemiology has gone
through various phases. The first phase is referred to as
the sanitary phase. It was based on the miasma theory
that illness was related to poisoning by foul emanations
from soil, air, and water. During this phase, public health
efforts focused on improving sanitation. This approach
to illness prevailed until the discovery of microscopic
organisms that were linked to disease, which led to the
germ theory and the communicable disease phase of epi-
demiology. This phase led to the examination of single
causes for a disease and worked well in a world where com-
municable diseases were the number one killers. With the
emergence of antibiotics and the reduction of communicable
disease, the life expectancy of populations increased,

frequency distribution of the number of human deaths
by placing a hash mark on a city street map. Upon visual
inspection of the map it became clear to Snow that there
were residential patterns of deaths. He demonstrated that
greater numbers of cholera deaths were clustered within
the vicinity of a specific public water source, the Broad
Street water pump. The number of cholera deaths near
the Broad Street pump far exceeded the deaths in other
areas of London (Fig. 3-1).

Snow’s work illustrated the three central elements re-
lated to his investigation: person, place, and time. The
person variable can be defined as the number of human
cholera deaths. Place is visually demonstrated by the
street mapping method Snow used to count human
deaths by street of residence. Finally, the time variable in
Snow’s study was the 5-year period between 1849 and
1854 when the Lambeth Company drew community
water from the contaminated source, the Thames River.
In the 150 years since Snow’s community disease map-
ping, epidemiologists have developed more effective and

C H A P T E R 3 n Epidemiology and Nursing Practice 57

Figure 3-1 Snow map.
(Published by C.F. Cheffins,
Lith, Southhampton Buildings,
London, England, 1854, in Snow, J.
[1885]. On the mode of commu-
nication of cholera (2nd Ed.).
John Churchill, New Burlington
Street, London, England. http://
www.ph.ucla.edu/epi/snow/
snowmap1_1854_lge.htm)

7711_Ch03_055-076 21/08/19 11:06 AM Page 57

especially those in developed countries. This resulted in
the emergence of noncommunicable diseases and a new
phase in epidemiology, the risk factor phase. This phase
of study is still a mainstay of epidemiological investiga-
tions. It relies on the linking of exposures to the occur-
rence of injury or disease and helps us identify risk
factors that, when reduced, may result in a subsequent
reduction in morbidity and mortality. The most recent
phase in epidemiology is the ecological model as pro-
posed by Susser and Susser in the 1990s.7,8 This helps
move the science of epidemiology to a broader perspec-
tive and, as explained in Chapter 1, reflects not only
the biological and behavioral influences on health but
also a deeper understanding of the role of the physical
environment and the underlying conditions in the social
environment that create poor health.

Risk Factors
Risk factors are a foundational concept in epidemiology.
The World Health Organization (WHO) defines a risk
factor as “any attribute, characteristic, or exposure of an
individual that increases the likelihood of developing a
disease or injury.”9 Although there are several ways to
classify risk factors, we will explore three major categories
of risk factors: behavioral, environmental, and genetic.

Behavioral Risk Factors
The CDC began the now nationwide Behavioral Risk
Factor Surveillance System (BRFSS) in 1984.10 They in-
tended to study the way that human behavior influences
health and wellness, and identify behaviors that might
influence health conditions, such as the impact of under-
age drinking on the risk of unprotected sex. This human
health behavioral survey is the largest telephone survey
assessment in the world. The BRFSS provides timely
health behavior data for policy makers in all 50 states as
well as the District of Columbia, Puerto Rico, U.S. Virgin
Islands, and Guam. These data are effective in providing
health-related trend analysis and serve to guide and direct
local, state, and national pro-health initiatives. Figure 3-2
presents national-level trended data on tobacco use.11 It is
exciting to see that the Healthy People 2020 goal for ado-
lescent smoking has been reached! The BRFSS can be used
to present population-level trend data related to many
behavioral risk factors. For community-based health
educators, these data are an effective resource to assist in
planning community health interventions.

Environmental Risk Factors
Is it possible that the community in which one lives
and/or works puts one at an increased or decreased risk

for developing a given illness or disease? Yes, it does. The
Agency for Toxic Substances and Disease Registry
(ATSDR) Web site provides useful information on ad-
verse health effects linked to health-related environmental
risk from exposure ranging from arsenic to zinc and
everything in between (see Web Resources on DavisPlus).
Often, increased environmental risk for residents of com-
munities is related to specific industries located in and
around the community. By mapping industries related to
hazardous waste, it is possible to identify populations at
greater risk for disease at the local and state levels. The
federal government has set aside funds referred to as the
Superfund to clean up uncontrolled hazardous waste sites
across the country through the Environmental Protection
Agency (EPA). The states with the greatest number of
Superfund clean-up sites include New Jersey, Pennsylvania,
and New York, with more than 100 Superfund sites per
state. The EPA Web site at http://www.epa.gov/superfund/
provides information on identifying possible industry-
related environmental hazards.

Public health professionals working in environmental
health often focus on three critical areas in assuring the
health of the public: safe air quality conditions, safe water
supplies, and safe soils throughout the nation’s agricul-
tural industry. The majority of the human health risks

58 U N I T I n Basis for Public Health Nursing Knowledge and Skills

19
97

19
99

20
01

20
03

20
05

20
07

20
09

20
11

20
13

20
15

20
17

Adults (%)**

Percentage of high school students who smoked cigarettes on at least 1
day during the 30 days before the survey (i.e., current cigarette use).
(Youth Risk Behavior Survey 1997-2017)

Percentage of adults who were current past 30-day cigarette smokers
(National Health Interview Survey 1997-2017)

P
er

ce
nt

ag
e

(%
)

Students (%)*

Figure 3-2 Trends in Current Cigarette Smoking by
High School Students* and Adults** United States 1997
to 2017. (Source: 11a, 11b.)

7711_Ch03_055-076 21/08/19 11:06 AM Page 58

are associated with what we breathe and ingest. It is
important to keep in mind that the environmental risks
affecting humans are indeed vast, including automobile
safety, seatbelt use, and safe conditions throughout pub-
lic recreational facilities. Public health professionals use
a combination of education, engineering, and enforce-
ment to achieve our mandated goals and objectives.
There are more details about the role of public health
science and environmental health in Chapter 6.

Genetic Risk Factors (Genomics)
The field of genetic epidemiology otherwise known as
genomics seeks to understand and explain heritability
of factors that have an impact on the development of
illness and disease. The past 2 decades have witnessed the
expansion of research into genetic markers for disease.
We will likely see a transformation in the evaluation,
assessment, and tools surrounding genetically relevant
strategies at the population level because of emerging
individual-level genetic knowledge.

Application of genomics to population health poses
some practical and ethical dilemmas. First, at the pop-
ulation level, the purpose is to develop interventions
relevant to the population that will result in a general
improvement of health at the population level. Genetic
testing is done at the individual level and usually results
in individual decision making related to potential risk
for development of disease. For diseases such as cystic
fibrosis that are related to one gene, genetic testing can
help with early identification and treatment for those
born with the disease and may assist parents make
childbearing decisions prior to conception. However,
most diseases occur due to multiple factors and are
linked to more than one gene as well as numerous other
risk factors. Evidence on the benefit of genetic screen-
ing for most diseases is limited. In addition, genetic
testing can be costly.

A good example of the controversy over the benefits
of genetic testing is the issue of BRCA1 and BRCA2. These
human genes are referred to as tumor suppressors. Based
on recent research, it is apparent that mutation of these
genes is associated with hereditary breast and ovarian
cancers.12 The company that developed the screening test
for BRCA1 and BRACA2 initiated an advertising campaign
encouraging women to have the genetic screen. Though
the National Cancer Institute lists possible options for
managing cancer risk for those with a positive screen, it
acknowledges that the evidence concerning the effective-
ness of these strategies is limited. Testing can cost up to
$3,000 for those who do not know their family history.
The high cost raises the ethical question of taking a

universal approach to screening all women for this
genetic risk factor, especially as less than 10% of all breast
cancers are genetically related and the direct benefit of the
testing in reducing cancer rates is not known. Genomics
is a growing field with the potential benefit of better
understanding the role individual genetic makeup plays
in an individual’s health. However, as the BRCA1 and
BRCA2 screening example illustrates, the applicability of
genomics to population-level interventions from a prac-
tical and ethical standpoint has still not been determined.

Epidemiological Frameworks
There are several frameworks guiding the field of epi-
demiology such as the epidemiological triangle, the web
of causation, and the ecological model. The latter two
frameworks evolved from the epidemiological triangle
framework. Public health professionals continue to use
these and other frameworks to assist in a better under-
standing of health phenomena.

The Epidemiological Triangle
The classic model used in epidemiology to explain the
occurrence of disease is referred to as the epidemiological
triangle. There are three main components to the trian-
gle: agent, host, and environment (Fig. 3-3). In commu-
nicable diseases, the model helps the epidemiologist map
out the relationship between the agent or the organism
responsible for the disease and the host (person) as well
as the environmental factors that enhance or impede
transmission of the agent to the host.

Although this model is ideally suited for explaining
the transmission of an infectious agent to a human host,

C H A P T E R 3 n Epidemiology and Nursing Practice 59

Figure 3-3 Epidemiological triangle.

Environment

Agent Host

7711_Ch03_055-076 21/08/19 11:06 AM Page 59

it is now applied to noncommunicable diseases, such as
lung cancer, with a specific exposure, such as cigarette
smoke, representing the agent or causative factor. The
agent can be viewed as the causative factor contributing
to noninfectious health problems or conditions. The
agent may be biological (organism), chemical (liquids,
gases), nutritive (dietary components or lack of dietary
components), physical (mechanical force, atmospheric
such as an earthquake), or psychological (stress). The
host is the susceptible human or animal, whereas the
environment is all of the external factors that can influ-
ence the host’s vulnerability to the risk factors related to
the disease.

The value of this model lies in the fact that it helps in
the development of interventions. For example, in the
case of the H1N1 outbreak, epidemiologists first worked
at isolating the agent. Based on the type of agent, a
flu virus, it was clear that the environment needed for
transmission was both the breathing in of air droplets
that contained the virus and coming in contact with the
virus via a fomite, that is, an inanimate object such as a
water faucet. Based on this information, three prevention
interventions were instituted. The initial approach
focused on the environment. To reduce exposure of
people to the virus in the environment, all those with
signs and symptoms of H1N1 were asked to stay home
and to cough into their arms rather than their hands.
Uninfected individuals were also instructed to use hand
sanitizers. The second approach was aimed at protect-
ing the host (person) through the development and
distribution of the H1N1 vaccine. The use of a vaccine
reduced the susceptibility of hosts to the agent, which,
in turn, reduced further introduction of the virus into
the environment. In this example, no interventions were
aimed at the agent because no viable options were avail-
able to directly eradicate the agent.

The Epidemiological Constants of Person,
Place, and Time
In addition to the epidemiological triangle, there are three
constants that are the foundation for any epidemiological
investigation: person, place, and time (Fig. 3-4). The
person aspect typically includes demographic variables
including age, gender, and ethnicity. Place considerations
include such variables as city resident, office building user,
or downhill skier. Finally, the third constant, time, is a
critical dimension of consideration. Conditions in one lo-
cation with the same subset of individuals can change
substantially as a product of the passage of time. It is
important to keep in mind that this model is the founda-
tion upon which our understanding of illness and disease

are built and can help guide investigations into a health
issue in a population.

Who, What, When, Where, Why, How, and How
Long: To further understand the use of the epidemio-
logical triangle and the constants of person, place, and
time, seven questions have been used to conduct an
epidemiological investigation. These questions have most
often been used to examine the epidemiology of commu-
nicable diseases. The who question relates to the person,
the place question to where, the when and how long ques-
tions to time, the what to the causative agent, and the
why and how to the mechanism for acquiring disease,
such as the mode of transmission in communicable dis-
eases. These seven questions provide an effective model
by which illness can be analyzed at the population level in
order to develop interventions that will improve health
and/or prevent disease. This approach is an example of nat-
uralistic experimentation, a study that occurs in the natural
world and not in a controlled laboratory environment.

60 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Person

Place Time

Figure 3-4 Epidemiological constants.

n CULTURAL CONTEXT
Epidemiology is rooted in asking questions, collecting
and analyzing data, and making informed decisions to
influence policy or practice. Understanding the cultural
context of a given population is critical in all steps of the
process. Differences across ethnicity, geography, race,
nationality, or religion can potentially affect risk factors
or perceptions of health and risk. Are you asking the

7711_Ch03_055-076 21/08/19 11:06 AM Page 60

Causality
Although the seven questions help the investigator learn
about the occurrence of disease, that knowledge only
begins to provide a broader understanding of the mul-
tiple factors that could be related to the occurrence of
the disease. Epidemiologists investigate possible causes
of disease to better understand how to prevent and treat
disease. The term cause is traditionally used to indicate
that a stimulus or action results in an effect or outcome.
For example, if you turn on a light switch, the observed
effect is that the light bulb lights up. When it comes to
epidemiology, causality refers to determining whether
a cause-and-effect relationship exists between a risk
factor and a health effect. In health, causes can include
a number of things related to person, place, and time.
Using the light switch example again, it may be first
assumed that the singular cause for lighting the bulb is
the physical act of flipping the switch. In actuality, there
are other factors involved, including the presence of
a source of electrical energy, a working electrical con-
nection between the switch and the light, and a light
bulb that is not burned out.

As presented throughout this chapter, epidemiologi-
cal studies typically report measures of associations based
on population-based correlations; that is, an increase
or decrease in the amount of the risk factor and the fre-
quency of the risk factor are parallel to the increase or
decrease of the incidence of the health issue. It is always
important to keep in mind that correlation, the fact that
two variables are correlated with one another, does not
necessarily mean that one factor causes the other. For ex-
ample, heavy smokers often have a yellow stain on the

fingers that hold the cigarette. Although the presence of
yellow stains on the fingers may be correlated with lung
cancer, the yellow stain is not the cause of lung cancer.

To examine the possibility of causality, the first step
is to determine whether there is a statistical relationship
between the risk factor and the health issue. In other
words, can the association between the two be attributed
to chance alone—does the association between the
two occur at a frequency higher than what could be
attributed to chance? After determining that the relation-
ship does not occur by chance alone, the next step is to
determine whether the relationship is causal. In some
cases, the relationship between two variables is statisti-
cally significant, but the relationship is noncausal.
For example, in a group of schoolchildren, height may
be statistically correlated with grade level; that is, the
higher the grade level, the taller the children, but grade
level is not the causal factor for the increase in height.

A causal relationship is present when there is a direct
or indirect relationship between the two factors. If it
is a direct relationship, then the factor causes the disease.
For example, the mumps virus directly causes mumps.
A nondirect relationship exists when the factor con-
tributes to the development of the disease through its ef-
fect on other variables. Being overweight does not
directly cause disease, but it adversely affects the body,
thus increasing the risk of cardiovascular disease and
diabetes, for example.

Results from studies conducted in the field can be
limited because sources of error might be present. These
errors most likely relate to assumptions of causality. For
example, error can occur when deciding who was actu-
ally exposed to a potential risk factor and who was not.
There can be errors in how some important variable was
measured and errors relating to who received a vaccine
and who did not.

C H A P T E R 3 n Epidemiology and Nursing Practice 61

right questions to understand risk factors that might be
particular to the population? Are you using the correct
terminology so that the population of people under-
stands the question in the way that it is being asked?
One of the best ways to ensure that a survey or out-
break investigation is conducted in a way that respects
the cultural context is to involve people from the
population in creating and executing the research or
investigation. This can provide critical information for
access to key informants, asking appropriate and rele-
vant questions, and understanding the data within the
perspective of the population. Thus, although epidemio-
logic principles are broad and apply locally to globally,
it is important to always frame epidemiology questions
and investigations within the appropriate cultural
context.

l APPLYING PUBLIC HEALTH SCIENCE
Public Health Science Topics Covered:
• Applied Epidemiology
• Health Promotion

Smoking and tobacco use are considered by the
WHO to be among the biggest public health threats
because they kill up to half of the people who use to-
bacco.13 Smoking increases the risk for noncommunica-
ble diseases like cardiovascular disease or lung cancer
and also increases the risk for communicable diseases
like tuberculosis as described in the cellular to global
section of this chapter. However, smoking’s influence is

7711_Ch03_055-076 21/08/19 11:06 AM Page 61

62 U N I T I n Basis for Public Health Nursing Knowledge and Skills

not limited to people who use tobacco; it also affects
children, families, and communities through second-hand
smoke exposure. In addition, 80% of the 1.1 billion
smokers globally live in low- and middle-income coun-
tries where the burden of disease for tobacco-related
conditions and premature death is high.13

To think about how to understand the impact of
smoking within a specific population, an epidemiologist
can explore who is smoking within their community
and who might be exposed to smoke (person), where
the sources of smoke or tobacco exposure are within
a community (place), and how the population of smok-
ers has changed (time). This information is then used
to develop community-specific health improvement
initiatives that target those populations at greatest risk
for harm from smoking or tobacco use. The first
step in the investigation of any illness is to begin with
inquiry. Ask questions across the seven areas of who,
what, when, where, why, how, and how long.

Jane Paterson is a public health nurse employed by
the City Health Department of River City, a hypothetical
midwestern city with a population of 75,000 and a mix
of urban and suburban residents. One of the primary
objectives of Jane’s job is to develop community-based
health promotion and disease prevention initiatives tar-
geting smoking with a focus on youth. According to the
most recent U.S. Census data available, there are
3,000 urban and 7,000 suburban River City residents
aged birth to 18 years. Of the 3,000 urban residents in
this age group, 1,500 have used some form of tobacco
product. Of the 7,000 nonurban residents in this
age group, 1,000 have used some form of tobacco
product.

To understand the smoking data among youth in
River City, Jane considers the tools in her epidemio-
logic toolbox. She needs to ask questions to under-
stand who smokes, why they smoke, what risk factors
influence their decision to smoke, how youth are
obtaining cigarettes, how much they cost, and what
factors might influence their decision to quit. She also
needs to look at the data to explore what common
risk factors for smoking, such as poverty or parents
who are smokers, might be influencing the youth of
River City. She needs to understand who already
smokes and who is at risk for future smoking to de-
velop an evidence-based intervention that targets these
specific populations. The data from the U.S. Census
informed Jane that there was a higher percentage of
youth who smoked from the urban areas of River City,
but do these percentage differences suggest an actual

difference in the risk of smoking between urban and
nonurban youth? See Box 3-5 later in the chapter to
look at the calculation of odds ratio to explore the
difference in smokers from urban and nonurban
areas and an explanation of odds ratios further in
this chapter.

In addition, Jane needs to understand the risk fac-
tors within River City and what community factors
might influence youth smoking. Jane explored legisla-
tion regarding smoking and found that River City has a
low tax on cigarettes compared with other cities and
counties in the area. She also noted that the public
schools were not smoke-free zones and, although
restaurants were supposed to be smoke-free, there
was minimal enforcement of these regulations espe-
cially in places where older adolescents tended to
congregate. Thus, on a community level, risk factors
for smoking influenced the relatively low cost of
tobacco products and the limited bans on public
smoking.

Finally, Jane wanted to explore trends over time
to understand how smoking had changed over the
past 10 years in the community. Jane had previous
data from community assessments that documented
smoking in River City, and she found that there was
an overall decrease in the percentage of adults who
smoked, but that the smoking rates for youth remained
largely unchanged. Jane realized that, to develop a
more thorough understanding of youth smoking, she
needed a bit more data about smoking. So, she used
the CDC Web site and the Youth Risk Behavioral
Survey to understand the specific risk factors related
to youth smoking.14 She was also able to access infor-
mation from her state to compare the smoking rates
in River City to state levels.

Once Jane had looked at the data on smoking, she
reported to her supervisor at the Health Department
that she felt that a multiprong intervention was needed
to prevent smoking, to provide smoking cessation
incentive for youths that smoked, and to advocate
for policy-level interventions such as proposing an
increased tax on tobacco products and extending the
smoke-free zones in the community. She was able to
advocate for her programming because she had data
that demonstrated that River City had higher smoking
rates compared with other cities in her region and
fewer community-based interventions, such as smoke-
free schools and high tobacco taxes. Jane also pro-
posed conducting a survey of high school students
in the schools within River City, selecting some

7711_Ch03_055-076 21/08/19 11:06 AM Page 62

Web of Causation
One difficulty for Jane is determining which risk factors
for youth smoking are priority concerns for River
City. Multiple factors are correlated with smoking
among youth including environmental risk factors both
internal and external, parental smoking habits, gender,
race, poverty, and educational status of the youth
and their parents. Untangling the risk factors to deter-
mine what type of intervention should be developed is
a challenge. To help understand the multiple factors
that contribute to the development of disease, epidemi-
ologists use a framework called the web of causation.
This framework or model can be used to illustrate the
complexity of how illness, injury, and disease are deter-
mined by multiple causes and are at the same time af-
fected by a complex interaction of biological and
sociobehavioral determinants of health (Fig. 3-5).15,16,17

It helps health-care providers develop more compre-
hensive strategies to reduce disease- and injury-related
morbidity and mortality through primary and second-
ary prevention measures.

The term web is used because the model acknowledges
the complexity related to occurrence of disease.15 Simply
stated, the spider is the reason the fly is caught in the web.
What are the factors that converged, resulting in the
ill-fated fly being caught in the web? The fly selected
the path that led him to the web, he was ill equipped to
extract himself from the web once entangled, the spider
selected that specific location to construct his web, etc.
The list of predetermining factors is endless. The fact is,
for both the fly caught in the spider’s web as well as for
humans, there is frequently no one single cause for an
undesirable outcome but a convergence of circum-
stances, actions, inactions, and behaviors.

Ecological Model
The ecological model has been used in recent years to
design health promotion efforts and understand health
behavior. The terms health promotion and health behav-
ior have been used during the past 25 years to help
understand the interventions that can be done to help
maintain and improve health (health promotion), and the
behaviors that contribute either positively or negatively
to overall health (health behaviors). The ecological model
provides a formal theoretical foundation on which public
health nursing has established a professional identity and
knowledge base.

Ecological studies use groups, not individuals, as the
unit of analysis.18 Conclusions from ecological studies
should be considered with caution. The classic notion
of the stork bringing the baby to new parents is a con-
temporary manifestation of what one might suggest
could have been an ecological study, demonstrating
the ecological fallacy discussed later in this chapter.
Anchored in the pagan belief that storks brought babies
to expecting mothers, the arrival of storks in northern
Germany coincided with the storks’ spring and the
increase in the number of human births. The increased
birth rates in spring might have something to do with
the 9-month elapsed time between summer and normal
human gestation. Analyses of health-related behaviors
at the group level are carried out by epidemiologists,
providing the evidence by which practice-based health-
care providers can begin the development of interven-
tions using the ecological model approach. An effective
ecological model defines, understands, changes behav-
ior, and ultimately promotes population-level health
and wellness.

C H A P T E R 3 n Epidemiology and Nursing Practice 63

urban and some nonurban schools, to better understand
why students start smoking and what might motivate
them to quit to develop an effective school-based
intervention to reduce youth smoking. Jane used her
epidemiology skills to understand the existing data and
how that might inform smoking reduction efforts but
also to help her understand gaps in the data so that she
could plan the next steps for developing an effective,
tailored public health intervention.

Endocarditis

Bacteria
(External

Environment)

Bacteria
Reservoir
(Human)

Hereditary
(Genetics)

Bacteremia
(Human)

Antibiotic
Prophylaxis

Cardiac
Abnormalities

Oral/Dental

Figure 3-5 Web of causation and endocarditis.

7711_Ch03_055-076 21/08/19 11:06 AM Page 63

Tools of Epidemiology: Demography
and Biostatistics
The science of epidemiology requires the use of particu-
lar tools to help epidemiologists study health and
wellness as well as determine which interventions will
help improve the health of populations. Among these
tools are demography and biostatistics. Understanding
how to apply demography and biostatistics helps nurses
in all settings to provide better care and promote the
health of the populations they serve.

Demography
Demography is the population-level study of person-
related variables or factors. The field of demography
has been around since the early 20th century. Warren
Thompson, an early pioneer, developed the demographic
transition model used today to explain the shift from
high birth and death rates to low birth and death rates
within populations.19 Warren Thompson is to the field
of demography as Florence Nightingale is to nursing and
John Snow is to epidemiology. Establishing methods for
tracking populations over time adds to the methods of
tracking disease established by John Snow. Public health
and health-related disciplines use demography and asso-
ciated methods to better understand population-level
patterns related to health phenomena.

Typically, person-related variables are compared over
two or more time periods to establish trends within
the population of interest. Comparing demographic
data from time 1 to time 2 is fundamental to the promo-
tion and establishment of relevant prohealth environ-
ments, policies, and behaviors across time. For example,
comparing the percentage of the population below the
poverty level in a particular community from 2010 to
2020 can help identify changes in the population that
may affect access to health care. Another example is to
put together a visual depiction of demographic data
using the demographic transition model (Fig. 3-6). This
model refers to population change over time, especially
in relation to birth and death rates.

One measure of the health of populations used to
compare populations from a global perspective is life ex-
pectancy. Life expectancy is the average number of years
a person born in a given country would live if mortality
rates at each age were to remain constant in the future.20

Based on 2015 estimates worldwide, there is a wide
range among countries in relation to the average life ex-
pectancy at birth (50.1 years in Sierra Leone to 83.7 years
in Japan).20 One of the reasons for lower life expectancy

in low- and middle-income countries is that they expe-
rience more difficulty with control and eradication
of communicable diseases and the illnesses associated
with maternal, child, and women’s health. Also, many of
these countries lack the health benefits of more stable
economies with advanced industrial and technological
developments. The study of trends across time results in
interventions including policy reform, re-engineering,
educational initiatives, and enforcement of standards
and laws to assure the health of the public. Public health
is a dynamic interdisciplinary field associated with other
fields such as political science, sociology, criminology,
and psychology. Ultimately, the sociobehavioral determi-
nants of health contributing to the health of individuals
are affected substantially by subsystems such as political,
social, and environmental factors.21

Obtaining Population Data
A challenge for public health professionals is obtaining
current and accurate population data. There are various
sources of data from the local to the international level.
Data are obtained initially through various routes
including surveys, mandatory health data reports, inde-
pendent research, and hospital data, to name a few.
Some of the data are available on the Internet, whereas
other data are protected and special permission is
needed to obtain them.

Census Data: Census data are extremely useful
sources of demographic data. These public domain data
are available on the official U.S. Census Bureau Web site
(see Web Resources on DavisPlus) as well as in multiple
formats upon special request. It is advised that public
health researchers, health promotion planners, and other

64 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Figure 3-6 Demographic transition.

1 2

Time

Total Population

Birth Rate

Death Rate

3 54

B
ir

th
s/

D
ea

th
s

pe
r

1,
00

7711_Ch03_055-076 21/08/19 11:06 AM Page 64

professionals charged with developing and implement-
ing health promotion and disease prevention initiatives
access and review local, regional, and state-level
data provided in the U.S. Census. Accessing U.S. Census
data related to a population located in a specific geo-
graphical area is a very effective starting point when
seeking to quantify a health-related phenomenon.
Demographic variables include gender, race, housing,
economic level, age, and other relevant data. However,
census data reflect populations within a specific geo-
graphical area. The census data are available from
the national level down to the neighborhood or census
block level and are useful if the population of interest is
defined based on a geographical community. The data
can be viewed based on ZIP code, town, county, or state.
Accessing the Web site provides a mechanism for
exploring a town or county to determine what the pop-
ulation is, how many housing units are rented or owned,
and how many people living in the town or county have
an income below the poverty level.

Community Data: More typically, public health pro-
fessionals are asked to address community-level health
issues. Community data are valuable resources with both
strengths and limitations. Before addressing sources of
community data, it would be useful to review the discus-
sion of community in Chapter 1. Which of the following
is representative of a community—residents in Portland,
Oregon, diabetics in the tri-state area, women above age
65 years, or gay men in Houston, Texas? An answer of
“all of the above” would be correct. Community data are
not limited to simply a geographical location but can
take on additional characteristics such as disease status
(diabetes), sexual orientation (gay, lesbian, bisexual), and
demographics (race, ethnicity, and age). Examples of
typical opportunities for public health nurses and other
health-related professionals to use community data
include hospital-based initiatives, health plan initiatives,
nonprofit agency initiatives, special interest groups, and
local/state/federal initiatives.

One example of community data relating to the health
of residents in cities, states, and territories is the Behav-
ioral Risk Factor Surveillance Study (BRFSS) found at the
CDC Behavioral Risk Factor Surveillance System Fre-
quently Asked Questions section of its Web site. Disease-
specific data and health-planning and education resource
materials can be found at the American Diabetes Asso-
ciation Web site as well as at local area health-care agen-
cies (see Web Resources on DavisPlus). As previously
mentioned, if the community is a geographical commu-
nity, the U.S. Census data can be used to focus on demo-
graphic information such as the number of women older

than age 65 years. More challenging might be tapping
community-level data on variables such as sexual orien-
tation. Challenges in estimating these variables (e.g.,
number of gay men living in Houston, Texas) are diffi-
cult to overcome as there is a lack of accurate and reliable
data sources. Data relating to these more complex vari-
ables can be, and often are, generated through original
data collection at the community level.

The Nurses’ Health Study, now more than 30 years
old, is of special interest to nursing professionals.
Information on this study can be found on a Harvard
University Web site (see Web Resources on DavisPlus).
This study provides community-level data that have been
generalized to women’s health in the general population.
By seeking to better understand community-level data,
such as women’s health, a more complete understanding
of the factors influencing health and appropriate proac-
tive measures toward the improvement of women’s
health can be successfully achieved. Community data can
relate to person, place, and time variables and a myriad
of interactions between these three broad categories.
Responsible investigators should always take a critical
look at the sources of data and remain cognizant that
errors likely exist within any data to be used in the
development of community health programming. Poten-
tial sources of error should not halt efforts to promote the
health of the public but should be carefully considered
and reported openly.

Biostatistics
Biostatistics reflects the analysis of data related to
human organisms and is used in public health science
and other biological sciences. It examines variations
among biological organisms (people, mice, cells). Thus,
it is a core part of public health science.

Mean, Median, and Mode
Demographers use descriptive statistics as well as ad-
vanced inferential statistical methods to describe the size,
structure, and distribution patterns of populations and
subpopulations within geographically defined regions.
These measures include the computation of the mean,
median, mode, quartiles, and interquartile ranges. De-
mographers also compute the percent change in popu-
lations over time as well as estimate population counts
for the future. These come under the umbrella of descrip-
tive data analysis.

Most epidemiologists regard descriptive data analysis
as the initial step in analysis of demographic data. How-
ever, the analysis of data at the descriptive or inferential
level of analysis is only as good as the accuracy of the data

C H A P T E R 3 n Epidemiology and Nursing Practice 65

7711_Ch03_055-076 21/08/19 11:06 AM Page 65

being used. Though the accuracy of data and the methods
by which data are gathered go beyond the scope of this
text, public health scientists should ensure that they de-
velop thoughtful and evidenced-based original data col-
lection protocols and review published science carefully
to evaluate whether data were collected in an accurate
and meaningful way.

Determining the mean, the median, and the mode
uses basic math skills. All three are measures of central
tendency. The mean is what is commonly considered the
average, as it is the mathematical average of a set of num-
bers. The mean is calculated by summing the total of all
values and dividing by the total number of values in the
set. The median is the middle value in a set of values. For
example, if you have 20 individual patient blood pres-
sures, the 10th occurrence in an ordered set from lowest
to highest is the median. The mode is the value that oc-
curs more times within a data set than any other occur-
rence. To help you understand these basic concepts,
complete the question in Box 3-1.

Percent Change
It is useful to have a time 1 and a time 2 measurement to
determine a percent change related to a demographic
variable or health statistic. The time 1 measure is often
referred to as the baseline and can be used to establish
the proportion or percentage of illness or disease within
the population. This is often used to evaluate changes in
a population over time and is calculated by taking the
new number (B) and subtracting the original number
(A) then dividing the resulting number by the original
number A (Box 3-2). This information is quite valuable
when completing community assessments (see Chapter 4),
because it explains shifts in population that may have an
impact on the health of the community or the type of
interventions needed. For example, if there has been a
positive 20% change in the population who are over the
age of 85, then the community may have increased health
needs related to aging, but if the opposite has occurred,
a 20% decrease in those over the age of 85 and a 20% in-
crease in those aged 1 to 5 years, there may be less need
for interventions aimed at the very old and more inter-
ventions needed to support infant health.

Rates
To help in understanding the distribution of disease in a
population, epidemiologists calculate rates. In under-
standing the magnitude of a health-related phenomenon,
epidemiologists need both a numerator and a denomi-
nator. What does this statement mean? Imagine that a
health educator in Columbus, Ohio reports that there

66 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Methods Review
Mean, Median, Mode, Quartiles, and Interquartile Range
Twenty students have been admitted to the dual degree
MSN/MPH degree program. You have been asked by the
Dean of the College to report the average age of these
students.

Data Set [Not real persons]:
Name Gender Age in Years
1. Angela Jones F 23
2. Bill Baker M 32
3. Connie Clark F 22
4. Dennis Daniels M 24
5. Emily Edwards F 56
6. Frank Fitzgerald M 23
7. Georgia Grant F 24
8. Herald Hall M 22
9. Ingrid Israel F 22

10. James Jennings M 24
11. Kelly Karr F 22
12. Lawrence Lee M 35
13. Melissa Martin F 22
14. Nelson Newman M 21
15. Olivia Owen F 22
16. Paul Pierce M 31
17. Quinn Queen F 27
18. Robert Reynolds M 23
19. Sarah Salzman F 22
20. Timothy Tucker M 22
Q1: The mean, median, and mode are all measures of

central tendency—averages. You should report all
three.
A: Mean = 25.96
A: Median = 23
A: Mode = 22

BOX 3–1 n Calculating Population Mean, Median,
and Mode

Formula
(Time B–Time A)/Time A × 100 = percent change

Population 2010 2020 Percent
City A Time A Time B change
Hispanic 1,512 1,955 29.3%
85 years of age 215 92 –57.2%

or older

BOX 3–2 n Calculating Percent Change [Not from
an actual data set]

7711_Ch03_055-076 21/08/19 11:06 AM Page 66

are 12,500 smokers in his city and a health educator in
Columbus, Indiana reports that there are 11,800 smok-
ers in his city. Based on these two estimates, it is fair to
say that smoking is a greater problem in Columbus,
Ohio, than it is in Columbus, Indiana, correct? It is clear
that there are 700 more smokers in the Ohio city than
there are in the Indiana city. However, the denominator
is missing in this equation. By going to the U.S. Census
Bureau and learning what the city population estimate
was, we can effectively establish a denominator. It is
always advisable to use the same source if possible so that
comparable population estimates and associated collec-
tion methods are assured in establishing estimates. If the
estimated population for Columbus, Ohio is 730,657 and
for Columbus, Indiana, it is 39,059, then it is possible to
calculate the percentage. Now the facts are that 1.7% of
the population in Columbus, Ohio, smokes compared
with 30.2% in Columbus, Indiana!

Using these data from the two towns, we just calcu-
lated the rate of smoking in each population. To further
illustrate how a rate is determined, consider being the
health commissioner of Petersburg, Oregon, with a
population 5,000. Of the total population, 1,250 people
report that they are current cigarette smokers. The health
department receives a weekly report on the number of
influenza cases reported in the city in the month of
January (Table 3-1). One should assume that these data
are accurate and that no reporting error exists.

Given the data in Table 3-1 and the information on
how many people live in the city, we can construct pop-
ulation rates of influenza cases across the two classifica-
tions of smoker and nonsmoker. First, using the data in
the table, calculate the rate of influenza in smokers
during week 1. To do this, divide 50 by 1,250, which
illustrates a rate of 4%, or 4 in every 100 smokers came
down with the flu in week 1. In comparison, less than
1% of nonsmokers came down with the flu in week 1

(1 in 100). If one considers the total population percent-
ages by week, there was a spike in cases during the third
week of January. However, by breaking the data out by
smoking status, it is clear that there are variations in the
monthly pattern across the two groups. Therefore, a rate
represents the proportion of a disease or other health-
related event, such as mortality, within a population at a
certain point in time. It is the basic measure of disease
used by epidemiologists and other health professionals
to describe the risk of disease in a certain population over
a certain period of time.

How to Calculate: Calculating rates is a relatively
simple mathematical procedure, if one can secure an
accurate estimate of disease or illness in the population
to use as the numerator and an accurate total population
estimate to serve as the denominator (Box 3-3). Again,
using the data in Table 3-1, focus on the first cell
corresponding to week 1: smokers with influenza. The
numerator is 50 (week 1 influenza cases) and the denom-
inator is 1,250 (smokers residing in Petersburg, Oregon).
The number 100 represents a constant, in this case per
100 smokers. The constant could be 1,000 or 10,000 de-
pending on the frequency of the disease in the popula-
tion. This approach allows for the presentation of rates
based on various constants. One may express a rate in
terms of 1,000 or 10,000 rather than 100 if the number
of cases is small. For example, infant mortality rate is
expressed as the number of infant deaths for infants less
than age 1 year per 1,000 live births.

Types of Rates: Mortality and morbidity are two
commonly used rates in epidemiology as well as within
the health-care professions. Mortality refers to the num-
ber of deaths within a given population. To calculate
the mortality rate, take the number of deaths within a
specified time-period and divide it by the total number
of individuals within the same population during the
same time period. A commonly used mortality rate is the

C H A P T E R 3 n Epidemiology and Nursing Practice 67

TABLE 3–1 n Fabricated Data—Influenza in Anytown, USA

Week Influenza Smoker Influenza Nonsmoker Total Influenza

Number of New Cases Number of New Cases Number of New Cases

1 50 (4.0%) 20 (0.5%) 70 (1.4%)

2 40 (3.2%) 25 (6.8%) 65 (1.3%)

3 80 (6.4%) 50 (1.35%) 130 (2.6%)

4 700 (56.0%) 100 (2.7%) 800 (16.0%)

1,250 (Smokers) 3,700 (Nonsmokers) 5,000 (Total Population)

7711_Ch03_055-076 21/08/19 11:06 AM Page 67

infant mortality rate, as this measure is considered an
effective metric by which to gauge the health-care “sys-
tems” of a nation. To calculate the infant mortality rate,
take the number of infant deaths among those ages birth
to 365 days and divide by the total number of live births
during the same 365-day period. To establish a rate,
include a multiplier that represents the previously men-
tioned constant (e.g., × 1,000). Morbidity refers to the
number or proportion of individuals experiencing a
similar disability, illness, or disease. Examples of condi-
tions and diseases reported using morbidity are the num-
ber of infants within a county with pertussis (“whooping”
cough), the number of new mothers delivering at
St. Ann’s in 2020 experiencing postpartum depression,
the number of returning service men and women expe-
riencing post-traumatic stress disorder (PTSD), and
the number of adults in the United States living with
diabetes. Note that the challenge in reporting these con-
ditions as rates is in accurately establishing the denomi-
nator or the total number of individuals at risk for the
condition in question.

Attack rates are calculated by placing the number of
ill or diseased people in the numerator and dividing by
the total number of ill plus well people (in the susceptible
population) in the population of interest, then multiplying
by a given multiplier (e.g., 100,000). The secondary attack
rate can be calculated by taking the number of new cases
of a disease or illness among the contacts of the initial
(primary) cases, dividing by the number of people in the
population at risk, then multiplying by a given multiplier
(e.g., 100,000).

Prevalence, Incidence: Prevalence and incidence
rates are used by epidemiologists to demonstrate the
burden of disease or illness within the population of
interest. However, these practitioners must carefully
consider when and how to report these rates, as they can

be misleading. What is the difference between preva-
lence and incidence? Incidence can be best understood
as the number of new cases of a disease or illness at a
specific time or period of time. Prevalence is the total
number of accumulated cases of a disease or illness both
new and pre-existing at a given time.

Imagine that you are a public health official and that
you have been serving the people of New York City
for the past 25 years. In 1994, the total number of newly
diagnosed cases of HIV was 2,500 and the total number
of existing or prevalent cases in 1994 was 5,000. In 2014,
20 years later, the number of newly diagnosed cases of
HIV is 1,000 and the total number of existing or preva-
lent cases is 50,000. The change in annualized new HIV
cases went from 2,500 to 1,000 and the prevalence went
from 5,000 to 50,000 over the 15-year period. This
20-year change shows a decrease in new cases, whereas
the prevalence rate comparing the difference across
the 20-year period is a 10-fold increase. Given these data,
would it be fair for a reporter from the New York Times
to feature a headline of “HIV in New York City Drasti-
cally Increases 10-fold Since the Mid-1990s!” or “HIV in
NYC Decreases After 20 Years of Prevention Educa-
tion”? Both headlines are accurate, yet neither is a fair
nor accurate account of the state of HIV in the city.

A prevalence rate is basically the number of existing
cases (numerator) divided by the total number of persons
in the population (denominator). The rate calculated
using the information in Table 3-1 can be understood as
a point prevalence or the number of ill people divided by
the total number of people in the population “group” at
a specific point in time. An associated measure, referred
to as the period prevalence, is calculated as the number
of ill people divided by the estimate of the average num-
ber in the population during a specified time period. An
application of period prevalence might be the number of
people living with a chronic disease within a given pop-
ulation during a specified time, such as a year. Asthma is
a chronic disease that might be effectively presented
using a period prevalence.

In addition to prevalence, there are other rates
reported by epidemiologists that are important to under-
stand and use appropriately (Table 3-2). They are inci-
dence rate, attack rate, and secondary attack rate. An
incidence rate can be calculated by placing the number of
new cases diagnosed in a given period of time divided by
the total number at risk in the population over that same
time period and multiplying by a given multiplier (e.g.,
100,000). For example, the incidence of H1N1 in a school
during a specified period of time would be the number of
new cases of H1N1 divided by the denominator, those

68 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Using the data in Table 3-1, focus on the first cell corre-
sponding to week 1—smokers with influenza.

The rate of influenza was calculated using the follow-
ing formula:

(Number of cases [numerator] ÷ population
[denominator]) × a constant = rate per 100; 1,000;

10,000; or 100,000.

For this case:

(50 ÷ 1,250) × 100 = 4.0%

BOX 3–3 n Calculating Rates

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children in the school who had not had H1N1 in the
past. Those children who had had H1N1 would be re-
moved from the denominator to indicate those children
at risk.

A good way to examine the difference between the in-
cidence and prevalence rate is the prevalence pot (Fig. 3-7),
defined in Chapter 2. The prevalence pot represents all
the current cases of a disease in a population. Entering
into the pot are the new cases reflected by the incidence
rate. Exit from the prevalence pot occurs by one of three
events: death, cure, or disability. For some diseases such
as HIV/AIDS the only way a case leaves the prevalence
pot is through death. For other diseases such as polio, all
three options occur. The size of the prevalence pot de-
pends both on the incidence rate and on the duration of
the disease. Over time the prevalence pot for HIV/AIDS
in the United States has grown not because of dramatic
increases in the incidence of HIV/AIDS but because of
the pharmaceutical interventions that have extended
life expectancy. For other serious health threats such as
the 2017-2018 H3N3 virus, the prevalence pot grew
rapidly with the increase in incidence but dropped
rapidly once incidence rates dropped because of the
short duration of the disease.

The incidence and prevalence rates are affected by fac-
tors such as the number of people being screened for the
disease and the number of people surviving with a posi-
tive HIV status. During the early 1980s and into the
1990s, few people survived a positive diagnosis for more
than a few years. Thus, the absence of effective medical
treatment options would have resulted in higher death
rates and subsequently lower prevalence rates. As screen-
ing tests became more widely available and stigmatizing
labels began to be reduced, more people became willing
to be screened for HIV. What is missing from the pres-
entation is the number of people tested who were not
positive for HIV. The lesson to be learned is that data

reporting does not necessarily result in effective interpre-
tation. Careful, cautious, and intentional epidemiological
data reporting is a critical task of the public health infor-
mation officer.

Comparing Dependent and Independent Rates:
Data in Table 3-1 provide a useful illustration of inde-
pendent and dependent rates. The weekly influenza rates
independent of smoking status for the month of January
are 15.0, 12.5, 26.0, and 16.0 per 100 persons, respectively.
Simply stated, these weekly rates are independent of the
smoking status of the individuals within the population.
The converse is true for dependent rates where the rates
of influenza by smoking status by week range from
approximately 40% to 32%, spiking to 64%, and finally
dropping to 56%. The week 3 spike pattern is also
reflected in the nonsmoking population. However, the
proportion of nonsmokers with influenza is consistently
25% to 50% lower than that estimated for smokers. There-
fore, a public health official might accurately state that

C H A P T E R 3 n Epidemiology and Nursing Practice 69

Figure 3-7 Prevalence pot.

Death

Leaving the pot

New Cases
People newly

diagnosed

The
Prevalence Pot:

Total Current
Cases

All people with
the disease

Entering the pot

Disability

Cure

TABLE 3–2 n Differentiating Rates

Measure

Point prevalence

Incidence rate

Attack rate

Secondary attack rate

Multiplier

e.g., 100,000

e.g., 1,000

Numerator

Number ill

Number of new cases over
specified time

Number of new cases during
an epidemic period

Number of new cases among
contacts of known cases

Denominator

Population at risk at specific
point in time

Total number at risk during
time period

Total number in population
at start of epidemic period

Total number of population
at risk

7711_Ch03_055-076 21/08/19 11:06 AM Page 69

influenza rates (independent of smoking) for Petersburg,
Oregon, for January ranged between 12.5% and 26%. In
addition, dependent rates adjusted for smoking status for
the city and time-period demonstrated a substantially
greater proportion of influenza among smokers.

The terms independent rates and dependent rates
are also used to describe rates that are independent or
not independent of each other. For example, if you
were concerned with the infant mortality rate in city Y
compared with the infant mortality rate in city X, the
two rates would be independent of each other. By con-
trast, if you wanted to compare the rates between city
Y in state X and the rate in state X, the rates are
dependent; that is, all of the cases in city Y are included
in the count of cases in state X because the city is in
state X.

Descriptive and Analytical Epidemiology
Now that we have examined the basic demographics of
the population of interest, what else can be done to learn
about the specific health issue? There are three broad
categories of epidemiological studies that help to answer
questions about the health of populations: descriptive,
analytical, and experimental studies. The majority of
epidemiological investigations, particularly community-
based public health investigations, are defined as either
descriptive or analytical. In descriptive or observational
case control and cohort studies, the investigator has
no control over the exposure or nonexposure status of
subjects. By contrast, experimental epidemiology con-
sists of the research methodology whereby the investiga-
tor has direct control over the subject’s assignment to
exposure status. Clinical trials fall into the latter classifi-
cation. Experimental studies tend to fall under the
authority of clinical research scientists and are housed in
academic research centers, federal agencies, or private
research and development agencies, such as pharmaceu-
tical companies.

Descriptive Epidemiology
Descriptive epidemiology refers to the analysis of
population and health data that are already available. It
includes the calculation of rates (e.g., mortality) and an
examination of how they vary according to demographic
variables (e.g., gender, race, socioeconomic status).22

Similar to demography, descriptive epidemiology pro-
vides an understanding of the general features of
the population of interest. In contrast to demography,
the epidemiologist shifts from a broad population demo-
graphic representation to one that illustrates aspects

of health, wellness, and/or disease considerations within
the population.

Analytical Epidemiology
Analytical epidemiology involves examining health-
related data to determine the association between risk
factors and the occurrence of a health phenomenon. In
descriptive epidemiology, the epidemiologist can use the
findings to formulate a hypothesis about possible causes
for the health phenomenon. In analytical epidemiology,
the purpose is to test the hypothesis. There are three
basic types of studies that use analytical epidemiology
methods: the case-control study, the cohort study, and
the clinical trial. The study may use a cross-sectional
design that reports health-related information for a spe-
cific point in time. Or the study may use a prospective,
retrospective, or longitudinal design related to data
collected in more than one time period.

Cross-Sectional Studies
Cross-sectional studies or surveys examine risk factors
and disease using data collected at the same point in
time. It is easy to remember that a cross-sectional study
provides an estimate of the disease status or frequency
at one point in time; thus, it is truly a cross section of
the disease or illness within the population of interest
at a given moment in time. It is also called a prevalence
study. For example, numerous health surveys are
conducted by the National Center for Health Statistics
as a means of determining the prevalence of disease at
a given point in time. They are relatively easy to admin-
ister, and the data can be collected in a rather short pe-
riod of time. However, because they are cross-sectional,
they do not provide a temporal, or time-related, se-
quence of events. For example, if nurse Jane in River
City wanted to determine specific risk factors for smok-
ing among adolescents, she might conduct a survey of
the students through the school system to ask about
specific smoking habits and risk factors. Jane might
also ask whether any of the students’ parents smoked.
However, because Jane collected data at one point in
time, she cannot with confidence assert that parental
smoking preceded smoking initiation by the student.
However, the data can provide valuable information on
which risk factors might be related to smoking among
the youth in River City.

The cross-sectional design methods are not limited to
the study of disease or even illness factors. For example,
this research design methodology can be used to evaluate
satisfaction with health-care–related services within a
community.

70 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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Case-Control Studies and Odds Ratio
The case-control study design allows the epidemiologist
to compare the ratio of disease in those exposed to a risk
factor with those who were not exposed to the same risk
factor. Using the case-control method, the epidemiolo-
gist has a specified number of people with a disease or
illness. These individuals who are defined as diseased
or ill are the “cases.” The epidemiologist then must seek
to establish a representative group of people without the
disease or illness as the controls. Then both the cases and
controls are measured related to a specific exposure or
multiple exposures.

A standard two-by-two table is used to divide
individual-level or person-specific data into disease
status (yes/no) and exposure status (yes/no). The odds
ratio (OR) is defined as the odds of having a disease or
condition among the exposed in comparison with the
odds of those who were not exposed. The calculation of
the OR is a relatively simple mathematical procedure.
The OR is mathematically expressed as [OR = AD/BC]
(Box 3-4). The epidemiologist then determines whether
the OR for those with the disease who have experienced
exposure is significantly greater than the controls by
calculating confidence intervals and p-values for each OR
point estimate. This calculation goes beyond the intro-
ductory nature of this text. Intermediate and advanced
epidemiology textbooks can and should be consulted to
gain depth of understanding of these calculations.

Take, for example, individuals with oral cancer of the
gums. The researcher hypothesizes that people who use
or have a history of using smokeless tobacco (chewing
tobacco) are at greater risk of developing oral cancer. The
researcher now needs a group of individuals to serve as
the controls. To construct the two-by-two table and
establish the risk of oral cancer from chewing tobacco,
she needs a group of individuals who have not been ex-
posed to chewing tobacco. The cases are the individuals
with oral cancer who are asked to report on exposure
variable and use of chewing tobacco. The challenge is to
find a fair representative group that fits into the control
or “no disease” category. Often studies of this nature are
conducted using controls at the same health-care facility

with a different disease or illness. In this scenario, skin
cancer patients will be used as controls. The biological
plausibility of developing skin cancer as a result of
using chewing tobacco is unlikely but could indeed be a
confounder. A confounder is a studied variable that can cause
the disease that is also associated with the exposure of
interest. Confounders can make it difficult to establish a
clear causal link unless adjustments are made for their
effects. Confounders are potential limitations in all epidemi-
ological studies; methods of controlling for confounders are
addressed in advanced epidemiological textbooks.

Case-control studies have limitations. There can be
effects from multiple determinants of health, the com-
plexity of additive, and/or interactive exposures on
health. There are also potential problems related to the
representativeness of the cases and the controls, that is,
how well they reflect the target population. Another issue
is accurately determining exposure. Case-control studies
are done retrospectively; that is, disease has already
occurred in the cases. For both cases and controls, deter-
mining whether individuals have been exposed requires
obtaining a history from the individuals rather than
through direct observation of the exposure. See Box 3-5
for a case-control study of the smoking among youth in
River City.

Cohort Studies and Relative Risk
Cohort studies are studies that follow a specific popula-
tion, subset of the population, or group of people over a
specified period of time. Cohort studies can be effective
in generating a wealth of data relating to the population

C H A P T E R 3 n Epidemiology and Nursing Practice 71

Disease Disease
Status (Yes) Status (No)

Exposure status (Yes) A B
Exposure status (No) C D

BOX 3–4 n Calculating Odds Ratio

Set up a two-by-two table for children aged birth to
18 years with residency (urban/nonurban) on one axis
and smoking status (yes/no) on the other axis.

Answer:
Smoker Smoker
(Yes) (No) Totals

Urban 1,500 1,500 3,000
Non-urban 1,000 6,000 7,000
Totals 2,500 7,500 10,000

Calculate the appropriate measure of association.
HINT: Either relative risk or odds ratio.

Answer: Odds ratio — AD ÷ BC = 1,500 × 6,000 ÷
1,500 × 1,000 — [OR = 6.0] Interpretation: River City
youth between the ages of birth to 18 years living in
the urban district have six times the risk of smoking as
compared with nonurban youth.

BOX 3–5 n Case-Control Study for River City

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of interest. The epidemiologist has substantial control
over the data collection process; therefore, cohort studies
have strong validity. This validity comes with high costs
that include actual direct costs in personnel as well as
costs in time from data collection to the generation of
findings and conclusions. Two types of cohort studies are
found in application:

• Prospective
• Retrospective (also called historical)

Two Web links are provided in the following section.
The first directs you to the Fels Longitudinal Study
established in 1929, the longest-running continuous
human life span and development study in the world.
This longitudinal study is housed at the Wright State
University Boonshoft School of Medicine in Dayton,
Ohio, and can be accessed at https://medicine.wright.
edu/epidemiology-and-biostatistics/fels-longitudinal-
study-collection. The second is to the Framingham study,
a commonly referenced cardiovascular health study
established in 1948. Both studies are longitudinal and
provide useful data to researchers on human populations
over time. Information on the Framingham study can be
accessed at http://www.framinghamheartstudy.org.23

The relative risk is the measure of association used for
cohort studies. Relative risk is determined by comparing
the incidence rate in the exposed group with the inci-
dence rate in the non-exposed group. This measure is
calculated by dividing the number of people in the
yes/yes (cell A) divided by the row total (cells A+B)
divided by the number of people in the yes/no (cell C)
divided by that row total (cells C+D) (Box 3-6).

For example, if we were interested in exploring the
risks of using oral birth control pills and stroke (these are
fabricated data), we could follow 500 women from age
18 to 25 during a specific time period. We would divide
these women into two groups: those taking an oral birth
control pill (250) and those using alternative birth con-
trol or none (250). We find that after following these
500 women during the 32-year study, among those who
were taking the pill, 100 suffered a stroke and 150 had no
stroke, whereas among those not taking the pill, 24 had

a stroke and 225 had no stroke. How would the relative
risk be calculated?

Confounder WARNING
Of the 100 women taking oral contraception, 90 were
cigarette smokers. What additional information is needed
to establish a confounder effect based on tobacco use? As
explained earlier, a confounder is another variable that
may actually account in whole or in part for the relation-
ship between the observed variable (taking the pill) and
the outcome (stroke).

Most cohort studies use a prospective longitudinal
approach that requires following a group over a long
period of time, which can be 30 years or more. An exam-
ple is the Nurses’ Health Study that began in 1976.
The purpose of the study was to examine the long-term
effects of oral contraceptives.24 The researchers have
added to this important study with the Nurses’ Health
Study II in 1989 and the Nurses’ Health Study III in 2008.
Data are collected from participants every 2 years with a
sustained 90% response rate. Clearly, this type of design
is limited in application because waiting more than
30 years to establish conclusive results can be problem-
atic. In addition, the notion of confounders, or factors
affecting the outcome other than the factor of interest, is
a limitation. Despite these challenges, data from large co-
hort studies have contributed greatly to our understand-
ing of risk factors related to disease. The Framingham
heart study is still ongoing today, spanning three gener-
ations.23 Prior to the study, the common belief was that
cardiovascular disease was part of the aging process. The
information obtained in the study changed the approach
to the prevention and treatment of cardiovascular disease
and continues to contribute to our understanding of
cardiovascular disease today.

There are times when a cohort study is done retro-
spectively. Imagine a situation in which 500 women
today are asked to report on their past 32 years of history.
Specifically, data are collected on all 500 women relating
to oral contraception usage and stroke. Note: In this ret-
rospective study design, you can add a variable such as
cigarette smoking. This design methodology provides the
researcher with the opportunity to report findings in the
present relating to the variables of interest. Recall is often
a problem with any study design that seeks to collect data
from the subjects based on their recall regardless of the
recall period. Often an individual can’t remember what
he or she ate for breakfast a week ago, or what his or her
last fasting blood sugar was. Imagine how much error
might be present in collecting health behavior data from
the general population. Sources of error in this design

72 U N I T I n Basis for Public Health Nursing Knowledge and Skills

HINT: (A ÷ [A + B]) ÷ (C ÷ [C + D])

Stroke No Stroke Total
Oral pill 100 150 250
No oral pill 25 225 250

BOX 3–6 n Calculating Relative Risk

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also include subject attrition or discontinued participa-
tion, a concern known as right censoring, which is beyond
the scope of this introductory text; confounding; and
other issues related to following a large cohort over a
long period of time.

Clinical Trials and Causality
Clinical trials represent a special type of epidemiological
investigation and the related research methods are a spe-
cial subset. Clinical trials vary widely in their method, but
generally have a control and an experimental group, and
require random assignment to one of these groups. The
control group is not exposed to a treatment, medication,
or therapy, whereas the experimental group is exposed
to the treatment or intervention of interest. The two
groups are then compared to evaluate whether there are
statistically significant differences in outcomes between
the two groups. Clinical trials are more likely to result
in findings that lend themselves to causal statements
of relationships. Cohort and case-control studies can
demonstrate an association between two variables, but a
clinical trial gets much closer to establishing causality.
That said, causality is always a challenging goal to attain
and causal assumptions within clinical research trials
should be carefully considered.

Outbreak Investigations
Outbreak investigation is fundamental to field epidemi-
ology and pivotal to the role of epidemiologists, public
health nurses, and public health workers. As previously
confirmed, epidemiology is truly an applied science. Epi-
demiologists use quantitative data analysis methods at
the population level to better understand health-related
circumstances within communities. The unit of analysis
is groups of people, not the individual. It is critical to
remain cognizant of the risk of committing an ecological
fallacy. The fallacy refers to the erroneous assumption
that one can draw conclusions for individuals based on
group findings, which occurs when the researcher draws
conclusions at the individual level based solely on the
observations made at the group level. An example of an
ecological fallacy can be illustrated based on a study of
obesity in women in two cities. Consider that the women
in City A had a higher body mass index (BMI) on average
than the women in City B. It would be a fallacy to con-
clude, just based on these averages, that a randomly
selected woman from City A would have a higher BMI
than a randomly selected woman from City B. Because
the BMI reported in the study reflected an average
and not a median, there is no information about the

distribution of BMI values in the two cities, and a ran-
domly selected individual woman from City A may
have a lower BMI than a randomly selected woman from
City B.

Although much of the work of public health nurses
and public health workers is focused on implementing
initiatives that prevent disease or illness, the outbreak in-
vestigation is in response to elevated levels of a disease
or illness within the defined population. The outbreak
investigation is one of the more commonly recognized
applications of epidemiology by the general public.
Examples of commonly recognized outbreak investiga-
tions include foodborne illness investigations resulting
from salmonella; gastroenteritis illness investigations at
community daycare centers resulting from Shigella; com-
munities with elevated numbers of pediatric asthma
emergency room visits and subsequent hospitalization;
health-care providers with unusually high numbers of
patients with uncontrolled type 2 diabetes; employees
with elevated levels of asbestosis; communities with un-
expectedly high numbers of infants with elevated blood
lead level; and, on a global level, the Ebola outbreaks in
Africa. Outbreak investigations are an important appli-
cation of epidemiology because of the truly applied na-
ture of the inquiry. The investigation is not simply an
academic exercise but an opportunity to initiate disease
or illness investigation, analyze data collected within the
community or workplace, interpret data, implement
health promotion and risk reduction interventions, and
evaluate short- and long-term health and the effects of
wellness on the population. Precipitating factors relating
to person, place, and time are essential as is an awareness
of disease or illness etiology. Outbreak investigations
can occur in relation to communicable diseases, chronic
disease, and exposure to toxic agents.

Investigation strategies are dependent on the type of
agent resulting in illness, the communicability of the
illness, the virulence of the agent, and the infectivity of the
agent. The infectivity of the agent is defined as the propor-
tion of persons exposed to an infectious agent who become
infected by it and the specific route of infection. As pre-
sented earlier in this chapter, three key aspects of tracking
disease within a population and developing strategies to
reduce the spread and severity of outbreaks are contingent
on person, place, and time considerations. The importance
of effective surveillance of disease and illness is vital in es-
tablishing expected levels of illness within the population.
The CDC maintains publicly reportable data on a number
of diseases (see Web Resources on DavisPlus).

Illnesses such as influenza and pertussis have seasonal
variations and can be substantially reduced through

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preventive vaccination. The number of reported in-
fluenza cases typically spikes annually from December
through March. Public health community-wide vaccina-
tion campaigns are initiated in the autumn each year in
an attempt to prevent disease through targeted immu-
nization at the population level. A vaccine for the pre-
vention of pertussis was developed in the 1940s, and
aggressive public health childhood immunization initia-
tives resulted in a low number of reported cases nation-
ally in the mid-1970s. Unfortunately, the number of
pertussis cases has increased during the past 30 years
with an increasing proportion of cases among the adult
and older segments of the U.S. population.25

Communicable Disease Outbreaks
Communicable diseases can be the result of a point source
or a common source followed by secondary spread within
the population. Typically, person-to-person spread is
observed as with the case with the Ebola virus. However,
communicable diseases such as the West Nile virus are
spread through vectors, specifically insect to human. The
21st century has witnessed a substantial reduction of
diseases as a result of improved environmental condi-
tions and sanitation systems. Person-to-person spread
of communicable disease continues to present substan-
tial challenges to professions charged with promoting
health and reducing the burden of disease at the popu-
lation level. Unlike systems, which can be re-engineered
to eliminate risks of exposure, strategies addressing
person-to-person transmission of disease can be daunting.
Global public health and disease prevention initiatives
such as hand hygiene education and safe sex practices
are initiatives seeking to address person-to-person spread
of communicable diseases. See Chapter 8 for further in-
formation on how to investigate a communicable disease
outbreak.

Noncommunicable Disease Outbreaks
In the latter decades of the 20th century, chronic dis-
eases have replaced communicable diseases as the most
significant disease classification in high-income coun-
tries. Simply stated, as a result of aggressive interven-
tions during the past 100 years, the mortality rate from
communicable diseases has dramatically declined, con-
tributing to higher life expectancy. With this increased
life expectancy, more people are surviving long enough
to develop noncommunicable diseases that occur later
in life such as cardiovascular disease. Often referred to
as lifestyle diseases, illnesses related to poor diet, a lack
of exercise, and tobacco and alcohol use have become
epidemic. Some typically diagnosed noncommunicable

diseases include heart disease, type 2 diabetes, cancer,
and chronic obstructive pulmonary disorder (COPD).
Initiatives including tobacco cessation programs, bal-
anced nutrition education, and exercise/fitness programs
have been and continue to be developed to combat the
negative impact of noncommunicable diseases.

Although not necessarily demonstrative of traditional
outbreak investigation, noncommunicable diseases can
be studied with epidemiological methods comparing
risk factors such as tobacco use and BMI, and the pres-
ence or absence of disease states. Unlike communicable
diseases in which there exists a direct cause-and-effect
relationship between the exposure and the onset of dis-
ease, noncommunicable diseases are usually connected
to multiple risk factors, and it can be harder to demon-
strate a direct cause and effect. This presents challenges
in both demonstrating direct causes of disease and
changing destructive behaviors within the population
that compromise health.

Exposure to Toxins
Similar to noncommunicable diseases, exposure to toxins
has emerged as a substantial risk to human health and
wellness. As with noncommunicable diseases, a direct
cause-and-effect relationship is difficult to prove. In fact,
toxic substances often have thresholds below which
exposures do not present human health risks but above
which can prove to have adverse and at times fatal con-
sequences. The movement during the past 40 years has
been to advance the study of risk exposure to potentially
toxic substances. Organizations including the National
Institute for Occupational Safety and Health (NIOSH),
CDC, EPA, and ATSDR have made substantial gains
in research and policy to reduce toxic risks adversely
affecting the health of the public.

Surveillance
James Maxwell, a physician in the 1800s, once said
“We owe all the great advances in knowledge to those
who endeavor to find out how much there is of any-
thing.”26 This could be a summary of epidemiology but
also specifically of surveillance, which focuses on deter-
mining and monitoring “how much there is” of diseases,
health conditions, environmental disasters, or other risk
factors. The CDC defines public surveillance as “the on-
going, systematic collection, analysis, and interpretation
of health-related data essential to planning, implemen-
tation, and evaluation of public health practice.”27 Sur-
veillance principles are used when universities provide
information on interpersonal violence on campus, the CDC
reports on communicable disease outbreaks or changes

74 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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to the rates of tobacco use, or the WHO provides
national and global level estimates on the prevalence of
tuberculosis infection. All these reports are based on col-
lecting and interpreting data to make practice or policy
recommendations.

There are two main types of surveillance: passive and
active. Passive surveillance is when data are collected
based on individuals or institutions that report on health
information either voluntarily or by mandate. The onus
for collecting and reporting of the data to public health
or governmental agencies is on health-care providers or
public health professions in the field. For example, day-
care centers are often required to report an increase in
the number of cases of communicable disease like hand
foot and mouth (caused by an enterovirus) to the local
or state health departments so that the health depart-
ments can report and monitor communicable diseases.
One of the challenges in passive surveillance is ensuring
that those reporting the data have adequate resources to
collect accurate data. If the data is inaccurate or only
some agencies are reporting the data then there is a risk
that the data will be biased or will not reflect the actual
conditions of the population. Surveillance in low- and
middle-income countries can be particularly challenging
where local and national governments may not have ad-
equate resources to accurately collect morbidity and
mortality data. The consequence of poor surveillance
data is that it can be difficult to accurately prioritize
health-care resources on a national and global level be-
cause the true levels of disease are poorly understood.

One example using the results of surveillance to
understand the impact of disease is the global burden of
disease. As will be discussed in more detail in Chapter 9,
the burden of disease is defined by the WHO as the dif-
ference between a population’s actual health status and
the “ideal” health status if everyone were to live to their
fullest potential and life span. It is measured in the years
of life lost to both premature mortality and disability.28,29

These data include information about the impact of a
health problem on a population using indicators such as
monetary cost, mortality, and morbidity, and refers to
this as the burden of disease. To help measure the burden
of disease, statisticians calculate the disability-adjusted
life years (DALY) that considers not only mortality
but also the morbidity and the disability associated with
a disease or risk factor. Such reports are compiled by
organizations like the WHO based on global surveillance
reports and other local and national data sources. These
data help researchers evaluate the impact of interven-
tions and identify areas for action (see Chapter 9 for
additional information and how to calculate DALY).

A second type of surveillance is active surveillance,
which involves the deployment of public health profes-
sionals including nurses to identify cases of a disease or
health condition under surveillance. This could involve
reviewing medical records, interviewing health-care
providers or hospital administrators, and surveying those
exposed to the condition. Active surveillance is typically
used in an outbreak where there is a sudden change in
the number of cases of a particular disease or condition.
The Ebola responses in Sierra Leone and Liberia provide
examples of active surveillance where multiple organiza-
tions including the CDC and WHO were involved
in finding cases, tracking the spread of disease, and
deploying staff to prevent further transmission.

C H A P T E R 3 n Epidemiology and Nursing Practice 75

t CASE STUDY
Investigating Motor Vehicle
Crashes using Epidemiology

Learning Outcomes
• Apply epidemiology methods to a public health

concern.
• Explore sources of epidemiologic data on a national,

state, and local level.

You are a public health nurse at your state’s health
department tasked with identifying one of the leading
causes of mortality and morbidity, and working with a
local university to design a study to further explore
risk factors related to the identified cause. After com-
paring state-level surveillance data to national data,
you realize that motor vehicle crashes (MVCs) are
a leading cause of death and injury in your state.

Discussion Points
• Using the seven questions for epidemiologic investi-

gations, list what type of information you would like
to gather about MVCs.

• Identify where you might find additional information
regarding MVCs on a local, state, or national level.

• If you were to design an epidemiologic study to
gather more data on MVCs in your state, what type
of study could you design? What are the pros and
cons to your study design?

n Summary Points
• Epidemiology provides the scientific basis for under-

standing the occurrence of health and disease.
• An epidemiological investigation revolves around

person, place, and time.

7711_Ch03_055-076 21/08/19 11:06 AM Page 75

• An understanding of risk factors for disease
from an individual and ecological perspective
is essential for the development of effective
interventions.

• The two-by-two table is a principle pertaining to
epidemiological investigation and analysis.

• Epidemiological investigations include descriptive
and analytical epidemiology.

• Surveillance, both passive and active, helps to
identify and respond to public health concerns
such as outbreaks of communicable diseases.

REFERENCES

1. Martin, N., & Montagne, R. (2017, May 12). U.S. has the
worst rate of maternal deaths in the developed world.
NPR. Retrieved from https://www.npr.org/2017/05/12/
528098789/u-s-has-the-worst-rate-of-maternal-deaths-
in-the-developed-world.

2. Centers for Disease Control and Prevention. (2017). Preg-
nancy mortality surveillance system. Retrieved from https://
www.cdc.gov/reproductivehealth/maternalinfanthealth/
pmss.html.

3. Friis, R.H., & Sellers, T.A. (2014). Epidemiology for public
health practice (5th ed.). Boston, MA: Jones & Bartlett.

4. World Health Organization. (2017). Global tuberculosis
report 2017. Retrieved from http://www.who.int/tb/
publications/global_report/en/.

5. Snow, J. (1965). Snow on cholera. Cambridge, MA: Harvard
University Press.

6. Lilienfeld, A.M., & Lilienfeld, D.E. (1980). Foundations of
epidemiology (2nd ed.). New York, NY: Oxford University
Press.

7. Susser, M., & Susser, E. (1996a). Choosing a future for
epidemiology: I. Eras and paradigms. American Journal
of Public Health, 86(5), 668-673.

8. Susser, M., & Susser, E. (1996b). Choosing a future for
epidemiology: II. From black boxes to Chinese boxes and
eco-epidemiology. American Journal of Public Health,
86(5), 674-677.

9. WHO. (n.d.). Risk factors. Retrieved from http://www.
who.int/topics/risk_factors/en/.

10. CDC. (2018). Behavioral risk factor surveillance system.
Retrieved from https://www.cdc.gov/brfss/index.html.

11a. CDC. (2017). Youth risk behavior survey 1997-2017. Data
retrieved from https://www.cdc.gov/healthyyouth/data/
yrbs/.

11b. CDC. (2017). National health interview survey 1997-2017.
Data retrieved from https://www.cdc.gov/nchs/nhis/
index.htm.

12. National Cancer Institute. (2018). BRCA mutations: cancer
risk and genetic testing. Retrieved from http://www.cancer.
gov/about-cancer/causes-prevention/genetics/brca-fact-sheet.

13. WHO. (2018). Tobacco. Retrieved from http://www.
who.int/mediacentre/factsheets/fs339/en/.

14. CDC. (2018). Youth and tobacco use. Retrieved from
https://www.cdc.gov/tobacco/data_statistics/fact_sheets/
youth_data/tobacco_use/index.htm.

15. Krieger, N. (1994). Epidemiology and the web of causation:
Has anyone seen the spider? Social Science Medicine, 39(7),
887-903.

16. Diez Roux, A.V. (2007). Integrating social and biological
factors in health research: A systems review. Annals of
Epidemiology, 17(7), 569-574.

17. Shapiro, S. (2008). Causation, bias and confounding: A
hitchhiker’s guide to the epidemiological galaxy, part 2.
Principles of causality in epidemiological research: Con-
founding, effect modification, and strength of association.
Journal of Family Planning and Reproductive Health Care,
34(3), 185-190.

18. Reifsnider, E., Gallagher, M., & Forgione, B. (2005). Using
ecological models in research on health disparities. Journal
of Professional Nursing, 21(4), 216-222.

19. Lee, P.R., & Estes. C.L. (2003). The nation’s health (7th ed.).
Burlington, MA: Jones & Bartlett.

20. WHO. (2016). Life expectancy increased by 5 years since
2000, but health inequalities persist. Retrieved from
http://www.who.int/mediacentre/news/releases/2016/
health-inequalities-persist/en/.

21. Szklo, M., & Nieto, F.J. (2012). Epidemiology: Beyond the
basics (3rd ed.). Boston, MA: Jones & Bartlett.

22. Babbie, E. (2016). The practice of social research (14th ed.).
New York, NY: Wadsworth.

23. National Heart, Lung and Blood Institute & Boston University.
(2018). Framingham heart study. Retrieved from http://
www.framinghamheartstudy.org/.

24. The Nurses’ Health Study. (n.d.). Retrieved from http://
www.nurseshealthstudy.org/

25. CDC. (2018). Pertussis (whooping cough). Retrieved from
https://www.cdc.gov/pertussis/surv-reporting.html.

26. Gordis, L. (2014). Epidemiology (5th ed.). Philadelphia, PA:
Elsevier Saunders.

27. Thacker, S.B., & Birkhead, G.S. (2008). Surveillance. In:
M.B. Gregg (Ed.), Field epidemiology. Oxford, England:
Oxford University Press.

28. Murray, C., & Lopez, A. (1996). The global burden of disease:
A comprehensive assessment of mortality and disability from
diseases, injuries, and risk factors in 1990 and projected to
2020. Cambridge, MA: Harvard University Press.

29. Murray, C., & Lopez, A. (2013). Measuring the global
burden of disease. The New England Journal of Medicine,
369, 448-457.

76 U N I T I n Basis for Public Health Nursing Knowledge and Skills

7711_Ch03_055-076 21/08/19 11:06 AM Page 76

KEY TERMS

Aggregate data
Assets
Census block
Census tract
Community
Community-based

participatory research
(CBPR)

Community Health
Assessment

Community Health
Assessment and
Group Evaluation
(CHANGE)

Comprehensive
community assessment

Deidentified data
Focus group
Geographic information

system (GIS)

Health impact assessment
Inventory of resources
Kinship/Economics/

Education/Political/
Religious/Associations
(KEEPRA)

Key informant
Mobilizing for Actions

Through Planning and
Partnerships (MAPP)

PhotoVoice
Population
Population pyramid
Primary data
Qualitative data
Quantitative data
Rapid needs assessment
Secondary data
Windshield survey

n Introduction
Assessment, the first step in the nursing process, is fo-
cused on determining the health status and needs of an
individual. In public health practice, a community
health assessment is a strategic plan that describes the
health of a community by collecting, analyzing, and
using data to educate and mobilize communities; de-
velop priorities; obtain resources; and plan actions to im-
prove health.1,2 Assessment is one of the three core public
health functions established by the Institute of Medicine
(IOM)3 in 1988 (see Chapter 1) and is critical to the work
of public health, especially as it relates to the other core
functions, policy development and assurance.3

Nurses conduct community assessments as the first step
in the development of health programs and interventions
aimed at optimizing the health of a community or popula-
tion. For example, Dulemba, Glazer, and Gregg (2017)
conducted a community assessment prior to developing an
action plan for persons with chronic obstructive pul-
monary disease (COPD) who were residing in east-central
Indiana and west-central Ohio.4 Other health-care profes-
sionals and community partners have come together and
used the principles of community health assessment to bet-
ter understand the health needs of vulnerable groups. For
example, a team in Chicago utilized a community partici-
patory method to do an assessment in a Mexican immi-
grant community.5 A thorough assessment prior to putting

Chapter 4

Introduction to Community Assessment
Christine Savage and Joan Kub

LEARNING OUTCOMES

After reading the chapter, the student will be able to:
1. Define community health assessment within the context

of population health.
2. Describe six approaches to conducting an assessment

(comprehensive community assessment, population
focused, setting specific, problem focused, health impact,
rapid needs assessments).

3. Describe two assessment frameworks (MAPP,
CHANGE).

4. Use secondary data to identify health characteristics of a
community.

5. Describe qualitative and quantitative methods to collect
primary data for conducting an assessment.

6. Describe the use of multiple techniques and tools
(geographic information system [GIS], PhotoVoice) to
conduct community assessments.

7. Discuss the usefulness of community assessments.
8. Use the frameworks in conducting a hypothetical

assessment of a community.
9. Analyze primary and secondary data to identify strengths

and needs of a community.

7711_Ch04_077-106 22/08/19 11:35 AM Page 77

in place community/population health interventions not
only provides needed information on risk factors within
the community, but also increases the understanding of the
complex interactions between multiple aspects of a com-
munity that impact health such as culture, environment,
infrastructure, and resources. It also provides a method of
assessing the resources of the community as well as the per-
spectives of those who live in the community. Conducting
assessments in partnership with the community is an es-
sential component and provides buy-in from the beginning
as evidenced by the assessments referenced earlier when
conducted in both an urban and a rural community.

Just as an individual nursing assessment requires
special skills, a community assessment also requires a
unique set of skills to systematically examine the health
status, needs, perceptions, and assets or resources of a
community. Some of the skills or competencies needed
to conduct such an assessment include selecting health
indicators, using appropriate methods for collecting data,
evaluating data, identifying gaps, and interpreting and
using data. Basic community health assessments skills for
frontline public health professionals, also referred to as
Tier 1 professionals, are set out by the Council on Link-
ages Between Academia and Public Health Practice
(Box 4-1).6 Note, of the eight competency domains for
public health professionals, assessment/analytical com-
petency is the first domain. As with the nursing process,
assessment is the first step in the process for achieving
optimal health in populations and communities.

Definitions of Community
and Community Health
Defining the concepts of community and community
health is critical in thinking about a community
assessment.

A community, as defined in Chapter 1, is a group of
individuals living within the same geographical area,
such as a town or a neighborhood, or a group of individ-
uals who share some other common denominator, such
as ethnicity or religious orientation. In contrast to aggre-
gates and population, individuals within the community
recognize their membership in the community based on
social interaction and establishment of ties to other
members in the community, and often participate in col-
lective decision making.

There is a great deal of media interest in the health of
communities. Media outlets often use various indices
such as mental wellness, lifestyle behaviors, fitness,
health status, and nutrition to identify the healthiest
cities in our country. Public health agencies also focus

78 U N I T I n Basis for Public Health Nursing Knowledge and Skills

on defining the health of a community. At the national
level there are programs with goals to improve the
health of communities such as the Centers for Disease
Control and Prevention’s past program Partnerships to
Improve Community Health (PICH).7

Three important characteristics help define the health
of a community: health status, structure, and competence.
Selected biostatistics provide vital information about lead-
ing health issues in a community. Statistics commonly
used when doing a community assessment related to
health and disease are covered in Chapter 3. These statis-
tics include indicators such as mortality rates and morbid-
ity rates (the incidence and prevalence of disease).
Mortality is often depicted by crude rates or age-adjusted
rates. Next there is the structure of a community, which
includes the demographics of the community as well as
the services and resources available in the community. The
demographic data include such indicators as age, gender,
socioeconomic indicators, racial/ethnic distributions, and
educational levels. The community health services and re-
sources include information about the resources available

Analytic/Assessment Skills—Tier 1
1. Describes factors affecting the health of a community
2. Identifies quantitative and qualitative data and

information
3. Applies ethical principles in accessing, collecting,

analyzing, using, maintaining, and disseminating data
and information

4. Uses information technology in accessing, collecting,
analyzing, using, maintaining, and disseminating data
and information

5. Selects valid and reliable data
6. Selects comparable data
7. Identifies gaps in data
8. Collects valid and reliable quantitative and

qualitative data
9. Describes public health applications of quantitative

and qualitative data
10. Uses quantitative and qualitative data
11. Describes assets and resources that can be used for

improving the health of a community
12. Contributes to assessments of community health

status and factors influencing health in a community
13. Explains how community health assessments use

information about health status, factors influencing
health, and assets and resources

14. Describes how evidence is used in decision making

BOX 4–1 n Core Assessment Competencies
for Public Health Professionals

Source: (6)

7711_Ch04_077-106 22/08/19 11:35 AM Page 78

Comprehensive Assessment
Since the 1988 IOM report, The Future of Public Health,
improving health in populations or communities has
been linked to performing comprehensive assessments.3
There is a mandate for public health agencies to regu-
larly and systematically collect, assemble, analyze, and
make available information on the health of the com-
munity, including statistics on health status, community
health needs, and epidemiological studies of health
problems.12 In addition, the Affordable Care Act re-
quires that nonprofit hospitals conduct community
health assessments.13 Data regarding demographic and
health characteristics of the entire population are col-
lected in these assessments. A comprehensive commu-
nity assessment is the collection of data about the
populations living within the community, an assessment
of the assets within a community such as the local health
department capacity, and identification of problems and
issues in the community (unmet needs, health disparity)
and opportunities for action.14

Since 1992, the CDC has guided communities in con-
ducting assessments, making health decisions, and de-
veloping policy. There are a number of tools available
for conducting community assessments such as the
Community Health Assessment and Group Evalua-
tion (CHANGE) tool that includes a process for con-
ducting a comprehensive assessment of a community.
Other tools are available such as Mobilizing for Actions
Through Planning and Partnerships (MAPP) as well
as some that are specific to a one aspect of community
health such as PACE-EH (Chapter 6), which targets
environmental health (Table 4-1).14

Population-Focused Assessment
A population, as defined in Chapter 1, is a larger group
whose members may or may not interact with one an-
other but who share at least one characteristic such as
age, gender, ethnicity, residence, or a shared health
issue such as HIV/AIDS or breast cancer. The common
denominator or shared characteristic may or may not
be a shared geography or other link recognized by the
individuals within that population. For example, per-
sons with type 2 diabetes admitted to a hospital form
a population but do not share a specific culture or place
of residence and may not recognize themselves as part
of this population. In many situations, the terms aggre-
gate and population are used interchangeably. An as-
sessment can be focused on a specific population for
purposes of planning and developing intervention pro-
grams. A population-focused assessment, for example,
might focus on pregnant women or immigrants living

in the community as well as service use patterns, treatment
data, and provider/client ratios.

Finally, the health of a community may be conceptu-
alized as effective community functioning, a concept de-
veloped by Cottrell in the 1970s and expanded by
Goeppinger and Baglioni in the 1980s.8,9 Conditions and
select measures of community competence include com-
mitment to the community, conflict containment, accom-
modation (working together), participant interaction,
decision making, management of the relationships with
society, participation (use of local services), awareness of
self and other, and effective communication. These com-
munities value connections between people in the com-
munity as well as those outside of the community. A
competent community is able to identify its needs,
achieve some goals and priorities, agree on ways to im-
plement those goals, and collaborate effectively.10,11 The
establishment of a Neighborhood Watch program to ad-
dress growing crime in a community is an example of ef-
fective functioning in which the community comes
together, works to come up with a solution to a problem,
and promotes a higher level of functioning by pulling to-
gether to address an issue.

Types of Community Health Assessments
The purpose of assessments is to gather information and
identify areas for improving the health of communities
and populations. Assessment is the first step in the
process of health planning and provides essential data
needed to decide where best to allocate community re-
sources. Assessments also provide baseline data. For ex-
ample, if the community is concerned about the health
of infants and mothers, a community assessment can
provide the data needed to determine what the actual sta-
tus of maternal and infant health (MIH) is for the com-
munity; whether problems exist for the community as a
whole; or whether there is a disparity in MIH based on
socioeconomic status, ethnicity, or geographical location
in the community. Baseline data on premature births, in-
fant mortality, and vaccination rates help health planners
determine whether the intervention had an impact dur-
ing the evaluation phase of health planning (Chapter 5).
The key is to understand what type of assessment is best.
There are several types of community health assessments:

• Comprehensive assessment
• Population-focused assessment
• Setting-specific assessment
• Problem- or health-issue-based assessment
• Health impact assessments
• Rapid needs assessment

C H A P T E R 4 n Introduction to Community Assessment 79

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within a community. One community assessment was
conducted to examine the health needs of Hispanic
immigrants, especially in relation to the issue of
adolescent pregnancy. The findings provided the in-
formation needed for the development of new inter-
ventions that would engage adolescents and other
stakeholders.15

A population-focused assessment can also focus on a
certain age range or a population with a specific health
characteristic that may put the group at risk (e.g., chil-
dren or, specifically, children with disabilities). In health
departments, nurses are often involved with writing
grants to serve the needs of mothers and children (see
Chapter 17). Identifying health indicators of interest is a
beginning step in the process of conducting this type of

assessment. For example, the World Health Organiza-
tion (WHO) identified 11 maternal-child health indica-
tors (Box 4-2).16 These indicators provide insight into the
health of this population and a mechanism for tracking
accomplishment in improving these indicators over time.

Setting-Specific Assessment
Assessments can also be focused on a specific setting.
Assessments of this nature may focus on identifying
strengths and weaknesses of an organization or policies
and programs within an organization. Similar to other
assessments, a setting-specific assessment requires a
clear understanding of the purpose of the assessment to
proceed in an organized manner. An occupational
health assessment conducted within a company will

80 U N I T I n Basis for Public Health Nursing Knowledge and Skills

TABLE 4–1 n Community Assessments Tools

Author, Date
Model Released or Updated Brief Description

Association for Community Health
Improvement, Community
Health Assessment toolkit

(http://www.assesstoolkit.org/)

Catholic Health Association
(http://www.chausa.org/

communitybenefit)

Mobilizing for Action through
Planning and Partnerships (MAPP)

(http://www.naccho.org/programs/
public-health-infrastructure/mapp)

State Health Improvement Planning
(SHIP) Guidance and Resources

(http://www.astho.org/WorkArea/
DownloadAsset.aspx?id=6597)

Community Health Assessment
and Group Evaluation (CHANGE)

(https://www.cdc.gov/healthy
communitiesprogram/tools/
change/pdf/changeactionguide )

Protocol for Assessing Community
Excellence in Environmental
Health (PACE-EH)

(http://www.naccho.org/topics/
environmental/PACE-EH)

American Hospital
Association,
updated 2011

Catholic Hospital
Association,
updated 2012

National Association
of County and
City Health
Officials and
CDC, 2001

Association of State
and Territorial
Health Officials
and CDC, 2011

CDC, updated 2010

National Association
of County and
City Health
Officials and CDC,
2000

• Toolkit for planning, leading, and using community
health needs assessments

• Provides six-step assessment framework and practical
guidance

• Access to the full toolkit requires paid membership

• For hospital staff who conduct or oversee community
health needs assessments and plan community benefit
programs

• Focus on collaboration, building on existing resources,
and using public health data

• Framework for community health improvement
planning at the local level

• Strong emphasis on community engagement and
collaboration for system-level planning after identifying
assets and needs

• Framework for state health improvement planning
• Emphasis on community engagement and

collaboration for system-level planning after identifying
assets and needs

• Tool for all communities interested in creating social
and built environments that support healthy living

• Focus on gathering and organizing data on community
assets to prioritize needs for policy changes

• Users complete an action plan

• Tasks to investigate the relationships among what they
value, how their local environment impacts their
health, and next steps

• For local health agencies to create a community-based
environmental health assessment

Source: (14)

7711_Ch04_077-106 22/08/19 11:35 AM Page 80

most likely consist of a description of the company, the
working population, the health programs, and stressors
present at the worksite. The same principles apply in as-
sessing a school setting. The PHN must identify indica-
tors relevant to the setting. Health indicators relevant to
an industrial setting might include work-related injury
or days absent. At a school setting the assessment would
most likely begin with a description of the school, the
history, policies, support services, the actual school
building from an environmental perspective, the popu-
lation (teachers, staff, and students), and the existing
programs with an emphasis on health. There are many
additional tools that can be used to assess components
of school health. The School Health Index,17 a tool avail-
able through the CDC, addresses physical activity,
healthy eating, tobacco use prevention, unintentional
injury, violence prevention, and asthma rates within a
school system (see Chapter 18).

This type of health assessment treats the setting as the
community and considers the population located in the
setting. Thus, a setting assessment includes components
of a comprehensive assessment and a population assess-
ment. Taking the example of a health assessment con-
ducted at an industrial worksite by an occupational
health nurse (see Chapter 20), it would be helpful to col-
lect and analyze data relevant to the environment, the re-
sources available to promote health, and health statistics

specific to the population. According to the CDC, a
workplace assessment involves obtaining information re-
lated to the health of employees within the workplace set-
ting, including protective and risk factors to identify
opportunities to improve the health of the workers.18

Problem- or Health-Issue-Based Assessment
Assessments can also focus on a specific problem or
health issue. In many cases, assessments and tool kits for
specific health issues can be found on the Internet. For
example, obesity is a growing problem in the United
States, and communities are identifying the need to pro-
mote an understanding of the policies, practices, and en-
vironmental factors that contribute to the nutrition and
physical activity choices within a community. An assess-
ment can help a community identify physical activity and
nutrition policies, practices, and environmental condi-
tions within the local community at large, such as work-
sites, school systems, and the health-care delivery system.
Assessments can help identify specific issues related to
the health issue and can also be population and/or setting
specific. They can also help reach vulnerable populations
and identify health needs such as an assessment of the
transgender population conducted in Wisconsin. The
community assessment helped identify that health-care
providers play a key role in facilitating access to care for
this population.19 Often assessments related to a specific
health issue include analysis of data to help determine
who is at risk for the disease, such as the use of a case
control study (see Chapter 3).

Health Impact Assessment
There are two other types of assessments: health impact
assessment (HIA) and rapid needs assessment. The
WHO notes that there are several definitions of a HIA.
The main definition it has adopted is based on a 1999
European Centre for Health Policy definition of an HIA.
According to the WHO, an HIA “… is a means of assess-
ing the health impacts of policies, plans, and projects in
diverse economic sectors using quantitative, qualitative,
and participatory techniques.”20 A growing awareness of
the multiple determinants of health, with a focus on the
environment, has resulted in an increased focus and uti-
lization of HIAs throughout the world. HIA methods are
used to evaluate the impact of policies and projects on
health, and a successful HIA is one in which its findings
are considered by decision makers to inform the devel-
opment and implementation of policies, programs, or
projects. HIAs are often associated with assessments of
the environment or assessments focused on the social in-
fluences of large projects. Zoning laws, for example, may

C H A P T E R 4 n Introduction to Community Assessment 81

1. Maternal mortality ratio
2. Under-5 child mortality, with the proportion of

newborn deaths
3. Children under 5 who are stunted
4. Proportion of demand for family planning satisfied

(met need for contraception)
5. Antenatal care coverage (at least four times during

pregnancy)
6. Antiretroviral prophylaxis among HIV-positive

pregnant women to prevent HIV transmission and
antiretroviral therapy for (pregnant) women who
are treatment-eligible

7. Skilled attendant at birth
8. Postnatal care for mothers and babies within 2 days

of birth
9. Exclusive breastfeeding for 6 months (0–5 months)

10. Three doses of combined diphtheria-tetanus-
pertussis immunization coverage (12–23 months)

11. Antibiotic treatment for suspected pneumonia

BOX 4–2 n The WHO 11 Indicators of Maternal,
Newborn, and Child Health

Source: (16)

7711_Ch04_077-106 22/08/19 11:35 AM Page 81

increase the availability of walking paths that in turn may
help to reduce the prevalence of obesity in a community.
Examples of these types of assessments include an HIA
of urban transport systems21 or the value of assessing im-
pact of policies on health inequities.22 An HIA provides
advice to a community on how to optimize the health of
the community, is conducted prior to implementing a
community-level intervention, and includes specific
steps (Box 4-3).20,23

Rapid Needs Assessment
Another type of assessment is a rapid needs assessment,
a tool that helps establish the extent and possible evolu-
tion of an emergency by measuring the present and
potential public health impact of an emergency, deter-
mining existing response capacity, and identifying any
additional immediate needs.24,25 This type of assessment
was first used in international settings during the 1960s
to assess for immunization coverage, morbidity from
diarrheal and respiratory diseases, and service coverage.
In the 1970s, it was used in the smallpox eradication pro-
gram in West Africa and was then adapted by the WHO
for the Expanded Program of Immunization to assess
immunization coverage in the 1980s. At the national
level, the CDC, the Federal Emergency Management
Agency, and the U.S. Public Health Service (USPHS)
have all adopted a rapid needs assessment format when
responding to a disaster. A rapid needs assessment is an
effective use of limited resources and in general involves
a straightforward collection of data. It is undertaken
immediately after a disaster or event usually during the
first week. The goal is to understand immediate needs,
determine possible courses of action, and identify
resource requirements.25

Concepts of Relevance to Community
Assessments
There are important concepts relevant to conducting a
community assessment discussion: needs, assets, and the
use of community-based participatory research. These
reflect the importance of working with a community
while maximizing the strengths of the community rather
than focusing on deficits within the community. In the
past, community assessments were done by outsiders
and, for the most part, highlighted where the health gaps
were without acknowledging assets within the commu-
nity or including the community as a partner.

Needs Assessments Versus Asset Mapping
Initially, community assessments were based on the
premise that the purpose of a community health assess-
ment was to identify needs. In 1995, Witkin and
Altschuld defined a needs assessment as “a systematic
set of procedures undertaken for the purpose of setting
priorities and making decisions about program or or-
ganizational improvement and allocation of resources.
The priorities are based on identified needs.”26 A need
was considered a discrepancy or a gap between what is
and what should be.26

In contrast with this view of community health assess-
ments, Kretzmann and McKnight published a landmark
book that made the argument that an assessment should
focus on the positive assets of a community rather than
on its deficits. Assets are useful qualities, persons, or
things. They combined this concept of assets with the
concept of mapping, that is, exploring, planning, and lo-
cating, and proposed that community assessments
should include asset mapping. Some of their ideas grew
out of the plan to rebuild troubled urban communities
based on capacity building.27 According to Kretzmann
and McKnight, a needs approach characterizes commu-
nities as a list of problems, makes resources available to
service providers instead of residents, contributes to a
cycle of dependence, and focuses on maintenance and
survival strategies instead of development plans. By con-
trast, an asset mapping approach focuses on effectiveness
instead of deficiencies, builds on interdependencies of
people, identifies how people can give of their talents,
and seeks to empower people.27

The assets approach, based on Kretzmann and McK-
night’s work, is based on constructing a map of assets
and capacities. Three aspects of a community can be in-
cluded in an asset map: (1) people, (2) places, and (3) sys-
tems.27 People include individuals and families living
within the community; places include the resources

82 U N I T I n Basis for Public Health Nursing Knowledge and Skills

• Screening (identifying plans, projects, or policies for
which an HIA would be useful)

• Scoping (identifying which health effects to consider)
• Assessing risks and benefits (identifying which people

may be affected and how they may be affected)
• Developing recommendations (suggesting changes

to proposals to promote positive health effects or to
minimize adverse health effects)

• Reporting (presenting the results to decision makers)
• Monitoring and evaluating (determining the effect of

the HIA on the decision)

BOX 4–3 n Major Steps in Conducting a Health
Impact Assessment (HIA)

Source: (20)

7711_Ch04_077-106 22/08/19 11:35 AM Page 82

within the community such as schools, businesses, recre-
ational facilities, and health-care resources. Systems in-
clude both formal systems such as government and
churches as well as informal systems within the commu-
nity such as neighborhood organizations. These systems
are not always discrete and separate but, rather, influence
each other.28 Although these approaches of needs and
assets appear diametrically opposed, the reality is that
comprehensive community assessments consist of the
identification of both weaknesses and strengths. Identi-
fying the strengths as well as the problems is critical in
the analysis of data.

Community-Based Participatory Research
The second concept of particular relevance to assessment
is community engagement in the process of the assess-
ment. There are various terms used to describe this
approach including community engagement, citizen
engagement, public engagement, translational science,
knowledge translation, campus-community partner-
ships, and integrated knowledge translation.34 In this
book, we use the term community-based participatory
research (CBPR). The definitions related to this ap-
proach all include engagement of members of the com-
munity as full partners in the process of assessment. The
idea is to use a collaborative approach that combines the
knowledge and interest of the community members with
the expertise of the professionals. The end goal is to
achieve change that will work toward improving the
health of the community.29-31

CBPR emphasizes the essential principles of capacity
building, shared vision, ownership, trust, active partici-
pation, and mutual benefit.29 A benefit of this approach
is that it is a colearning process wherein the researchers
and community members contribute equally and achieve
a balance of research and action. In addition, it is a way
of providing culturally competent care. For the PHN
working with the community, it is important to be aware
of the principles of CBPR. One of the first steps in the
community assessment is to engage partners in the
process and to develop a common vision.30

The engagement of communities in the community
assessment process using CBPR methods has become an
accepted method for not only engaging the community
in the process but also engaging the end users in the ac-
tion that will be taken to improve health.31 When using
CBPR methods, it is important to evaluate the possible
ethical issues that can arise. These include issues of
power, fairness, appropriate selection of representatives,
obtaining consent, upsetting community equilibrium,
and issues of dissemination of sensitive data.29,32

Assessment Models/Frameworks
Models or frameworks provide the structure and guid-
ance for conducting an assessment. PHNs can choose a
model based on what best fits the type of assessment that
is being conducted. Examples of models that can help
guide a comprehensive community health assessment
are the Community Health Assessment and Group Eval-
uation (CHANGE) tool and the Mobilizing for Actions
Through Planning and Partnerships (MAPP) strategic
model.

Community Health Assessment and Group
Evaluation
The CDC based the CHANGE tool on the socioecolog-
ical model (see Chapter 2) to help communities build
an action plan based on identified assets and areas for
improvement. The stated purpose of the CHANGE
tool is “to enable local stakeholders and community
team members to survey and identify community
strengths and areas for improvement regarding current
policy, systems, and environmental change strate-
gies.”33 The process provides a community with the
foundation for conducting a program evaluation. The
idea is to start with the end in mind and include eval-
uation in the beginning of the assessment process.33

This tool includes a set of Microsoft Office Excel
spreadsheets that communities can use to manage the
data they collect. The tool provides a guide to doing a
community assessment and helps with prioritizing
areas for improvement.

CHANGE uses an eight-step process for conducting
the assessment (Table 4-2) and was updated in 2018.
The first three steps focus on gathering and educating
the team. Steps 4 through 6 involve gathering, in-
putting, and reviewing data from the assessment. The
last two steps are the development of an action plan
starting with an analysis of the consolidated data.
CHANGE is a tool to help a community complete an
assessment that not only provides a diagnosis but also
ends with the presentation of an action plan. The idea
is to create a living document that the community can
use to prioritize the health needs of the community and
provide a means for structuring community activities
around a common goal.33

Mobilizing for Actions Through Planning
and Partnerships
The National Association of County and City Health
Officials in cooperation with the Public Health Practice
Program Office, CDC, developed a planning tool for

C H A P T E R 4 n Introduction to Community Assessment 83

7711_Ch04_077-106 22/08/19 11:35 AM Page 83

improving community health. The tool was developed
with input from a variety of organizations, groups, and
individuals who made up the local public health system
between 1997 and 2000 (Fig. 4-1). The vision for imple-
menting MAPP is for “communities [to achieve] im-
proved health and quality of life (QoL) by mobilizing
partnerships and taking strategic action.”34

The MAPP assessment model was based on earlier
models used by public health departments (PHDs)
such as the Assessment Protocol for Excellence in Pub-
lic Health (APEXPH), which was released in 1991.35

Building on the concepts included in the APEXPH
model, MAPP strengthened the community involve-
ment component of assessment and aligned the
model with the 10 essential public health services (see
Chapter 1).34 The MAPP tool includes the full scope of
health planning including assessing, diagnosing, devel-
oping an intervention, implementing the intervention,
and evaluating the effectiveness of the intervention. By
contrast, CHANGE focuses on assessment and diagno-
sis with evaluation built in as the goal (see Table 4-2).
Communities and PHDs have used MAPP across the
country because it includes an action phase, providing
a comprehensive approach to improving the health of
a community.

The focus of the first five phases of MAPP is the process
involved in working with the community on strategic
planning and conducting four separate assessments. The
MAPP handbook34 contains access to the tools, resources,
and technical assistance needed to conduct the assessment,

including a toolbox to provide an explanation and the
many examples of assessments that have been conducted.
The MAPP process has six phases: (1) organizing for suc-
cess and partnership development, (2) visioning, (3) per-
forming the four assessments, (4) identifying strategic
issues, (5) formulating goals and strategies, and (6) moving
into the action cycle.

Phase 1: Organizing for Success
and Partnership Development
This phase is focused on identifying who should be in-
volved in the process and developing the partners who
will participate in the process. The recommended part-
ners include the core support team and a steering com-
mittee. The core team does the majority of the work
including recruiting participants. The steering commit-
tee provides guidance and oversight to the core support
team and should broadly represent the community. It is
important to obtain broad community involvement
during this phase that includes inviting persons to serve
on the steering committee and informing the commu-
nity of opportunities for involvement that will occur
throughout the planning process.34

Phase 2: Visioning
This phase is done at the beginning of the assessment
process and is focused on mobilizing and engaging the
broader community. An advisory committee guides
the effort by conducting visioning sessions, resulting
in a vision and values statement. The following are

84 U N I T I n Basis for Public Health Nursing Knowledge and Skills

TABLE 4–2 n Best Practice Approach to Public Health Assessment: Comparison of MAPP With CHANGE

Mapp Change

Phase 1: Partnership

Phase 2: Visioning

Phase 3: Assess residents, public
health system, community
health, and forces of change

Phase 4: Identify strategic issues

Phase 5: Formulate goals and
strategies

Phase 6: Action cycle

Action Step 1: Assemble the Community Team.
Action Step 2: Develop team strategy.

Action Step 3: Review all five CHANGE sectors.

Action Step 4: Gather data.
Action Step 5: Review data gathered.
Action Step 6: Enter data.

Action Step 7: Review consolidated data.
Action Step 7a: Create a CHANGE Summary Statement.
Action Step 7b: Complete the Sector Data Grid.
Action Step7c: Fill Out the CHANGE Strategy Worksheets.
Action Step 7d: Complete the Community Health Improvement Planning Template.

Action Step 8: Build an action plan.

Source: (33)

7711_Ch04_077-106 22/08/19 11:35 AM Page 84

some sample questions that can guide brainstorming
during this phase:

• What does a healthy community mean to you?
• What are the important characteristics of a

healthy community for all who live, work, and
play here?

• How do you envision the local public health system
in the next 5 or 10 years?

Phase 3: Performing the Four Assessments
Four assessments form the core of the MAPP process.
The assessment phase results in a comprehensive picture
of a community by using both quantitative and qualita-
tive methods and consists of the following:

Community Themes and Strengths Assessment:
This provides important information about how the res-
idents feel about issues facing the community. It also
provides qualitative information about residents’ percep-
tions of their health and QoL concerns. Some questions
to guide this assessment include:

• What is important to your community?
• How is QoL perceived in your community?
• What assets do you have that can be used to improve

community health?

Local Public Health System Assessment (LPHSA):
This focuses on the organizations and entities that con-
tribute to the public’s health. It is concerned with how
well the public health system collaborates with other
public health services. The LPHSA answers the following
questions:

• What are the components, activities, competencies,
and capacities of your local public health system?

• How are the essential services being provided in your
community?

Community Health Status Assessment: The com-
munity health status assessment is largely focused on
quantitative data about many health indicators. These in-
clude the traditional morbidity and mortality indicators,
QoL indicators, and behavioral risk factors resulting in
a broad view of health.

Forces of Change Assessment: This is an analysis of
the external forces, positive and negative, that have an im-
pact on the promotion and protection of the public’s
health. It is concerned with legislation, technology, and
other impending changes that can influence how the pub-
lic health system can work. It answers questions such as:

• What is occurring or might occur that affects the health
of our community or the local public health system?

C H A P T E R 4 n Introduction to Community Assessment 85

Figure 4-1 Mobilizing for
Action Through Planning and
Partnerships (MAPP). (Source:
National Association of County
and Community Health Officials.
[2013]. Retrieved from http://
www.naccho.org/topics/
infrastructure/MAPP/index.cfm.)

7711_Ch04_077-106 22/08/19 11:35 AM Page 85

• What specific threats or opportunities are generated
by these occurrences?

Phase 4: Identifying Strategic Issues
During this phase, the assessment data are used to deter-
mine the strategic issues the community must address to
reach its vision. Some questions to help the community
in determining the important strategic issues include the
following:

• How large a public health issue is the item?
• Can we do it?
• Is it reasonable, feasible, and financially cost

effective?
• What happens if we do nothing about it?

Phase 5: Formulating Goals and Strategies
Goals and strategies are formulated for each of the strate-
gic issues. A community health improvement plan is
often created during this phase. Both the steering com-
mittee and the core team work together to “… identify
broad strategies for addressing issues and achieving goals
related to the community’s vision.”34

Phase 6: Moving Into the Action Cycle
This is the phase in which the actual planning, imple-
menting, and evaluating of the strategic plan takes place.
Phases 5 and 6 are described in more detail in Chapter 5,
which is focused on health planning.34

A Comprehensive Community Health
Assessment
MAPP and CHANGE are examples of frameworks that
provide blueprints for conducting a community health
assessment. Regardless of the framework, the first step is
engagement of partners in the process. As described in
the CHANGE tool, this first action step involves assem-
bling a diverse and representative community team. The
team then establishes the purpose of the assessment. This
begins with a clarification of how the community is being
defined. Is the community being defined in relation to a
clear geopolitical community such as a city or a county,
or is the community a neighborhood that may not have
clear geopolitical boundaries? For example, a group of
researchers was conducting a focused assessment of ma-
ternal and infant care in subsidized housing in Winton
Hills, Ohio, a neighborhood located within the Cincin-
nati, Ohio, metropolitan area. It had no political stand-
ing (it was designated as a town or city but did not
have governmental systems in place). Instead, it was a

neighborhood that roughly matched a designated ZIP
code, so for the purposes of the assessment the commu-
nity was defined based on a specific ZIP code.36

Once the community has been defined, it is important
to identify indicators and the sources of data for those
indicators. This step often involves a discussion of the
history of the community and the proposed project.
Through these efforts, the team can identify sources of
data that are already in existence. In some cases, previous
surveys have been conducted that can provide good base-
line data to help understand trends and changes in the
community. Other data can be obtained from national-
level surveys; the U.S. Census Bureau; and sources of
local data, such as reports on crime, motor vehicle acci-
dent, and fire.

Next, the team can develop a timeline to help guide
the assessment. A timeline helps the team decide at
what point each step in the assessment will take place,
the estimated time for completing each of the steps,
and who will be responsible for each step. If the team
is using the CHANGE model, the members will try
to understand the total picture and will include as-
sessment of five sectors of the community: (1) the
community-at-large sector, (2) the community insti-
tution/organization sector, (3) the health-care sector,
(4) the school sector, and (5) the worksite sector. Once
this is complete, the team will then begin to gather
data for each sector and evaluate the quality of the
data. Different methods can be used to collect data, in-
cluding obtaining secondary data available from other
sources and collecting primary data. Primary data
includes any data collected directly by the assessment
team, in contrast to secondary data, which is the
examination of data already collected for another
purpose such as census data. Under step 4 in the
CHANGE model, the different primary data collection
methods listed that can be used include doing a wind-
shield survey, PhotoVoice, doing a walkability audit,
conducting focus groups, and administering a survey
to individuals.

Windshield Survey
A windshield survey is an example of primary data
collection that can help the team get an initial under-
standing of the community and is sometimes viewed
as part of a preassessment phase. The windshield sur-
vey is what it sounds like—a drive-through or walk-
through the community to observe the community.
The idea is to observe the community to help in
understanding it prior to conducting a more formal
assessment.

86 U N I T I n Basis for Public Health Nursing Knowledge and Skills

7711_Ch04_077-106 22/08/19 11:35 AM Page 86

A windshield survey is the first step in taking the pulse
of the community. The questions a windshield survey can
begin to answer include:

• Are there obvious health-related problems?
• What is the perspective of the media in relation to

the community?
• What does the community look like?

Just by driving around, key issues related to the envi-
ronmental health of the community can be observed,
such as the number of for-sale signs, the amount of green
space, the number of bars, the number of churches, the
number of open (or closed) businesses, and the general
upkeep of the community. Clean streets, well-kept parks,
busy grocery stores, and religious places of worship with
multiple services offered are signs of a healthy commu-
nity. By contrast, trash in the streets, vacant lots, multiple
bars, vacant places of worship, boarded-up businesses,
and a lack of grocery stores are all visual indicators of a
community that may have some serious health challenges.

A windshield survey can also provide information on
the demographics of a community. Observations made

while driving through (or walking around) can provide
a beginning understanding of the age groups in the com-
munity simply by observing how many children, older
adults, or young people are on the street. This can be
time-dependent. For example, in the early morning,
young parents and children may be observed as the chil-
dren walk to the school. Later in the morning, older
adults may be observed.

The use of a windshield survey template provides guid-
ance when conducting a windshield survey. A template in-
cludes a list of specific aspects of the community to be
aware of during the drive/walk through and provides a
place to make observations (Table 4-3). It is important to
record the observations while conducting the survey
rather than filling them in later. Be sure to add observa-
tions that stand out even if they are not included in the
template. The template should serve as a guide but may
not cover all of the information that emerges. For example,
in one windshield survey the team was struck by the use
of black metal fencing around a neighborhood composed
solely of subsidized housing. Later, when conducting
interviews with key informants they discovered that the

C H A P T E R 4 n Introduction to Community Assessment 87

TABLE 4–3 n A Sample Template for Conducting a Windshield Survey

Area Suggested Prompts for Observation Findings Follow Up Needed

Prior to
conducting
the survey

Green space

Community
Organizations

Health Care

Transportation

Food, beverages
and tobacco

• Establish geopolitical boundaries that define the community
• Access census data for overall information based on census

track or ZIP code
• Obtain other secondary data as determined by the survey team

• Parks
• Playgrounds
• Trees and other plantings

• Churches
• Senior citizen centers
• Others?

• Pharmacies
• Clinics/physician’s offices
• Hospitals
• Dentists

• Bus and trolley lines
• Trains
• Cars

• Big chain grocery stores
• Corner markets
• Farmers’ markets
• Liquor stores
• Bars
• Vaping and hookah lounges

Continued

7711_Ch04_077-106 22/08/19 11:35 AM Page 87

residents felt the fencing further confirmed their percep-
tion of being separated from the larger urban community.

One approach to observing the formal institutions
within a community is to examine the interrelationship be-
tween different aspects of a community, often referred to
as KEEPRA (Kinship/Economics/Education/Political/
Religious/Associations) . It provides a list of categories to
consider while collecting observational related data:

• Kinship—What observations can you make about
family and family life?

• Economics—Does the community appear to have
a stable economy or are there signs of economic
decline or economic growth?

• Education—What observations can you make related
to schools and other educational institutions such as
libraries and museums?

• Political—Is there evidence of political activity in
the community such as signs supporting someone’s
candidacy for elected office?

• Religious—Are there any mosques, churches, or
synagogues in the community?

• Associations—What evidence do you see of neighbor-
hood associations? Business associations? What other
resources are present such as recreation centers?

Using the CHANGE list of sectors is another possible
approach to conducting an observational review of the
formal institutions in a community:

• Community-at-Large Sector includes community-
wide efforts that have an impact on the social and
built environments such as improving food access,
walkability or bikeability, tobacco use and exposure,
or personal safety.

• Community Institution/Organization Sector
includes entities within the community that
provide a broad range of human services
and access to facilities such as childcare
settings, faith-based organizations, senior
centers, boys and girls clubs, YMCAs, and
colleges or universities.

• Health-Care Sector includes places where
people go to receive preventive care or treatment,
or emergency health-care services such as
hospitals, private doctors’ offices, and community
clinics.

• School Sector includes all primary and secondary
learning institutions (e.g., elementary, middle,
and high schools, whether private, public, or
parochial).

88 U N I T I n Basis for Public Health Nursing Knowledge and Skills

TABLE 4–3 n A Sample Template for Conducting a Windshield Survey—cont’d

Area Suggested Prompts for Observation Findings Follow Up Needed

Entertainment

Housing

Business

Education

People

Environment

Other
observations

• Theaters (movie and live)
• Concert halls

• Types of housing (single family, apartments, subsidized housing
• Appearance of houses and lawns
• Abandoned houses/apartment buildings

• Store fronts
• Types of businesses (dollar stores, pawn shops, check cashing

vs. upper end stores)
• Empty store fronts

• Schools (public/private)
• Colleges/universities
• School bus routes

• Gender, ethnicity, and age distribution by time of day
• Appearance
• Interactions

• Air quality
• Cleanliness of community

• Add other observations that do not fit into the previous
categories

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C H A P T E R 4 n Introduction to Community Assessment 89

• Worksite Sector includes places of employment such
as private offices, restaurants, retail establishments,
and government offices.33

Secondary Community Health Data Collection
Once the windshield survey is complete it is often helpful
to review secondary data prior to collecting more pri-
mary data. Examples of secondary data sources include
census data, crime report data, national health survey
data, and health statistics from the state or local depart-
ment of health. What is usually available is aggregate
data, data that do not include individual level data, such
as infant mortality rate. Many of the sources of aggregate
level community data are accessible via the Internet. Ob-
taining other sources of secondary data, especially data
at the individual level, usually requires seeking permis-
sion and is usually provided as deidentified data, that is,
data that does not include individual identifiers.

An essential component of a community health as-
sessment is the review of sociodemographic data. From
a geographical perspective, the team can access census
data relevant to their community from the U.S. Census
Bureau. These data provide the team with information
on the number of people in their community; the num-
ber of households; and information related to age, gen-
der, marital status, occupation, income, education, and
race/ethnicity. The U.S. Census Bureau collects census
data in the United States every 10 years. The data are re-
ported at the aggregate level based on geopolitical per-
spective. Aggregate data are obtainable at the national,
state, county, metropolitan area, city, town, census track,
or census block. According to the U.S. Census Bureau, a
census tract is a relatively permanent statistical subdivi-
sion of a county that averages between 2,500 and 8,000
inhabitants that is designed to be homogeneous with re-
spect to population characteristics and economic status.
A census block is an area bounded on all sides by visible
features. Examples of boundaries provided by the U.S.
Census Bureau include visible boundaries such as roads,
streams, and railroad tracks, and by invisible boundaries
such as the geographical limits of a city or county. Typi-
cally, it is a smaller geographical area, but in some rural
areas a census block may be large.37 The data provide a
snapshot of the population every 10 years. In between
those years, changes may occur, and local data may be
needed to supplement census data especially toward the
end of a decade.

Another source of secondary health data at the aggre-
gate level about a community is the PHD. Examples of
public health information related to morbidity and mor-
tality, and potentially available at the PHD include the

crude mortality rate, the infant mortality rate, motor ve-
hicle crash rate, and the incidence and prevalence rates
of communicable and noncommunicable diseases. To
get a better understanding of the rates, it helps to obtain
age-specific mortality rates for leading causes of death
and age-adjusted, race-, or sex-specific mortality rates.
An example of Web-based sources of health-related ag-
gregate data at the county level is the Web site main-
tained by the University of Wisconsin Population Health
Institute and sponsored by the Robert Wood Johnson
Foundation. It provides information on health indicators
at the county level with comparative statistics at the state
and national levels.38 Another source of data is vital sta-
tistics. These statistics provide information about births,
deaths, adoptions, divorces, and marriages. These data
are available through state public health departments.

Information on the health of a community can also be
obtained from surveys that are conducted routinely at
the national level and often at the regional level. The Na-
tional Center for Health Statistics (NCHS), a division of
the CDC, provides data about the prevalence of health
conditions in the United States. The NCHS manages sur-
veillance systems including the National Health Inter-
view Survey (NHIS) and the National Health and
Nutrition Examination Survey (NHANES). The NHIS
surveys approximately 35,000 households annually. The
survey focuses on a core component of health questions
including health status and limitations, injuries, health-
care access and use, health insurance, and income and
assets. In addition, a supplement is used each year to re-
spond to new public health data needs as they arise.39 The
NHANES is an annual survey that began in the 1960s
and combines an interview with medical, dental, and lab
tests, and physiological measures.40 The Behavioral Risk
Factor Surveillance System (BRFSS), administered by the
CDC, is a telephone survey of 350,000 adults in 50 states,
the District of Columbia, Puerto Rico, the U.S. Virgin Is-
lands, and Guam. It has been conducted on an annual
basis since 1984 and collects information on health risk
behaviors, preventive health practices, and health-care
access primarily related to chronic disease and injury.42

The CDC also publishes the Morbidity and Mortality
Weekly Report, which reports communicable diseases and
health concerns by state with each publication providing
current state- and city-level incidence data on reportable
diseases. Other examples of aggregate health data include
the annual report to Congress and other reports to Con-
gress on health-related issues such as alcohol and drug
use (see Chapter 11). Other sources of health data in-
clude cancer registries and the National Institute of Oc-
cupational Safety and Health (NIOSH). The National

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Cancer Center of the National Institutes of Health main-
tains 11 population-based cancer registries. They provide
data on the number of individuals diagnosed with cancer
during the year. NIOSH monitors exposures to environ-
mental factors in work settings.

Secondary data are also available that are not specific
to individuals, that is, data related to the environment.
The Environmental Protection Agency (EPA) collects
data on environmental pollutants and the Department
of Transportation collects data on the number of vehi-
cles using the roads. Another example is information
obtained and maintained by the U.S. Department of
Agriculture (USDA), which includes information on
farmers markets, the Food Access Research Atlas, and
the Food Desert Locator, an online map highlighting
thousands of areas where, the USDA says, low-income
families have little or no access to healthy fresh food.42

Secondary sources of local data also exist but may not
be readily available in aggregate form on the Internet.
These include information on the organizations within
the community such as hospitals, schools, and police
department information. Gathering the data from var-
ious local organizations (minutes, reports) may be help-
ful in relation to the different sectors included in the
CHANGE model such as information about the
schools. Although these records may be helpful to some
extent, there are limitations. Records of any nature
often have limitations because they may not be com-
plete, may not be in a usable format, or the keepers of
the data may not be willing to provide the information
to the community assessment team. The list of available
secondary data is long and interesting, and should be
reviewed as the first step to avoid the more expensive
process of having the team collect the data.

Primary Community Health Data Collection
When the review of the available secondary data is com-
plete, the next step is to determine gaps in the data and
decide what further data needs to be collected by the
team. The CHANGE model provides a list of possible
methods and suggests that multiple methods should be
used (two or more).33 These data are then combined with
the secondary data to determine needs and assets.

Inventory of Resources
The agencies and organizations present in a community
often have a significant effect on health. The CHANGE
handbook has sample organizational questionnaires that
can be used for each of the five sectors to help collect data
on different organizations such as health-care organiza-
tions and schools.33 The use of these questionnaires can

help the team gather essential information about the re-
sources within the community.

Quantitative Data: Surveys
When gaps in data are identified, one method for obtain-
ing the missing data is to conduct a survey to collect
community level quantitative data. Quantitative data are
data that can be assigned numerical values such as the
number of new cases of tuberculosis or the assigning of
a number to a categorical variable such as ethnic group.

A first step in conducting a community health survey
is to outline the purpose of the survey. The team decides
on the information needed then decides on the target
population and the method for obtaining a representa-
tive sample of the population and the survey delivery
method. For example, a hypothetical community assess-
ment team in county X found that the members did not
have enough information on the health-related quality
of life (HRQoL) of older adults living in their commu-
nity. The county had just completed a telephone health
survey, and this population was underrepresented. After
careful consideration they decided that their target pop-
ulation was in fact those older than age 65 who were not
currently residing in a health-care facility. The use of an
e-mailed survey seemed to pose even more problems re-
lated to response rate than did a telephone survey. So
they decided that a face-to-face approach was best to de-
liver the survey. The team members decided they needed
to reach those living in different areas of the county as
well, so they put together a sampling process that would
help them include older adults living in different areas of
the county. This example demonstrates that conducting
a survey can be complex and may include issues related
to time, which requires careful planning. The advantages
of surveys include their cost-effectiveness and ability to
make inferences about a population based on the repre-
sentativeness of the sample. A survey allows for the col-
lection of a large amount of information from a large
number of individuals.

Defining the Sample: There are several approaches
to defining the sample. Defining the community or target
population is once again the critical step. If the focus of
the assessment is on adolescents within a specific school,
the sampling will be based on the adolescents in that
school; however, if the purpose of the assessment is to
say something about adolescents in the city, a different
sampling approach is needed.

Sampling Approaches: Once the target population is
defined, there are several types of sampling approaches.
A simple random sample involves a list of the eligible in-
dividuals and then selection is made based on a random

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selection, possibly based on using a list of random num-
bers. Convenience sampling is a common approach that
takes into consideration the availability of participants.
Some different types of convenience sampling include
quota sampling, which involves a fixed number of sub-
jects; interval sampling, which is the selection of subjects
in a sequence (i.e., every eighth person); or snowball sam-
pling, which starts with a small group of participants and
then uses those participants to identify other participants.
One other type of sampling used with large numbers is
systematic sampling, in which a list of the possible par-
ticipants is presented, and the number needed for the
sample is divided into the total population. For example,
from that point, n, every nth person is chosen.

Methods for Conducting a Survey: There are also
several methods for conducting a survey. A survey can
be mailed, done by telephone, given in certain settings as
a written document or by computer, or conducted
through a face-to-face interview. The format for the sur-
vey is determined based on consideration of cost, re-
sources, and preference. In some cases, the choice of the
format may be determined by the study participants, as
noted in the previous example of the survey conducted
with the older adults in the county.

Deciding Items to Be Included in a Survey: Choos-
ing and developing the items to be included in a survey
is another decision to be made in planning the actual as-
sessment. Most health surveys use a quantitative ap-
proach; that is, the questions are closed-ended and can
be entered into a database using statistical software to
help with analysis. Some surveys also include open-
ended questions that allow respondents to provide infor-
mation not asked in the survey questions.

Evidence-Based Tools for Community Assess-
ment: There are several health status evidenced-based
instruments available for conducting a community
health assessment. One example is the CDC HRQoL
questionnaire, either the 14-item or 4-item set of
Healthy Days core questions (CDC HRQoL– 4).43 The
questionnaire is based on the broad concept of QoL as
it relates to health. Assessment of QoL includes subjec-
tive evaluations of both positive and negative aspects
of life. Health is only one aspect of QoL. Other aspects
include employment, education, culture, values, and
spirituality. The advantage of using the CDC HRQoL
questionnaire is that it allows for comparison of the
community sample with national benchmarks. The
HRQoL has been in the State-based Behavioral Risk Fac-
tor Surveillance System (BRFSS) since 1993.

Other reliable and valid tools are available to include
in an assessment. The challenge is to find a tool that

matches the information needs based on gaps in knowl-
edge related to the health of the community you are
assessing and the utilization of the right format for
obtaining the data. Most community health assessment
surveys include multiple instruments to assess the health
of the community. Along with the 4-item HRQoL ques-
tionnaire, the team may decide to include a number of
other tools within the survey such as a tool that measures
satisfaction with available of health care. The key is to use
valid and reliable tools whenever possible.

Qualitative Data
Although quantitative data can provide a wealth of in-
formation, other approaches to data collection provide
an opportunity to gather more in-depth information
about the health of a community. One approach to
achieving this is to gather qualitative data, that is, data
that cannot be assigned a value and that represent the
viewpoint of the person providing the information.
These data are not generalizable to a large population but
can provide insight into the how, why, what, and where
of the phenomenon being studied, in this case, the health
status of a community.

Focus Groups: The most commonly used method for
collecting data when conducting a community assess-
ment is the focus group(s). A focus group is an interview
with a group of people with similar experiences or back-
grounds who meet to discuss a topic of interest. It is usu-
ally a one-time event that is semistructured and informal,
and there is a facilitator and possibly a cofacilitator who
guide the discussion.44 A focus group typically includes
six to eight participants. The facilitator(s) use an inter-
view guide that has unstructured open-ended questions
for purposes of discovering opinions, problems, and
solutions to issues. The interview generally lasts for 1 to
2 hours. Once the focus group has been conducted, an
analysis of either the transcribed tape recording or notes
from the group session consists of examining the data for
patterns that emerge, common themes, new questions
that arise, and conclusions that can be reached.44

Key Informants: Another approach to gathering more
in-depth data is to conduct individual interviews with key
informants. A key informant is often represented as a gate-
keeper, one who comes closest to representing the com-
munity. Although interviews can be time consuming,
interviews with one or more key informants can provide a
wealth of information about the opinions, assumptions,
and perceptions of others about the health of a community.
The interview can be conducted face-to-face or over the
telephone, and the tool to conduct the interview can be
structured, semistructured, or unstructured. A structured

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interview is more formal, with specific identical questions
being asked of each person interviewed. A semistructured
interview is less structured, with a list of questions that
guide the interview but with time for a more relaxed con-
versation. An unstructured interview is conducted by ask-
ing questions that seem appropriate for the person being
interviewed.

The next consideration is who to interview. This really
depends on the purpose of the assessment and the inter-
view. If a PHN wants to learn more about the resources
for adolescents in a community, the nurse will want to
interview personnel in health clinics and recreation cen-
ters, school nurses, parents, and adolescents about their
perceptions of resources and needs in the community. If
there is a need to learn about the needs of the older adults
living in the community, the sites for identifying key in-
formants may now shift to health clinics, senior citizen
centers, nursing homes, long-term care sites, seniors
themselves, and organizations representing them. If it is
a comprehensive assessment, it is important to make sure
that everyone is represented. It is important to include
business representatives, government employees, and
members of voluntary organizations. Another issue to
examine is the makeup of the community based on eth-
nicity to make sure that each group’s members have had
a chance to voice their opinions. For example, during a
community assessment conducted in Lancaster County,
Pennsylvania, the team realized they would have a zero-
response rate on the telephone health survey for residents
in the county who belonged to the Amish community
because they do not use telephones. To address this issue,
the team conducted focus groups with both the women
and the men in the Amish community.45

Determining the type of interview to conduct with a
key informant, face-to-face or by telephone, requires
some thought about the advantages and disadvantages
of both formats. Some of the advantages of face-to-face
interviews are flexibility, ability to probe for specific an-
swers, ability to observe nonverbal behavior, control of
the physical environment, and use of more complex
questions. The telephone interview needs to be shorter
but allows for the ability to interview people who do not
have the time to meet face-to-face. It is important to
summarize the interview immediately, especially if it is
not being recorded. An analysis of the interview data is
similar to the analysis of focus group data. The commu-
nity health assessment team reads the notes or tran-
scripts from the interviews and identifies common
themes between key informants as well as specific issues
for the group they represent. To help verify the infor-
mation provided by a key informant, it is helpful to use

triangulation, a technique that allows the interviewer to
verify the information with another source.

PhotoVoice: PhotoVoice is another qualitative
methodology used to enhance community assessments. It
is based on the theoretical literature on education for crit-
ical consciousness, feminist theory, and community-based
approaches to document photography.46,47 PhotoVoice in-
volves having community members photograph their
everyday lives within the context of their community, par-
ticipate in group discussions about their photographs, and
have an active voice in mobilizing action within the com-
munity. When using this technique in a community assess-
ment, residents can be provided with disposable cameras
and asked to take pictures that reflect family, maternal, and
child health assets and concerns in the community. From
these photographs, the participants’ concerns will be high-
lighted, and concerns such as developing safe places for
recreation and making improvements in the community
environment can emerge.

Additional Tools and Strategies
Community Mapping: Community mapping is an-

other step during the assessment phase that can be used
in the initial windshield survey, during the inventory
data collection, during interviews, and in more advanced
analyses of both assets and problems in a community.
The advantages of mapping assets are that the strengths
of the community are outlined and can be used then in
developing an action plan. Mapping allows the commu-
nity assessment team to visualize the community and to
study concentrations of disease, to identify at-risk pop-
ulations, to better understand program implementation,
to examine risk factors, or to study interactions that affect
health. It is a process of collecting data through direct
observation and using secondary data sources to describe
the physical characteristics of a neighborhood or com-
munity, the location of institutions and resources, and
the social and demographic characteristics of a commu-
nity. It has the potential to provide data that can help
identify place-based social determinants of health that
could then lead to interventions at the individual and the
community level to initiate precise risk reduction and
mitigation.48 In the study by Aronson and colleagues,
primary data were collected by walking through the com-
munity with residents noting categories of interest.
Secondary data collected included housing inspection
data, liquor license data, crime reports, and birth certifi-
cates. The purpose of this assessment was to study the
community context and how it might contribute to
infant mortality, with an evaluation of Baltimore
City Healthy Start, a federally funded infant mortality

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prevention project. The Healthy Start Program was an
initiative whose purpose was to reduce infant mortality
by providing comprehensive services to women and their
children and partners, and at the same time to contribute
toward a neighborhood transformation. The researchers
mapped vacant houses, liquor stores, and crime data. The
data showed that participation in the prevention pro-
gram was higher in lower risk census blocks. Changes
were made to obtain better penetration of the program
based on these findings.49

Geographic Information System (GIS): A geo-
graphic information system (GIS) is a tool that is increas-
ingly used in public health. GIS is a computer-based
program that can be used to collect, store, retrieve, and
manipulate geographical or location-based information.50

GIS databases consist of both spatial and nonspatial data.
Nonspatial data include demographic or socioeconomic
data that can be identified by geographical boundaries,
whereas spatial data are assigned by exact geographical lo-
cation by geocoding or address matching. It is used glob-
ally to help identify populations at risk such as maternal
and infant populations in Iran and in the U.S.51,52 In the
study conducted in Iran related to maternal health, they
were able to identify priority geographical areas.51 In New
Jersey, researchers used GIS to link neighborhood charac-
teristics with maternal infant outcomes.52 The GIS maps
generated demonstrated the associations between adverse
birth outcomes, poverty, and crime.52

Analysis of the Data
Once the data have been collected, it is important to an-
alyze them. The CHANGE model includes three action
steps related to this phase of the assessment: (1) review
the data, (2) enter the data, and then (3) review the con-
solidated data. Reviewing the data refers to having the
team brainstorm, debate, and reach consensus on the
meaning of the data. Entering the data is the process of
transcribing the data into a software program such as
Excel to help with the analysis and interpretation of the
data. Data are then rated by all researchers. Reviewing
the data includes four steps: (1) create a CHANGE sum-
mary statement, (2) complete a sector data grid, (3) fill
out the CHANGE strategy worksheets, and (4) complete
the Community Health Improvement Planning tem-
plate. Doing so provides the foundation for the final step
in CHANGE, building the community action plan.33

Making sense of the collected data is done via a variety
of ways. One of the most important points to consider is
what changes over time or noticeable trends. Sociodemo-
graphic comparisons include changes from one census
data collection period to another. The time-period for

comparing disease trends varies by the prevalence of dis-
ease. A communicable disease outbreak may be monitored
on a weekly or monthly basis, whereas trends in heart dis-
ease might require a trend analysis during a 5-year period.
Trends can help identify improvements or declines in
health indicators in the community over time, such as the
infant mortality rate, or they can be used to determine
whether there have been changes in the demographics of
the population over time. For example, is the population
aging or have there been changes in home ownership?

The health indicators and the demographics of the
community can be compared with other populations such
as similar local jurisdictions, the state, and ultimately na-
tional data. The data can also be compared within the
community. Do disparities exist on key health indicators
such as prevalence of disease or access to needed re-
sources? These analyses allow the team to interpret the
statistics to identify the important health issues for the
community. It is a complex process that involves combin-
ing the information obtained from all sources and coming
to conclusions. The CHANGE handbook provides an ex-
cellent guide for a team to use to complete the analysis. It
often requires having a member of the team who not only
is familiar with software but who also has a background
in statistical analysis so that the team can compute rates
and complete a meaningful presentation of the data.

Postassessment Phase: Creating,
Disseminating, and Developing an Action Plan
In the final action step outlined in the CHANGE model,
the community assessment team builds a community ac-
tion plan.33 This requires the development of a project
period with annual objectives and should reflect the data
that were collected. The result of a community health as-
sessment should include a brief narrative describing the
adequacy of services currently provided in relation to the
overall needs of the community. It should highlight the
areas of need in the community that are not met and list
any additional resources that could be developed to meet
any unmet needs in the community.

Evaluating the Assessment Process
Evaluating assessments is as important as conducting as-
sessments to better understand their impact. It involves
including stakeholders in reviewing the findings and
having an opportunity for feedback. To use the data to
help identify priorities, teams may seek validation from
stakeholders or they may engage in a more collaborative
process to help come to a final decision on priorities.53

This is done at the end of the assessment phase and be-
fore the beginning of the planning phase (Chapter 5).

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94 U N I T I n Basis for Public Health Nursing Knowledge and Skills

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Sick Little Town
Public Health Science Topics Covered:

• Assessment
• Epidemiology and biostatistics

The director of nurses (DON) at a regional Visiting
Nurse Association (VNA) that covered a large regional
area including four rural towns noticed that there was
an increase in patients being referred for home visiting
services from Small Town, a small rural community
within their service area. They provided follow-up care
for persons following a hospitalization and well-baby vis-
its for mothers and infants deemed to be at risk such as
premature infants and teenage mothers. The VNA was
part of a large medical center that had just launched its
“We are community!” campaign. The DON approached
the vice-president responsible for community outreach
services, pointed out the increase to him, and suggested
that a community assessment might help to identify
what was behind the increased admissions. The vice-
president stated that this matched the medical center’s
“We are community!” campaign and asked the DON
whether her team would be willing to form a task force
to conduct an assessment of the community to uncover
the reason for the increase in admissions, better under-
stand the health issues and strengths within the commu-
nity, and at the same time build a better bridge to the
community. He authorized a certain part of the DON’s
workload to include leading the assessment project and
authorized her to designate two of her visiting nurses as
members of her initial outreach team.

The next day the DON met with the two of her
home health nurses, Sonja and Viki, who covered Small
Town. She also invited Donna, the PHN who worked
for the county health department, to meet with them
and join their assessment team. As they began, Sonja
remembered from her public health nursing course
that it was important to start with a model to guide the
assessment. She also remembered doing a windshield
survey for her community health project in school.
“I drive around Small Town frequently to see my
patients, and I never thought about really looking at
the town from a community assessment point of view.”
Viki agreed and suggested that not only should they
do a windshield survey, but they should also invite
members of the community to join them.

Donna told them the county PHD was in the planning
stages of a county assessment, so the concerns of the
visiting nurses were in line with efforts just beginning at

the PHD where they were using the CHANGE model33

to guide the process. She conveyed the health concerns
of the visiting nurses to the head of the county PHD
who then agreed to support the VNA’s work assessing
Small Town as a part of their overall comprehensive as-
sessment for the county thus setting up a collaborative
effort between the VNA, the regional Medical Center
and the county PHD.

For their next step, Sonja, Viki and Donna made a
list of those who should be a part of the CHANGE
committee and planned how to get broad community
involvement. They used the CHANGE guidelines to
help develop their process. Sonja and Viki, who had
been working in the community and knew some key
stakeholders in the community, and the PHN asked the
county PHD epidemiologist to assist with the data
collection and analysis.

The core team then began building a CHANGE
committee that could help broaden community
involvement. When completed, the preliminary
CHANGE committee consisted of four residents of the
community; the school nurse; the director of the
community recreation center; a member of the police
force; the CEO of the regional medical center; Donna,
the PHN from the county PHD; the two visiting
nurses, Sonja and Vicki, and their DON; the PHD epi-
demiologist; and the publisher of the town newspaper.

The CHANGE committee and the core team next
began to work on developing the team strategy process
included in the CHANGE model. One of the visiting
nurses was worried that the project was no longer
under the control of the medical center. Donna ex-
plained that having the assessment come from the com-
munity rather than the medical center would truly
support the medical center’s “We are community!”
campaign. Further, she explained that the CHANGE
model would conclude with a community action plan.
She explained that having a clear picture of the health of
Small Town USA required buy-in from multiple con-
stituents within the community.

The core team expanded to reflect the diversity of
the community. The team talked with the town historian
to find former community initiatives and built communi-
cation strategies for keeping the community informed by
writing an article for the weekly newspaper, seeking
input and suggestions. After running the article, the edi-
tor reported getting many e-mails about the campaign
with suggestions for information that the team should
include. The committee worked to bring this input
together and came up with a final vision statement:
“Small Town, the place to be for healthy living.”

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C H A P T E R 4 n Introduction to Community Assessment 95

The next logical step was to map out the borders of
Small Town, located in the state of Massachusetts along
a small river, using local maps. The town included a total
of 75 square miles and was a 35-minute drive from the
medical center. Four towns bordered Small Town, three
of which had a smaller population than Small Town. The
town with the slightly higher population was to the east
of the town and could be reached by a main road that
went through Small Town. It took 20 to 25 minutes to
drive from the center of Small Town to the center of
each of the other four towns. Most of the population
lived in the center of town. The outskirts of town were
wooded and included a small state park.

Collect Secondary Data: Sociodemographic Data

Descendants from the Mayflower and their contempo-
raries initially settled the town. That gave the team a
starting point for the original culture—English and Puri-
tan. These early settlers had moved west to farm. Man-
ufacturing grew over time with the river providing a
source of power for mills. The founding families built
mills and brought more settlers to the area to work in
the mills. Merchants then came to sell goods to the
workers. The town developed an informal class system
of workers, owners, and merchants. Although the first
wave of workers was Irish, eventually most of the
workforce came from French Canada. The team found
that many of the residents of the town had last names
that were French. By World War I, the Irish section of
town was small and was considered the lowest rung of
the social classes. The church with the largest congrega-
tion was the Catholic Church, because this was a town
of few owners and many workers, almost all of whom
were Catholic. Thus, Small Town had a firm class struc-
ture as well as three major ethnic groups—English,
French Canadian, and Irish—for most of its history.

In the 1970s, when the town was the recipient of
state funds to build subsidized housing for families on
welfare, there was an influx of families into the town who
were at or below the poverty level, all of whom were
white and most of whom were single mothers. They be-
came the new lowest rung on the class ladder. By 2015, a
few Hispanic families from Puerto Rico were moving into
the town. Despite this modest influx, the majority (89%)
of the population still identified themselves as white.

Knowing the history, the team’s next step was to
complete a demographic assessment of the town
beginning with specific demographic indicators that
were available from the U.S. Census Bureau includ-
ing gender, age, race, home ownership, and income.
They constructed a population pyramid related

to the age of the population from estimates using
the 2016 American Community Survey data and the
2010 census data located on the U.S. Census Bureau
Web site American Fact Finder for 2010, and com-
pared it with the population of the United States
(Fig. 4-2).54

Male Female

-6
Percent

-4 -2 0

Ye
ar

100+
95–99
90–94
85–89
80–84
75–79
70–74
65–69
60–64
55–59
50–54
45–49
40–44
35–39
30–34
25–29
20–24
15–19
10–14

5–9
0–4

2 4 6

Male Female

-6
Percent

-4 -2 0

Ye
ar

100+
95–99
90–94
85–89
80–84
75–79
70–74
65–69
60–64
55–59
50–54
45–49
40–44
35–39
30–34
25–29
20–24
15–19
10–14

5–9
0–4

2 4 6

Figure 4-2 Population pyramids: Small Town (top) and
the United States (bottom). (Source: A, Data from Centers for
Disease Control and Prevention [2010]. Community Health
Assessment and Group Evaluation [CHANGE] action guide:
Building a foundation of knowledge to prioritize community
needs. Atlanta, GA: U.S. Department of Health and Human
Services; B, Data from U.S. Census Bureau, Population Division.)

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96 U N I T I n Basis for Public Health Nursing Knowledge and Skills

100
105

0
0

United States Virgin Islands: 2050

5 5

100
105

0
0

United States Virgin Islands: 2100

5 5
(Thousands)

100
105

0
0

United States Virgin Islands: 1950

FemalesMales

100
105

0
0

United States Virgin Islands: 2010

5 5

A population pyramid can tell you a lot about a
population. If the pyramid has a broad base and a small
top, it is an example of an expansive pyramid in which
there is most likely a rapid rate of population growth.
A population pyramid with indentations that even out
from top to bottom indicates slow growth. A stationary
pyramid has a narrow base, with equal numbers over
the rest of the age groups and tapering off in the oldest
age groups. A declining pyramid is one that has a high
proportion of people in the higher age groups. In 2010,
the population pyramid for North America met the
definition of a slow growth pyramid. The projected
2050 pyramid for North America is a classic example of
a stationary pyramid. By contrast, the population pyra-
mid for Somalia in 2010 demonstrated a clear example
of an expansive pyramid, indicative of rapid population

growth. However, it also indicated that the longevity of
the population was lower than in North America. By
2050 the population pyramid for Somalia is projected to
match the 2010 pyramid for North America, indicating
that population growth is projected to slow (Fig. 4-3).55

The team examined their population pyramid
and compared it to the U.S. Data (Fig. 4-2), and made
some conclusions about the population in Small Town.
What would they be? How does Small Town compare
with the United States? Note the larger base and the
wide top. This indicates that the population seems to
be made up of young families and older adults with a
smaller number of in the 45-year to 59-year range.
These data provided the team with a starting point for
understanding the possible reason for the increase in
requests for home health services.

Figure 4-3 United States
populations pyramids
compared with population
pyramids of Somalia. A,
United States; B, Somalia.
(Data from Worldlifeexpectancy
available at http://www.
worldlifeexpectancy.com/
world-population-pyramid.)A

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C H A P T E R 4 n Introduction to Community Assessment 97

100
105

0
0

Somalia: 2050

4 2 2 4

100
105

0
0

Somalia: 2100

4 2 2 4
(Millions)

100
105

0
0

Somalia: 1950

4 2

Males Females

2 4

100
105

0
0

Somalia: 2010

4 2 2 4

Figure 4-3—cont’d B

The epidemiologist from the county PHD recom-
mended that they track the population based on age
and race, and determine the percent change from
2010 to 2016 using census track data. Percent change
(see Chapter 3) represents the change in a variable
from one point in time to another. They were sur-
prised at the simplicity of the math required to
calculate the percent change. The epidemiologist
explained that they should subtract the old value
from the new value. They then would divide this by
the old value. Then when they multiplied the result
by 100, they had the percent change. He showed
them how to set it up in an Excel file so that they
could enter all the population numbers they were
interested in, set up the formula, and then have
a table ready for distribution to the committee
(Box 4-4, Table 4-4). Percent change can tell a lot

New value minus the old value divided by the old value
times 100 equals the percent change.
Example:
If the town’s population in 2000 was 2,000, and in 2010
it grew to 2,520, the percent change is 26%:

2,520 – 2,000 = 520

520/2,000 = 0.26 × 100 = 26%

BOX 4–4 n Percent Change

about a population. In the case of Small Town, the
percent change in the Hispanic population showed a
shift in the town. In 2010, almost 97% of the popula-
tion was white. In 2016, 89% of the population
was white. This information can also help estimate

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98 U N I T I n Basis for Public Health Nursing Knowledge and Skills

TABLE 4–4 n Percent Change for Demographic
Characteristics in Small Town USA,
2010–2016

2010 2016 % Change

Total

Male

Female

White

Black

American Indian

Asian

Other

Two or More
Races

Hispanic

Vacant Housing
Units

Population 25 Years
or Older

High School
Graduates

Bachelor’s Degree
or Higher

Mean Travel Time
to Work

Median Household
Income

Families Below
Poverty Level

9,611

4,766

4,845

9,223

124

195

213

6,056

4,974

848

29.5

$43,750.00

171

10,164

5,039

5,125

9,018

122

101

152

693

189

6,591

–2%

58%

14%

–25%

23%

255%

–11%

changes in the population in the future. If the current
trend continues with a 2% decline in the white popu-
lation and a 255% increase in the Hispanic population
during the next 6 years, what would the population
look like in 2021?

Using Census Bureau data, the team looked at
gender, age, race, home ownership, poverty level,
crime, and fire safety. As discussed earlier in the
section Secondary Community Health Data Collec-
tion, secondary data are collected for a different
purpose from the current study or assessment. In
this case, the federal government collected census

data. These data are collected every 10 years, the
decennial census, to compile information about the
people living in the United States. In addition, the
census bureau conducts the American Community
survey to provide 5-year estimates. These data
provide the federal government with the information
needed for the apportionment of seats in the U.S.
House of Representatives. The U.S. Census Bureau
also conducts many other surveys and is a rich
source of secondary population data. The Census
Bureau provides these data in aggregate format
and by law cannot release data in a way that could
identify individuals.56

To access the census data, the team went to
the American FactFinder section of the U.S. Census
Bureau’s Web site and were able to print out a
sheet that included the estimates for 201654 including
general, social, economic, and housing characteristics.
Under economic characteristics, they found that,
in Small Town, 67% of the population older than
age 16 were in the workforce, and the median
household income was $42,625. The fact sheet
also listed comparative percentages for the United
States so that they could compare Small Town
with the nation. Small Town statistics were compara-
ble to the national statistics on all the economic
indicators except poverty. In Small Town, 18.5% of
the families lived below the poverty level compared
with 15% of the U.S. population. They were also
able to print out fact sheets for the county, the
state, and the surrounding towns, thus comparing
Small Town with its neighbors. The economic
indicators between the closest neighboring town
and Small Town differed in relation to income, with
Small Town having a lower median household income
($38,564 compared with $46,589), although the
poverty level statistics were approximately the same.
Again, compared with the state, the town had a
lower median income ($38,564 compared with
$75,297).

The team then reviewed the other demographic
categories. A few facts were noted as possibly being
important. First, the median value of the houses in
Small Town USA was lower than in the rest of the
state ($173,600 versus $358,000) and the percentage
of the population older than age 25 with a bachelor’s
degree or higher was lower than in the rest of the
state (14% versus 41%). Based on the review of the
demographics, a picture was beginning to emerge
of the town. What would your impressions be?

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C H A P T E R 4 n Introduction to Community Assessment 99

What further data would you need if you were
on this team?

Health Status Assessment Using
Secondary Data

At this point, Sonja wondered about the actual health
of the town. She reminded the team that this project
was started because of the increased requests for
visiting nursing services and suggested that the team
look at the Massachusetts Department of Health
Community Health Profile that included a health status
indicator report for Small Town. This report provided
information on health indicators and reduced the need
for the team to find these data themselves. This report
used secondary sources of data collected by PHDs,
referred to as vital records including information
on death certificates, reportable diseases, hospital
discharges, and infant mortality.

The health status indicators chosen by the
Massachusetts Department of Health included
perinatal and child health indicators, communicable
diseases, injury, chronic disease, substance use
and hospital discharge data. The core group brought
the published information to the larger community
group for discussion. One of the members of the
community group noted that at the top of the report
was a section on small numbers and wanted to know
what that meant. The epidemiologist explained that
the numbers of cases for each indicator are placed in
a cell in a table. Sometimes the numbers in these
cells for smaller towns contain small numbers. The
general rule of thumb, he explained, is that if there
are fewer than five observations (or cases) then
the rates are usually not reported. If they are
reported, then rates based on small numbers should
be interpreted very cautiously, because there are
not enough cases to create a base from which to
draw conclusions.

The perinatal and child health indicators included
births, infant deaths, and other perinatal and postnatal
data from 2016. They found a small numbers problem
right away with only one infant death in 2016. How-
ever, Small Town had a higher low-birth-weight rate
than the state (9.4 per 100 live births versus 7.4 per
100 live births). They also found that the rate of births
to teenage mothers was higher than the rate for the
state (12.5% versus 9.4%). There were no differences
in prenatal care in the first trimester or the percentage
of mothers receiving publicly funded prenatal care
compared with the rate for the state.

On most of the other indicators, Small Town had
lower or similar rates to the state. The rates that
were higher than the state rates were those for
cardiovascular deaths (397 per 100,000 deaths versus
214 per 100,000 deaths) and for hospital discharges
related to bacterial pneumonia (495.3 per 100,000 deaths
versus 329.6 per 100,000 deaths). The team also noted
that some of the rates were age-adjusted, and they
wanted to know more about the process. The county
epidemiologist explained that crude rates may not be
as good an indicator because populations may differ
on a characteristic, in this case age, which accounts
for some of the difference between the rates in two
populations. For example, if death rates for cardiovas-
cular disease in a city in Florida with a high proportion
of retirees in the community were compared with
the rates in a town that has a younger population,
the crude death rate would most likely be higher in
the Florida community. Adjusting the rate based on age
allows for comparing rates in such a way that controls
for the age variance between the two populations. The
age-adjusted rate is the total expected number of
deaths divided by the total standard population times
100,000, which is why the rate is expressed as per
100,000 deaths.
Comparing Rates
The team concluded that there was a difference
between Small Town and the state in relation to low
birth weight, teen births, bacterial pneumonia, and
cardiovascular disease–related deaths. A member of
the team living in the community wanted to know
whether these differences should cause concern.
The epidemiologist agreed to compare the town’s rates
with the rates of the state and the four towns adjacent
to Small Town to help determine whether the differences
were significant, that is, not attributable to chance. He
also explained that he would use a different approach
to compare the rates between Small Town and
Massachusetts than he would when comparing the
town with the rates of the other four towns. When
comparing the rates between the town and the state,
the rates are dependent, that is, the cases in the town
are included in the total number of cases for the state.
But when comparing the different towns with one
another they are independent rates, because the cases
in one town are not included in the number of cases
in the other town. When he was done, he reported
that all the rates were significantly higher than the
state rates. However, only three rates—bacterial pneu-
monia, teen births, and cardiovascular disease–related

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100 U N I T I n Basis for Public Health Nursing Knowledge and Skills

TABLE 4–5 n BRFSS Adult Data for Small Town

Prevalence in Prevalence in
Health Behavior Small Town USA Massachusetts

Current smoking
(2010-2016)

Binge drinking
(2010-2016)

Overweight

Leisure-time
activity

19%

18%

67%

68%

18%

17%

54%

74%

deaths—were significantly higher than the rates in the
adjoining towns.

The team was also interested in gathering secondary
data regarding behavioral risk factors. One of the mem-
bers reminded the group that the Behavioral Risk Fac-
tor Surveillance System (BRFSS) was available for the
community. Since 1984, the BRFSS has been tracking
health conditions and risk behaviors.41 The assessment
committee was interested in lifestyle factors affecting
premature mortality. The lifestyle risk factors that they
were particularly interested in were tobacco use, alco-
hol use, exercise, and nutritional patterns. Some of
these findings can be seen in Table 4-5. Based on these
data, they concluded that nutrition and obesity were
important risk factors that might help explain the
higher cardiovascular mortality rate.

Health Status Assessment Using Primary Data

At this point, one of the members of the community
who regularly attended the meetings stated that this
information was good, but it was all just numbers and
rates, and did not really capture how the individuals in
the town viewed their own health. Others agreed, and
they asked whether there was a way to collect data from
people living in the town about how healthy they thought
they were. They concluded that they could conduct a
survey. In addition, the committee members realized they
needed to complete an inventory of resources first
to have a better idea of the resources within the commu-
nity. They divided the community up and identified
common resources in which they were interested. They
wanted more information about schools, recreation
centers and activities, neighborhood associations,
churches, health-related clinics, hospitals, and agencies.
They used the CHANGE handbook to help guide their
data collection related to these organizations.33

Health Status Surveys

When this was complete, it was time to begin the
survey. Donna explained that a survey could be
constructed to collect health-related information from
individuals by using a paper-and-pencil method. Unlike
the secondary data they had been reviewing, a survey
relies on self-report in which individuals respond to
the survey designed for a specific purpose in the
assessment. She further explained that a health survey
is quite useful when doing a comprehensive community
health assessment, because the researchers can decide
ahead of time what information they need and provide
information missing from the secondary data sets.
Donna also told them that they did not have to
reinvent the wheel; in other words, different surveys
were available for them to review and adapt to their
own community. She showed them a survey that
included questions related to specific health indictors
including HRQoL, protective health practices (see
Chapter 3), and behavioral health issues. It also had
space at the end for open-ended questions.

The members of the team who were residents of
the community began making suggestions on how to
improve the survey. The member who worked in the
fire department thought that questions should be
added about safety, and one of the other community
members wanted to know whether people were using
the recreation center or the new playground. As the
discussion continued, the team built a survey that
included key health issues that the team decided were
important—safety, recreation, nutrition, and number
of hospitalizations in the past year. They also addressed
issues related to the cultural relevance of the survey
and the language used. The final survey was four pages
long and was approved by the members of the commit-
tee who lived in the community as being culturally
appropriate.

Modifying the survey took some time, but Donna
explained that it was better to take the time now
rather than rush, then find out they had missed a key
piece of information. The team considered how to
distribute the survey. They seriously considered the
telephone survey approach, but someone pointed out
that many households in the town no longer had a
landline, especially younger families. The editor of the
town newspaper offered to distribute the survey in
an issue of the paper (an example of a convenience
sample); however, the problem with getting people to
return the survey was raised. Another approach for
conducting the survey was discussed: taking the survey

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C H A P T E R 4 n Introduction to Community Assessment 101

door to door and having members of the community
administer it. This approach seemed the most feasible.
Donna explained that they could do a stratified random
selection of households. Stratification would allow
them to include different types of households based
on home ownership. According to the Census Bureau
data, Small Town USA had 3,660 housing units, of
which 68% were owner occupied, 26% were renter
occupied, and 5.8% were vacant. The team members
decided they wanted to attempt to get a minimum of
10% of the households to respond to the survey in the
two strata. Then someone else spoke up and said that
the community was split, with the growing Hispanic
population living in one part of town in less expensive
housing. They turned to the epidemiologist, who

helped them come up with a strategy to include an
adequate sample based on both ethnic group and home
ownership. Once they identified the strata and their
actual representation in the population, random sam-
pling was then used to select the households. The
final number of households that needed to be surveyed
was approximately 400. The community members
of the committee formed a subcommittee to recruit
volunteers in the community to administer the survey.
Donna agreed to train the volunteers in the adminis-
tration of the survey.

With the help of the epidemiologist, they analyzed
the data and prepared a report on the survey for the
community (Box 4-5). The editor of the paper included
the report as an insert in the weekly paper. The core

Health Survey Report
Small Town USA, Massachusetts
Vision: “Small Town USA, the place to be for healthy living”

To help provide information about the health of Small
Town USA and to obtain recommendations from the
community, a health survey was conducted. This report
includes the findings from this survey.
Methods
A random sample of households was selected to complete
a door-to-door survey. The survey included items designed
to measure HRQoL and access to care.
Findings
Of the 400 surveys that were completed, a total of 396
were included in this analysis. Four were not included
because they contained incomplete data. The majority
(80%) of the respondents were female, 95% identified
themselves as white. The mean age was 52 with a range
from 27 years of age to 95. Twenty-two percent of the
respondents were older than 64. Only 8% of the respon-
dents lived alone, with 56% reporting that there were three
or more in their households. Forty-three percent reported
that a child younger than 18 years of age lived in their
household. Ninety-five percent reported that they had
health insurance, and 60% reported having dental insurance.
Health-Related Quality of Life: The majority of respondents
reported that their general health was good, very good, or
excellent (see the following figure on general health). In
relation to the two questions related to physical function,
15% of respondents stated that they were limited physi-
cally “a lot” on the first question and 13% on the second.
In relation to the two questions related to physical role,
9% responded all or most of the time they accomplished
less and/or were limited in the work they could do.

The responses on the next two sections of the SF-12,
vitality and pain, had interesting results. Only a little more
than half of the respondents (52%) reported having energy
(vitality) all or most of the time, and 23% reported that
pain at least moderately interfered with their activities.
Thirty-two percent reported that their physical and/or
emotional health interfered with their social activities.

The last section of the SF-12 relates to emotional
health. More than a quarter of the respondents reported
that they felt downhearted or depressed at least some of
the time (see the following figure on mood) and 8% felt
calm only a little or none of the time. In relation to the
two questions related to emotional health and their role,
11% responded all or most of the time that they accom-
plished less than they would like and 6% were limited in
the work they could do.
Access to Care and Health Practices: The majority of
respondents (84%) reported that they had had a checkup
in the past year. However, 30% reported that they did not
get care when they needed it, with the majority of these
respondents reporting that the reason was lack of money
or insurance. The majority of respondents received
screening in the past year, with 95% reporting they had
had their blood pressure checked, 75% had their choles-
terol checked, and 67% had their blood sugar checked.
Less than half (48%) had received a flu shot.

Half of the respondents (51%) stated they had a
medical condition, and the majority of these (40%) re-
ported a cardiovascular-related diagnosis. Only 7.5% of
respondents reported that they were current smokers,
and almost half (48%) reported that they did not drink
alcohol at all. Of those that reported alcohol use,
25% were daily drinkers.

BOX 4–5 n Sample Report on Findings from a Health Survey

Continued

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102 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Obesity: Of the 94 respondents, height and weight infor-
mation was available for 89 respondents. Using the stan-
dard calculation, a body mass index (BMI) was computed
for each respondent. Using the national guidelines, 55% of
the respondents were overweight or obese. One quarter
of respondents met the criteria for obesity.
Conclusions
There is a match between one of the findings of the health
survey and the suggestions given by the respondents.
With the majority of the respondents having a BMI greater
than 25, the suggestions to develop nutrition and exercise
programs would address this issue. However, although
respondents rated their general health at the high end, a
large percentage reported issues having to do with depres-
sion, pain, and the negative impact of both their emotional
and physical health on their daily role and ability to func-
tion. Suggestions were made to address some of these

issues, but only two respondents mentioned mental health
in the open-ended questions. Also, although most respon-
dents indicated that they had health insurance, insurance
and access to care were listed in the open-ended ques-
tions section. Finally, there were numerous suggestions
to include support programs for various health issues.
Suggestions ranged from new moms, to seniors, to reach-
ing out to those who were homebound and/or ill.
Recommendations
1. Develop a healthy eating and physical exercise program.
2. Review models for support programs for seniors, new

moms, and families experiencing illness and adapt for
this community. Include links to existing programs such
as Meals on Wheels.

3. Put together an informational packet on existing health
services in the community with a focus on helping those
with limited or no health insurance.

BOX 4–5 n Sample Report on Findings from a Health Survey—cont’d

members of the team met to discuss where they
were with the MAPP model that they were using. They
decided that they had been mainly focused on the
Community Health Status Assessment and they now
had data on the traditional morbidity and mortality
indicators, QoL indicators, and behavioral risk factors.

The team members then decided to review how to
create their CHANGE summary statement as outlined
by the CHANGE model. One of the community mem-
bers suggested that they use the town hall format
to have an open town forum on the health of the
community. He said that the current town governance
structure lent itself to obtaining this more qualitative
data from the community and could also reengage
the community in the work they had been doing. They
enlisted the help of the town moderator and the town
selectpersons to help run the meeting. The members
of their committee who represented different sections
of the community, such as the Hispanic member and
the member living in the senior housing complex,
agreed to encourage their neighbors and friends to
attend.

On the day of the forum more than 900 members
of the community attended, more than triple the num-
ber that usually attended town hall meetings. The town
moderator opened the meeting with one question:
“How healthy a community is Small Town?” During the
next 2 hours the community engaged in a lively debate
over how healthy the community was and what health

problems they thought the town had (Fig. 4-4). The
talk began with the lack of health care. The plant in the
neighboring town had closed 6 months earlier, and
many local people were now signing up for health care
through the state health exchange. Some people were
now threatened with foreclosure on their homes. The

Figure 4-4 Town Hall participation. Raising her hand to
pose a question, this African-American woman was one
of a number of attendees to a town hall meeting held on
behalf of the Agency for Toxic Substances and Disease
Registry (ATSDR). The purpose of these meetings is to
collect community concerns and share health messages
about local environmental issues. (Source: Centers for Disease
Control and Prevention/Dawn Arlotta.)

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C H A P T E R 4 n Introduction to Community Assessment 103

cost of gasoline had gone up, making it more problem-
atic to get to the doctor.

One community member brought up the rise in
teen births and wanted to know why there was not a
family planning clinic in town. This brought opposition
from several people. The town moderator demon-
strated his skills in working with the community. He
carefully brought the discussion back to the vision of
healthy living and away from the more polarizing issue
of family planning. People then shared opinions about
the difficulty of obtaining prenatal care and well-child
services because none were available in the town. Even
the federally subsidized program for Women, Infants,
and Children that provides supplemental foods to
women and children at nutritional risk no longer had
an office in town. Finally, one person stood up and said
that the air seemed to be thicker. Someone else volun-
teered that there were too many wood stoves burning
because of the high cost of heating oil, and that was
why the air was hard to breathe. Others chimed in
and stated they had to keep their thermostats down
because they could not afford the oil, and that their
children had more colds in winter.

After the forum ended, committee members com-
pared their notes and concluded that access to care
was a major concern for members of the community.
They discussed the heated debate that occurred when
teen pregnancy was raised. The members of the com-
mittee who lived in the community reminded everyone
that Small Town has a large population of French
Canadians as well as the growing community of
Hispanics who had opposed family planning clinics in
the past. The committee acknowledged that, for this
community to be successful, the issue of teen preg-
nancy would need to be addressed within the culture
of the community. They were also interested in looking
into the issue of heating and possible reduction in air
quality. They concluded that the town forum had added
additional information to their assessment. An interest-
ing finding was the value of the town moderator, and it
was suggested that he be added to the committee.

The use of the sector approach to the assessment
included in the CHANGE model helped to guide the
team in including an examination of the components,
activities, capacities, and competencies of the local
public health system. By this time, the momentum
for the assessment had raised a certain amount of
enthusiasm in the community. New members were
eager to join the activities. The subcommittee consisted
of Donna, the local fire department representative, a

local physician in the community, and the vice-president
of the hospital who met to discuss how the Ten Essential
Public Health Services were being provided in the com-
munity. Organizations within the community providing
the services were then identified and gaps were noted.
The assessment revealed that many organizations in
the community were providing more than one of the
essential services. The essential services that received
the most attention by several agencies were service #1,
monitoring health status to identify community health
problems; service #3, informing, educating, and em-
powering people about health issues; and service #7,
linking people who needed personal health services
and assuring the provision of health care.

Weaknesses of the public health system included a
need to develop better use of technology such as GIS
(see previous discussion) to better understand vulnera-
bilities. Another weakness was limited activities and
resources for teens, especially those teens who were
pregnant. With a recent economic downturn, there
was some concern about the adequacy of the workforce.
The recent budgetary cuts in public health prevented
the public health system from exploring new and
innovative solutions to health problems.

The team now came together to reach consensus
in relation to the data collected. The broad categories
that the committee considered important to consider
were: (1) trends or patterns over time; (2) factors that
are discrete elements such as a change in a large ethnic
population; and (3) events of a one-time occurrence.
The core steering committee helped to lead the brain-
storming sessions with the final identification of three
major trends in the community:

1. Changing demographics
2. Emerging public health issues—teen pregnancy in

particular
3. Shifting funding streams within the health department,

particularly a loss of a grant that focused on maternal
child issues

The core team members next began the final analysis
of the data as a means for determining priorities and
building the community action plan. They examined
trends over time, compared statistics in different juris-
dictions, and identified high-risk populations. The primary
data corroborated the secondary data in several areas,
including cardiovascular health, teen pregnancies, and
bacterial pneumonia. Analysis of both the secondary
and primary data indicated that access to care was a key
issue. The BRFSS data and the survey data supported

7711_Ch04_077-106 22/08/19 11:35 AM Page 103

• In interpreting the level of health of a community, it is
important to join secondary data with the primary data.
One needs to consider trends or changes over time,
comparison of local data with data from other jurisdic-
tions, and an identification of populations at risk.

• Prioritization of health issues is based on several crite-
ria: magnitude of the problem, seriousness of the con-
sequences, feasibility of correcting, and other criteria
as determined by the community assessment team.

104 U N I T I n Basis for Public Health Nursing Knowledge and Skills

the need to address some lifestyle behavior issues. The
additional assessments supported the need to examine
the resources both within the community and the local
health department, including the lack of support for
young teens in the community and the local health
department.

The team used the forms suggested by CHANGE
to outline the strengths and problems identified both
through secondary data and primary data. The data
were presented at another town meeting. This was
followed by the core committee and steering commit-
tee prioritizing the problems based on the criteria of
magnitude of the problem, seriousness of the problem,
and feasibility of correcting the problem. In the case of
Small Town, the assessment process informed the
county of the need for a program to address teen
pregnancy. This seemed to be a primary concern of
most people in the community. This was followed by
the need for additional resources to address the needs
of older adults, especially as they related to increased
cardiovascular health needs, bacterial pneumonia, and
growing problems with being overweight. The down-
turn in the economy and the changing workforce
were important issues. The report highlighted the
importance of providing resource information to
those experiencing difficulties. Their next steps
included completing the final report and the beginning
development of an action plan.

n Summary Points
• The purpose of an assessment is to provide an

accurate portrayal of the health of a community to
develop priorities, obtain resources, and plan actions
to improve health.

• There are seven different approaches to assessment,
varying from comprehensive assessments to more spe-
cific narrow assessments focused on a health problem,
a specific health issue, or population. Other types of as-
sessments include HIAs and rapid needs assessments.

• Frameworks or models can be used to guide the
community assessment process. Two models include
MAPP and CHANGE.

• Assessment data consist of both secondary and
primary data.

• Qualitative methods of data collection include focus
groups and key informant interviews. Quantitative
methods often include surveys.

• Newer techniques of collecting data include the use
of GIS and PhotoVoice.

t CASE STUDY
Exploring Your Town

Many of us think we know a lot about our town, but
we do not know the particulars. How many residents
own their home and how many are renters? How many
vacant homes are in our town? Has the population got-
ten older, poorer, or richer? The U.S. Census Bureau
has already aggregated much of the data that answer
these questions and more. It is possible to drill down
right to your own neighborhood if you know your cen-
sus tract. To obtain census tract data, you must first
identify the census tract number. This can be identified
by a street address or by consulting a census tract map.
If you have a street address, use the street address
search.
1. Go to American Factfinder at http://factfinder.

census.gov.
2. Enter the name of a town in which you are interested.

What information can you find about the percentage
of families living in poverty? What is the mean income?

3. Identify census tract information.
4. If you have a street address, use the Select

Geographies drop-down box to determine in
which census tract a family lives in. What does
this information tell you about the neighborhood?

5. If you do not have an address, use the reference
map feature by selecting Maps from the left menu
and then Reference Maps.

6. Select a state from the map and zoom so that you
can see census tract boundaries. Determine the
correct tract number.

7. Switch to search (on the top menu) and select the
Geography tab.

8. Show more selection methods and more geographi-
cal types.

9. Change the search boxes with the name of the
state, county, and tract number.

10. Search for the map of the census track to determine
the population.

7711_Ch04_077-106 22/08/19 11:35 AM Page 104

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107

KEY TERMS

Community capacity
Community diagnosis
Community organizing
Formative evaluation
Goal

Health program planning
Impact
Objective
Outcome
Output

Process evaluation
Program evaluation
Program implementation
Resources
SMART objectives

Social justice
Summative evaluation

n Introduction
We all want to live in healthy communities. A healthy com-
munity is a place where children are safe to play and learn;
a place where there are educational and employment
opportunities; a place with safe, affordable housing; and a
neighborhood with good communication and support. In
a healthy community, if teenagers use alcohol, older adults
have difficulty accessing health care, or the percentage of
obese adults increases, the community works together with
other collaborative partners to solve the problem. Program
planning can lead to increased community capacity to solve
these problems and create healthier communities.

Community program planning is the process that
helps communities understand how to move from where
they are to where they would like to be.1 Health program
planning is “a multistep process that generally begins
with the definition of the problem and development of
an evaluation plan. Although specific steps may vary, they
usually include a feedback loop, with findings from pro-
gram evaluation being used for program improvement.”2

Planning occurs at the local level with both public and pri-
vate agencies, at the state and federal levels, and also as part
of strategic planning for the public’s health at the global
level. Today, public health program planning is one of the

10 essential public health services that should be under-
taken in all communities.3 Program planning is most
successful when the community is a collaborative partner,
bringing together resources to achieve agreed-upon goals
and increasing community capacity. Community capacity
refers to the ability of community members to work to-
gether to organize their assets and resources to improve the
health of the community. It is the ability of a community
to recognize, evaluate, and address key problems. Building
community capacity can increase the quality of the lives of
individual community residents; it can promote long-term
community health and increase community resilience. The
community as a whole can become self-reliant in identify-
ing root causes of health problems and achieving identified
outcomes. It can be quite self-sustaining when community
members are empowered to make their own decisions
about interventions and outcomes. Community capacity
building is about working in partnerships and supporting
community members in their decision making.4

Health program planning is a four-step process that
includes assessment, developing of interventions, imple-
menting interventions, and evaluating the effectiveness
of interventions. It is the same basic steps of the nursing
process applied to populations rather than individuals.
It begins with the assessment phase covered in Chapter 4.

Chapter 5

Health Program Planning
Gordon Gillespie, Christine Savage, and Sara Groves

LEARNING OUTCOMES

After reading the chapter, the student will be able to:
1. Discuss the use of Healthy People 2020 in health

program planning.
2. Identify components of different health planning

models.
3. Describe the steps in writing community diagnoses.

4. Explain the importance of evidence-based practice in
program planning.

5. Describe the process of writing goals, objectives, and
activities for a health program.

6. Discuss the different types and value of program evaluation.

7711_Ch05_107-127 21/08/19 11:04 AM Page 107

Based on the assessment, the collaborative community
partners arrive at a community diagnosis. They then
decide what action would be most productive to improve
the health of the community and begin to plan a program
or programs to address the priority health issues identi-
fied. Once the plan is in place, they act (implement the
plan). The final stages are to evaluate how well the plan
addressed the priority issue and, if it works, how best to
sustain the program.4 The program could involve such
things as policy change, health education, or the creation
of new public health services. Frequently, it means put-
ting in place a program to address the community health
diagnosis with the goal of improving health outcomes
for the population, reducing the risk of disease, and/or
minimizing the impact of disease. Program planning
follows the same process for the population level that
the nursing process uses with individuals and is similar
to the development of a care plan in the nursing process
and the evaluation of the effectiveness of the intervention.

National Perspective
Program planning has been an integral part of public health
practice since its conception and has received a lot of at-
tention in the past 30 years. In 1988, the Institute of Med-
icine (IOM) (now the Health and Medicine Division of the
National Academies, Engineering, and Medicine) published
a landmark report focusing on the future of public health
(see Chapter 1). In this document, public health practice
was recognized as population focused, not individual
focused, health planning was recognized as important at
the local level, and the core public health functions of as-
sessment, policy development, and service assurances were
identified.5 The IOM report of 2002 further defined public
health practice and the shift from individuals to popula-
tions with the essential engagement of the community and
diverse partners in the practice of public health.6 The 2012
IOM report strongly advocated for increased funding of
public health and population-level interventions.7 Public
health nurses (PHNs) today embrace this population focus
with their community-based assessments, health planning,
population-based program designs and interventions,
program evaluation, and policy development.8 Both PHNs
and nurses working in other settings need skills related to
engaging community partners in these program efforts and
how to make successful programs sustainable. Keller and
colleagues have been instrumental in identifying the areas
of community organizing, coalition building, collaborating,
social marketing, and policy development9,10 within the
Intervention Wheel Practice Model (see Chapter 2). All
of these perspectives are useful in health planning and
program design, implementation, and evaluation.

108 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Healthy People
A key federal effort that provides a tool for community
public health planning in the United States is Healthy
People (HP), a national compilation of disease prevention
and health promotion goals and objectives for better
health (see Chapter 1). During the past 4 decades, HP has
become a part of health planning at the local, state, and
federal levels. HP provides a guide to communities wish-
ing to implement HP guidelines.11 The guide uses MAPIT
(Mobilize, Assess, Plan, Intervene, and Track progress)
to help communities set targets and identify indicators of
success (Box 5-1).

In addition, one of the topics included in HP 2020 is
educational and community-based programs.12 Thus,
HP acknowledges the need for health planning at the
community level and provides clear objectives and strate-
gies for population-based health programs.

n HEALTHY PEOPLE 2020
Health Planning and Evaluation

Targeted Topics: Educational and Community-Based
Programs
Goal: Increase the quality, availability, and effectiveness
of educational and community-based programs designed
to prevent disease and injury, improve health, and
enhance quality of life.
Overview: Educational and community-based programs
play a key role in:

• Preventing disease and injury
• Improving health
• Enhancing quality of life

Health status and related health behaviors are
determined by influences at multiple levels: personal,
organizational/institutional, environmental, and policy
based. Because significant and dynamic interrelation-
ships exist among these different levels of health
determinants, educational and community-based pro-
grams are most likely to succeed in improving health
and wellness when they address influences at all levels
and in a variety of environments/settings.
Midcourse Review: Of the original 107 objectives,
10 were archived for HP 2020, 7 were developmental, and
90 were measurable. At the midcourse review, 12 objec-
tives had met or exceeded the 2020 targets, 11 were im-
proving, and 16 had demonstrated little or no detectable
change. In addition, 17 objectives were getting worse,
31 had baseline data only, and 3 were informational only.

Source: (12)

7711_Ch05_107-127 21/08/19 11:04 AM Page 108

Healthy People goals and objectives were first pre-
sented in 1979, and they have continued to influence
the nation, not just to assess health status but also to
project improved status with outcome measurement
(see Chapter 1). The Healthy People document in 1979
established national health objectives for the first time
and provided the structure for the development of state
and community health plans. The first 10-year plan had
five goals, each established for distinct age groups,
and 226 objectives.13 The success of the first plan was
limited. The reasons may have included too many goals,
not enough significant interest generated in the public
health and community arenas, and a lack of political
support.14

The next 10-year plan, Healthy People 2000 (1990–
2000), replaced the first five goals with three new goals,
22 priority areas, and 319 objectives that included
specific subobjectives to measure outcomes with special
populations experiencing health disparities. The goals
were: (1) increase the span of healthy life for Americans,
(2) reduce health disparities among Americans, and
(3) provide access to preventive health services for all
Americans. These goals and objectives were influenced
by the first 10-year plan, but they also were influenced
by a concern for high-risk populations and the need to
increase community organizing to better plan health.
In the evaluation of the objectives at the end of the sec-
ond decade of HP, there were some excellent out-
comes, but there were situations in which health
worsened.

The support for Healthy People as a planning tool
grew and has now become part of the local, state, and
national public health practice.11 The Healthy People 2010
(2000–2010) plan continued to build on previous Healthy
People plans and refined the goals to two: (1) increase
quality and years of life and (2) eliminate health dispar-
ity. It had more detailed objectives and 28 specific focus
areas to help measure outcomes. HP 2020 built on these
previous efforts and included 42 topics (Box 5-2).15

All health-related agencies are encouraged to use this
document and its indicators, such as a school for its
breakfast program and industry in its worksite wellness
programs. The proposed HP 2030 plan is continuing to
foster change in health behavior, but it also looks at long-
range planning and priority programs for target popula-
tions. The intention of HP is to continue to guide efforts
to plan, implement, and evaluate health promotion and
disease prevention interventions for the nation. This is
an important document to review and implement when
planning health programs. It gives guidance in writing
program objectives and identifying appropriate health
indicators.

Overview of Health Program Planning
To provide population-focused care, it is necessary to
have skill in health program planning and evaluation.
Issel states the purpose of health program planning is “to
ensure that a program has the best possible likelihood of
being successful, defined in terms of being effective with
the least possible resources.”16 To design appropriate
programs, nurses who are part of a team must contribute
to the completion of a reliable community assessment,
participate in analyzing the community data, construct
the community diagnoses, prioritize needs, and deter-
mine resource availability. Using this information, the
nurses, other public health staff, community partners,
and community members can begin the program plan-
ning process.

Health Program Planning Models
A number of models are available to assist with health
program planning and evaluation. Program planning
begins with a clear statement of the health problem. The
assessment helps the team developing health programs
to identify the priority health problems for the popula-
tion and/or community. Following the establishment of
the health priority, the team then works to understand
the underlying factors contributing to the problem. As
explained by Issel, this is the first step in deciding what
intervention(s) are the best choice for addressing the

C H A P T E R 5 n Health Program Planning 109

Implementing HP using MAPIT
Healthy People is based on a simple but powerful model
that helps to:

• Establish national health objectives
• Provide data and tools to enable states, cities, commu-

nities, and individuals across the country to combine
their efforts to achieve them

Use the MAPIT framework to help:

• Mobilize partners
• Assess the needs of a community
• Create and implement a plan to reach HP objectives
• Track a community’s progress

BOX 5–1 n Healthy People

Source: U.S. Department of Health and Human Services. (2018). Program planning.
Retrieved from https://www.healthypeople.gov/2020/tools-and-resources/
Program-Planning.

7711_Ch05_107-127 21/08/19 11:04 AM Page 109

These models all incorporate basic steps, and there are
multiple resources that can be used to assist with each
step (Table 5-1).

PRECEDE-PROCEED Model
Planning is essential to guarantee appropriate use of
resources. One of the oldest models for program planning
comes from Lawrence Green’s well-researched PRECEDE-
PROCEED model. Two other community health planning
models in current use that can assist in program planning
include Community Health Assessment and Group
Evaluation (CHANGE) Action Guide and Mobilizing
for Action Through Planning and Partnerships (MAPP)
(see Chapter 4). The CHANGE model (see Chapter 4) has
eight phases and only the last phase, develop the commu-
nity action plan, deals with program planning. MAPP’s ac-
tion cycle is the program planning phase.

A model not discussed in Chapter 4 is the PRECEDE-
PROCEED model, which gives insight into how to de-
velop an educational program that will positively change
health behavior. This model, designed in 1968, has gen-
erated evidence-based practice (EBP) in many diverse
areas of health education. Green started out with two
ideas: (1) health problems and health risks are caused by
multiple factors, and (2) efforts to produce change must
be multidimensional, multisectoral, and participatory.17

The PRECEDE component letters stand for Predis-
posing, Reinforcing and Enabling factors, and Causes
in Educational Diagnosis and Evaluation. When a
community uses the PRECEDE process, it begins with
a comprehensive community assessment process as
described in Chapter 4. When the assessment phase is
complete, the model provides guidance on how to exam-
ine the administrative and organizational issues that
need to be dealt with before implementing a program
aimed at improving the community’s health. The final
steps of PRECEDE relate to the design, implementation,
and evaluation of a program. Evaluation includes exam-
ining data related to process, outcome, and impact objec-
tives and indicators established during the development
phase of the program planning.

Green believed that the more active and participatory
the program interventions were for the recipients of the
program, the more likely the recipients were to change
behavior. Green also noted that, for behavior change
to take place, recipients must be willing to work with
the program; the ultimate decision to change behavior
remains up to the recipients. The second half of the
model is the PROCEED component that was devel-
oped from the work with the PRECEDE component.
PROCEED goes beyond the recipients of the interventions

110 U N I T I n Basis for Public Health Nursing Knowledge and Skills

1. Access to Health Services
2. Adolescent Health
3. Arthritis, Osteoporosis, and Chronic Back Conditions
4. Blood Disorders and Blood Safety
5. Cancer
6. Chronic Kidney Disease
7. Dementias, including Alzheimer’s Disease
8. Diabetes
9. Disability and Health

10. Early and Middle Childhood
11. Educational and Community-Based Programs
12. Environmental Health
13. Family Planning
14. Food Safety
15. Genomics
16. Global Health
17. Health Communication and Health Information

Technology
18. 30 Health-Care-Associated Infections
19. Health-Related Quality of Life and Well-Being
20. Hearing and Other Sensory or Communication

Disorders
21. Heart Disease and Stroke
22. HIV
23. Immunization and Infectious Diseases
24. Injury and Violence Prevention
25. Lesbian, Gay, Bisexual, and Transgender Health
26. Maternal, Infant, and Child Health
27. Medical Product Safety
28. Mental Health and Mental Disorders
29. Nutrition and Weight Status
30. Occupational Safety and Health
31. Older Adults
32. Oral Health
33. Physical Activity
34. Preparedness
35. Public Health Infrastructure
36. Respiratory Diseases
37. Sexually Transmitted Infections
38. Sleep Health
39. Social Determinants of Health
40. Substance Abuse
41. Tobacco Use
42. Vision

BOX 5–2 n HP 2020’s 42 Topics

Source: https://www.healthypeople.gov/2020/topics-objectives.

problem and ultimately improving the health of the pop-
ulation and/or community.16

Most program planning models use a systems ap-
proach and provide guidance on how to identify the
problem and then systematically apply the best solution.

7711_Ch05_107-127 21/08/19 11:04 AM Page 110

C H A P T E R 5 n Health Program Planning 111

TABLE 5–1 n Steps in Health Program Planning

The types of steps generally used in program planning are listed here, along with selected resources that may be useful at
each step.

Using Evidence-Based Resources for Program Design, Implementation, and Evaluation

Step Description Suggested Resources

1–5

Identify primary health issues in your
community.

Develop measurable process and
outcome objectives to assess
progress in addressing these health
issues.

Select effective interventions to help
achieve these objectives.

Implement selected interventions.

Evaluate selected interventions
based on objectives; use this
information to improve the
program.

All of the above.

• Community Health Assessment and Group Evaluation (CHANGE)
• County health rankings
• National Public Health Performance Standards
• MAPP (Mobilizing for Action Through Planning and Partnerships)

• HP Leading Health Indicators
• HEDIS (Healthcare Effectiveness Data and Information Set)

performance measures

• The Guide to Clinical Preventive Services
• Health Evidence
• National Guideline Clearinghouse

• Partnership for Prevention
• CDCynergy

• Framework for Program Evaluation in Public Health
• CDCynergy

• The Community Health Promotion Handbook: Action Guides to
Improve Community Health

• Cancer Control P.L.A.N.E.T. (Plan, Link, Act, Network With
Evidence-Based Tools)

• Community Tool Box
• Diffusion of Effective Behavioral Interventions (DEBI)

and reflects an effort to modify social environment and
promote healthy lifestyle, which evolved as a clear need.
PROCEED involves Policy, Regulatory, Organizational
Constructs in Education, and Environmental Design.17

This model has served as the basis for other health pro-
gram planning and assessment models, such as MAPP
and CHANGE (see Chapter 4).

Logic Model
Another model used by many program planners is the
logic model. A logic model provides the underlying
theory that drives the program design. This model guides
a team in the careful planning of a well-thought-out
program. A logic model approach to program planning
can result in a plan that is clear to implement and evalu-
ate; is based on theoretical knowledge; and includes
a clear understanding of resources, time, and expected
outcomes. Logic models are such useful tools for program

evaluation that many grant agencies now require a logic
model in their grant application.18

The concept of a logic model is it logically moves like
a chain of reasoning from the planned work to the
intended results in five steps, starting with input and
resources to program activities to outputs to outcomes
to impact (Fig. 5-1). The model is read from left to right.
The first two components make up the planned work of
the health program:19

1. Resources (inputs) are those items needed and
available for the program. This includes human
resources, financial resources, equipment, institu-
tional resources, and community resources.

2. Next come the activities that produce the program
intervention. It can involve processes such as
health education, as well as tools, technology, or
other types of activities classified as the intended
intervention.

7711_Ch05_107-127 21/08/19 11:04 AM Page 111

The next three components of a logic model make up
the intended results:

3. Outputs are the direct product of the activities of
the program, for example, a class completed on fam-
ily planning, immunization for tetanus, or a service
from the dentist. This is the process component of
program evaluation. Successful output occurs when
the program’s intended outcome is achieved.

4. Outcomes are the intended results or benefits of the
planned intervention and are those items that the
team plans to measure. This can include a change in
knowledge, skills, behavior, or attitude. The outcomes
should be reasonable, realistic, and significant. The
short-term and medium-term outcomes are the
objectives, which reflect the previously discussed
characteristics. In program planning, it is always
important to think about potential unexpected or
unintended outcomes if a program is implemented.

5. Impact is the program goal, producing long-term
change in the community. This may often occur only
after the program has been in effect for 5 to 8 years
and even after the program funding has ended.19,20

Although linear reasoning occurs in all logic models,
the model can come in all sizes and shapes. Some organ-
izations have added other components and complexities
to the model to help with particular clarification of the

program design. Two areas can be added and can help in
understanding the theory of the logic model. First, the
assumptions the program planners have made, such as
principles behind the program development; how and
why a change in strategies will work; and any research
knowledge and clinical experience. Second is a listing
of external factors (culture, economics, demographics,
policies, priorities) that will affect both resources and the
program activities (see Fig. 5-1). A logic model is built
on the community assessment, a clear identification of
the problem, and best solutions within the context of the
community in which the program will take place.

A logic model is a good tool for everyone involved in
the program to use to help them organize their thoughts
and ideas to work cooperatively for the same outcomes.
It helps the program implementers understand why the
activities are structured the way they are, helping to
maintain the integrity of the program. The model is not
static and can be adjusted and improved as the need
arises with good, ongoing review and evaluation. If you
are entering the program as an implementer after the
design has been established, the logic model, read from
left to right, offers you an excellent road map of what
resources are available for implementation, what program
is to be produced, with what results.

If you are entering the program as one of the stake-
holders to help with the design, it is often best to start

112 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Problem

Priorities

Input Activities
Output Outcome Impact

To provide this
program, we will
need the
following
resources:

Activities: In order to
address the problem,
we will conduct the
following activities:

Outputs: We expect
that once completed
or underway, these
activities will
produce the
following evidence of
service delivery:

We expect that if
completed or
ongoing, these
activities will lead
to the following
changes in 1–3
then 4–6 years.

We expect that if
completed, these
activities will lead
to the following
changes in 7–10
years.

Assumptions External

Figure 5-1 The basic logic model.

7711_Ch05_107-127 21/08/19 11:04 AM Page 112

from what you hope the program will have as an impact
(goal), move to the left identifying objectives (outcomes),
and then determine which activities and output would
help the community reach the intended objectives. Then
you establish what resources are necessary to implement
the intended activities.

In the program planning stage, you read a logic model
from right to left. However, as previously noted, there is
nothing static in the program planning process. As
you complete the different sections you may find that you
need to rewrite objectives based on the best practices
you have found in the literature about a particular activ-
ity you would like to implement. You may find you have
fewer resources than what you need to implement a

particular activity, which will change your intended
outcomes. You can try various scenarios to determine
which one is the best fit for the community and the
organization, identifying strengths and weaknesses of
the plan.

By the end of the process, the stakeholders will be able
to see visually how the program goal(s) relate directly to
the objectives that, in turn, relate directly to the program
activities and the resources available. An example of a
logic model is presented for the Elwood Community
incorporating the assessment data, goal, objectives,
activities, and output (Table 5-2).

The logic model is not the only tool available for pro-
gram planning and, like all tools, has its drawbacks. In

C H A P T E R 5 n Health Program Planning 113

TABLE 5–2 n Logic Model: Program to Create Social Integration Among Elmwood Residents

Resources Activities Outputs Outcome Impact

• Space in residential
building including
heat and electricity

• Support (human
and material) from
the Primary Public
School

• Support from the
community center
(staff) at the
residential site

• PHN time, 8 hours
per week for the
program and other
time for nursing care
of the population

• Residents of the
facility

• Support of time
and resources from
the two local
churches

• Additional community
support

1. A senior outreach
program to the
public schools for
2 hours twice
a week

2. A reading program
for young children
attending the
Primary Public
School

3. Creation and
maintenance
of a resident
organization
with one of its
objectives being
the improvement
of communication
among residents

4. Presentation/
discussion groups
twice a month
with initial church
leadership;
suggested first
topics include:
a. safety in the

community
b. celebrating

differences in
culture and
ethnicity

• 15 seniors are
working with
30 children at the
Primary Public School

• There is a reading
session once a month
with 10 seniors and
20 first grade children
for 1 hour at the
housing site

• There is an Elmwood
Community
Association that has
elected leaders and
representatives from
both buildings that
meets regularly

• There is a larger
community
organization that is
meeting regularly to
unite against crime in
the community

• The churches are
working together
to provide twice-
monthly interactive
programs at
Elmwood

1. Establishment of a
volunteer school
program run by
Elmwood
residents to work
with 50 children
at the school and
25 children on
site within
6 months

2. Development of
consistent monthly
programs in each
building with a
minimum of
40 resident
attendees that
foster social
interaction by
October 2023

3. Formation of
a resident
community
organization

• Meaningful
communication
occurs among
the elderly
population in
the two senior
high-rise
Elmwood
residential
buildings

• Seniors are
integrated into
the community,
feeling valued

Assumptions: (1) If residents of the Elmwood Buildings work together on programs and reach out to the community, the
communication among themselves will increase. (2) If the residents believe their work is meaningful and interesting, they will convey
this to other residents, the program will expand, and there will be increased communication. (3) If the residents are offered interesting
and appropriate programs in the building, they will attend, have more interaction, and communication will continue to increase.

7711_Ch05_107-127 21/08/19 11:04 AM Page 113

evaluating the use of the logic model, researchers have
found that the emphasis on activities and outcomes has
decreased the importance of understanding the rationale
for the program choice.20 Other tools such as concept
mapping (a pictorial relation of concepts and relation-
ships), a geographic information system (GIS; a computer-
based program that can be used with geographical
or location-based information; see Chapter 4), and
community mapping (a visual map representation of
resources and information corridors) are useful but also
are limited. The University of Maryland, like many uni-
versities and organizations, created a program plan that
can be modeled by others when developing a new pro-
gram.21 The tools are comprehensive and interactive,
such as the Decision Support System (DSS), which is a
step-by-step program planning series that gives on-screen
feedback; Empower, which is based on the PRECEDE/
PROCEED model; and the Outcome Toolkit, which
facilitates planning and data analysis to make commu-
nity improvement efforts measurable and accountable.

The logic model can serve several functions in addi-
tion to the actual program plan. For example, one group
of researchers used the logic model to provide “. . . stake-
holders with a common framework for the innovation
or further development of pharmaceutical care”.22 It also
helped the staff to discuss and specify assumptions they
all held in common. For example, one assumption within
the community was that all families have strengths,
and appropriate job training and related activities will
prevent homelessness. This then helped them to better
define their goal: to prevent homelessness and move
families to self-sufficiency. Mulroy and Lauber also were
able to limit their activities and more precisely determine
immediate and intermediate outcomes. These authors
agreed that logic modeling helped provide an analytical
structure for better outcome development and better
program management and evaluation.

One group developed the ¡Cuídate! Program using
the logic model as a means to “… plan, implement, and
evaluate a sustainable model of sexual health group pro-
graming in a U.S. high school with a large Latinx student
population”.23 The nurses believed the logic model was
most helpful in providing a visual diagram that could be
easily communicated to others. It became the heart of the
program development and identified the future direction
for the program.

Key Components of Health Program Planning
The important components of health program planning are:

• Active involvement of the community as a partner
• Skill and time to do a competent assessment

• Shared conclusions with the partners of the needed
interventions

• Actual program planning, interventions, and
evaluation1

Nurses at all levels of practice are involved in these
processes, and it is critical nurses understand program
planning to make significant contributions to the process.

As part of health program planning, nurses need to be
involved in community organizing because this plays
a pivotal role in successful planning as was recognized
in the focus of HP 2020 and in the Centers for Disease
Control and Prevention (CDC) assessment and program
model CHANGE (see Chapter 4).24 Community organ-
izing is bringing people together to get things done. It is
helping people to act jointly in the best interest of their
community. Most frequently, community organizing
occurs with poorer communities that are disenfran-
chised, uniting people to gain power and fight for social
justice. The process is inclusive of everyone in the com-
munity and is a powerful tool for health planning and
program design. The role of the nurse in community
organizing is not one of leadership but one of listener,
facilitator, and developer of community leadership skills.
It is to provide opportunities for the development of new
relationships within the community.1

Inclusion of the community begins during the assess-
ment phase (see Chapter 4) and continues through the
action and evaluation phases. The key is to assemble
a representative team from the community to help develop,
implement, and evaluate a community health program.
The CHANGE manual provides a guide on how to begin
to assemble a team (Box 5-3). The public health system
described by the CDC (Figure 5-2) also stresses the
importance of including the community and provides
extensive guidance and examples on how to accomplish
this. This includes bringing together a diverse group,
actively recruiting members, and developing a plan for
engaging the larger community in the process.1

Social Justice
Another key construct central to health program planning
is social justice (see Chapter 7). Improving the health
of everyone in the community often requires addressing
social injustices. It is also a basic underlying construct of
public health. Social justice dictates that society is based
on the constructs of human rights and equity. The idea
is that those who have plenty will be willing to share with
those who do not have enough to provide for equity.
In a just health-care system, everyone should have the
basic opportunities for a healthy life. Poverty, illness,
and premature mortality are a tragic waste of human

114 U N I T I n Basis for Public Health Nursing Knowledge and Skills

7711_Ch05_107-127 21/08/19 11:04 AM Page 114

resources that defy the dignity and inherent worth of
the individual. Social justice dictates everyone should
have access to basic health services, economic security,
adequate housing and food, satisfactory education, and
a lack of discrimination based on race or religion. It
is more often the distal social determinants (income,
education, housing, racism) that are more impactful to
changing the health status of individuals and populations
than putting into place programs that change individual
behavior in communities with limited resources. Pro-
viding adequate education leading to employment with
a satisfactory income for housing and food can make a
greater impact on health than teaching low-income
individuals how to use their minimal income for healthy
foods or better housing. Communities with scant resources
frequently organize around issues of disparity. As they
build their skills in organizing and create change within
the community, they build community capacity and
work toward social justice. As the community capacity
increases, the health of the community improves.
Community members learn how to be independent in
identifying their problems, the root causes, and the
skills to solve these problems.

C H A P T E R 5 n Health Program Planning 115

Action Step 1: Assemble the Community Team
Assembling a community team starts the commitment

phase of the community change process. Representation
from diverse sectors is a key component of successful
teamwork; enables easy and accurate data collection;
and enables data assessment, the next phase of the
community change process. All members of the commu-
nity team should play an active role in the assessment
process, from recommending sites within the sectors to
identifying the appropriate data collection method. This
process also ensures the community team has equitable
access to and informed knowledge of the process,
thereby solidifying their support. Consider the makeup
of the community team (10 to 12 individuals maximum
is desirable to ensure the size is manageable and to
account for attrition of members). Include key decision
makers—the CEO of a worksite or the superintendent
of the school board—to diversify the team and use the
skill sets of all involved.

BOX 5–3 n Assembling the Community Team

Source: Centers for Disease Control and Prevention. (2018). Community
health assessment and group evaluation (CHANGE) tool. Retrieved from
https://www.cdc.gov/nccdphp/dnpao/state-local-programs/change-tool/
index.html

Monitor
Health

ResearchResearchResearch

Diagnose
& Investigate

Inform,
Educate,

Empower

Mobilize
Community
PartnershipsEnforce

Laws
Develop
Policies

Link
to/Provide
Care

Assure
Competent
Workforce

Evaluate

Sy
st

em
Management

A
S

S
U

R
A

N
C

P
O

LICY DEVELOPMENT

ASSESSMENT

Figure 5-2 The 10 essential public health services.
(From Centers for Disease Control and Prevention. [2018]. The
public health system. Retrieved from https://www.cdc.gov/
stltpublichealth/publichealthservices/essentialhealth
services.html)

n CELLULAR TO GLOBAL
The social determinants of health (see Chapter 7)
play an important role in the development of humans
and their ability to achieve optimal health. Pregnant
women require adequate health and health care to
deliver a healthy infant. When access to foods that
support healthy eating patterns and access to primary
care are limited, fetuses are less likely to develop
healthily in utero. The fetuses then have a greater risk
for being born premature and/or with long-term physi-
cal or cognitive limitations. These limitations can later
manifest with decreased educational attainment and
increased poverty. Challenges to the social determi-
nants of health are unique to each individual country
but occur in all developing and developed nations
across the globe. Increased health program planning
that directly addresses these determinants will assure
the highest likelihood for health for all.

The nurse must always consider social justice in pro-
gram planning. In making the decision about public
health action, there is the consideration of equitable dis-
tribution of benefits and burdens based on needs and
contribution of the community. The community must
decide the minimum goods and services required, how
they can be acquired, and what programs will best serve

7711_Ch05_107-127 21/08/19 11:04 AM Page 115

the population with the available resources. In 2008,
Buchanan warned against public health paternalism
where individual rights are limited for the greater public
good. He argued that if communities are given freedom
to make choices, including the level of availability of
those choices, they will achieve good health.25 Striking a
balance between public health mandates and community
freedom of choice continues to present a dilemma for
public health today as evidenced by vaccine requirements
for attendance at schools.

Working to ensure universal health care has a great
impact on health planning in the United States and is a
social justice action particularly important to the PHN.
It was a major platform promise during President
Obama’s first campaign and resulted in the establish-
ment of the Patient Protection and Affordable Care Act
(ACA). The American Nurses Association has long been
a supporter of health-care reform and supported the
passing of the ACA.26 Although the future of the ACA
is uncertain, the positive impact of the ACA to date has
been documented,27-29 and it can have a major impact
on the health of the entire population. Nurses can also
advocate, support, and work for the distal social deter-
minants of a better educational systems, better child
welfare, better housing laws, and better occupational
and environmental protection. These actions will help
the nation achieve the objectives set out in HP 2030, with
people living longer and leading more active lives with
less health disparity.

Community Diagnoses
Community diagnoses have been used in public health
by multidisciplinary groups for many years, evolving
separately from nursing and medical diagnoses, which
tend to focus on individual need. Community diag-
noses represent the last phase of the community assess-
ment process and the first phase of the health program
planning process. A clear statement of the health prob-
lem and the causal reasons or theories for it provide the
basis for designing a health program that will actually
improve the health issue. A community diagnosis is a
summary statement resulting from the community
assessment and the analysis of the data collected. The
diagnosis guides the community team’s thinking in
how to design the program and what components are
necessary. A community-specific diagnosis is needed
because each community is unique in how the problems
are manifested and solved. There are many types of
community diagnoses and most share many parts in
common, but the more detailed and complete the diag-
noses, the easier it is to tailor them to an appropriate
program.

Nursing community diagnoses generally contain four
parts:30 (1) the problem, (2) the population, (3) what the
problem is related to (characteristics of the population),
and (4) how the problem is demonstrated (indicators of
the problem).16,30

116 U N I T I n Basis for Public Health Nursing Knowledge and Skills

w SOLVING THE MYSTERY
The Case of the Lonely Older Adults
Public Health Science Topics Covered:
• Assessment
• Community diagnosis

The PHN, Meghan, is working with a geriatric popu-
lation in the Elmwood senior high-rise, composed of
publicly funded housing units. Her employer, the city
health department, has allocated her one day a week
for health programming in these two closely spaced
buildings located in the inner city of a moderately large
urban area. To determine what kind of programs
would be most useful, Meghan enlisted community
partners in the Elmwood community and the city
housing authority to do an assessment to help identify
community strengths and health needs.

During the assessment, residents of the buildings
were interviewed, as were both formal and informal
leaders. The assessment group toured the Elmwood
buildings looking at the apartments and other resources
that were part of the units. They spoke with key
community informants including the employees in the
neighborhood schools and local churches. The group
evaluated community safety and resources within walk-
ing distance of the Elmwood buildings, which included
supermarkets, pharmacies, banks, health-care facilities,
social service resources, and local stores. They reviewed
demographic data, vital statistics, and other community
indicators for the neighborhood, and compared the
data with the city and with other areas in the United
States. The community partnership, with the help of
the PHN as a member of the team, summarized their
assessment findings. One of the identified problems,
which was at the top of the list for many residents, was
the lack of meaningful activities for the residents within
their apartment buildings. The residents were justifiably
concerned about safety outside their buildings and had
many mobility issues, which resulted in boredom and
isolation, without an avenue for social communication.

Meghan had initially imagined she would implement
an educational program, for example, teaching the resi-
dents about the health benefits of eating vegetables, the
correct way to take their medications, or the impor-
tance of a low-fat diet. This was based on the type of

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C H A P T E R 5 n Health Program Planning 117

interventions she had already been doing in the build-
ings one-on-one with individual clients. However, she
was more than willing to explore a community-specific
program that would facilitate social interaction. To do
this, with the help of her community partners she elab-
orated this problem in a community diagnosis (Box 5-4).

Meghan also decided to include mediating and mod-
erating factors as part of her community diagnosis.30

This allowed her not only to examine the health prob-
lem, the population, indicators, and causal factors but
also how the problem was mediated by specific moder-
ating factors and the presence of antecedent factors
(those behaviors that existed prior to the health prob-
lem).30 It is frequently important to know that some
behaviors may directly cause the problem and others
may be more indirect. Moderating factors can make
the problem better or worse. Mediating factors occur
between the causal factors and the outcomes, and are
significant when designing the program because they
alter outcome. Increased details of the specific health
problem can contribute significantly in determining the
best program design.

In reviewing the analysis of the assessment,
Meghan noted that in the Elmwood senior buildings
the housing authorities mixed two ethnic neighbor-
hood groups that had been hostile to each other for
the past 20 years. Also, 15 years ago two of the large
churches in this community held different positions
on several neighborhood political and religious issues,
and each congregation had united against the other with
several harsh words spoken in public. The churches had
subsequently left the decaying neighborhood, but many
of the congregants were still living in the community.

This antecedent information contributed to a better
understanding of the current problem of limited com-
munication among Elmwood residents that led to social
isolation.

The assessment committee had also spoken with the
community center staff 10 blocks from Elmwood. The
workers were frustrated at not attracting more senior
clients for their multiple programs and expressed con-
cern they might need to discontinue these programs
due to lack of participation. They admitted they had
done little marketing to the seniors at Elmwood, had
no means to transport residents of the apartments
to their center, and had little knowledge of the com-
munity dynamics, especially in relation to the senior
population. They did provide escort services for
schoolchildren coming to the community center
because of a recent outbreak of gang violence in the
area. They had not considered that this might also have
an impact on the seniors’ decision not to come to the
center.

The local churches confirmed that there had been
community discord, and many of their current older
members were still angry. This had caused some
friction in the current churches, but the pastors were
working on mediating these factors to create more
united congregations and better sharing among the
memberships. All of the local churches provided trans-
portation to services on Sunday and Wednesday
evenings. They currently had no other outreach to
the senior residential buildings.

When visiting the primary school one block from
the senior housing, the teachers and principal talked
about a lack of resources in the school. They repeat-
edly mentioned the need for many of the children to
have more one-on-one interactions to increase their
basic skills of reading and writing. With this additional
information, Meghan added to the community diagno-
sis, and she now had a clearer understanding of some
of the origins of the problems and the mediating and
moderating factors that could help design a program
that not only would provide opportunity for more
social interaction among the senior residents but also
could enhance the health of the entire community
(Fig. 5-3).

Having completed the community diagnosis, Meghan
explained to the team it was time to begin the program
development phase. She explained they would work
together with the stakeholders from all aspects of
the identified community to determine how they
could solve the problem of the lonely older adults.
Meghan said they first must decide who will receive

Problem: Lack of meaningful social interaction resulting in
social isolation.

Population: Older adult population in the two Elmwood
senior residential buildings.

The isolation of the older adults was related to no
formal programs in the building, limited social contact
among residents, inadequate community safety, and resi-
dents’ restricted mobility as indicated by residents being
able to name only one other person in the building, the
fact that no one spoke to others while waiting for the
elevator, the neighborhood had the second highest crime
rate in the city, 62% of residents complained of loneli-
ness, and 59% of the residents had mobility problems.

BOX 5–4 n Community Diagnosis

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118 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Antecedent
Hostile ethnic
groups, discordant
churches, decaying
community, age of
resident

Causal Factors
No community
organization, no
program in building,
high crime, client
immobility, no
resident social
interaction

Moderating
Neighborhood
gangs, no
transportation, no
community center
outreach

Mediating
Primary school,
community center,
local churches,
public health nurse

Health Problem
Elderly social
isolation,
loneliness

Impact
Social integration
among Elmwood
residents

Figure 5-3 Diagram of community diagnosis for Elmwood Senior Housing.

the intervention. They needed to decide whether it
would be individuals, families, communities, or a whole
system. She cautioned that this was the time to care-
fully consider what interventions would be most
appropriate and effective, and if there was evidence
to confirm their decision. The team would together
decide what immediate effects they would like this
program to have and what long-term effects they
might expect. All of this should be reflected from their
community diagnosis and would guide the community
discussion.

Meghan stressed this approach because she knew
the clearer and more rational the explanation for
solving the problem, the stronger the program would
be. This was the time to discuss what kind of program
activities the group would like to implement and what
evidence-based practices existed to help guide the devel-
opment of a program. The team began with a review
of the literature, looking not only for established
approaches but for new and innovative ones as well.
Their discussion was tempered by resources, nature of
the community, culture of the community, and other
distal variables that influence receptivity to different
types of programs. Much of the information gathered
during their assessment helped them to think about
what might work in their community.

The discussions were somewhat time intensive
because of the multiple agendas of the people at the
table, different approaches to problem-solving, varied
understanding of the process of program planning,
different cultural and communication styles, and differ-
ent expectations. Yet Meghan persevered and helped

guide the discussion, allowing members to voice their
opinions, and then bringing them back to the task at
hand. Because she had worked in the community for a
long time, she was able to help interpret cultural and
value differences, facilitate communication, and encour-
age the planning team to use the community diagnosis
statement to guide the design.

Megan carefully considered who should participate
in the discussion. Based on the community diagnosis,
Meghan specifically invited leadership from the school,
churches, and community center. After she reviewed
the community diagnosis with the group, the school
representative immediately repeated the need for help
with more one-on-one activity with the students at the
school and mentioned several ways the seniors could
participate. The school representative said they could
provide on-site orientation at Elmwood for the seniors
who would be willing to come to the school. He first
suggested a 3-week training program, after which they
would provide escorts to the school one block away
on Tuesdays and Thursdays for the seniors to work
2 hours each of these days with the children. The
Elmwood residents at the meeting asked whether the
school also could bring some of the children to the
Elmwood buildings once a month for story time with
those seniors whose mobility was more limited. Several
community members suggested this could be accom-
plished by creating the Elmwood Community Action
Committee, which could meet jointly with school
representatives to design the reading program. The
community center offered to provide staff to help
support these meetings. The community center saw

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C H A P T E R 5 n Health Program Planning 119

this as an opportunity to get involved with a program
the seniors would attend and were happy to do it at
the Elmwood site. Other ideas included on-site,
church-sponsored discussion groups about ways to
decrease crime in the community and participatory
cultural presentations (food, music, beliefs) from
different ethnic groups in the community. At the
end of the brainstorming meeting there were more
than eight suggestions, and several people agreed to
research programs similar to these for more in-depth
applications, successful outcomes, and identification
of potential problems when applied to other
communities.

Once the planning group reached consensus about
the broad aspects of the program design, Meghan ex-
plained to them the next step was to write the goals
and objectives for the program. She pointed out there
were two important points to remember at this stage
of program development. The creation of a program is
a process, and as a process the planning is fluid. She
explained to the group they might decide on an inter-
vention, only to change it later as they start to write
goals and objectives and identify indicators, and that
this was a normal part of the process. Likewise, the
goals and objectives might change as the group more
carefully defined the program activities. However, she
stressed it was important in the final program design
that the activities and outcomes correspond to the
goals and objectives agreed on by the team, and this
was again reflected in the process and outcome evalua-
tion. She stated members of the group would need to
be responsible for monitoring the process and making
sure the goals, objectives, activities, and evaluation all
worked together. She volunteered to be part of this
subgroup.

She then explained to the team the second consid-
eration was how best to write the goals and objectives
and determine health indicators. She cautioned that a
very large group discussion could be time consuming
and result in poorly worded objectives. The team
decided to appoint a smaller task force to write these
up and present them back to the full group. They asked
Meghan to be the facilitator for this task force.

When the task force had its first meeting, Meghan
began with an overview of how to write goals and
objectives for the program plan and how they formed
the framework of the plan. She explained that goals and
objectives are different and each has a specific purpose.
A goal is a broad statement of the impact expected
by implementing a program, that is, a short general

statement of the overall purpose of a program with a
focus on the intention of the program. In most situa-
tions, it is a statement of outcome, rather than activity,
and frequently projects to a future situation, such as
5 years from program initiation. There are usually only
a few goals for a program. There may be only one goal
for a simple program and two or three for a more
complex program. Because it is a general statement,
there are usually no actual outcome measurements in
it, but the goal should be realistic and reachable.

Meghan provided the team with examples. One
example of a goal she provided was from a colleague
of hers who was a high school nurse who developed a
program to prevent teen pregnancies. The goal of that
program was to prevent all teenage pregnancies at
Reed High School. Another example she provided was
from a community in Alabama concerned about the
increase in obesity in all age groups. They designed a
community-based fitness program with the goal of
providing opportunities for all community residents
to increase or maintain the necessary physical activities
for them to be physically fit. After much discussion the
task force decided that the goal for the program was
the following:

To increase meaningful communication among the older
adult population in the two senior high-rise Elmwood residen-
tial buildings.

The next step for the task force was to come
up with specific objectives for the program. Megan
explained that objectives clarify the goal, are an out-
come measurement, and keep the program focused on
the intended intervention. She knew writing objectives
was not easy, but she also understood well-written
and well-thought-out objectives were components for
the success of the program and key in the process of
program planning. Objectives include who will achieve
what by how much by when. They are measurable, time-
limited, and action-oriented. She suggested they use
an accepted approach to writing objectives first intro-
duced in 1981 called SMART objectives. SMART
stands for Specific, Measurable, Assignable, Realistic,
and Time-related.31 She explained SMART objectives
are action-oriented and specify the goals and the
desired results in a concrete, well-defined, and detail-
focused statement. A specific objective answers the
six “w” questions: who, what, where, when, which,
and why. An objective that is measurable tells you the
measurement criteria to determine when you have
succeeded in meeting the objective, the most essential

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120 U N I T I n Basis for Public Health Nursing Knowledge and Skills

component of an objective. An objective that is
achievable is one that can attain the desired outcome
in the prescribed time frame. An objective that is
realistic is one in which the resources (economic,
human, skills) are available to implement the action.
An objective that has defined time parameters indi-
cates when this objective will be achieved and pro-
vides a deadline. All of these components working
together in one objective can give you the clearest
outcome measure.

The task force began to write up their objectives.
They made sure there was an objective for every
major program activity with a description and desired
outcome that was clear to everyone. They hoped this
would decrease confusion among stakeholders and
the larger team when they presented it to them. They
also realized it needed to be clear to those who would
implement the program.

As they reviewed each objective, they examined
how each would help guide the intended implementa-
tion of the program. They asked whether the objec-
tives would work well taken all together and would
reflect the goal for the program. Meghan explained
this program was somewhat complex. To help provide
clarity, the group first added some level objectives that
gave more detail. They also added process objectives
to measure what the staff would do, how much they
would do, and during what time period.

Meghan knew she needed to become very familiar
with the objectives and the indicators identified for
this program as well as other programs she worked
with for the health department. She was particularly
concerned with ensuring the integrity of these programs
when implemented and ensuring the right data were
collected for the program evaluation phase. As the
objectives were developed, Meghan identified indica-
tors with which to measure the objectives chosen by
the group and helped demonstrate how the program
performed. She knew that good indicators are relevant
to any health program; are scientifically defensible,
when possible; are based on national benchmarks; are
feasible to collect; are easy to interpret and analyze;
and changes can be tracked over time.32 The team
developed clear and specific objectives and then were
able to identify appropriate indicators to measure what
was expected to change. The indicators they chose
were practical and specific steps were in place to
collect the necessary data.

The Elmwood task force presented their final draft of
the goals and objectives to the larger community team.

The team accepted the draft and began to move into
the implementation of the program.
Goal:
To increase social communication among the older
adult population in the two senior high-rise Elmwood
residential buildings.
Objectives:
1. To establish a volunteer school program run by Elmwood

residents to work with 50 children at the school and
25 children on-site within 6 months.

2. To develop consistent monthly programs in each building
with a minimum of 40 resident attendees that foster
social interaction by October 2023.

n CULTURAL CONTEXT
When assessing communities, analyzing data, and
designing programs, the partnership must always con-
sider the culture, ethnicity, and language of the commu-
nity. It is important for staff and community members
to feel secure asking questions and gaining information,
so they feel comfortable with the culture of the com-
munity the program serves. It also is important that
organizations have clearly stated values that endorse
cultural competency and sensitivity.

Although cultural competency is always an essential
component in program planning, in some programs it
takes on a central role. Aitato and colleagues in Hawaii
noted in their assessment that cancer is the leading
cause of death for Samoans in the United States.33

They concluded the design of a program aimed at
decreasing morbidity and mortality related to cancer for
this population required a culturally relevant approach.
When designing the program, they linked the Samoan
beliefs about health and illness with the need for early
cancer detection. They reviewed the sociological and
cultural literature to better understand appropriate
interventions. Through their examination of the culture
they found that most Samoans were fatalistic and pas-
sive in response to cancer. This also was observed
in clinical settings. Aitato et al. also reported church
affiliation was exceptionally important for this immigrant
group, especially because it provided them a commu-
nity where they could practice their traditional lifestyle.
Based on this evidence, the program designers used a
community-based participatory research method to
gather information within the Samoan churches.
Through focus groups, the Samoans as a community
determined the most appropriate programs, including
the need to use the Samoan language, the serving of

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Evidence-Based Practice in Program
Planning
It is important to use EBP in the steps of program plan-
ning. The development of a health program begins
with a review of the literature for similar problems, the
population-based approaches to solving the problem(s),
and the evidence that the approach worked. Look at the-
ory and rationales for these other programs and see how
they relate to your program. Look for similar programs
in similar communities and see whether your strategies
are also similar. Note whether the strategies in these
other communities produced their expected outcomes.
If you want to try something unique, see whether there
is anything in the literature that allows you to build your
own rationale for the effectiveness of your selected
approach. Arguments for using a specific intervention are
strongest when there is demonstrated previous success
with the method, especially with a similar population.

C H A P T E R 5 n Health Program Planning 121

appropriate Samoan food, and the need to recognize a
traditional leader.

Integrating cultural components into program plan-
ning is essential. Take, for example, the Discovery
Dating program in a western U.S. tribal middle
school.34 The two facilitators of the program were a
Native American PHN from the western tribal commu-
nity and a Native American community health educator
from a different tribal community. The use of two facili-
tators from two different tribal communities showed
an understanding that a great deal of diversity exists
between tribes in relation to language, spiritual prac-
tices, gender roles, and customs among tribal groups.34

n EVIDENCE-BASED PRACTICE
Engagement of the Older Adult

Practice Statement: Social isolation poses a significant
health risk for older adults.
Targeted Outcome: Engagement with the community
Supporting Evidence: Intergenerational programs at
schools that include older adults and young children are
shown to have a beneficial impact on both (Fig. 5-4).
The children receive additional attention, and the
older adults feel needed and appreciated. Specifically,
researchers found that older adults had increased self-
esteem and better health. Children at risk for failure
did much better in these programs, and all the children
had a more positive attitude toward older adults.

Figure 5-4 Adopt a Grandparent. (From the Centers for
Disease Control and Prevention, Richard Duncan, MRP, Sr. Proj.
Mngr, North Carolina State University, the Center for Universal
Design, 2000.)

Another finding was the older adults had a calming
effect on the classroom. In one study, the researchers
compared two programs, one with a formal design
with older adults receiving pretraining and one
accepting volunteers and integrating them into the
classroom without any training. The final outcome of
effectiveness was the same.
Recommend Approaches: Promote an intergenera-
tional program between older adults and school-aged
children.

Sources
1. Kaplan, M.S. (2001). School-based intergenerational

programs. Retrieved from http://unesdoc.unesco.org/
images/0020/002004/200481e .

2. David, J., Yeung, M., Vu, J., Got, T., MacKinnon, C.
(2018). Connecting the young and young at heart: An
intergenerational music program: Program profile.
Journal of Interpersonal Relationships, 16(3), 330-338.

3. Gualano, M.R., Voglino, G., Bert, F., Thomas, R.,
Camussi, E., & Siliquini, R. (2018). The impact of
intergenerational programs on children and older
adults: A review. International Psychogeriatrics, 30(4),
451-468.

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Resources for Evidence-Based Programs
The Community Tool Box, created by the University of
Kansas, offers additional suggested resources for infor-
mation on promising evidence-based programs or
programs with interesting new interventions.1 A central
suggestion in the Community Tool Box is networking
with local and state agencies, and checking public and
private professional organizations or advocacy groups
to see whether they have published information on
evidence-based programs.

The importance of integrating evidenced-based pro-
grams into public health departments was underlined
by the National Association of County & City Health
Officials’ (NACCHO) nationwide support system to dis-
seminate Chronic Disease Self-Management Programs
through local health departments (LHD) into commu-
nities. With the support of the CDC, NACCHO has
provided grants to LHDs with emerging evidence that
they are successfully implementing these programs in
the communities they serve.35 They acknowledged that,
according to the literature, merely gaining knowledge
about nutrition and fitness frequently did not translate
into behavior change. Based on their review of the liter-
ature, setting goals, strengthening self-efficacy, and using
theory of change had more success in actually changing
behavior than just providing information. They also
found that multifaceted community efforts have increased
physical activities. With this evidence, they designed
their program.

Determining whether a program has good evidence
to support it can be accomplished using a few different
approaches. First, examining both the quantitative and
qualitative data from studies, as well as from the current
program, provides essential information. Even simple
statistical analysis can help determine whether a program
is thriving, whether participants are reaching their out-
comes, and whether positive things are happening in the
community. Good indicators that the community likes
the program are the continued use of the program by
participants and ongoing program growth. However, it
is important to know whether there are outside factors
contributing to program success that might make it diffi-
cult to duplicate the program in other communities
or with other groups. Another issue may be that the out-
comes are really a measurement of behavior change
and not real outcomes. When reviewing program data,
it is important to note whether there is a researched the-
oretical framework to support the intervention, whether
the statistical analysis is clear, whether there are enough
participants to make conclusions, whether the target
outcomes are appropriate, and whether the program

reached these targets. In reviewing the program, it helps
to evaluate whether the indicators seemed appropriate
and whether the tools were well designed. It also helps
to think about the usefulness of the indicators of the
program. Did the intervention reach the intended pop-
ulation, and is this population similar to or different from
the intended population? It also is important to be aware
of what resources were used and to compare the amount
of resources available for your program. In the 1990s,
Lisbeth Schorr, a well-known social analyst, identified
seven characteristics of highly effective programs still
relevant today.36 Although they are focused on programs
aimed at improving the health of children, they can also
be applied to other populations. Effective programs:

• Are comprehensive, flexible, responsive, and
persevering

• See children in the context of their families
• Incorporate families as parts of neighborhoods
• Have a long-term, preventive orientation, a clear

mission, and continue to evolve over time
• Are well managed by competent and committed

individuals with clearly identifiable skills
• Have staff who are trained and supported to provide

high-quality, responsive services
• Operate in settings that encourage practitioners to

build strong relationships of mutual trust and respect

Many of these attributes are part of effective program
planning, implementation, and evaluation, and include
looking at communities and not just individuals, being
flexible and persevering, having clear goals, forming
partnerships and working collaboratively, and having
passion on the part of staff for the work and for social
justice. In successful programs, the staff is nurtured and
supported, and the program is well managed.

Program Implementation
After the program has been designed and the logic model
solidified, it is time to implement the program. Program
implementation encompasses the resources needed to
provide a program as well as the mechanism for putting
the program in place. Prior to putting a program in place,
it is important to map out exactly how this will be done.
For example, when implementing a screening program,
it is important to know how many participants are
anticipated, how many screening tools/how much equip-
ment will be needed, how many personnel are needed,
and what the flow for participants from arrival through
the screening and referral process will be. Nurses are
frequently part of the implementation team and assist in

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adding the necessary detail to the actual program activ-
ities. Ervin identified five stages related to program
implementation:30

1. Community accepting the program
2. Specifying tasks and estimating needed resources
3. Developing specific plans for program activity
4. Establishing a mechanism for program management
5. Putting the plan into action

Partnering with the community from the beginning
of the planning process facilitates community interest
and ownership of the program, which should be cultur-
ally and politically specific and acceptable. Although
adequate resources to implement the program were iden-
tified in the planning, it is important to confirm that
the resources are available and adequate, and how these
resources are to be used in the program activities and
evaluation.

The implementation team needs to make certain the
indicators for the outcomes are identified and a mecha-
nism is in place to collect the data. Everyone needs to
know the steps of the program. It may be necessary to
write protocols and procedures for the intervention. If
additional staff members are needed, they need to be
hired and undergo orientation. There also may be a need
for additional staff training. Several program evaluations
have stressed the importance of pilot testing the program
or components of the program and the planned evalua-
tion before implementation of the complete program, as
was done in one study in China that helped to identify
challenges related to the implementation of a community-
based stable coronary artery disease management pro-
gram.37 The first was the importance of establishing
a personal working relationship with the community.
They also suggested the program leader strive to build
partnerships by listening, observing, and integrating the
experiences between the program and the community.
They found it was best to be flexible and emphasized
simplicity when implementing community activities.

Program Evaluation
Project management and program evaluation are inex-
tricably linked whether in public health programs, a
health program, or in an acute care setting.16,38 Program
evaluation is the systematic collection of information
about the activities, outputs, and outcomes to enhance a
program and its effectiveness. Evaluation is defined as
the systematic acquirement and analysis of information
to provide useful feedback. Evaluation is essential to
good management and program design, and evaluation

strategies should be developed prior to the project man-
agement and programs being implemented. Evaluation
is used to evaluate the effectiveness of the program and
provide information to guide any needed improvement
of the program. Through evaluation you strengthen the
project. Programs need to be evaluated for multiple
reasons. You need to know whether objectives and goals
are being met. From the evaluation you can determine
whether the:

• Activities are implemented as they were designed
• Program is cost effective
• Intervention and program theories are correct
• Time line is appropriate
• Program should be expanded or duplicated in

another location

Evaluation helps with program planning, program
development, and program accountability. Frequently
the PHN works with comprehensive collaborative com-
munity interventions that are complex to evaluate, as
there may be no clear cause and effect with multiple
interventions. Often the program operates within the
unique local political issues, and circumstances of the
community demand a customized evaluation to really
understand what is happening. PHNs and other local
providers can help interpret this information for the
interior or exterior evaluators or as part of an evalua-
tion team.

Percy provided a good example that underscores the
necessity for program evaluation.39 She described a
school health program in one school district that was
so busy providing good health care to the schoolchild-
ren that the district failed to design and implement an
evaluation plan. Without an evaluation of the program,
the district was unable to determine whether the pro-
gram was effective. Because the program required a
registered nurse (RN) in each school, the lack of eval-
uation data resulted in an inability to demonstrate the
need for the added cost of the school health nurses.
The city council members had budget constraints and
needed to cut programs. Without the evaluation data,
the nurses could not show the council members the
importance of this nursing intervention. To have a
more cost-effective budget, the city council replaced
the nurses with nursing assistants. When the city tried
to extend this cost savings to another school district,
the nurses in the second school district had already
been evaluating their program routinely, and they had
excellent outcome data to demonstrate the effective-
ness of having an RN in each school. Their program
did not get cut.

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Evaluation of family and individual care, community
services, and programs has grown over the past several
decades as a response to the stakeholders, especially
the funders, who need to know whether the nurse and
colleagues from other disciplines are successful in im-
proving health and are doing so in a cost-effective manner.
Most grant agencies funding these types of interventions
now require evaluation.

Evaluation Models
Formative Evaluation
There are several models for program evaluation. One
model is to divide the evaluation into either formative or
summative or both. Formative evaluation occurs during
the development of a program, while the activities are
forming and being implemented for the first time. It is
an ongoing feedback on the performance of the program,
identifying aspects needing improvement and providing
opportunities to offer corrective suggestions. Formative
evaluation is concerned with the delivery of the program
and the organizational context, including structure and
procedures. This is an opportunity to examine what
happens in the reality of the implementation, and it
provides the opportunity to see whether the program
outputs can really create the change necessary to meet
the objectives and goals. Usually a formative evaluation
is internal and ongoing, with the staff constantly assess-
ing the strengths, weaknesses, barriers, and unexpected
opportunities of these new program activities. The activ-
ities and outputs are the dynamic part of the program
and lend themselves to formative evaluation. The pro-
gram can positively respond to the evaluation and can
change interventions, change the way outcome measure-
ments are collected, or change other parts of the program
design to better meet the program goals and objectives.
It is appropriate to change things if the program is not
working as well as possible.

Process Evaluation
Process evaluation is a type of formative evaluation used
to investigate the process of delivering the program or
technology, including alternative delivery procedures.
The main concern with process evaluation is to docu-
ment to what extent the program has been delivered and
whether the delivery was what was defined in the pro-
gram design. There should be detailed information on
how the program actually worked (the program opera-
tions), any changes made to the program, and how those
changes have had an impact on the program. It is also
important for an evaluator to be aware of any outside
environmental events or intervening events that may

have influenced the program activities. This type of data
can be collected by noting actual numbers related to the
interventions, such as the number of people attending
a class, the number of pamphlets handed out, or the
number of screening tests performed. Qualitative data
collection methods can include, among others, direct
observations, in-depth interviews, focus groups, and
review of documents.

The importance of formative evaluation should
not be underestimated. It is a strong tool in helping to
improve the activities and output of a program and for
determining whether the theoretical understanding of
how the program will influence change is accurate and
appropriate.

Summative Evaluation
Summative evaluation occurs at the end of the program
and is the evaluation of the objectives and the goal. It is
judging the worth of the program at the end of the activ-
ities and discovering whether the program achieved the
intended change. It is an assessment of the outcome
and impact of the benefits the selected population has
received by participating in the program. It evaluates
the causal relationship and the theoretical understanding
of the planned intervention. It also can examine program
cost, looking at cost-effectiveness and cost benefit.40

When conducted on well-established programs, it
allows funders and policy makers to make major deci-
sions on the continuation of programs and determine
how the outcomes could influence policy at the local to
the national levels.

As more hospitals strive for magnet status, baccalau-
reate nurses are being called to initiate health programs
in acute care settings and to evaluate their effectiveness.
In public health settings, the PHN is often responsible
for managing community-based programs in which
evaluation is essential to the sustainability of the pro-
grams. Several nonprofit funding agencies and the CDC
offer suggestions on how to do internal evaluations and
when to seek external evaluator assistance.

Nine Steps of Program Evaluation
The W.W. Kellogg Foundation identified essential steps
for developing a program evaluation that is useful for
both smaller programs and for the complex multiactivity
community program interventions that many organiza-
tions implement (Box 5-5).40 The first four steps occur
in the program planning stage, the next three in the im-
plementation of the program, and the last two after the
program evaluation is complete. Program evaluation is
an integral part of the program design, and the program

124 U N I T I n Basis for Public Health Nursing Knowledge and Skills

7711_Ch05_107-127 21/08/19 11:04 AM Page 124

evaluation plan should be in place before the program is
initiated.

Step 1: Step 1 is completed before the program begins.
It identifies from among the stakeholders who
should be included on the evaluation team, staff
representation, and what community representation
and participants are needed in the program.

Step 2: In step 2, evaluation questions are created. All
participants need to help phrase questions that will be
useful in reflecting the program theory, improving the
program, and determining effectiveness. These ques-
tions can include the following: What data do you
need to collect? What kind of information is needed?
What do we want to accomplish? What do we need to
know about the program? How will we know when we
have accomplished our goal? Where do we find the
data, and what indicators do we need? The questions
also will involve how this information is communi-
cated to others: Who is the audience for the results?
What kind of information should we tell them?

Step 3: Step 3 is the creation of a budget. The amount
of the budget varies depending on several compo-
nents such as the size of the program, the number of
staff needed to carry out the evaluation, the need for
other resources such as software for data entry and
analysis, and the length of time needed to complete
the evaluation.

Step 4: In step 4, a decision must be made about
whether the evaluation will be internal or have an
external evaluator. If you decide on an external eval-
uator, it is good to identify that person, so the evalu-
ator can be a part of the program planning process
from the beginning. These are all components of the
planning and occur as the program is designed.

Step 5: Steps 5 through 7 occur during the program
implementation phase. In step 5, data collection
methods are determined.

Step 6: In step 6, data are collected.
Step 7: In step 7, the results are analyzed and interpreted.
Step 8: After the completion of the evaluation, in step 8

the findings and new perceptions of the program are
communicated to the stakeholders. It is important
that the appropriate information is communicated
to the identified audiences.

Step 9: In step 9, evaluation information is used to show
evidence for or to improve the program. The better
informed we are, the better we are at making good
program decisions. This may be sharing with funding
agencies to receive more funding for the successful
program; it may be to change some of the program
activities and outputs to improve outcomes; or it may
be to refine the population served, to help change
policy, or to discontinue the program (see Box 5-5).
When developing the process for health program

evaluation, it is important to be as objective as possible.
Some of the ethical dilemmas that can emerge during
program evaluation include:
• Pressure to slant the findings in the direction wanted

by key stakeholders
• Compromised confidentiality of data sources
• Response on the part of the evaluator to one interest

group more than to others
• Misinterpretation or misuse of the findings by the

program stakeholders
• Evaluator using a familiar tool to collect data rather

than a more appropriate one
The team can use these points to examine the methods

chosen to evaluate a program as a means of eliminating
as much bias as possible.

Through successful programs, communities can im-
prove their health. These programs can be synergistic
in creating positive change and lead to new policies with
an even wider influence on health. The purpose of health
programs is to strive for a community in which everyone
is safe, environments support health, actions are taken
to prevent and control acute and chronic disease, and
individuals and families can thrive.

C H A P T E R 5 n Health Program Planning 125

Program
1. Select the evaluation team.

Planning Stage
2. Develop the evaluation questions.
3. Have a budget in place for the evaluation.
4. Decide whether to use an internal or external evaluator.

Program Implemented
5. Determine data collection methods.
6. Collect the data.
7. Analyze and interpret the results.

Evaluation Complete
8. Communicate findings.
9. Improve the program.

BOX 5–5 n Nine Steps in Developing a Program
Evaluation

Source: W.K. Kellogg Foundation. (1998). W.K. Kellogg Foundation evaluation
handbook. Battle Creek, MI: Author. Retrieved from https://www.wkkf.org/
resource-directory/resource/2010/w-k-kellogg-foundation-evaluation-
handbook.

7711_Ch05_107-127 21/08/19 11:04 AM Page 125

n Summary Points
• Health planning occurs across health-care settings

including public health settings, primary care, acute
care, and schools, with the focus on improving the
health of the populations served.

• Healthy People provides a framework of goals and
indicators that can help in creating health programs
for our communities.

• All models of program planning include the commu-
nity as a partner, and it is important that the com-
munity is involved in every step of the process.

• Health planning includes community assessment,
community diagnoses, program design, program
implementation, and program evaluation.

• Using logic modeling can help create a well-structured
program with clear indication of how to do both
process and outcome evaluation of the program.

• Every program should be evaluated, and evaluation
begins when you start designing the program.

• Formative, process, and summative evaluations each
provide important information about the program
and how to make it more effective.

REFERENCES

1. Center for Community Health and Development at the
University of Kansas. (2018). Community tool box: A model
for getting started. Retrieved from https://ctb.ku.edu/en/
get-started#plan.

2. U.S. Department of Health and Human Services. (n.d.).
About the community guide. Retrieved from https://www.
thecommunityguide.org/about/about-community-guide.

3. Centers for Disease Control and Prevention. (2017).
National public health performance standards. Retrieved from
https://www.cdc.gov/stltpublichealth/nphps/index.html.

4. Fawcett, S.B. (2018). Section 3. Our model of practice: Build-
ing capacity for community and system change. Retrieved
from https://ctb.ku.edu/en/table-of-contents/overview/
model-for-community-change-and-improvement/building-
capacity/main.

5. Institute of Medicine. (1988). The future of public health.
Washington, DC: National Academies Press.

6. Institute of Medicine. (2002). The future of the public’s health
in the 21st century. Washington, DC: National Academies
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7. Institute of Medicine. (2012). For the public’s health: Investing
in a healthier future. Washington, DC: National Academies
Press.

8. American Public Health Association: Public Health Nursing
Section. (2018). Public health nursing. Retrieved from http://
apha.org/apha-communities/member-sections/public-health-
nursing.

9. Keller, L.O., Schaffer, M., Lia-Hoagberg, B., & Strohschein, S.
(2002). Assessment, program planning, and evaluation in
population-based public health practice. Journal of Public
Health Management and Practice, 8, 30-43.

10. Keller, L.O., Strohschein, S., Lia-Hoagberg, B., Schaffer, M.
(2004). Population-based public health interventions: Practice-
based and evidence-supported. Part I. Public Health Nursing,
21(5), 453-468.

11. U.S. Department of Health and Human Services. (2018).
Program planning. Retrieved from https://www.healthypeople.
gov/2020/tools-and-resources/Program-Planning.

12. U.S. Department of Health and Human Services. (2016).
Educational and community-based programs (ECBP).

126 U N I T I n Basis for Public Health Nursing Knowledge and Skills

l APPLYING PUBLIC HEALTH PRACTICE
The Case of Program Evaluation
at Elmwood
Public Health Science Topics Covered:

• Assessment
• Community diagnosis

The Elmwood Senior Housing program was designed
to increase social integration and has been in place
for 9 months. The activities include residents work-
ing in the public schools in an intergenerational
program, the first and second graders each coming
to Elmwood once a month for a 2-hour reading
program, the solidification of an Elmwood community
organization, and weekly discussion and activity
programs at the center with assistance from the
community center and the local churches. The PHN
and other members of the team have been doing
ongoing process evaluation and are now meeting
to discuss the implementation of their outcome
evaluation plan.

To answer the following questions, use the estab-
lished goal, outcomes, and output in the logic model
(Fig. 5-1) developed by the community group. You
also can reference the Community Tool Box from
Center for Community Health and Development at

the University of Kansas (https://ctb.ku.edu/en/table-
of-contents), Evaluating Community Programs and
Initiative, Chapters 36–39.

1. What data would you collect as part of the process
evaluation? How would these data help you in the
formative process of your program? Would you
change activities based on these data?

2. What would have been the steps in setting up the
evaluation plan? What might be your evaluation
questions? What would be your indicators? What
kind of data should you collect? How would you
specifically know whether your program has been
successful?

7711_Ch05_107-127 21/08/19 11:04 AM Page 126

Retrieved from https://www.cdc.gov/nchs/data/hpdata2020/
CH11_ECBP .

13. Public Health Service. (1979). “Healthy People”: The Surgeon
General’s report on health promotion and disease prevention.
Washington, DC: U.S. Government Printing Office, DHEW.

14. Chrvala, C., & Bugar, R. (Eds.). (1999). IOM report. Leading
health indicators for “Healthy People 2010”: Final report.
Washington, DC: National Academies Press.

15. U.S. Department of Health and Human Services. (2018).
2020 topics and objectives – objectives A-Z. Retrieved from
https://www.healthypeople.gov/2020/topics-objectives.

16. Issel, L.M. (2018). Health program planning and evaluation:
A practical, systematic approach for community health
(4th ed.). Sudbury, MA: Jones & Bartlett.

17. Green, L.W., & Kreuter, M.W. (2005). Health program plan-
ning: An educational and ecological approach (4th ed.).
New York, NY: McGraw-Hill Higher Education.

18. W.K. Kellogg Foundation. (2004). Logic model development
guide. Battle Creek, MI: Author. Retrieved from https://
www.wkkf.org/resource-directory/resource/2006/02/wk-
kellogg-foundation-logic-model-development-guide.

19. Centers for Disease Control and Prevention, Division for
Heart Disease and Stroke Prevention (n.d.). Evaluation guide:
Developing and using a logic model. Retrieved from https://
www.cdc.gov/dhdsp/docs/logic_model .

20. Ball, L., Ball, D., Leveritt, M., Ray, S., Collins, C., Patterson, E.,
Chaboyer, W., et al. (2017). Using logic models to enhance
the methodological quality of primary health-care interven-
tions: guidance from an intervention to promote nutrition
care by general practitioners and practice nurses. Australian
Journal of Primary Health, 23(1), 53–60. https://doi-org.ezp.
welch.jhmi.edu/10.1071/PY16038.

21. University of Maryland Extension. (2017). Guide to
2018 University of Maryland extension program planning.
Retrieved from https://wiki.moo.umd.edu/display/umean-
swers/Program+Planning+and+Implementation?preview=
%2F84902254%2F121897117%2FUME+Program+Planning+
Guide+2018 .

22. Moltó-Puigmarí, C., Vonk, R., van Ommeren, G., & Hegger,
I. (2018). A logic model for pharmaceutical care. Journal of
Health Services Research & Policy, 23(3), 148–157. https://
doi-org.ezp.welch.jhmi.edu/10.1177/1355819618768343.

23. Serowoky, M.L., George, N., & Yarandi, H. (2015). Using the
program logic model to evaluate ¡Cuídate!: A Sexual health
program for latino adolescents in a school-based health center.
Worldviews on Evidence-Based Nursing, 12(5), 297–305.
https://doi-org.ezp.welch.jhmi.edu/10.1111/wvn.12110.

24. Centers for Disease Control and Prevention. (2018). Com-
munity health assessment and group evaluation (CHANGE)
tool. Retrieved from https://www.cdc.gov/nccdphp/dnpao/
state-local-programs/change-tool/index.html.

25. Buchanan, D. (2008). Autonomy, paternalism, and justice:
Ethical priorities in public health. American Journal of Public
Health, 98, 15-21.

26. American Nurses Association. (2015). Health care reform.
Retrieved from https://www.nursingworld.org/practice-
policy/health-policy/health-system-reform/.

27. Blewett, L. A., Planalp, C., & Alarcon, G. (2018). Affordable
Care Act impact in Kentucky: Increasing access, reducing
disparities. American Journal of Public Health, 108(7),
924-929.

28. Frean, M., Gruber, J., & Sommers, B. D. (2017). Premium
subsidies, the mandate, and Medicaid expansion: Coverage
effects of the Affordable Care Act. Journal of Health Economics,
53, 72-86.

29. Rice, T., Unruh, L. Y., van Ginneken, E., Rosenau, P., &
Barners, A. J. (2018). Universal coverage reforms in the USA:
From Obamacare through Trump. Health Policy, 122(7),
698-702.

30. Ervin, N., & Kulbok, P.A. (Eds.). (2018). Advanced public and
community health nursing practice: Population assessment,
program planning, and evaluation. New York City, NY:
Springer Publishing.

31. Doran, G.T. (1981). There’s a S.M.A.R.T. way to write man-
agement’s goals and objectives. Management Review, 70(11),
35-36.

32. United Nations Fund for Population Activities. (2004). Pro-
gramme manager’s planning monitoring & evaluation toolkit.
Retrieved from https://www.betterevaluation.org/sites/
default/files/stakeholder .

33. Aitato, N., Braun, K., Dang, K., & So’a, T. (2007). Cultural
considerations in developing church-based programs to
reduce cancer health disparities among Samoans. Ethnicity
and Health, 12(4), 381-400.

34. Schanen, J.G., Skenandore, A., Scow, B., & Hagen, J.
(2017). Assessing the impact of a healthy relationships
curriculum on Native American adolescents. Social Work,
62(3), 251–258. https://doi-org.ezp.welch.jhmi.edu/10.
1093/sw/swx021.

35. National Association of County & City Health Officials
(2018). Chronic disease resources. Retrieved from https://
www.naccho.org/programs/community-health/chronic-
disease/resources.

36. Schorr, L. (1997). Common purpose: Strengthening families
and neighborhoods to rebuild America. New York, NY:
Anchor Books.

37. Shen, Z., Jiang, C., & Chen, L. (2018). Evaluation of a train-the-
trainer program for stable coronary artery disease manage-
ment in community settings: A pilot study. Patient Education
& Counseling, 101(2), 256–265. https://doi-org.ezp.welch.
jhmi.edu/10.1016/j.pec.2017.07.025.

38. Ramos Freire, E.M., Rocha Batista, R.C., & Martinez, M.R.
(2016). Project management for hospital accreditation: a case
study. Online Brazilian Journal of Nursing, 15(1), 96–108.
Retrieved from http://search.ebscohost.com.ezp.welch.jhmi.
edu/login.aspx?direct=true&db=rzh&AN=115736473&site=
ehost-live&scope=site.

39. Percy, M. (2007). School health. Quality of care: or why you
HAVE to evaluate your program. Journal for Specialists in
Pediatric Nursing, 12(1), 66-68.

40. W.K. Kellogg Foundation. (2017) The step-by-step guide to
evaluation: How to become savvy evaluation consumers.
Battle Creek, MI: Author. Retrieved from http://ww2.wkkf.
org/digital/evaluationguide/view.html#p=10.

C H A P T E R 5 n Health Program Planning 127

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Chapter 6

Environmental Health
Christine Savage

LEARNING OUTCOMES

After reading the chapter, the student will be able to:

KEY TERMS

1. Describe the role of nursing in environmental health.
2. Describe the impact of the built environment on health.
3. Use the principles of home visiting and an environmental

health assessment to identify health risk factors at the
family and community level.

4. Examine the concept of exposure to hazardous
substances from a cellular to global level.

5. Explain the concept of environmental justice.
6. List social, behavioral, cultural, and physical characteristics

that increase susceptibility to health effects associated
with environmental exposures.

7. Discuss gene-environment interaction.
8. Describe issues related to air and water quality.

Air Quality Index (AQI)
Ambient air
Ambient air standard
Area sources
Blood Lead Level (BLL)
Bioaccumulation
Built environment
Community environmental

health assessment

Criteria air pollutants
Environmental exposure
Environmental health
Environmental justice
Environmental

sustainability
Exposure
Gene-environment

interaction

Half-life
Integrated pest

management
International building

codes
Latency period
Mobile sources
Point sources
Risk assessment

Routes of entry
Safe Drinking Water Act
Toxicity
Warm handoff

n Introduction
Whether tainted water in Flint, Michigan; air pollution
on the rise in low income countries;1 airborne mercury
pollution in Victoria, Australia;2 or natural disasters
and climate change,3 our environment has a direct rela-
tionship with our health. The environment affects the air
we breathe, the food we eat, the water we drink, and the
availability of resources to sustain our economies. The
environment also influences our exposure to toxins and
infectious agents, and access to resources that support
healthy living.

Hardly a day goes by without a report in the media
that links environmental conditions to human health.
High rates of childhood asthma, industrial explosions,
hurricanes and other natural disasters, as well as reports
of polluted water and air remind us of the many ways
we are affected by the world around us and how the
health of individuals and communities strongly depends

on environmental determinants. The adverse environ-
mental impact of human-made and natural disasters
such as the lack of potable water and lead exposure in
Flint, Michigan, and numerous hurricanes as well as
the day-to-day aspects of the environment in which we
live, work, and play can cause immediate or long-term
benefits or harm.

The World Health Organization (WHO) defines
environmental health as follows:

Environmental health addresses all the physical, chemical,
and biological factors external to a person, and all the re-
lated factors impacting behaviors. It encompasses the as-
sessment and control of those environmental factors that
can potentially affect health. It is targeted toward prevent-
ing disease and creating health-supportive environments.
This definition excludes behavior not related to environ-
ment, as well as behavior related to the social and cultural
environment, and genetics.4

128

7711_Ch06_128-156 21/08/19 11:03 AM Page 128

This perspective of environmental health extends
beyond food, air, water, soil, dust, and even consumer
products and waste. It includes all aspects of our living
conditions, the use and misuse of resources, and the
overall design of communities. The ecological models
of health promotion (see Chapter 1) encompass the en-
vironment in which we live.5 Using an ecological ap-
proach requires an understanding that individuals and
populations interact with their environment. In an ed-
itorial, one author stressed the need for interventions
aimed at protecting the natural environment as an up-
stream approach to improving our health.6

The broad scope of environmental determinants of
health is obvious with the inclusion of 68 main and sub-
objectives under the Healthy People 2020 (HP 2020) topic
of environmental health.7 Based on the midcourse review,
six of these were archived and four were developmental,
which left 58 that were measurable.

The WHO’s 10 facts on environmental health pub-
lished in 2016 illustrated the association between the en-
vironment and health.10 Almost a quarter of all deaths
globally were attributable to the environment. Five key
factors emerged through an analysis of data related to the
global burden of disease attributable to the environment
(Table 6-1). Twenty-two percent of the disability-adjusted
life years (DALY) (see Chapter 9) were attributable to
the environment, and low-income countries (LIC) bore
more of the burden of disease associated with the envi-
ronment. Age and gender play a role in risk for environ-
mental attributable disease with children, older adults, and
males at higher risk. Although communicable diseases
are the main cause of environmentally attributed deaths
in Sub-Sahara Africa, there has been a shift globally to
noncommunicable diseases as the main cause of deaths
are attributable to the environment. The list of diseases
associated with the environment include cardiovascular
diseases, diarrheal diseases, and lower respiratory infec-
tions. The environmental factors associated with these
diseases include ambient and household air pollution,
water, sanitation, and hygiene.10

C H A P T E R 6 n Environmental Health 129

n HEALTHY PEOPLE 2020
Environmental Health

Targeted Topic: Environmental Health
Goal: Promote health for all through a healthy
environment.
Overview: Humans constantly interact with the
environment. These interactions affect quality of
life, years of healthy life lived, and health disparities.
The WHO defines environment, as it relates to health,
as “all the physical, chemical, and biological factors
external to a person, and all the related behaviors.”1

Environmental health consists of preventing or
controlling disease, injury, and disability related
to the interactions between people and their
environment.

The HP 2020 Environmental Health objectives
focused on six themes, each of which highlighted an
element of environmental health:

1. Outdoor air quality
2. Surface and groundwater quality
3. Toxic substances and hazardous wastes
4. Homes and communities
5. Infrastructure and surveillance
6. Global environmental health7

Midcourse Review: Of the 58 measurable objectives
in the Environmental Health Topic Area, 10 of them met
or exceeded their 2020 targets, 11 were improving,
10 showed little or no detectable change, and 11 objec-
tives were getting worse. Sixteen objectives had base-
line data only (Fig. 6-1).8

28%
Base line
Getting worse
Little or no change
Improving
Met or exceeded

19%

17%

19%

17%

Healthy People 2020 Midcourse Review:
Environmental Health

Figure 6-1 Healthy People Midcourse Review for 2020.

Healthy People 2030 Proposed Framework
and Environmental Health
There are seven proposed foundational principles
for the HP 2030 proposed framework. One pertains
specifically to environmental health and reflects the
ecological model:

“What guides our actions … Healthy physical, social,
and economic environments strengthen the potential to
achieve health and well-being.”9

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The Role of Nursing in Environmental
Health
Nurses, particularly those in the field of public health,
play a significant role in preventing harm from occurring
and in restoring well-being to all who face hazardous
conditions in their environment. Nurses are among the
environmental health professionals with the responsibil-
ity to detect and assess the presence of environmental
hazards as well as the health risks they pose, and to act
to protect the health of populations.11

In 2007, the American Nurses Association (ANA)
published a report titled ANA’s Principles of Environmen-
tal Health for Nursing Practice With Implementation
Strategies.11 According to the report, registered nurses
play a critical role in both assessing environmental health
issues and addressing them. The report included 10 prin-
ciples (Box 6-1) for healthy safe environments that are
applicable across settings.

Armed with an appreciation for the complexities of the
interaction of environment and health, nurses are leaders
in defining and encouraging solutions. As experts in
educating individuals and communities, and appreciat-
ing the value of leading by example, nurses are catalysts
in improving the health of the environment, thus

improving health. The environmental health issues in
the ANA report specific to nursing practice include:
(1) knowledge of the role environment plays in the health
of individuals, families, and populations; (2) ability to
assess for environmental health hazards and make appro-
priate referrals; (3) advocacy; (4) utilization of appropri-
ate risk communication strategies; and (5) understanding
of policies and legislation related to environmental
health. The ANA principles were designed to help sup-
port the nurse in the role of environmental health
activist.11

Approaches to Environmental Health
A useful framework to use in examining human-
environment interactions and their potential impact
on health of individuals, families, and communities is
the well-established epidemiological triangle, which
describes the relationship between an agent (exposure),
host (human), and environment (the complex setting
in which agent and host come together) (see Chapters 3
and 8). In actuality, the epidemiological triangle is a
simplistic model and must be placed in the context of
the real world to better appreciate the importance of the
triangle point—environment—that brings agent and
host together in the places we live, that is, housing,

130 U N I T I n Basis for Public Health Nursing Knowledge and Skills

TABLE 6–1 n Global Burden of Disease Attributable to the Environment

Percent of Deaths Attributable Percent of the DISEASE BURDEN in
Five Key Factors to the Environment DALYs Attributable to the Environment

Environmental risks and the global
burden of disease

Environmental impacts on health
are uneven across life course
and gender

Low- and middle-income countries
bear the greatest share of
environmental disease

Total environmental deaths are
unchanged since 2002, but show
a strong shift to noncommunicable
diseases

The evidence on quantitative links
between health and environment
has increased

23%

The highest number of deaths
per capita attributable to
the environment occurs in
sub-Saharan Africa

22%

Men: 22.8% versus women: 20.6%

The diseases with the largest environmental
risk include cardiovascular diseases, diarrheal
diseases, and lower respiratory infections.
Ambient and household air pollution, and
water, sanitation, and hygiene are the main
environmental drivers of those diseases.

A greater share of the estimates of the
burden of disease attributable to the
environment can now be determined using
more robust methods than previously used.

7711_Ch06_128-156 21/08/19 11:03 AM Page 130

schools, workplaces, recreational spaces, communities,
and, ultimately, the world (Fig. 6-2).

The approach in the United States for handling envi-
ronmental health in the past was usually at the state and
local health department level rather than at the federal
level. Local health departments focused on sanitation and
waste management to provide potable (safe, drinkable)
water. However, maintaining healthy air and reducing
pollutants in water, air, and soil became an issue that
crossed state borders. In 1970, the U.S. Environmental
Protection Agency (EPA) was formed with the mission
to protect human health and to safeguard the natural
environment—air, water, and land—by writing and
enforcing regulation based on laws passed by Congress.12

The EPA is a regulatory body that performs environmen-
tal assessments, does research, educates, and sets and
enforces national environmental standards. Since the
early 1970s there have been multiple federal laws passed
by Congress. This legislation includes the Clean Air Act;

the Occupational Health and Safety Act; the National
Institute of Occupational Safety and Health; the Clean
Water Act; and the Comprehensive Environmental Re-
sponse, Compensation, and Liability Act, also known as
the Superfund; among others. The growing concerns
among the American people about the environment have
created pressure to increasingly monitor and regulate the
environment. These concerns have clashed with con-
cerns by industry of overregulation resulting in a relaxing
of some of these regulations in 2017 and 2018. Thus, the
health benefits of regulating industry and pollution of the
environment often conflicts with the economic benefits
of relaxed regulations.

In the United States, there is a network of environmental
health specialists housed in the Centers for Disease Control
and Prevention (CDC) National Center for Environmental
Health that, using the epidemiological triangle (Fig. 6-2),
works collaboratively with the Environmental Health Serv-
ices Network to identify and prevent environmental factors
that can produce disease. Their stated purpose is to help
identify underlying environmental factors, assist with
improving prevention efforts, train environmental health
specialists, and help strengthen the collaboration among
different disciplines and services involved in improving
environmental health.13 Key issues include the built
environment, toxic materials, air and water quality, and
environmental stability.

C H A P T E R 6 n Environmental Health 131

1. Knowledge of environmental health concepts is
essential to nursing practice.

2. The Precautionary Principle guides nurses in their
practice to use products and practices that do not
harm human health or the environment and to take
preventive action in the face of uncertainty.

3. Nurses have a right to work in an environment that
is safe and healthy.

4. Healthy environments are sustained through multi-
disciplinary collaboration.

5. Choices of materials, products, technology, and
practices in the environment that impact nursing
practice are based on the best evidence available.

6. Approaches to promoting a healthy environment
respect the diverse values, beliefs, cultures, and
circumstances of patients and their families.

7. Nurses participate in assessing the quality of the
environment in which they practice and live.

8. Nurses, other health care workers, patients, and
communities have the right to know relevant and
timely information about the potentially harmful
products, chemicals, pollutants, and hazards to which
they are exposed.

9. Nurses participate in research of best practices that
promote a safe and healthy environment.

10. Nurses must be supported in advocating for and
implementing environmental health principles in
nursing practice.

BOX 6–1 n ANA’s Principles of Environmental
Health for Nursing Practice

Environmental assess-
ment determines: “Why
was the agent present
in the environment
in such a way that
the host could
be exposed?”

Interaction between
host and environment

Interaction between
agent and environment

Epidemiology deter-
mines: “Who was

exposed?” “When?”
“Where?” “How?”

Interaction between host and agent

Epidemiology determines: “What disease?”
Lab identifies and/or confirms agent.

Environment
(EHS-Net)

Agent Host

Figure 6-2 Environmental health specialists and the
epidemiologic triangle.

Source: (11)

7711_Ch06_128-156 21/08/19 11:03 AM Page 131

The Built Environment
The built environment, the human-made surroundings
created for the daily activities of humans, reflects the
range of physical and social elements that make up a
community.14 Scientists are examining how the structure
and infrastructure of a community facilitate or impede
health. Poor communities often have a built environ-
ment with limited resources, higher pollution, poorer
maintenance of buildings, fewer options for outside ac-
tivities, a smaller selection of goods (including groceries),
and limited transportation, all leading to poorer health
(e.g., lead poisoning, asthma, cancer). There is consider-
able interest in examining how communities can modify
their built environment to promote the health of the
community residents.14,15

An example of the relationship between the built
environment and health is obesity. There is strong
evidence that aspects of the built environment, such as
food availability and access to recreational opportuni-
ties, are associated with obesity.10 Many programs have
been instituted to help reduce the epidemic of obesity
in the United States with growing evidence of the com-
plexity of the built environment including the role not
only of walkability but air pollution.16

Hazardous Substances
The probability that individuals will be adversely affected
by a hazardous substance depends on three major fac-
tors: (1) its inherent toxicity, that is, ability to cause harm
to humans; (2) whether it enters the body and reaches
susceptible organs; and (3) the amount that is present.
Toxicologists are fond of summarizing the teaching of
Renaissance alchemist Paracelsus with the phrase “the
dose makes the poison.” In other words, it is very impor-
tant to recognize that the mere presence of an agent, even
if it is known to have toxic properties, does not necessar-
ily mean there is a risk to health. For example, we know
that lead can harm several organ systems (as presented
in an example later in this chapter). However, it must
first be ingested or inhaled, or it will not reach the organs
that are sensitive to its effects. When an x-ray technician
uses a lead apron for protection from radiation, lead is
serving a helpful function and will not cause toxicity to
the gastrointestinal, nervous, or hematological system
because it is not in a form that allows it to be absorbed.
However, if lead is heated and the fumes are inhaled, or

132 U N I T I n Basis for Public Health Nursing Knowledge and Skills

n EVIDENCE-BASED PRACTICE
Obesity and the Built Environment

Practice Statement: An increasing number of studies
have documented that obesity, which has reached
epidemic proportions in the United States, is related
to several aspects of the built environment.17-19

Targeted Outcome: Reduction in prevalence of obesity.
Evidence to Support: The same risk factors that
promote weight gain in individuals—increased caloric
intake and decreased physical activity—apply on a
larger scale to populations. Several measures have been
used to describe the risk factors for obesity, but the
evidence continues to point to the influence of the
built environment on diet and activity.17 For example,
physical activity is associated with community attributes
such as road connectivity, presence of sidewalks, avail-
ability of safe play areas, and residential density. Dietary
influences include the number and proximity of fast-
food restaurants, availability of healthy food choices,
and the cost of food. Specific risk factors may differ
between urban and suburban settings, but the relation-
ship between the built environment and obesity per-
sists in both.18 Disparity in obesity prevalence based on
race and socioeconomic status may in part be associ-
ated with the built environment.19

There are many resources available to communities
to address factors related to diet and the built environ-
ment. The recommendations include the following
interventions at the community level:

1. Improve availability of affordable healthier food and
beverage choices in public service venues

2. Improve geographical availability of supermarkets in
underserved areas

3. Improve availability of mechanisms for purchasing
foods from farms

4. Provide incentives for the production, distribution,
and procurement of foods from local farms

5. Discourage consumption of sugar-sweetened
beverages

To address factors related to physical activity and
the built environment, communities should:

1. Increase opportunities for extracurricular physical
activity

2. Improve access to outdoor recreational facilities
3. Enhance infrastructure that supports walking
4. Support locating schools within easy walking

distance of residential areas
5. Improve access to public transportation
6. Enhance traffic safety in areas where people

are/could be physically active20-22

7711_Ch06_128-156 21/08/19 11:03 AM Page 132

if chips of lead paint are ingested, then there is a definite
risk of lead poisoning. Many other substances, such as
solvents, can enter the body through skin contact. These
three pathways or routes of entry—ingestion, inhalation,
and dermal absorption—differ in their importance ac-
cording to the specific substance. Also, do not be fooled
into thinking a substance is not hazardous just because
its effects are not seen immediately. Cancer, for example,
often develops many years after an exposure occurs.
These time lags, known as latency periods, can interfere
with our ability to identify cause-and-effect links and
hamper our ability to anticipate and prevent negative
health effects.23

Exposure Risk Assessment
The process used by policy makers and other regulators
to evaluate the extent to which a population may suffer
health effects from an environmental exposure is called
exposure risk assessment. Exposure risk assessment
involves four steps: (1) hazard identification (described
in more detail later); (2) dose-response assessment (based
on experiments that look for a correlation between an
increase in harmful effects and an increase in quantity
of a substance); (3) exposure assessment (consideration
of the level, timing, and extent of the exposure); and
(4) risk characterization. This last step brings together
the information from the first three steps to guide a
judgment about the risk of health problems to those
who are exposed. That judgment is never without its
uncertainties.

Types of Exposures
Environmental exposures can be broadly categorized as
chemical agents, biological agents, physical hazards, and,
perhaps less commonly recognized, psychosocial factors.
To identify a hazard, we are interested not only in what
agents are present but also whether (and how) they can
affect human health.

Chemical Agents
Examples of chemicals are easily named, and many
are well known for their dangers to human health. For
example, carbon monoxide is produced by combustion
and is typically encountered in automobile exhaust and
home-heating emissions. Specific metals and pesticides
affect many body systems, sometimes accumulating
in the body and, because they release over time, per-
petuating their effects over a long period of duration.
Lead, for example, is stored in the bone, where it can
slowly release over time to cause deleterious health
effects long after the actual exposure has occurred. As

a final example, environmental cigarette smoke contains
thousands of chemicals, some of which are associated
with cancer.

Although we have knowledge of the actions of some
of the chemicals that are in current use, these represent
only a minor proportion of those that might be toxic.
There are more than 80,000 chemicals in use worldwide,
some natural and some made by humans. The Agency
for Toxic Substance and Disease Registry (ATSDR)
provides detailed information on chemicals. Using their
portal, you can search out information on chemicals and
how they may affect health.24

Biological Agents
The category of biological agents clearly includes infec-
tious agents that are well known to nurses, such as
bacteria, viruses, and other organisms such as rickettsia
(Chapter 8). However, there are many others. Some
molds are known to have effects on the respiratory sys-
tem and possibly other more systemic outcomes. Also,
there are many documented hazards associated with
plant and animal contact. Toxic plants and fungi such as
poisonous mushrooms and inedible plants are not always
thought of as environmental hazards. Likewise, allergens
such as dust mites, cockroaches, and pet dander are
serious but often unrecognized sources of biological
hazards.

Physical Agents
Even more varied are the hazards classified as physical
agents, defined as those responsible for the injurious
exchange of energy. Examples include heat and cold, all
forms of radiation, noise, and vibration. Other physical
forms of environmental risk for bodily injury include
events such as falls, vehicle crashes, and crush injuries,
as well as hazards associated with violence, such as knife
or gunshot wounds (see Chapter 12). These are environ-
mental hazards that nurses and the public health system
work to prevent and mitigate.

Psychosocial Factors
Finally, psychosocial factors form a category of environ-
mental risk to health that is less frequently included in
a formal environmental risk assessment. However, it is
important to recognize that communities and individuals
that live in fear or experience stress, panic, and anxiety
associated with real or perceived threats are subject to
psychosocial conditions that affect not only health and
safety but also overall well-being. These must be consid-
ered in a comprehensive assessment of environmental
determinants of health.

C H A P T E R 6 n Environmental Health 133

7711_Ch06_128-156 21/08/19 11:03 AM Page 133

Mixed Exposures
Rarely do environmental hazards exist independently.
Almost all scenarios that pose environmental risks to
health combine more than one threat, and these combi-
nations often act synergistically to raise the level of dan-
ger. Chemicals usually exist as mixtures, as is the case
with cigarette smoke, which contains at least 70 carcino-
gens.25 Interaction and a subsequent increase in hazard
may also occur when different agents are combined. For
example, noise (a physical hazard) in the presence of
some chemicals may result in what is called ototoxicity.
Ototoxicity is damage to the inner ear, that results
due to exposure to pharmaceuticals, chemicals, and/or
ionizing radiation.26 An additional example is the danger
related to combining household products. Mixing clean-
ing agents that contain ammonia with others containing
chlorine leads to the production of chloramines, which
are much more toxic than ammonia or chlorine alone.

The Environmental Health History
Understanding environmental exposures and the detri-
mental health effects they can cause is only one step
along the way to protecting the health of individuals,
families, and communities. That knowledge must then
be applied to strategies to effect change. The amount of
exposure to an environmental risk varies based on the
proximity to the exposure. Those that occur in the work-
place are often more concentrated than those in the
general environment. This reflects two key components
of environmental exposure to hazardous substances:
time and location.28 At the individual level, an environ-
mental exposure assessment begins with time and place.
An assessment should include three components: an
exposure survey, a work history, and an environmental
history.28 The exposure survey reviews any exposures
past and present as well as exposures for members of
the household. The work history asks about presence of
hazardous substances in the workplace, and the envi-
ronmental history includes potential exposure within
the community. 28

These questions are only guidelines and should prompt
further questions when appropriate. Actions required to
address environmental health hazards often raise the
ethical question of when to choose the public good over
individual rights. For example, in the case of lead poison-
ing, should homeowners and landlords be required to
pay for the cost of lead abatement? Another example is
the ban on smoking in public places. The ban reduces the
population’s exposure to the harmful effects of secondary
smoke yet limits the rights of individual smokers.

134 U N I T I n Basis for Public Health Nursing Knowledge and Skills

n CULTURAL CONTEXT OF OUR
ENVIRONMENT

Our culture influences how we live within our environ-
ment as well as how we view the importance of that
environment. Consider the practice of Fung Shui, based
on the concepts of Yin and Yang that influences how
objects are placed within a home to help positively
affect the energy flow. In a classic article Goodenough
addressed the problem of possible conflict between
how a professional might perceive a specific environ-
ment and how those living in that environment may
perceive it. He stated that “…the environment in which
people live is a part of their culture.”29 Thus those liv-
ing in a community may have specific perceptions about
their environment that is different from professionals
sent in to evaluate the environment from a health per-
spective. Therefore, as stressed by Goodenough, it is
important to account for the cultural perception of the
environment through the eyes of those living in the
community when conducting an environmental health
assessment and to be aware that your cultural percep-
tion may differ from that of the community. This opens
the opportunity for communication and partnership
with a community when working to improve the health
of an environment.

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Peeling Paint
Public Health Science Topics Covered:

• Screening
• Case finding
• Advocacy
• Policy

Jane, a nurse working at a county health department
based in a large, urban, midwestern city, was asked to
participate in the county lead-screening program to
identify families exposed to lead in their environment.
The usual method for determining if a child has been
exposed to lead is to screen for the amount of lead in
blood, which is referred to as the Blood Lead Level
(BLL). Measurement of BLLs is done in micrograms
of lead per deciliter of blood (μg/dL). Based on recent
surveillance data, i.e., the percent of children under
the age of 5, it appeared that not all of the children
in the high-risk neighborhoods had been tested. Due
to the higher percent of children with confirmed BLL
of ≥10 μg/dL in the county, the health department felt
it was important to once again initiate an outreach

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C H A P T E R 6 n Environmental Health 135

program to get children tested. The goal of this sec-
ondary prevention screening program was twofold:
(1) to identify current cases and initiate medical man-
agement if needed and (2) to identify what measures
should be taken to prevent further harm to children in
these families and other community members.

Jane began her review of the problem with Healthy
People (HP) 2020 objective EH-8-1: “To reduce BLL
in children aged 1–5 year”. She found that the method
for measuring BLL in children was revised in 2014.
The baseline measure was 5.8 μg/dL with a target of
5.2 μg/dL. The objective was that the concentration level
of lead in blood samples would be below the baseline
measure for 97.5% of the population aged 1-5 years.
This would reflect a 10% improvement.7

She then reviewed the HP 2020 midcourse review
to determine if the target had been met at the national
level. The report stated that: “The concentration level
of lead in blood samples at which 97.5% of children
aged 1–5 years were below the measured level (EH-8.1)
decreased from 5.8 µg/dL in 2005–2008 to 4.3 µg/dL in
2009–2012, exceeding the 2020 target (Table 12–2).” 8

Now that she had information at the national level,
she began examining the surveillance data at the county
level available on the CDC Web site.30 She found that,
of the 7,031 children tested in 2015, 6% were above
the desired level and 1.3% had confirmed BLL 10 μg/dL
or higher (see Table 6-1). In comparison to national
levels, the county was not meeting the HP 2020 target.
She then accessed the current county data and found
that the percent of children with a BLL above the
desired level had increased to 7.5%, a concerning
trend. In addition, 2% of children had confirmed BLLs
of 10 μg/dL or higher. She was also surprised to see
that, based on the most recent population estimates,
the total number of children aged 5 or younger in the
county was 56,967. Thus, only about 12% of all children
had been tested. If the target population was those
living below the poverty level, the county had still
come up short in the testing program because 16% of
households in the county were living below the poverty
level. In addition, she was aware that, with new gentrifi-
cation of older neighborhoods, the risk for exposure
might not be limited based on income. Based on these
data she began to develop a lead poisoning outreach
screening program for the county.

In the case of lead, a well-known hazard to children,
screening in this program consisted of measuring the
concentration of lead in the blood to estimate the
amount of lead that had been absorbed into the body,
and at the same time providing all the parents with

health education information about lead. Jane used the
current CDC recommendations on childhood lead
poisoning prevention guidelines in relation to BLL that
would require initiation of prevention measures. The
prior BLL that triggered interventions was 10 to
14.9 μg/dL but was changed in 2012 to a BLL value of
5 μg/dL based on evidence that even lower levels
of exposure increase the risk for adverse health
outcomes in children (Fig. 6-3).31

Jane then reviewed the 10 approaches to interven-
tion related to lead poisoning provided by National
Center for Healthy Housing (Box 6-2).32 Many of the
recommendations would need action at the county
level, but policy items seven and eight matched the use
of public health nurses (PHN) in an outreach home
visit program. These two items were: (7) Improve
blood lead testing among children at high risk of
exposure and find and remediate the sources of their
exposure; and (8) Ensure access to developmental and
neuropsychological assessments and appropriate high-
quality programs for children with elevated blood lead
levels. For item seven, for children with a BLL value
of 5 μg/dL or higher, a home visit would allow for an
assessment of the home environment and teaching
parents to remediate any sources of exposure as
well as connect parents with resources to assist with
remediation especially for renters. For item eight, a
home visit with children with a BLL value of 10 μg/dL
or higher would allow for further assessment of the
child and assist parents in obtaining high quality programs
for their children. Jane’s work to not only research the
problem, but also to seek funding for a program for
addressing the issue, is an excellent example of nurse
advocacy related to environmental health issues as
listed in the previously mentioned ANA report.11

In the home visiting program Jane designed, parents of
children screened with a BLL value at or above 5 μg/dL
received a home visit from a PHN and were provided
with an environmental assessment of their home,
education regarding dietary and environmental actions
to reduce the lead poisoning, and help with lead abate-
ment in their homes if needed. The home visit also
included providing the parents with information on
their legal rights as tenants/homeowners. They were
also provided with follow-up BLL monitoring for their
child. If a child in the home had a BLL value at or above
10 μg/dL, the PHN would provide the parent with in-
formation on how to access the resources they would
need for further developmental assessment. The PHN
would also provide information about on-going inter-
vention as needed based on the severity of the BLL.

7711_Ch06_128-156 21/08/19 11:03 AM Page 135

136 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Number of children tested
Percent of children with BLLs �5 µg/dL
Percent of children with confirmed BLLs �10 µg/dL

N
um

be
r

of
c

hi
ld

re
n

te
st

B
LLs as %

children tested
U.S. Totals Blood Lead Surveillance, 1997–2014

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

4,500,000

4,000,000

3,500,000

3,000,000

2,500,000

2,000,000

1,500,000

1,000,000

500,000

8.00%

7.00%

6.00%

5.00%

4.00%

3.00%

2.00%

1.00%

0.00%

Figure 6-3 U.S. Totals Blood Lead Surveillance, 1997-2014. Comparison of the number tested with the percentage
confirmed. (From the Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/nceh/lead/data/Website_
StateConfirmedByYear_1997_2014_01112016 .)

While the health department mounted a screening
campaign for lead poisoning, Jane and other PHNs at
the health department began conducting the home
environmental assessments for all children who had a
BLL ≥5 μg/dL. They were all experienced in conduct-
ing home visits. They understood that, to achieve the
goals of the program, that is, to reduce lead exposure
in the home and assist parents in accessing resources
for their children, it was important to conduct the
home visits using basic principles. First was to under-
stand that they were guests in the family’s home. Next,
it was important to identify the parent’s concerns as a
first step toward forming a partnership with the parents.
To meet the goals of the program they would explain
to the parents changes they could make to reduce
exposure and obtain assistance. The best approach is

to use motivational interviewing skills (Chapter 11).
The four principles that they routinely employed in
their home visits were: (1) expressing empathy for a
client or parent’s point of view; (2) supporting self-
efficacy by highlighting a client’s or parent’s success at
solving problems in the past; (3) remembering to roll
with any resistance they may encounter by helping the
client or parent define the problem and seek their own
solutions; and (4) developing discrepancy, which they
knew could be accomplished through helping a parent
or client examine the difference between current
behavior and future goals.33

Based on the findings of their assessments, the PHNs
assisted parents who were found to have lead-based
paint in their homes or apartments to engage the
county level coordinated abatement efforts. The PHNs

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C H A P T E R 6 n Environmental Health 137

1. Reduce lead in drinking water in homes built before
1986 and other places children frequent.

2. Remove lead paint hazards from low-income housing
built before 1960 and other places children spend
time.

3. Increase enforcement of the federal Renovation,
Repair, and Painting (RRP) rule.

4. Reduce lead in food and consumer products.
5. Reduce air lead emissions.
6. Clean up contaminated soil.
7. Improve blood lead testing among children at high

risk of exposure, and find and remediate the sources
of their exposure.

8. Ensure access to developmental and neuropsycho-
logical assessments and appropriate high-quality
programs for children with elevated blood lead levels.

9. Improve public access to local data.
10. Fill gaps in research to better target state and local

prevention and response efforts.

BOX 6–2 n Policies to Prevent and Respond
to Childhood Lead Poisoning

also educated parents and others in the home about
how to prevent further lead exposure. Together the
PHNs developed a community level education program
about lead poisoning and how the health department
and community could work together to eliminate lead
exposure. With extensive interventions the health
department hoped to meet the Healthy People targets
related to lead poisoning in children aged 5 and under.

Prior to making her first home visit, Jane reviewed
the pathophysiology of lead poisoning in children. She
found that young children are at greater risk because
they are more likely to ingest materials containing lead
and absorb more of the lead when it is ingested. A
child or fetus is especially vulnerable to the effects of
lead and many other toxic substances because their
developing organ systems are at high risk of damage.
Toddlers are more likely to put items contaminated
with lead, such as paint chips, in their mouths, making
screening most useful at 1 and 2 years of age. Ingestion
of lead, the most common route, can have an irreversible
negative effect on the child’s developing central nervous
and hematopoietic systems. Thus, children exposed
to lead can have lifelong health issues. Even with low
levels (<5 μg/dL) a child’s cognitive and behavioral development can be slowed, resulting in learning disabilities.33 Children with high levels of lead are at increased risk for serious effects such as encephalopathy marked by seizures and even coma. These effects can lead to long-term, sometimes irreversible damage. In contrast, the more mature central nervous system of adults is better protected from the effects of lead so that damage to peripheral nerves, rather than the central nervous system, is more likely. Inhalation rather than ingestion is the more common route for lead poisoning in older children and adults.34 Jane was assigned to conduct a home visit with the family of a 2-year-old child who had a BLL of 13 μg/dL. Bobby and his family lived in an older building in one of the poorest sections of the city. As Bobby’s mother, Sharon, greeted her at the door, Jane noticed that overall the apartment needed major maintenance with older appliances and walls that had not been painted in a while. Due to the initial purpose of the visit, she began her visits with Sharon by letting her know that she was doing the follow-up on Bobby’s positive lead screening that Sharon had requested after getting the results of Bobby’s BLL test. Remembering the value of using a motivational interviewing approach, Jane began the conversation by asking Sharon what her concerns were and what goals she had. Sharon stated that she was very upset not just about Bobby but her older child. She said that she and her husband were struggling to make ends meet and they took this apartment because they could afford it, but now she found that there were many problems and their landlord was not responsive. Jane repeated back to Sharon what she had heard, that Sharon was worried about her other child, and she was concerned about the condition of the apartment. Jane encouraged Sharon to tell her a little more about herself and her family so that she could help her address her two concerns, the health of her children and how to correct some of the issues with the apartment. Sharon told Jane that she had rented the apartment for a little more than a year and lived there with her husband and their two children, 2-year-old Bobby and another child in first grade. Sharon held Bobby in her lap for the first half of the interview, but Bobby got restless and slid off of her lap to play on the carpet. Jane built on Sharon’s concerns about her children and suggested that Sharon give her a tour of the house to see where the lead might originate. Jane used her knowledge of environmental risks associated with lead poisoning in children to guide her assessment. In the United States, leaded gasoline and paint were both banned around the same time in the early 1970s. Thanks to these policy interventions, average BLLs in children have been steadily dropping.34 7711_Ch06_128-156 21/08/19 11:03 AM Page 137 138 U N I T I n Basis for Public Health Nursing Knowledge and Skills However, the threat remains serious especially in communities with a large number of older homes and lead water pipes such as the serious problem in Flint, Michigan.35, 36 Jane wondered how Bobby became poisoned with lead despite the new regulations. Lead poisoning is a good example of environmental risks in the built environment. Although lead paint has been banned, buildings built before 1978 often contain lead paint. Many cities have initiated lead abatement programs to remove this paint. This population-based policy approach to the problem is one of the best examples of how legislation can improve public and environmental health.37 However, not all cities have successfully removed all lead paint from city residential buildings, and it is especially problematic in the poorer neighborhoods where older buildings are not well maintained. Jane learned that Bobby played with his toys on the floor of a room in which the paint was peeling from the windowsills. Suspecting that lead-based paint was largely responsible for the child’s elevated levels, she noted the condition of all of the house’s painted surfaces and found that many of them were chipping, especially on the baseboards and windowsills, and marred with tooth marks (Fig. 6-4). Paint in older homes is known to be high in lead content, and its availability to a child is a strong indication that the paint is a major source of exposure. Even children who do not directly ingest the peeling paint are at major risk of exposure from lead dust that sloughs from the painted surfaces and contaminates floors and toys that, through the common hand-mouth behavior of children, are ingested or inhaled. Based on the results of her home environment assessment, Jane explained to Sharon how Bobby probably ingested the lead, primarily through the paint chips. Sharon wondered how the lead paint could be removed. Jane explained that there were steps that could be taken with the landlord to remove the lead- based paint; because precautions are needed when doing any removal or work on painted surfaces in homes built before 1978, it would need to be carefully done. However, there were steps Sharon could take now to reduce paint chips and airborne particulates including keeping the apartment clear of paint chips and dust, and keeping it well ventilated. Jane asked Sharon if she would like to set up an appointment with technicians from the health depart- ment who would come to the home to verify and measure the lead content of the paint and help Sharon identify sources for assistance with the removal of lead from her home. Sharon readily agreed and expressed relief that someone would help her remove the threat to her children. Jane commended Sharon on all the steps she had previously taken to attempt to address the peeling paint in the apartment. Jane further explained that, depending on the state of the home, it might be necessary to physically abate the exposure by entirely removing the paint, which means moving the family either temporarily or permanently to a more suitable, lead-free living environment. Jane explained that there were resources through the county public health department and the housing authority to help the family if this step was necessary. Remembering Sharon’s other goal, Jane asked Sharon about Bobby’s health. Sharon reported that he complained occasionally of stomach pain, but she was surprised by the elevated BLL because she had seen no real symptoms of lead poisoning. Jane explained that frequently there are no signs of poisoning and that the results of the poisoning take time to manifest. That is Figure 6-4 Removal of baseboards with lead paint. (From CDC/Aaron L. Sussell, 1993.) 7711_Ch06_128-156 21/08/19 11:03 AM Page 138 C H A P T E R 6 n Environmental Health 139 why screening is so important. Jane suggested that Sharon take Bobby for a full checkup at the county’s child health clinic or with the child’s local provider, and that Sharon and the older child should also be screened for lead poisoning. Pregnant women with high lead levels can transmit lead to their unborn children because it crosses the placental barrier, and lead can also be transmitted in breast milk, affecting both mother and unborn child. Jane also explained that stomach pain can be a sign of lead poisoning and urged Sharon to tell the doctor about Bobby’s complaints. To facilitate the process of setting up an appoint- ment, Jane used what is called a warm handoff. This is used in health care as a means for transferring care between two members of the health-care team, in this case the visiting PHN and the primary care provider who would be able to further assess Bobby for lead poisoning and begin treatment if needed. As in this case the warm handoff is done in front of the patient and family. Together Jane and Sharon set up these appoint- ments. In addition, Jane helped Sharon identify the best means for transportation to the appointment. Jane and Sharon then put together a plan that set mutual goals and a timeline for managing the lead poisoning. At this point, Jane noticed that Sharon still seemed worried. When prompted, Sharon said she had heard about lead poisoning but did not understand what it meant to her and her children. Jane went over the relationship between lead in the home environment and children’s health in more detail and explained to Sharon that Bobby’s BLL was of concern, and that the trip to the clinic would provide her with more informa- tion on Bobby’s health status. Jane commended Sharon for having Bobby screened and explained that early intervention can help mitigate the effects of lead poisoning. Sharon said that she had talked with the landlord about the apartment because of what she had seen on the news about lead poisoning and was assured that there were no problems. She also explained that her sister lived in the same building. Jane knew that finding an elevated BLL in one child had uncovered an environ- mental hazard that could affect all of the tenants in the building, especially the children. The affordability of the apartments and proximity to the school resulted in the building being home to many young families. Jane was aware that the environmental hazard also extended to mothers in the building who were pregnant or breast- feeding their babies. When questioned, Sharon stated that she had not received any information on the potential of lead paint in the apartments as required by law. Jane was concerned about Sharon’s story that the landlord had assured her that there were no environ- mental problems in the apartment. It is against federal law for landlords to withhold information on environ- mental hazards in their buildings.38 Specifically, to meet the federal requirements, landlords renting apartments in buildings built prior to 1978 must inform tenants about potential lead paint hazards prior to signing a lease. Jane was also concerned about the other children living in the building, because this was the only child in the building who had been screened. This resulted in two different levels of action. First, from an advocacy perspective, Jane reported the landlord for failure to disclose the fact the apartment contained lead paint and began to explore alternative housing for the young families living in the building. Second, she implemented her role of case finding. She asked Sharon whether she would introduce Jane to her sister and her neighbor, and help get all the children in the building screened. Thanks to Sharon, a few more of the children in the building were screened, and two of the children had elevated BLLs. Jane recommended further outreach to get all the children in the building screened and helped to put together an on-site screening day at the apartment building. Meanwhile, the health department and the housing authority for the city worked to en- sure that the landlord performed lead abatement in the apartment complex and insured that he followed the federal guidelines informing renters before signing a lease of potential lead exposure. Before ending her visit with Sharon, Jane explained steps that Sharon could take now to protect her family from further lead poisoning. She went over cleaning methods that included mopping hardwood floors with a weak bleach dilution to remove the dust, frequently wiping windowsills with a damp cloth, vacuuming with high-efficiency particulate air (HEPA) filters, and ensur- ing that the children are kept away from areas with active chipping and peeling paint.39 Jane also reviewed a secondary prevention strategy with Sharon that she could use to reduce the amount of lead a child absorbs and increase the amount excreted by providing a calcium-rich, high-iron, vitamin C–containing diet. Jane was aware that this might be more difficult for some families than for others. Impoverished areas, which represent low- income residents and poor social conditions, can be 7711_Ch06_128-156 21/08/19 11:03 AM Page 139 140 U N I T I n Basis for Public Health Nursing Knowledge and Skills thought of as “food deserts” where access to afford- able healthy food is greatly limited. Jane confirmed that Sharon was enrolled in the local Women, Infants, and Children (WIC) supplemental nutrition program and had access to the foods needed to implement this strategy. Due to her involvement in this lead poisoning outreach program, Jane became very interested in primary prevention for lead poisoning. It was clear that, although screening was important, it would be much better to prevent the problem in the first place. She became interested in the wider issue of the health of the built environment. Jane found that the main primary prevention approach is lead abate- ment, which is removal of lead-based paint in the home or workplace. As of April 22, 2010, a federal law went into effect that required that all contractors doing renovations, repair, or painting that disturbed more than 6 square feet in homes, schools, and child- care centers be certified in lead abatement.38 Jane found multiple state and municipal regulations that focused on reducing exposure to lead paint, lead paint dust, and soil contaminated from exterior lead- based paint. Despite all the regulations, Jane discovered that one of the big stumbling blocks to starting a successful lead abatement program in her county was cost. Because of the seriousness of exposure to lead, the federal government and states have strict lead abatement regulations that result in labor-intensive measures and require the use of specialized equipment. The high cost of abatement raises the question of whether the cost outweighs the benefit, and illustrates a common public health ethical issue of determining whether the benefits of a costly abatement program outweigh the rights of the individual homeowner or landlord to choose not to remove lead paint from a building. n CELLULAR TO GLOBAL Bobby’s lead exposure illustrates the fact the lead poisoning and health occur from the cellular level up to the global level. At the individual level, it enters the body through either the oral or respiratory route and ultimately causes permanent harm. However, lead exposure occurs because of the presence of lead in the ambient environment—primarily in paint and dust. In Bobby’s case the lead was in a form that resulted in ingestion as the most probable route of exposure, especially given the hand-mouth behavior of a small child. Yet the presence of lead and efforts to eliminate it require interventions that start at the individual level and expand to the global level. Lead poisoning is not confined to the U.S. Globally, in 2015, there were 494,550 lead-exposure associated deaths. In addition, there was a loss of 9.3 million DALYs due to the long- term effects lead has on health. The burden is highest in low- and middle-income countries.40 In Bobby’s case the source of the exposure was the built environment. Globally there are a number of other possible sources of exposure including traditional cosmetics, medicines, and lead-coated dishes and food containers. The WHO is working to eliminate lead poisoning via the global elimination of lead paint to meet Sustainable Develop- ment Goal target 3.9: “By 2030 substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contam- ination”; and target 12.4: “By 2030, achieve the envi- ronmentally sound management of chemicals and all wastes throughout their life cycle, in accordance with agreed international frameworks, and significantly reduce their release to air, water, and soil to mini- mize their adverse impacts on human health and the environment.”40 Environmental Justice and the Environment Economically disadvantaged populations and other vulnerable populations (see Chapter 7)—whether as a result of low income, social class, racial or cultural dif- ferences, age, health status, or other social indices of susceptibility—are frequently at greatest risk of exposure to environmental hazards. Vulnerable populations face challenges such as substandard housing, lack of access to health care, diminished resources such as nutritious food and safe places to play, poor working conditions, and absence of clean air and water. Those who are employed tend to work in riskier jobs. Disadvantaged communities tend to be located near industrial areas, highways, and rail transportation routes where certain types of cargo and exhaust pose dangers and where hazardous waste disposal sites exist.41,42 Environmental justice refers to fair distribution of environmental burdens.41 According to the EPA definition, it also refers to fair application of environmental laws, policies, and regulations regardless of race, color, national origin, or income.42 Social disadvantage can result in increased exposure to environmental risks as well as an increased susceptibility 7711_Ch06_128-156 21/08/19 11:03 AM Page 140 to the risks.43 Recognizing the link between environmen- tal health and social determinants of health, the WHO has the Department of Public Health, Environmental and Social Determinants of Health. The goal is to reduce both environmental and social risk factors (Box 6-3). For example, they have worked to promote safe household water storage and to manage toxic substances in both the home and the workplace. They work closely with the United Nations’ sectors on energy, transport, and agri- culture. They state that reduction in environmental and social risk factors would prevent nearly a quarter of the global burden of disease.43 C H A P T E R 6 n Environmental Health 141 This department advocates at the global and national level for the improvement of environmental health through its influence on policy. It accomplishes this by: • Assessing and managing risks (such as from outdoor and indoor air pollution, chemicals, unsafe water, lack of sanitation, ionizing and nonionizing radiation) and formulating evidence-based norms and guidance on major environmental and social hazards to health. • Creating guidance, tools, and initiatives to facilitate the development and implementation of policies that promote human health in priority sectors. BOX 6–3 n World Health Organization: The Department of Public Health, Environmental and Social Determinants of Health w SOLVING THE MYSTERY The Case of the Hazardous House Public Health Science Topics Covered: • Assessment • Health planning • Program evaluation The work done by Jane and her team on the lead screening outreach program resulted in the nurses identifying other environmental risk factors in the home, especially those associated with an increased risk of asthma. Jane and the other PHNs who worked on the lead poisoning outreach program initiated a county health department safe home program focused on asthma in collaboration with the school nurses (Chapter 18), the local Parent-Teacher Association (PTA), and the county pediatric hospital. The program was initiated because of increased prevalence of childhood asthma, lost school days for asthmatic children, and increased emergency department (ED) visits for acute asthma attacks. They were able to provide evidence that a home assessment program is a viable intervention that can help address the problem of uncontrolled asthma in children.44 First, the PTA and the school nurses conducted a campaign to promote the benefits of having a PHN from the public health department visit the homes of children with asthma to provide an environmental assessment, additional health education, and links to resources. The program contained three steps: (1) referral, (2) home inspection, and (3) development of a home safety plan. All students with asthma were referred to the health department PHN asthma team, who then contacted the parents of the children. The PHNs offered to provide an environmental assessment for possible pollutants in the home. When invited, the PHN con- ducted a home visit that focused on residential health. The team developed a protocol for conducting these home visits based on the Healthy Homes Manual developed by the CDC in 2006.45 Each visit began by explaining to family members that the PHN was using an assessment tool that had been adapted by the health department that was specifically designed to identify health hazards in the home in their area. Following the motivational interviewing principle used in the lead screening outreach program previously discussed, the PHN invited them to participate in the review of their home as full partners and began by asking them to share their goals and concerns. The team felt it was important to allow time at the beginning of the visit for parents to list the concerns they had as well as commend them for all they were currently doing to address their child’s asthma. This helped establish a partnership with the parents and provided the PHN with an understanding of the parents’ goals as well as their challenges. From there they could mutually build an intervention specifically targeted to maximize the use of available resources to help improve the health of their home environment and subsequently their child. The PHNs worked to develop a relationship with parents that was nonjudg- mental and that would help empower the parents with the knowledge and access to resources they needed to help reduce possible environmental risk factors for childhood asthma and to improve access to adequate care. On one visit Jane met a family with a 7-year-old boy, Joshua, who had repeated asthma attacks, multiple absences from school, and an increasing number of 7711_Ch06_128-156 21/08/19 11:03 AM Page 141 142 U N I T I n Basis for Public Health Nursing Knowledge and Skills ED visits. The family lived in a three-bedroom apartment in a 300-unit building in an inner-city neighborhood in New York State. There were other children in the home not in school: a 4-year-old, a 2-year-old, and a newborn. The mother, Betsy, reported that the 4-year- old was also being treated for asthma and that the other two children had frequent colds. When Jane asked Betsy about her concerns, Betsy shared that she was very concerned about all the missed school days. She was also exhausted by all the trips to the ED. Although she had been able to sign up for the Chil- dren’s Health Insurance Program (CHIP) that helped reduce the cost, getting to doctor’s appointments was difficult with three other small children. She didn’t have a car and her husband worked long shifts. She often had to cancel appointments because she didn’t have anyone to watch the other two children. Often when Joshua had an attack it meant she had to rush him to the ED with three other children in tow. Recognizing that Betsy’s focus was on access to care, Jane spent a little more time with Betsy to talk about their environment and the role it played in exac- erbating Joshua’s asthma. She explained that altering the environment might help reduce the number of attacks severe enough to require a visit to the ED. She also assured Betsy that she would help her find resources such as transportation and childcare to help her keep clinic appointments. Betsy seemed relieved that Jane understood her main concerns and invited Jane to begin her inspection of the home to help identify environmental risk factors that could be addressed. Beginning with the kitchen, under the sink they found cockroaches and evidence of mice. Jane noted that pesticides and cleaning products were stored in that location and a slow dripping faucet had resulted in an accumulation of a small amount of water in the space under the sink along with some mold. Betsy also kept the kitchen wastebasket under the sink where she disposed of food scraps. Betsy stated that she was constantly trying to deal with the cockroaches and the mice but had not been successful. She had not realized that the black smudges were actually mold. When Jane asked Betsy about whether anyone smoked in the home, she learned that both parents smoked. Jane also noted that there was worn wall-to- wall carpeting throughout the apartment. When they went into Joshua’s room he shared with his 4-year-old brother, Jane noted the large number of stuffed animals. With Betsy, Jane examined Joshua’s bed. Betsy explained that there was no money for mattress protectors or pillow covers. She also stated that, with four children, it was difficult to get to the laundromat to wash the sheets, so she only did them once every 3 to 4 weeks. Jane also asked Betsy about the medications she was using to treat Joshua’s asthma. Betsy confirmed that Joshua needed to administer his inhaler frequently and stated that she was careful about giving him his medications on time and regularly. After completing the overview of the home environ- ment, Jane discussed her findings with Betsy. Jane com- plimented Betsy on her adherence to the medication plan for Joshua. Jane explained that medications are less effective if there continue to be triggers in the environ- ment such as cigarette smoke, dust mites, and allergens related to vermin.46 She provided the mother with fur- ther information on risk factors for asthma, pulling up the CDC Web site on her tablet so Betsy could see a review of environmental risk factors. The main risk factors mentioned by the CDC were tobacco smoke, dust mites, outdoor air pollution, cockroaches, pets, and mold. The only home environmental risk factor that was not present in this home was pets. Jane and Betsy discussed actions the family could take to help reduce the risk. Jane began with the problem of secondhand smoke. She explained that this might also explain the frequent colds experienced by the infant.47 Jane asked Betsy whether either she or her husband would be interested in getting help to quit smoking. Betsy stated that they would consider this if it would improve the health of their children, especially Joshua. Jane gave Betsy information on resources such as local clinics that offer services for smoking cessation. She also encouraged Betsy and her husband to smoke only outside the apartment in a space that was not near where the children played or by an open window. Jane then discussed with Betsy the issue of cock- roaches and mice as serious health risks to families.46 Aside from producing allergens that can exacerbate asthma, they both carry a host of bacteria and viruses that are dangerous to people, including staphylococcus, streptococcus, Escherichia coli, and salmonella. Another hazard associated with pest infestation has to do with the types of chemicals and poisons used to fight them, such as aerosol spray insecticides and poisoned pellets, all of which put children at risk for poisoning. Serious health outcomes associated with pesticides include skin disorders, damage to the nervous system, poisoning, endocrine disruption, respiratory illness, cancer, and death. Jane described methods other than pesticides that Betsy could use for controlling pests within the apartment, beginning with removing food and standing 7711_Ch06_128-156 21/08/19 11:03 AM Page 142 C H A P T E R 6 n Environmental Health 143 water. Jane described how to use a separate container for food scraps with a tight lid that would provide a barrier to roaches and mice. She also explained how to store food in the pantry in plastic containers with tight lids rather than bags or cardboard containers. Jane again used her tablet to refer Betsy to the New York State Health Department’s Web site on the land- lord and tenant’s guide to pest control. Together they reviewed steps Betsy could take and what steps her landlord could take to address the rodent and cock- roach issue (Box 6-4). Jane also explained to Betsy that she could contact her local cooperative extension service for assistance with pest control. The practice described on the New York State Health Department’s Web site is known as integrated pest management, a program that includes caulking and sealing cracks and holes larger than a 16th of an inch, eating in one place in the home to consolidate the area that must be cleaned, getting rid of clutter where pests hide, storing food in containers with locking lids, preventing the accumulation of grease, and disposing of the trash nightly.48,49 Jane also explained about better chemical methods for fighting pests, such as the use of bait stations and gels that do not contaminate surfaces or the air, rather than poisons. She gave Betsy some mice snap traps to be used in place of the poisoned pellets, explaining that mice carry the poison from seemingly safe locations and drop it in places easily accessible to her young children. Jane also handed Betsy a brochure from the local poison control center with a magnet for the refrigerator and a child safety lock for the cabinets under the sink. The lock was for immediate short-term use until chemicals were moved to a safer site. Poisons, solvents, cleaners, and other types of household products should always remain in their original containers, so information contained on the labels will be available to inform emergency care or calls to a poison control center. Betsy stated that her sink has been leaking for some time, but her landlord was unresponsive to her request for its repair. The same was true of her furnace. Jane pulled up the New York State Tenants’ Rights informa- tion on the U.S. Department of Housing and Urban Development Web site for Betsy to review.50 Jane explained to Betsy that she would write up a housing code violation report that should result in the landlord making these repairs. With Betsy’s permission, Jane’s assessment of the home expanded to included risk factors beyond those associated with childhood asthma. In the utility room, Jane inspected the furnace and water heater and noted that the water heater was set to 140°F. She told Betsy that she should always make sure the heater is set below 120°F to prevent scalding and demonstrated how to lower the temperature. Jane also observed that the vent connecting the water heater to the fur- nace was not sealed, thereby allowing the release of combustion products, such as carbon monoxide. Jane explained to Betsy that, just like the gas stove upstairs, water heaters, dryer vents, and furnaces should be regularly maintained, and the level of carbon monoxide should be monitored. She provided Betsy with a carbon Proper Pest Management Practices for Landlords and Tenants: Integrated Pest Management is geared toward long-term prevention or elimination of pests that does not solely rely on pesticides. Integrated Pest Management follows the principles of preventing entry, inspecting, monitoring, and treating pests on an as-needed basis. These principles help manage pests by using the most economical means, and with the least possible hazard to people, property, and the environment. Pests thrive in environments where food, water, and shelter are available. If an undesirable environment is created, pests can be prevented, reduced, or eliminated. Using Integrated Pest Management: • Reduce pest problems by keeping the house, yard, and garden free from clutter and garbage. Food should not be left uncovered on counters. Food should be stored in tightly sealed containers or in the refrigerator. • Keep pests outdoors by blocking points of entry. Quality sealant or knitted copper mesh can be used along baseboards, pipes, drains, and other access points to seal cracks and repair holes. • If a pest problem arises, identify the pest and the extent of the infestation. Your local branch of Cooper- ative Extension office can offer assistance. • Use methods with the least hazard to people and pets, such as setting traps/bait, or using a flyswatter or fly ribbon paper. Bait and traps should be kept out of the reach of children and pets. • Remove trash on a regular basis and always use trashcans with tight-fitting lids. If pests can get in garbage, they will return repeatedly to get food. • If a certified pesticide applicator is needed, be sure that (s)he understands and follow Integrated Pest Manage- ment principles and practices. BOX 6–4 n New York State Landlord and Tenant Integrated Pest Control Source: (48) 7711_Ch06_128-156 21/08/19 11:03 AM Page 143 144 U N I T I n Basis for Public Health Nursing Knowledge and Skills monoxide detector with an alarm that emits a warning sound when carbon monoxide levels are too high. Assuring good ventilation, such as turning on the fan when cooking or making sure that a window is open, are other actions that families can take to make sure that the air their families breathe is as healthy as possible. While still on the topic of alarms, Jane asked whether the family had working smoke alarms, windows that could be opened on each floor, and a fire escape plan. Betsy showed Jane the smoke detector in the living room and then led Jane down the hall to see the other one, which she thought needed new batteries. Jane noticed that there was an extension cord running along the hall floor. While Jane helped Betsy change the batteries in the smoke detector she mentioned to Betsy the hazards associated with extension cords, including fire, tripping, and strangulation. Betsy explained that some of the outlets in the back rooms were not working. Jane went over how Betsy could address this with the landlord. The final two areas that Jane and Betsy discussed were the problems related to dust mites and mold. Jane suggested that Betsy add repair of the kitchen faucet to her request to the landlord. Meanwhile, Betsy could clean under the sink using a solution of 1/10 bleach to 9/10 water, thus eliminating existing mold. Betsy also explained that there were multiple sources of dust mites in the apartment including the carpets, the stuffed animals, and the bedding. Removal of the carpets should be added to the landlord requests. Removal of stuffed animals might be more difficult if the children were attached to them, but Betsy felt the boys were growing out of the stuffed animal phase and that she would be able to remove most of them and regularly wash the others. Betsy explained that she had limited money to spend on pillow case covers and mattress covers. Together they searched the depart- ment store Web sites on Jane’s tablet and located stores with reasonably priced mattress protectors and pillow covers that Betsy felt she could afford. When the visit was complete, Jane and Betsy had developed an action plan that included actions Betsy could take on her own, steps that she would need to take with help from the landlord, and the identification of available resources in the community. Betsy was encouraged by the resources that were available and the assistance that Jane had provided. Jane agreed to follow up with Betsy in 2 weeks to determine whether she needed further assistance. Over the course of 6 months, word spread among the parents of the school about how helpful the PHN visits were. Prior to starting the home visits, the PHN asthma team and the school nurse, Edward, had devel- oped an evaluation plan for the program (Chapter 5). They had collected baseline data on the key outcome indicators for children with asthma in the school includ- ing number of days absent, use of inhalers, number of acute asthma attacks during school, and number of pediatric ED visits related to asthma for children living in the school district. They also kept track of the num- ber of visits Jane made and the time each visit took. Based on these data they found significant improvement for the key outcome indicators and a significant drop in ED use for severe asthma episodes. These data helped them demonstrate that the cost of the PHN home visits were offset by the savings in health-care costs, the reduction in costs related to truancy, and overall improved health outcomes for the children. Environmental Health and Vulnerable Populations Vulnerability to health risks varies across populations based on age, gender, geographical location, and socioe- conomic status. This also holds true for environmental health risks especially for children and older adults. Children Physiological and behavioral characteristics increase vulnerability at each step of early development. Children playing on the ground and floor may spend their time in the most contaminated areas. For example, outdoor soil is often contaminated with heavy metals and pesticides, and hand-to-mouth behavior promotes ingestion of both seen and unseen agents. Children near parents who are washing work clothes may be playing amid toxins that have been carried home as particles from the workplace. Even toys may pose a risk for exposure to toxins including lead and cadmium.50,51 Children have ingested substances from unlabeled food containers that have been repur- posed to hold chemicals or were stored in an easily acces- sible place such as under the sink. Compared with adults, children have faster rates of absorption of most toxic substances and, once in the body, the toxic action can be deadlier because children have a higher metabolic rate, a faster rate of cell growth, and less developed immune and neurological systems. There are equally grave concerns for fetuses, which may be affected when a pregnant woman is exposed to toxins. Fetal body systems are selectively more vulnerable according to their stage of development and the timing of exposure. Although women are increasingly aware of the risks associated with 7711_Ch06_128-156 21/08/19 11:03 AM Page 144 alcohol and environmental tobacco smoke during preg- nancy, they are often less informed about the dangers of other environmental exposures. In addition, a pregnancy may not be recognized in time to avoid or minimize expo- sures. This is especially a concern during the first trimester, when the earliest differentiation of organ systems begins. For example, carbon monoxide, which is easily transported across the placental barrier, is potentially devastating to the developing fetus because of its sensitivity to hypoxia. Other substances that cross the placenta may accumulate in fetal tissue, leaving the newborn to begin life with a body burden of a toxin. In addition, breast milk can constitute an ongo- ing source of ingested toxins because some toxins will transfer from the mother to her milk. Environmental factors play a role in increasing the risk that children are exposed to toxins and infectious agents as well as risk of injury. In agricultural settings, children and adolescents are at risk of injuries from farm equipment and vehicles with an agriculture-related fatality of someone under the age of 18 occurring every 3 days.53 In urban settings, there are often limited spaces where children can play, and available play spaces may have faulty playground equipment, as well as exposure to chemical and biological waste or threats of violence (Chapter 12). An example of increased risk in urban playgrounds is the potential for ingestion of canine roundworms, genus Toxocara, found in the intestines of cats and dogs that are shed in the feces.54 If children get the microscopic eggs on their hands and then swallow them, the eggs soon hatch and the larvae migrate in the body and may reach the brain. The preva- lence is higher in poorer urban neighborhoods. For exam- ple, in New York City, three quarters of the parks in the Bronx tested positive for Toxocara eggs, but none of the parks in Manhattan did. This is partly due to a higher number of strays in poorer neighborhoods versus pets with regular veterinary care.55 Exposure to Toxocara may result in long-term damage to the brain.54,55 There is clearly a need for community education and assistance in identifying alternative, safer environmental conditions for children. The safety of children is an emo- tionally charged issue and one that can galvanize a com- munity and spur it to action, whether it is by committing or redistributing resources, enacting policy changes, or seeking other solutions. Nurses who understand the vul- nerabilities of children can be partners and change agents in this process. Older Adults Older adults are at the other end of the life span, and they face a different set of physical and behavioral char- acteristics and challenges than children or midlife adults (Chapter 19). Around the world, based on findings from multiple studies, researchers (e.g., Ralston, 2018; Zhou, 2017) continue to demonstrate the association between both the social and built environment and the psycho- logical, cognitive, and physical health of older adults.56,57 Not only is access to built resources such as potable water, sanitation, and adequate housing an important factor but so is the social environment. In addition, the movement to help seniors age in place (see Chapter 19) requires not only assuring a safe home environment but also access to community resources to support adequate nutrition and activity.56-59 In addition to changes in physical and mental func- tioning associated with age, older adults also experience increased rates of chronic health conditions, accounting for increased vulnerability to environmental health is- sues. Some age-related changes that increase risk from environmental hazards include hearing and vision loss, respiratory disease, increased fragility of skin, decreased rates of metabolism, and disorders such as osteoporosis and heart disease. When combined with social stressors in the environment, older adults’ vulnerability to envi- ronmental hazards appears to increase.60 Older adults also have higher body burdens of chem- icals that have been absorbed over their lifetimes. Some substances accumulate over time in the body, a process known as bioaccumulation. These toxic substances are commonly retained in tissues such as bone or adipose (fat) tissue and can become a long-term cause of poor health outcomes including cancer, organ damage (in par- ticular, to the kidneys, heart, and liver), cardiac disease, increased chance of stroke, and neurological, immuno- logical, and hematopoietic disorders. For example, lead is stored in the bone with a half-life (time over which only half of the amount is excreted) of more than 20 years. Its slow release over time is reflected by high BLLs that reach and damage target organs.61 Those whose organ systems are already compromised are at higher risk. For example, individuals with cardiac disease will be more seriously affected more quickly in oxygen-deprived atmospheres. In addition, many older adults tend to spend a greater amount of their time indoors, where indoor air pollutants and issues related to climate control may be an issue. In 2013, Gamble and colleagues, based on a review of the literature, called for increased research on the impact of extreme weather on older adults. They found that older adults are more vulnerable and, with the an- ticipated increase in extreme weather due to climate change, the impact could be greater.62 To understand how the environment plays a role, consider a hypothetical C H A P T E R 6 n Environmental Health 145 7711_Ch06_128-156 21/08/19 11:03 AM Page 145 Chicagoan, Mr. Roberts, age 78, who lives on the ninth floor of an 18-story high-rise apartment building for low- income older adults and disabled community members during an extreme heat wave. His wife died the year before, and his children live three states away. There are two elevators to serve the 180 occupants, but one of them regularly breaks down. Mr. Roberts had worked most of his life as a carpenter. When he was 62, he fell off a roof, sustaining a hip injury that ended his working career. Following the injury, he began to use a walker and developed failing eyesight. Because of his exercise limi- tations, he gained weight and developed type 2 diabetes. He tried to be adherent to therapy by checking his blood glucose, but his fixed income, travel distance to the closest supermarket, and solitary cooking situation stood in the way of eating healthy foods. Because of these problems, as well as fear of robbery by strangers who sometimes lurked in his building, he rarely went outdoors. Mr. Roberts mainly kept to himself, did not mix with his neighbors, and simply enjoyed his air- conditioned apartment with its pretty view of the city. During this hypothetical scenario, the temperatures soar above 110°F. As had occurred in the 1995 heat wave in Chicago,63 the city begins to experience brownouts, then power outages, resulting in a 3-day loss of power in Mr. Roberts’s building. The temperature inside begins to climb, particularly in the afternoon. Two days later, one of Mr. Roberts’s neighbors called the building’s manage- ment concerned that she hadn’t seen Mr. Roberts in a few days. When the maintenance person checks, he gets no answer to his knock, and assumes that Mr. Roberts had gone away with family. He leaves a note, the scope of his authorization, because, as in many municipalities, landlords are required to give 24-hour notice to a tenant before they can enter without the owner’s permission. Sadly, when the maintenance man enters the apartment the next day, he discovers that Mr. Roberts died during the heat wave. This scenario is typical of stories that pepper the news each summer in the United States. Mr. Roberts died of heat stroke, a direct result of an environmental hazard amplified by his age, health, and the built environment. Another issue for Mr. Roberts was his social isolation, a factor that may explain why more older men than women died in the 1995 Chicago heat wave.63 A heat wave is an example of a natural disaster (Chapter 22), but the built environment often increases the risk of morbidity and mortality, especially for the older adult. One of the contributing environmental factors that increases the vulnerability of older adults is a diminished ability to regulate body temperature; thus, external mechanical methods such as fans and air conditioners are needed to reduce the surrounding temperature. Unfortunately, this susceptibility often combines with other risk factors for heat injuries, particularly in urban settings. Seniors, who are more likely to stay indoors, often live in relative isolation with few social contacts, and those whose incomes cannot support telephones or sophisticated air-conditioning systems are at greater risk for heat-related illnesses. In several extraordinary heat waves, death rates from heat stroke were highest among the oldest age groups. For example, a severe heat wave in France for 3 weeks during August 2003 resulted in 14,800 deaths, mainly among women older than age 75. These deaths, especially when they occur in developed nations, are preventable, and as a result France set up a Heat Health Watch Warning system as well as prevention plans.64 Thus the environment—adequate cooling, ade- quate availability of water for hydration, and an effective method of communication—are key components to inter- ventions aimed at reducing environmental issues faced by older adults who are caught in a heat wave. Many issues also arise in cold climates concerning home heating. In addition to cold injuries and death that can result from lack of heat, many people use space heaters that use fuel such as kerosene. This type of space heater presents a serious fire hazard, as do other makeshift forms of sustaining home heat. Deaths have been caused not only by fire but also from carbon monoxide poisoning when fuels such as charcoal or wood have been burned indoors. There are programs in many locales to assist low-income or older clients. Power companies can provide informa- tion about these and, in most locations, cannot abruptly discontinue service before taking certain required steps. In addition, landlords must also abide by housing codes.50 For example, when it comes to heating spaces, most housing codes dictate a minimum temperature that must be achievable if the space is to be legally rented. There are many codes that apply to rental properties as illustrated in Solving the Mystery: The Case of the Hazardous House. You should know how to access the code in the community where you work and live and, if it is insufficient, advocate for adoption of the interna- tional building codes that are being used increasingly across the United States.65 Nurses are often key members of teams that intervene to prevent deaths like that of Mr. Roberts, beginning with those at the office of his primary care provider. Help with contacting the city’s social services department can also result in home visiting care. Many older people and oth- ers with disabilities are unaware of their eligibility for such services, and many others might be aware of these 146 U N I T I n Basis for Public Health Nursing Knowledge and Skills 7711_Ch06_128-156 21/08/19 11:03 AM Page 146 services but need assistance with applications. PHNs are involved in developing emergency preparedness and disaster management plans, and can help add to the plans’ outreach to those most vulnerable such as older adults or the homeless. Such plans include the establish- ment of warning systems and emergency cooling centers, monitoring of older adults and isolated persons during an extreme heat or cold event, and improving commu- nication and awareness among city officials and emergency medical services. Outreach by PHNs to tenant organiza- tions in buildings such as the one in which Mr. Roberts lived is a means of informing community members about available public health services, fostering better networking and communication among residents, and helping to strategize about safety concerns. Gene-Environment Interaction There is growing evidence that genetic factors are responsible for some degree of individual variability in susceptibility to toxic exposures. Gene-environment interaction is defined as “an influence on the expression of a trait that results from the interplay between genes and the environment.”66,67 In other words, genes interact with the environment either positively or negatively in a way that influences disease development. Often it involves a complex interaction between multiple genes and the environment. There is a growing body of research that identifies an increased risk for disorders such as diabetes, pulmonary disease, breast cancer, and other diseases when individuals with a specific genetic makeup encounter environmental exposures. In addition, some genes are thought to be protective and thus responsible for a decreased risk of environment-related health out- comes. This knowledge may someday be useful in iden- tifying individuals who are at higher risk and intervening by controlling their exposure. In 2006, the National In- stitute on Environmental Health Sciences established a 5-year genes and environment initiative in an effort to increase understanding of the interaction between environment and genes with a focus on asthma, diabetes, and cancer. The efforts of this initiative resulted in an increased understanding of the interaction between genes and environment, and helped to develop better ways to measure environmental exposures.68 Climate Change and Health News related to climate change continues to emerge. For example, there is new data that demonstrates that fresh- water input from melting ice shelves in the Antarctic in a warming climate is creating a feedback loop and will trigger more melting, which would trigger a rapid sea level rise.69 Changes in weather patterns, slowing of the ocean currents, rising of sea levels, and melting of glaciers are occurring across the globe.69-71 According to the WHO, climate change is the result of human activity especially in relation to the burning of fossil fuels.72 The WHO list of the key facts (Box 6-5) demon- strates that the impact on health is serious, that it includes both social and environmental determinants of health, and that it will have a greater impact on LICs. A good example related to the disparity between high-income and low-income communities is the hurricane season of 2017 with two major hurricanes impacting Houston, Texas, and Puerto Rico. Both areas suffered severe damage from the hurricanes, yet Hous- ton had more resources to restore power and aid per- sons who suffered losses due to the hurricane. Puerto Rico remained without power over the majority of the island for months, and the devastation and consequent lack of resources resulted in a large exodus of residents from the island to other parts of the United States, especially Florida. Climate change is associated with numerous extreme weather events including floods, droughts, hurricanes, heat waves, heavy downpours, and blizzards.73 These events result in increased risk of death, injury, and illness. C H A P T E R 6 n Environmental Health 147 • Climate change affects the social and environmental determinants of health: clean air, safe drinking water, sufficient food, and secure shelter. • Between 2030 and 2050, climate change is expected to cause approximately 250,000 additional deaths per year, from malnutrition, malaria, diarrhea, and heat stress. • The direct damage costs to health (i.e., excluding costs in health-determining sectors such as agriculture and water and sanitation), is estimated to be between USD $2-4 billion/year by 2030. • Areas with weak health infrastructure – mostly in developing countries – will be the least able to cope without assistance to prepare and respond. • Reducing emissions of greenhouse gases through better transport, food, and energy-use choices can result in improved health, particularly through reduced air pollution. BOX 6–5 n World Health Organization Key Facts Related to Climate Change Source: (72) 7711_Ch06_128-156 21/08/19 11:03 AM Page 147 For example, heat waves cause direct injury, such as heat exhaustion and heat stroke, which are particularly devastating for older adults and young children. Changes in atmospheric and weather conditions can also in- crease or exacerbate cardiovascular and pulmonary disease. There are also more indirect effects on health and well-being. Climate-related redistribution of vec- tors for diseases, such as mosquitoes, allows infections to reach new and broader populations, who are often the least immune. Decreased yield of crops brought about by droughts, floods, or other impacts on the natural environment will add to the current billion people in the world who have inadequate nutrition. In addition, populations are experiencing displacement due to climate change with resulting adverse health consequences.74 To help illustrate the complex interaction between climate change and health, the CDC created a figure that depicts the four aspects of climate change: rising temper- atures, increased number of extreme weather events, rising CO2 levels, and rising sea levels (Fig. 6-5). The next level depicts the impact on the climate, and on the out- side are the health effects.75 The WHO laid out specific actions needed to address climate change. These include: to advocate and raise awareness, to strengthen partnerships, and to enhance scientific evidence.76 In alignment with the WHO action plan, the Nursing Alliance for Healthy Environments published a report on climate change and nursing. The three areas for action on the part of nursing proposed in this report were research, advocacy, and practice. Their stance is that nurses are in a position “. . .to inform and mobilize society to act on climate change.”77 The issue of environmental sustainability reflects the concern of long-term effects on the health of populations related to climate change. Environmental sustainability reflects the rates in which renewable resources are harvested, the depletion of nonrenewable resources, and the cre- ation of pollution that can continue for an indefinite period of time. If the rates of population and diminish- ing resources continue indefinitely, then the environ- ment is not sustainable. Environmental sustainability was one of the millennium developmental goals of the WHO. The current Sustainable Development Goals (Chapter 1), have integrated the concept of sustainabil- ity across all goals related to improving the health of individuals with the environment playing a key role. As the next decades unfold, nursing will have a role in mitigating the impact of our changing climate from the local level to the global level. With the help of organi- zations around the world, there is optimism that we can make a difference.76,77 148 U N I T I n Basis for Public Health Nursing Knowledge and Skills Figure 6-5 Centers for Dis- ease Control and Prevention: Impact of Climate Change on Health. (From CDC. [2014], Retrieved from https://www.cdc. gov/climateandhealth/effects/ default.htm.) 7711_Ch06_128-156 21/08/19 11:03 AM Page 148 Air One of the issues related to climate change is the quality of the air we breathe. In 2018, an artist in London, England, Michael Pinsky, set up five geodesic domes (pollution pods) in the city. Each dome replicates the atmosphere of one of five places: Beijing, China; Sao Paulo, Brazil; London, England; New Delhi, India; and Norway’s Tautra Island. Many people visiting the pods were unable to remain in them long due to immediate respiratory problems.78 All animals depend on an ade- quate supply of oxygen to maintain life. A healthy envi- ronment requires not only air with an adequate supply of oxygen but also air that is free from pollutants. Air pol- lution has long been an issue, but with the arrival of the Industrial Revolution the quality of the air we breathe changed drastically. Industry and the need for energy have resulted in the emission of toxic chemicals into the air. The famous London fog was not a natural weather phenomenon, but rather arrived on the heels of the Industrial Revolution. Cities with high dependence on motor vehicles for transport, such as Los Angeles and London, have struggled with severe smog due to emis- sions from automobiles. In Pinsky’s London geodesic dome, the odor of diesel fuel dominated because it is one of the main pollutants of London air. In the 21st century, the continued emission of CO2 has resulted not only in the warming of the climate but a reduction in the quality of the air (Fig. 6-5). Ambient Air Ambient air is the air surrounding a place or structure and is also referred to as outdoor air. Poor ambient air quality is associated with increased mortality rates from pulmonary and cardiovascular disease.75,79 Air contam- ination may occur because of the emission of pollutants into the atmosphere at consistent concentrations over time, such as the emissions from factories. Scientists devised a mechanism to evaluate the current air quality called the ambient air standard. This refers to the high- est level of a pollutant in a specific place over a specific period of time that is not hazardous to humans. It is the number of parts per million per hour that are considered the safety limit. As evidenced by Pinsky’s geodesic domes, the amount of air pollution presents a serious health concern in many urban areas across all income levels. Variability in air quality often reflects the surrounding built environment. Populations located in the shadow of chemical plants and next to large equipment, railroad tracks, trailer trucks, and dusty access roads are often made up of lower socioeconomic groups, because the property values of homes located next to these sources of pollution are lower. Thus, the population is dispropor- tionately vulnerable to all types of hazardous exposures that come with living in an industrial area. In addition to the risks associated with chemicals emitted in indus- trial areas, these residents face the social strain brought on by these circumstances. Many outdoor air contaminants originate from major stationary sources, known as point sources, which include chemical plants, power plants, refineries, and incinerators. Alternatively, pollutants may be generated by transportation sources such as buses, trucks, and cars (on-road) and ships, planes, and construction equipment (off-road), all referred to as mobile sources. A third type, area sources, includes smaller sources of emission such as gas stations, dry cleaners, commercial heating and cooling systems, railways, and waste disposal facilities such as landfills and wastewater treatment operations.80 In 1970, the United States promulgated the Clean Air Act, which was reauthorized in 1990. The Clean Air Act, enforced by the EPA, specifies allowable limits, known as the National Ambient Air Quality Standards, for in- dustrial emission of a set of major air pollutants called the criteria air pollutants (Box 6-6).81 These are carbon monoxide, nitrogen dioxide, ozone, particulate matter, lead, and sulfur dioxide. Ground-level ozone and partic- ulate matter are the greatest threats to human health. Because particulate matter varies in size, separate stan- dards are set for all particles less than 10 micrometers (μm) in size (PM10) and for those less than 2.5 μm (PM2.5). The size of a particle determines the site of its deposition in the respiratory system. Particles less than 10 μm (less than the width of a human hair) are respirable; they are not removed in the upper airways, as are larger particles. Increased levels of PM10 air pollution appear to affect lung function and produce symptoms in asthma patients of all ages.73 The subset of particles that are less than 2.5 μm enter the alveoli and are associated with lung cancer and cardiovascular death.82 Vehicle traffic, in particular diesel exhaust, is an important source of par- ticulate matter. One way to evaluate the degree of air pollution in a specific area is the Air Quality Index (AQI) (Box 6-7).83 The AQI is computed by the EPA based on measures of the five criteria for air pollutants. Although the calculation of the AQI results in values on a scale of 0 to 500, these are generally reported to the public as six category levels: good, moderate, unhealthy for sensitive groups, unhealthy, very unhealthy, and hazardous. They are also denoted by colors that range from green to maroon. A value of 100 or less, corresponding to the levels of “good” and C H A P T E R 6 n Environmental Health 149 7711_Ch06_128-156 21/08/19 11:03 AM Page 149 150 U N I T I n Basis for Public Health Nursing Knowledge and Skills Description of Common Ambient Air Pollutants Carbon monoxide (CO): An odorless and colorless gas produced by incomplete combustion of fuels in vehicles, heating systems, lawn mowers, and other motorized machinery. Health effects: Reduces the oxygen carrying capacity of blood, deprives tissues of oxygen to potentially aggravate heart disease, harms fetuses, and dam- ages oxygen-sensitive organs. Nitrogen oxides (NOx): Levels are usually low in the United States. Plays a role in the production of ozone. Sources are vehicles, waste disposal systems, power plants, and silage on farms. Health effects: Lung irritant, aggravates asthma, and lowers resistance to infection; pulmonary edema at high concentrations; pulmonary fibrosis at long- term lower concentrations. Sulfur oxides (Sox): Sources are metal smelters and processes that burn sulfur-containing coal and oil, such as power plants and industrial boilers. Creates “acid rain” and smog. Health effects: Bronchoconstriction, aggravates and triggers asthma, long-term exposure pulmonary fibrosis, and possibly lung cancer. PM 2.5 and PM10: Sources are vehicles, and wildland and other types of fires. Health effects: Dangerous to those with heart and lung disease, causing shortness of breath, arrhythmias, angina, and myocardial infarction. Long-term expo- sures may be related to chronic obstructive lung disease (COPD), lung cancer, and cardiovascular disease. Lead: A widely used metal present in smelting operations, paint in old housing, water distribution systems, solder, painted items such as some toys, and many others. Organic lead compounds were once used in gasoline, accounting for 81% of transportation emissions in 1985. This quantity has been reduced substantially once lead was banned from this use. Lead often con- taminates air, water, food, soil, and bioaccumulates. Health effects: Damage to renal, gastrointestinal, reproductive, hematopoietic, and nervous system. Affects development and learning ability of children. Ozone: In the stratosphere, 6 to 30 miles above the earth, ozone is beneficial because it blocks the sun’s harmful ultraviolet rays. At ground level, ozone is a dangerous component of urban smog, produced by sources such as power plants, refineries, and chemical plants. Health effects: Irritates the respiratory system, aggra- vates and triggers asthma. BOX 6–6 n Criteria Air Pollutants Source: (82) The features of the AQI include: • A category that provides specific warnings for sensitive groups, such as children with asthma and others with special respiratory conditions • Detailed warnings about how all people should protect themselves and their families from harmful levels of air pollution • Warnings based on the most up-to-date scientific infor- mation on the known health effects of air pollution levels BOX 6–7 n Air Quality Index Source: (83) “moderate” (green and yellow), is the level set by EPA to protect public health. As the index increases, the health hazards associated with air pollution increase, first affecting the most sensitive individuals at levels of 101 to 150, and at higher levels, everyone. As levels above those classified as yellow (index of 100) are reached, individuals should reduce their levels of exertion and outdoor activities accordingly. The EPA provides a daily updated forecast of the AQI and more information about air pollutants on its Web site Air Now. This Web site provides the current AQI for areas around the country and includes information that can be used for teaching clients.83 Significant advances have been made in re- ducing ambient air pollution during the past 60 years. Continued efforts to improve the health of ambient air will require collaborative efforts within and across nations. Indoor Air Pollution With the exception of laws that ban smoking in public places and Occupational Safety and Health Administra- tion standards for workplace exposures, there is little regulation of indoor air contaminants. Several of these have been mentioned previously in this chapter in the discussion of the home evaluation, including environ- mental tobacco smoke, animal dander, cockroaches, and the spores of molds that grow in damp environments. Each of these agents can cause allergic reactions, and all are recognized triggers for asthma. Many pollutants exist in the home in the form of house dust, which may also be composed of heavy met- als, pesticides, gram-negative bacteria, and chemicals such as phthalates. The very young are especially at risk because they ingest more dust and are more susceptible to toxins. Home cleaning methods, which PHNs can teach families and reinforce during home visits, significantly reduce dust exposures over time periods as short as 1 week 7711_Ch06_128-156 21/08/19 11:03 AM Page 150 when practiced properly. Effective interventions combine the use of allergy-control bed covers, quality doormats, and vacuum cleaners with dirt finders and HEPA fil- ters. Chemicals associated with the materials used to build homes, such as formaldehyde, are another concern. Buildings that are well insulated, tightly sealed for efficient climate control, and lack windows that can be opened by occupants are more likely to retain indoor air pollutants, especially if the ventilation systems provide infrequent air exchanges per hour. Potable Water Just as all animals need oxygen to survive, all living things need water. The availability of potable water has, since ancient times, dictated where humans settle. Humans need water to sustain their own bodies and to sustain their crops and livestock. Water has also played a key role in commerce and the generation of hydroelectrical power. Water has become an important issue in the United States in areas that have limited access to water, especially in the Southwest and in Southern California. The lack of water contributed to the depth of the Depres- sion of the 1930s, creating the dust bowl on the Great Plains and one of the worse environmental disasters in the 20th century. The drought that hit the Midwest eco- nomically wiped out farmers and reduced the availability of food, resulting in 3 million leaving their farms and half a million migrating to other states.84 The quality of water is a major determinant of the health of a population. Both organic and inorganic contaminates are associated with adverse outcomes. According to the WHO: Water is essential for life. The amount of fresh water on Earth is limited, and its quality is under constant pres- sure. Preserving the quality of fresh water is important for the drinking-water supply, food production, and recre- ational water use. Water quality can be compromised by the presence of infectious agents, toxic chemicals, and radiological hazards.85 Inorganic Water Contaminants C H A P T E R 6 n Environmental Health 151 w SOLVING THE MYSTERY The Case of the Tainted Water Public Health Science Topics Covered: • Assessment • Epidemiology • Rates • Surveillance Flint, Michigan, became front-page news when evidence of lead-contaminated water surfaced. The process of how it happened and how it was discovered provides a special case study not only in the importance of safe drinking water but also the complexity of cultural, political, and monetary influences on decisions related to provision of potable water. In 2014, the city had an estimated population of 100,569 with 58% of the popu- lation identifying themselves as African American and 7.6% of the population under the age of 5.86 In that same year, the city decided to switch the water source for the city from Lake Huron through Detroit Sewer and Water Department to the Flint River. They were in the process of completing a new pipeline to Lake Huron, which would then allow them to join the Karengnondi Water Authority (KWA).87,88 Part of the reason for taking this course of action was the possible savings to the city of an estimated $200 million over 25 years. The problem was they did not add corrosion control chemicals to the water. Flint River water is more acidic than the water from Lake Huron, and lead as well as other metals in the aging pipes leached into the water.87 Within weeks of the switch, problems began to emerge including health problems, the smell and appearance of the water, and water main breaks.89 The city issued water boil alerts due to the evidence of E. coli and other contaminants in the water. The extent of the lead contamination was not understood at this point, but families began to purchase bottled water due to the boil alert. Due to work by Marc Edwards, a pro- fessor at Virginia Polytechnic Institute and State Univer- sity, and a local pediatrician, Mona Hanna-Attisha, the significant increase of BLLs in children after the switch to the Flint River water source was identified and pub- lished. The City of Flint ultimately switched back to using treated Lake Huron water supplied by DWSD, due in part to the study and the subsequent public outcry.90, 91 Edwards, in his report, issued information to residents on how to reduce their exposure to lead-contaminated water (Box 6-8).90 However, understanding the extent of the harm required further evaluation of the data. Zahran and colleagues examined four phases related to the expo- sure: prior to the switch, after the switch to the Flint River, after the boil advisory, and after the switch back to the original water source. They found that a total of 561 additional children in Flint exceeded a BLL of ≥5 μg/dL following the switch to the Flint River. They found that, after the switch back to the DWSD water system, elevated BLLs returned to the pre-Flint 7711_Ch06_128-156 21/08/19 11:03 AM Page 151 Safe Water from a Global Perspective The case of Flint, Michigan, demonstrates the impor- tance of a number of standard public health practices such as surveillance, case finding, timely public health alerts, and the need for maintaining adequate infra- structure. Globally, a major issue related to potable water is organic contaminates that increase the risk for communicable diseases (Chapter 8).93 Improvements have occurred over the last few decades. Currently 71% of the global population has access to safely managed drinking water and 89% have access to at least a basic service. Challenges remain with 50% of the global population projected to live in water-stressed areas by 2025.93 The main barriers to the provision of safe drinking water include setting it as a priority, financial capacity, sustainability of the water supply, sanitation, and hygiene behaviors. The main actions recommended by the WHO include increasing the supply of safe water, increasing the number of facilities for the sanitary disposal of excre- ment, and implementing safe hygiene practices.93 Community Environmental Health Assessment In addition to the environmental assessments discussed thus far that focused on individuals and families, a community environmental health assessment can be done as well. It is a means by which public health and environmental health professionals and agencies partner with community members, organizations, and each other to identify, prioritize, and address environmental health issues.94 One of the most widely used community assessment methodologies is the Protocol for Assessing Community Excellence in Environmental Health (PACE EH), developed in partnership between the National Association of County and City Health Officials (NAC- CHO) and the CDC.94 Communities that have imple- mented PACE EH consider it to be a successful tool for expanding the capacity of health agencies in essential environmental health services; engaging the community in problem-solving; and implementing action plans that use community resources to reduce health risks.95 According to the PACE EH guidebook (pp. ix, x), PACE EH is intended for use domestically and interna- tionally, and is being used in numerous locales to take a “collaborative community-based approach to generating an action plan that is based on a set of priorities that re- flect both an accurate assessment of local environmental health status and an understanding of public values and priorities.”94 It outlines a series of tasks, shown in Box 6-9, to accomplish this goal. Implementation of the PACE EH process is supported by several resources, including guidebooks in English and Spanish, other 152 U N I T I n Basis for Public Health Nursing Knowledge and Skills Until further notice, we recommend that Flint tap water only be used for cooking or drinking if one of the follow- ing steps are implemented: • Treat Flint tap water with a filter certified to remove lead (look for certification by the National Sanitation Foundation [NSF] that it removes lead on the label). • Flush your lines continuously at the kitchen tap, for 5 minutes at a high flow rate (i.e., open your faucet all the way), to clean most of the lead out of your pipes and the lead service line, before collecting a volume of water for cooking or drinking. Please note that the water needs to be flushed 5 minutes every time before you collect water for cooking or drinking. For convenience, you can store water in the refrigerator in containers to reduce the need to wait for potable water each time you need it. BOX 6–8 n Recommendations to Flint Residents Source: (90) River water period. Zahran concluded that if the city had issued warnings as soon as they had received com- plaints, much of the increase in BLLs might have been prevented.89 In 2018, the New York Times reported that the state of Michigan would no longer provide free bottled water because the water had met federal safety guidelines for 2 years. In addition, the City of Flint was on target to replace all of the affected pipelines by 2020 with just over 6,200 replaced so far and 12,000 still to go.92 This methodology guides communities and local health officials in conducting community-based environmental health assessments. PACE EH draws on community collaboration and environmental justice principles to involve the public and other stakeholders in: • Identifying local environmental health issues • Setting priorities for action • Targeting populations most at risk • Addressing identified issues BOX 6–9 n Steps in PACE EH Methodology* *PACE EH = Protocol for Assessing Community Excellence in Environmental Health Source: (94) 7711_Ch06_128-156 21/08/19 11:04 AM Page 152 publications, a toolbox with a number of materials and resources, and online and regional training. In addition to PACE EH methodologies, there are additional approaches to community assessment in current use, one of which is to conduct a health impact assessment (HIA). These assessments allow communities to examine the impact of city planning related to land use and policy on the health of the community. HIAs are being implemented at a growing rate throughout Europe to effectively gauge the health impacts of land use planning and policy decisions.96 n Summary Points • The environment plays a role in health from the cellular level to the global level. • Nurses play a crucial role in the promotion of optimal environmental health and mitigation of the effects of climate change. • The built environment contributes to the health of individuals, families, and populations. • Assessment and management of environmental issues are conducted at the individual, family, and community level. • There is an interaction between genetics and the environment. • Characteristics of populations, such as age, genetics, health status, and culture play a role in the interac- tions between health and the environment. • Climate change is affecting the environment with specific concerns related to air and water quality, an increase in extreme weather events, rising sea levels, and increased risk of communicable diseases. C H A P T E R 6 n Environmental Health 153 t CASE STUDY A Contaminated Town Learning Outcomes At the end of this case study, the student will be able to: • Describe the effects of an environmental toxin on the health of a population • Discuss polices related to environmental hazards • Apply primary, secondary, and tertiary prevention approaches to an environmental health issue Since the early 1900s, the major industry in the town of Libby, Montana, was the mining of vermiculite, a mate- rial used to insulate buildings. A contaminant of vermicu- lite is asbestos, which is well known for causing serious lung diseases, including cancer. Concerns about health problems among the town residents, not only the miners, began to surface when a reporter revealed the popula- tion’s high rate of asbestosis and related diseases. Con- taminated soil was the major source of asbestosis around town—near homes, schools, and many public places that included athletic fields—and the dust made its way indoors on vehicles such shoes, pets, and workers’ clothes. The mine was closed in 1990, but by then a large proportion of the townspeople had been exposed, with ongoing exposure because the asbestosis remained in the soil. In 2002, the EPA placed Libby on its National Priority List, thereby identifying the town as a site that appeared to warrant remedial action, leading to the test- ing and inspection of almost 5,000 residential and com- mercial properties. Cleanup operations began throughout the town. In 2009, the EPA declared the town of Libby a public health emergency. This status mobilizes funds to conduct further home-to-home cleanup and install health-care resources for those with asbestos exposure. 1. What type of hazardous agent is asbestos, what is the typical route of exposure, and what are its major health effects? Are there government standards that regulate the permissible amount of asbestos? 2. List the agencies that would partner to address this extensive environmental disaster. 3. What primary, secondary, and tertiary preventive actions can be applied to protect the public’s health? REFERENCES 1. World Health Organization. (2016). Air pollution levels rising in many of the world’s poorest cities. Retrieved from http:// www.who.int/mediacentre/news/releases/2016/air-pollution- rising/en/. 2. The Guardian. (2018). Coal-fired power stations caused surge in airborne mercury pollution, study finds. Retrieved from https://www.theguardian.com/australia-news/2018/apr/03/ coal-fired-power-stations-caused-surge-in-airborne- mercury-pollution-study-finds. 3. National Institute of Environmental Health Sciences. (2017). Climate and human health. Retrieved from https://www. niehs.nih.gov/research/programs/geh/climatechange/. 4. World Health Organization. (2018). Environmental health. Retrieved from http://www.searo.who.int/topics/ environmental_health/en/. 5. Richard, L., Gauvin, L., & Raine, K. (2011). Ecological models revisited: Their uses and evolution in health pro- motion over two decades. Annual Review Public Health, 3, 307-326. 6. Coutts, C.J., & Taylor, C. (2011). Putting the capital ‘E’ environment into ecological models of health. Journal of Environmental Health, 74(4), 26-29. 7711_Ch06_128-156 21/08/19 11:04 AM Page 153 7. U.S. Department of Health and Human Services. (2018). Healthy People 2020 topics: Environmental health. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/ objectiveslist.aspx?topicId=12. 8. National Center for Health Statistics. (2017). Chapter 12: Environmental health. Healthy People 2020 Midcourse Review. Hyattsville, MD: Author. 9. 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Envi- ronmental health specialists network (EHS-Net). Retrieved from http://www.cdc.gov/nceh/ehs/EHSNET/. 14. Gunn, L.D., Mavoa, S., Boulangé, C., Hooper, P., Kavanagh, A., & Giles-Corti, B. (2017). Designing healthy communities: creating evidence on metrics for built environment features associated with walkable neighbourhood activity centres. International Journal Of Behavioral Nutrition & Physical Activity, 141-12. doi:10.1186/s12966-017-0621-9. 15. Sarkar, C., & Webster, C. (2017). Healthy cities of tomorrow: the case for large scale built environment-health studies. Journal of Urban Health, 94(1), 4-19. doi:10.1007/s11524-016-0122-1 16. Hankey, S., Marshall, J.D., & Brauer, M. (2012). Health impacts of the built environment: within-urban variability in physical inactivity, air pollution, and ischemic heart dis- ease mortality. Environmental Health Perspectives, 120(2), 247-253. doi:10.1289/ehp.1103806. 17. Garfinkel-Castro, A., Keuntae, K., Hamidi, S., & Ewing, R. (2017). 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Clinical Infectious Dis- eases, 66, 206–212. https://doi.org/10.1093/cid/cix784. 55. Beil, L. (2018, January 16). The parasite on the playground. The New York Times. Retrieved from https://nyti.ms/ 2ELVbmS. 56. Ralston, M. (2018). The role of older persons’ environment in aging well: Quality of life, illness, and community context in South Africa. Gerontologist, 58(1), 111-120. doi:10.1093/ geront/gnx091. 57. Zhou, P., Grady, S.C., & Chen, G. (2017). How the built envi- ronment affects change in older people’s physical activity: A mixed-methods approach using longitudinal health survey data in urban China. Social Science & Medicine, 19, 274-84. doi:10.1016/j.socscimed.2017.09.032. 58. Szanton, S.L., Alfonso, Y.N., Leff, B., Guralnik, J., Wolff, J. L., Stockwell, I., Bishai, D., et al. (2018). Medicaid cost savings of a preventive home visit program for disabled older adults. Journal of the American Geriatrics Society, 66(3), 614-620. doi:10.1111/jgs.15143. 59. Szanton, S.L., Samuel, L.J., Cahill, R., Zielinskie, G., Wolff, J.L., Thorpe, R.J., Jr., Thorpe, R.J., et al. (2017). Food assistance is associated with decreased nursing home admissions for Maryland’s dually eligible older adults. BMC Geriatrics, 171-7. doi:10.1186/s12877-017-0553-x. 60. Ailshire, J., Karraker, A., & Clarke, P. (2017). Neighborhood social stressors, fine particulate matter air pollution, and cognitive function among older U.S. adults. Social Science & Medicine, 17, 256-63. doi:10.1016/j.socscimed.2016.11.019. 61. Agency for Toxic Substances and Disease Registry. (2011). Toxic substances portal: Lead. Retrieved from https://www. atsdr.cdc.gov/substances/toxsubstance.asp?toxid=22. 62. Gamble, J.L., Hurley, B.J., Schultz, P.A., Jaglom, W.S., Krishnan, N., & Harris, M. (2013). Climate change and older Americans: State of the science. Environmental Health Perspectives, 121(1), 15-22. doi:10.1289/ehp.1205223. 63. Kleinberg, E. (2002). Heat wave: A social autopsy of disaster in Chicago. Chicago, IL: University of Chicago Press. 64. Pirard, P., Vandentorren, S., Pascal, M., Laaidi, K., Le Tertre, A., Cassadou, S., et al. (2005). Summary of the mortality impact assessment of the 2003 heat wave in France. Euro Surveillance: Bulletin European sur les Maladies Transmissibles, 10(7), 153-156. 65. ICC—International Code Council. (2018). Retrieved from http://www.iccsafe.org/Pages/default.aspx. 66. National Institute of Environmental Health Sciences. (2018). Gene environment interaction. Retrieved from http://www. niehs.nih.gov/health/topics/science/gene-env/index.cfm. 67. National Human Genome Research Institute. (n.d.). Talking glossary of genetic terms. Retrieved from http://www.genome. gov/glossary/index.cfm?id=72. 68. National Institute of Environmental Health Sciences. (2011). The genes and environmental health initiative. Retrieved from http://www.genome.gov/19518663. 69. Silvano, A. Rintoul, S.R., Pena-Molino, B., Hobbs, W.R., van Wijk, E., Williams, G.D., et al. (2018). Freshening by glacial meltwater enhances melting of ice shelves and reduces for- mation of Antarctic bottom water. Science Advances, 4, 9467. DOI: 10.1126/sciadv.aap9467. 70. Environmental Protection Agency. (2016). Climate change indicators: Weather and climate. Retrieved from https://www.epa.gov/climate-indicators/weather-climate. C H A P T E R 6 n Environmental Health 155 7711_Ch06_128-156 21/08/19 11:04 AM Page 155 71. National Aeronautic and Space Administration. (2018). Global climate change vital signs of the planet: Sea level. Retrieved from https://climate.nasa.gov/vital-signs/sea- level/. 72. World Health Organization. (2018). Fact sheet: Climate change. Retrieved from http://www.who.int/mediacentre/ factsheets/fs266/en/. 73. U.S. Global Change Research Program. (2014). National cli- mate assessment. Retrieved from https://nca2014.globalchange. gov/highlights/report-findings/extreme-weather. 74. Schwerdtle, P., Bowen K., & McMichael, C. (2018). The health impacts of climate-related migration. BMC Medicine, 16, 1-7. doi: 10.1186/s12916-017-0981-7. 75. Centers for Disease Control and Prevention. (2016). Cli- mate effects on health. Retrieved from https://www.cdc.gov/ climateandhealth/effects/default.htm. 76. World Health Organization. (2018). Climate change and human health: What the WHO is doing for climate and health. Retrieved from http://www.who.int/globalchange/ health_policy/who_workplan/en/. 77. Anderko, L., Schenk, E., Huuing, K., & Chalupka, S. (n.d.). Climate change health and nursing: A call to action. Retrieved from https://envirn.org/climate-change-health- and-nursing/. 78. Yeginsu, C. (2018, April 22). How is the air in London? ‘We should be worried’. New York Times. Retrieved from https:// nyti.ms/2F8cSNc. 79. World Health Organization. (2018). Ambient (outdoor) air quality and health. Retrieved from http://www.who.int/ news-room/fact-sheets/detail/ambient-(outdoor)-air-quality- and-health. 80. Environmental Protection Agency. (2016). Air pollution emissions overview. Retrieved from https://www3.epa.gov/ airquality/emissns.html. 81. Environmental Protection Agency. (n.d.) National ambient air quality standards table. Retrieved from https://www.epa. gov/criteria-air-pollutants/naaqs-table. 82. Environmental Protection Agency. (2015). Consolidated lists under EPCRA/CERCLA/CAA §112(r). Retrieved from https://www.epa.gov/epcra/consolidated-list-lists-under- epcracerclacaa-ss112r-march-2015-version. 83. Environmental Protection Agency. (2016). Air now: Air quality index. Retrieved from https://airnow.gov/index. cfm?action=aqibasics.aqi. 84. Egan, T. (2006). The worst hard time. Boston, MA: Houghton Mifflin. 85. World Health Organization. (2018). Water. Retrieved from http://www.who.int/topics/water/en/. 86. U.S. Census Bureau. (2018). Quick facts: Flint Michigan. Retrieved from https://www.census.gov/quickfacts/fact/ table/flintcitymichigan/PST045216. 87. Abuelaish, I., & Russell, K.K. (2017). The Flint water contam- ination crisis: the corrosion of positive peace and human decency. Medicine, Conflict and Survival, 33(4), 242-249. doi:10.1080/13623699.2017.1402902. 88. Lin, J., Rutter, J., & Park, H. (2016, January 21). Events that led to Flint’s water crisis. The New York Times. Retrieved from https://nyti.ms/2k406rO. 89. Zahrana, S., McElmurryb, S.P., & Sadler, R.C. (2017). Four phases of the Flint Water Crisis: Evidence from blood lead levels in children. Environmental Research, 157, 160-172. https://doi.org/10.1016/j.envres.2017.05.028. 90. Edwards, M., (2015). Our sampling of 252 homes demonstrates a high lead in water risk: Flint should be failing to meet the EPA lead and copper rule. Flint water study: Blacksburg, VA, September 8. Retrieved from http://flintwaterstudy.org/ 2015/09/our-sampling-of-252-homes-demonstrates-a-high- lead-in-water-risk-flint-should-be-failing-to-meet-the-epa- lead-and-copper-rule/. 91. Hanna-Attisha, M., et al. (2016). Elevated blood lead levels in children associated with the Flint drinking water crisis: a spatial analysis of risk and public health response. American Journal of Public Health, 106, 283-290. 92. Fortin, J. (2018, April 18). Michigan will no longer provide free bottled water to Flint. The New York Times. Retrieved from https://nyti.ms/2uW6ubP. 93. World Health Organization. (2018). Fact sheets: Water. Retrieved from http://www.who.int/en/news-room/fact- sheets/detail/drinking-water. 94. Centers for Disease Control and Prevention. (2016). PACE EH—Protocol for assessing community excellence in environ- mental health. Retrieved from https://www.cdc.gov/nceh/ ehs/ceha/pace_eh.htm. 95. Florida Department of Health. (n.d.). PACE EH Project: The power of PACE EH. Retrieved from http://redevelopment. net/wp-content/uploads/2010/11/Thurs11-Role-of-Public- Health-The-Power-of-PACE-EH-Julianne-Price . 96. World Health Organization. (2018). Health impact assessment. Retrieved from http://www.who.int/hia/en/. 156 U N I T I n Basis for Public Health Nursing Knowledge and Skills 7711_Ch06_128-156 21/08/19 11:04 AM Page 156 157 Community Health Across Populations: Public Health Issues Chapter 7 Health Disparities and Vulnerable Populations Christine Savage, Beverly Baccelli and Sara Groves LEARNING OUTCOMES After reading the chapter, the student will be able to: KEY TERMS 1. Compare and contrast the concepts of health disparity, equity, and inequality from a local to global perspective. 2. Discuss the magnitude of health disparities both in the United States and internationally. 3. Define and explain the role of the social determinants of health and social justice in the health of populations. 4. Describe the concept of vulnerability from a population perspective. 5. Examine vulnerability of specific populations. 6. Compare and contrast population level strategies for improving health among different vulnerable groups. 7. Understand the role of culture when caring for vulnerable populations. Asylee Correctional population Discrimination Disparity Equity Food security Gene-environment interaction Health disparity Health gradient Health inequity Homelessness Illegal alien Immigrant Incarcerated population Marginalization Migrant agricultural worker Migrant worker Permanent Resident Alien Point in time estimate Poverty Poverty guidelines Poverty threshold Primary homelessness Refugee Secondary homelessness Social capital Social gradient Social determinants of health Social justice Socioeconomic status (SES) Stigma Sustainability Tertiary homelessness Vulnerability Vulnerable populations n Introduction In 2016, the infant mortality rate (IMR) for the World Health Organization (WHO) African Region was 52 per 1,000 live births compared to 8 per 1,000 live births for the WHO European Region with a range of 2 per 1,000 in Ice- land and 120 per 1,000 in Mozembique.1,2 Why is there such a disparity, or great difference, between these coun- tries? Is there anything that can be done to reduce this and other gaps in health outcomes between populations? Why are some populations at greater risk for adverse health out- comes compared to other populations? Answering these questions involves understanding the underlying social determinants of health-realated gaps in health outcomes between populations. Equity is the underlying concept behind optimum health as a basic human right. To explore this in more detail, consider three people: one tall, one medium height, and one short wanting to watch a ball game over a fence (Fig. 7-1). If all three are provided with a box that U N I T II 7711_Ch07_157-190 23/08/19 10:23 AM Page 157 is the same height, this represents the concept of “equal- ity.” Although they were all given the same resource to view the game, the shortest person is still not able to see the game. If instead they are provided with boxes at varying heights based on their stature, all of them get to see the game. Then there is “equity” among the three persons. When health equity does not exist, there are often dif- ferences in health outcomes. The terms used to describe gaps in health outcomes include health disparity and health inequity. Health disparity exists when “… a health outcome is seen to a greater or lesser extent be- tween populations.”3 The IMR (see Chapter 17) provides a prime example of disparity with higher rates between countries or between ethnic groups within a country. Identifying a disparity is the first step in understanding the underlying risk factors and the development of pos- sible interventions to reduce or eliminate the disparity. Health inequity describes avoidable gaps in health outcomes.3 For example, persons with type 2 diabetes who cannot afford the cost of medication and therefore are unable to take it as ordered will experience higher A1C levels and experience more adverse outcomes. The inequity in access to diabetic medications may be a major driver in the disparity in outcomes between lower- and middle-class persons. Drivers of health inequities are linked to the vulnerability experienced by some populations based on the social determinants of health including where they stand in the social hierarchy related to income, education, occupation, gender, race/ethnicity, and other factors.2 Addressing health inequity requires providing persons the opportunity for optimal health. This may require more services for those who have noncommunicable chronic diseases and are on a fixed income compared to persons in general good health and who are in higher in- come brackets. Nurses address health inequity in a variety of ways beginning with advocacy. For example, nurses on the front lines with patients who have difficulty affording their prescriptions advocate for those patients by identi- fying pharmacies that provide assistance as well as other sources of help to pay for medications. Nurses also advo- cate for health-care policies aimed at addressing health inequalities at the local, state, and national level. They also actively provide improved care for those in need through nurse-managed clinics or by working as outreach nurses for the public health department. Vulnerability is the degree to which an individual, population, or organization is unable to anticipate, cope with, resist, and recover from the impact of disease and disasters.4 An individual or group’s vulnerability can be affected by a number of factors, some of which can be changed, and some of which cannot. Vulnerability is es- pecially evident during a natural disaster (see Chapter 22). For example, those with fewer resources have a greater difficulty evacuating during hurricanes due to a lack of transportation and inability to pay for or find alternative shelter. After the hurricane, income level plays a large role in the ability to repair damaged dwellings and ob- tain needed supplies, as evidenced in Puerto Rico after Hurricane Maria. To understand the increased risk for experiencing health inequities, specific vulnerable pop- ulations have been identified based on race, ethnicity, age, gender, sexual orientation, history of incarceration, socioeconomic status (SES), exposure to violence and war (Chapter 12), and lack of a permanent residence.5 Vulnerability is not exclusively tied to social status. For example, frail elderly experience vulnerability related to impaired mobility and difficulty completing activities of daily living. However, when age-related frailty is combined with poverty, the vulnerability of that person increases. Nurses are often confronted with the dilemma of how best to care for a vulnerable person. For example, when discharging a hospitalized patient who has no permanent address or a family member to assist that patient, the nurse must seek resources to help the patient. This requires knowledge of the resources within the hospital, such as the social work department as well as resources within the community. Comparing life expectancy between countries helps to further demonstrate the health disparity between coun- tries. For example, Monaco’s estimated life expectancy in 158 U N I T I I n Community Health Across Populations: Public Health Issues Figure 7-1 Equality versus Equity. (“Interaction Institute for Social Change | Artist: Angus Maguire.” Retrieved from inter- actioninstitute.org and madewithangus.com.) 7711_Ch07_157-190 23/08/19 10:23 AM Page 158 2017 was 89.4 years whereas the estimated life expectancy in Chad was 50.6 years.6 For the U.S., in 2016, the esti- mated life expectancy was 78.6 years, a decline since 2015.7 There is also health disparity among populations within a country. These disparities are frequently seen as a health gradient wherein there is a series of progressively increasing or decreasing differences. The health gradient reflects the relationship between health and income at the population level with health gradually improving as income improves. The WHO uses the term social gradient, which refers to “… a gradient in health that runs from top to bottom of the socioeconomic spectrum. This is a global phenomenon, seen in low-, middle-, and high-income countries. The social gradient in health means that health inequities affect everyone.”8 The WHO utilizes the example of maternal mortality to describe social gradient (see Chap- ter 17). A comparison of the lifetime risk of maternal death during or shortly after pregnancy shows at the top of the gradient, a 1 in 17,400 risk versus 1 in 8 in Afghanistan.8 Caution must be taken when interpreting the under- lying risk factors contributing to the disparity. On the surface, it might appear that the disparity is due to genetic differences, when in fact, much of the health disparity between groups is driven by socioeconomic factors. Poverty and access to resources such as food, shelter, sanitation, and health care all play a role in im- proving life expectancy. Other risk factors must also be considered. Since 2015, life expectancy has been declin- ing in high income countries partially due to the rise in opioid overdoses in younger persons (see Chapter 11).9 Thus, where a person lives, level of vulnerability, and individual health behaviors play a role in increasing or decreasing an individual’s risk for premature death. Disparity and Inequity at the National and Global Level The WHO stated that “A characteristic common to groups that experience health inequities—such as poor or marginalized persons, racial and ethnic minorities, and women—is lack of political, social, or economic power. Thus, to be effective and sustainable, interventions that aim to redress inequities must typically go beyond reme- dying a particular health inequality and also help empower the group in question through systemic changes, such as law reform or changes in economic or social relationships.”10 Vulnerable groups with a higher level of risk of experiencing adverse health outcomes are also less apt to have a voice in creating opportunities to reduce health inequity. Health Disparity in the U.S. Comparing groups based on racial category provides a starting point for illustrating health disparities in the U.S. with the strong caveat that this does not mean that these differences are attributable to genetic differences but rather differences in availability of resources. Again, the IMR illustrates significant differences in birth out- comes. Although the overall IMR for the U.S. in 2016 was 5.9 per 1,000 live births, it was almost double for African Americans (11.4 per 1,000 live births) and much lower for Asians (3.6 per 1,000 live births) (Fig. 7-2).15 Yet when the data are examined based on geography, differences in IMR by state ranges from less than 1 per 1,000 live births (Vermont) to 9.1 per 1,000 live births (Alabama).15 Access C H A P T E R 7 n Health Disparities and Vulnerable Populations 159 Figure 7-2 Comparison of IMR within the United States. (From Centers for Disease Control and Prevention. [2018]. Infant Mortality. Retrieved from https://www.cdc.gov/ reproductivehealth/maternalinfanthealth/infantmortality.htm.) n CELLULAR TO GLOBAL A 2018 article in the New York Times utilized videos and photos to highlight the plight of mothers and newborn infants in South Sudan.13 The images of moth- ers and infants accompany the stark facts of limited physicians, electricity, equipment, and medication. Breastfeeding mothers must sleep out in the open. The reality in 2018: 1 in 10 babies brought to the clinic died, most from conditions that were treatable, such as respiratory infections. Because the mothers were unsure if their babies would survive, most were not even named. The lack of resources to treat respiratory infections in newborn infants contributes to the IMR in South Sudan (48.8 per 1,000 births in 2017),14 which then drives life expectancy (60.6 in 2017)6. U.S. Infant Mortality Rate 2016 by Race Non-Hispanic Black American Indian/ Alaskan native Native Hawaiian/ Pacific Islander Hispanic Non-Hispanic White Asian 11.4 9.4 7.4 5 4.9 3.6 12 10 8 6 4 2 0 7711_Ch07_157-190 23/08/19 10:23 AM Page 159 to resources and poverty are important risk factors for infant death and help explain the differences seen between racial groups that have a higher percentage living in poverty. Although IMR is just one example of health disparity among groups in the U.S., it underscores the ra- tionale for continuing to keep elimination of health disparities as a priority. HP 2030 continues to include elimination of health disparity as a priority as it has since Healthy People was first initiated. exposures and incorporates the full context of the com- munities in which an individual resides and their effect on health. Social Determinants of Health and Social Capital The social determinants of health are the social and en- vironmental conditions in which people live and work.19 These social determinants include neighborhood and the built environment (see Chapter 6), economic stability, education, social and community context, and health and health care (Fig. 7-3).19 These determinants are not only associated with risk for communicable and noncommu- nicable disease but are also associated with risk for men- tal health disorders, substance use disorders, injury, and violence. According to the WHO, social determinants of health account for “… the unfair and avoidable differ- ences in health status seen within and between coun- tries”.20 Social capital, defined by Lin in 1999 in terms of resources available to individuals and communities based on membership in social networks21, is another factor to consider when examining underlying factors contribut- ing to disparity in health outcomes. 160 U N I T I I n Community Health Across Populations: Public Health Issues n HEALTHY PEOPLE Disparities: Although the term disparities is often interpreted to mean racial or ethnic disparities, many dimensions of disparity exist in the United States, particularly in health. If a health outcome is seen to a greater or lesser extent among populations, there is disparity. Race or ethnicity, sex, sexual identity, age, disability, SES, and geographic location all contribute to an individual’s ability to achieve good health. It is important to recognize the impact that social deter- minants have on health outcomes of specific popula- tions. Healthy People strives to improve the health of all groups.16 Healthy People 2030 Framework and Health Disparities Addressing health disparities in the U.S. continues to be a priority in HP 2030. There are seven foundation principles for HP 2030 that guide the development of HP 2030 topics and objectives including: “Achieving health and well-being requires eliminating health disparities, achieving health equity, and attaining health literacy.”17 There are five overarching goals including: “Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all”.17 Social Determinants of Health, Social Capital, and Social Justice Health is a complex state that truly reflects a cellular to global model. It reflects a gene-environment interaction from the individual to the global level. For example, according to the National Institute of Environmental Sciences, “Nearly all diseases result from a complex inter- action between an individual’s genetic make-up and the environmental agents that he or she is exposed to.”18 The terms social determinants of health, social capital, and social justice help to further understand how this gene- environment interaction goes beyond environmental Social Determinants of Health Social Community and Context Economic Stability Neighborhood and the Built Environment Social Community and Context Health and Health Care Education Figure 7-3 Social determinants of health. (Data from National Institute of Environmental Sciences. [2018]. Gene- environment interaction. Retrieved from https://www.niehs. nih.gov/health/topics/science/gene-env/index.cfm.) 7711_Ch07_157-190 23/08/19 10:23 AM Page 160 24% Informational Little or no change Improving Met or exceeded 31% 27% 18% Healthy People 2020 Midcourse Review: Social Determinants of Health For all health-care providers, including nurses, under- standing social determinants of health and integrating that knowledge into plans of care results in improved outcomes. When patients come to the hospital for care, it is not always easy to understand the context of their daily lives because nurses are not interacting with them in their home environment. Yet with increasingly short hospital stays, nursing care that incorporates this context in the nursing plan of care and discharge instructions becomes even more important. Often patients go home with complex instructions and a need for medical supplies, yet lack the health literacy (see Chapter 2) and/or the resources to implement those instructions. This can re- sult in poor outcomes and a return to the hospital. At the tertiary prevention level, addressing this health inequity may include requesting an order for a home health nurse or home health aide on discharge, thus helping vulnera- ble patients improve their ability to self-manage the dis- ease. On the secondary prevention level, nurses in public health departments are on the front line with screening programs for vulnerable populations at high risk for disease such as lead poisoning or sexually transmitted infections. On the primary level, nurses provide educa- tion to at-risk populations. As explained in Chapter 2, understanding the social determinants of health is essen- tial to help identify persons at risk as well as patterning an intervention at the individual or community level that considers how the social and environmental conditions in which people live affects their ability to achieve opti- mal health. Social Justice Addressing health disparities comes under the umbrella of social justice, defined by the Merriam-Webster dictionary as “a state or doctrine of egalitarianism.”23 In other words, because health disparities represent a lack of equality in health outcomes among groups, it is important to adopt a doctrine of social justice related to C H A P T E R 7 n Health Disparities and Vulnerable Populations 161 Figure 7-4 Social determinants of health midcourse review. (Data from National Institute of Environmental Sciences. [2018]. Gene-environment interaction. Retrieved from https:// www.niehs.nih.gov/health/topics/science/gene-env/index.cfm.) Healthy People 2020 highlighted the importance of addressing the social determinants of health by includ- ing “Create social and physical environments that promote good health for all” as one of the four overar- ching goals for the decade. This emphasis is shared by the WHO, whose Commission on Social Determinants of Health (CSDH) in 2008 published the report, Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health.2 The emphasis is also shared by other U.S. health initiatives such as the Na- tional Partnership for Action to End Health Disparities 3 and the National Prevention and Health Promotion Strategy.19 Midcourse Review: For Healthy People 2020, there were eight primary objectives. The midcourse review included 25 related objectives from other topic areas for a total of 33 objectives that were all measurable. Eight were informational. For the other objectives, 10 showed little or no improvement, 9 were improving, and 6 met or exceeded the 2020 targets (Fig. 7-4).22 n HEALTHY PEOPLE Social Determinants of Health HP 2020 Goal: Create social and physical environments that promote good health for all. Overview: Health starts in our homes, schools, workplaces, neighborhoods, and communities. We know that taking care of ourselves by eating well and staying active, not smoking, getting the recommended immunizations and screening tests, and seeing a doctor when we are sick all influence our health. Our health is also determined in part by access to social and economic opportunities; the resources and support available in our homes, neighborhoods, and communities; the quality of our schooling; the safety of our workplaces; the cleanliness of our water, food, and air; and the nature of our social interactions and relationships. The conditions in which we live explain in part why some Americans are healthier than others and why Americans more generally are not as healthy as they could be. 7711_Ch07_157-190 23/08/19 10:23 AM Page 161 health and to strive to promote equal opportunities to maximize the health of individuals and communities. The CSDH convened by the WHO in 2005 concluded that “… social justice is a matter of life and death”.24 Although this report was completed more than a decade ago, the gaps in life expectancy among countries remain. Social justice continues to be a major issue at the policy level, with the U.S. continuing to debate whether health is a right or a privilege. At the global level, distribution of needed health services, as depicted in the case of newborn care in Southern Sudan earlier, continues to be hampered by poverty, war, and fragile infrastructure in low-income countries. The Intersection of Race, Poverty, and Place Although African Americans account for only 13% of the U.S. population, they account for almost 50% of persons infected with HIV when there is no biological or genetic basis for the difference.26 The driving factors are a “nexus of race, poverty, and place” as demonstrated in 2014 by Gaskin et al.27 Race is a social construct with no biological foundation and is not a useful clinical marker for disease. Instead, understanding the role of poverty and place should help drive the development of policies aimed at ad- dressing health disparity. Communities with a higher level of poverty are less apt to be able to provide community- level resources, which include grocery stores, parks and recreation facilities, quality schools, and public transporta- tion. There are also fewer employment opportunities and limited access to health care.27 Based on the WHO list of 10 facts on health inequities and their causes,26 addressing health disparity requires more than improving treatments for specific diseases. It requires a more complex approach in which health-care services link with social services.28 According to the WHO, “The lower an individual’s socioeconomic posi- tion, the higher their risk of poor health.”26 162 U N I T I I n Community Health Across Populations: Public Health Issues l APPLYING PUBLIC HEALTH SCIENCE The Case of the Doctorless Children Public Health Science Topics Covered: • Community assessment • Health planning Emily, a school nurse in a large community-based public elementary school, grew concerned due to the increasing diversity among the students. Many first- generation immigrants have moved into the lower- income, working-class community served by the school. Emily found that, among the students, 15 differ- ent languages were spoken at home as the primary language, particularly among the 40% of the students whose families came from Asia, Africa, South America, and Central America. The make-up of the rest of the students is: African Americans, 40%; second generation Hispanics, 10%; and whites, 10%. Emily reviewed the health statistics for the popula- tion at her school at the beginning of the school year. In this school, she found disparities in disease/illness rates compared with those in other schools in the district: • 32% were not completely immunized compared with 3% at other schools. • 51% had not received the required physical exam. • There was a higher than average rate of failure for the vision and hearing screening tests. • There was a higher absenteeism rate. • 67% had not seen a dentist compared with 31% at the other schools. • 24% of the children were overweight but not much more than the children in the other community schools. • Children between 5 and 8 years old had a higher rate of asthma than in other schools in the same district. Emily wondered if one of the issues facing these families was access to care. To help determine what barriers to health care the families might be experienc- ing, she examined the children’s school records in more detail as well as resources available within the neighborhood. She found that: • Few children had a primary care physician listed in their school record. • The nearest pediatric and family practice clinics required that families using the bus system make a minimum of two transfers. Emily wished to gather more data from the parents but was challenged by the language barriers and by the fact that most of the parents worked. She sought interpreters in the community for the different lan- guages spoken at home and then set up focus groups (see Chapter 4) with parents to help find out more about why the children had received less health care than children in the other schools in the district, especially preventive care. Although she was unable to conduct a focus group with all of the different groups within the community, she was able to include immigrant groups, Hispanics, 7711_Ch07_157-190 23/08/19 10:23 AM Page 162 C H A P T E R 7 n Health Disparities and Vulnerable Populations 163 African Americans, and whites. For all of the parents, a central issue was the difficulty of getting to the primary care clinics located outside the neighborhood because it required taking two to three buses with time-consuming transfers, and the offices were only open during working hours. They said the clinics were very crowded and, when they finally got to see some- one, they often had less than 10 minutes with the care provider. For the non-English-speaking parents, translators were rarely available. The parents, even those with English as their primary language, reported that going to the clinic had little value because often they did not understand what the health-care provider was telling them, the suggested steps for prevention weren’t always possible to carry out (“I can’t afford all that fancy fruit!”), and often minimal explanation was provided related to any prescriptions, including where to get them filled. When their children were really sick, most of the parents used the urgent care clinic in the community, but this required up-front payment, so they often delayed going until their child was really sick, which often meant a trip to the emergency room. The parents mentioned that the department of public health provides free immunization clinics and school physicals for a nominal charge, but they pointed out they cannot afford to miss a day of work without pay to bring the children. They wished the clinics were open on Saturday or in the evenings. Based on the data from these focus groups, Emily identified several factors in the health-care system that contributed to the health-care disparity at her school: • Limited access to care • Lack of primary care practitioners in the overbur- dened clinics • No primary health care in the immediate neighborhood • Health department clinics that meet at hours inacces- sible to the working population in the community • Limited public transportation • Lack of translators at the clinics She invited parents, teachers, and staff to attend a series of early evening meetings to strategize about how some of these factors could be mitigated to reduce the disparity. Several of the teachers and the school coun- selor saw this as an important component of school health and also agreed to attend. Emily suggested that the parents who do not speak English find someone who can translate for them and that the translators can also participate. She encouraged the families to bring others from the community. She pointed out that it is really a community issue and not just a school issue. Emily valued the time of all these stakeholders and tried to be organized to help them arrive at some clear outcomes by the end of the meeting. The group had three meetings. Participants offered suggestions and concrete plans to be implemented, some to be done at the school and others in the community. These suggested collaborative actions included the following: • Improve access to care. • With the partnership of the local public health de- partment, provide an immunization clinic and school physicals one evening a month (or on Saturday) at the school. • Negotiate with one of the primary care clinics outside the community and the board of education to provide a satellite comprehensive clinic at the school, developing underutilized school space. • Provide information at the school about the insur- ance and other health program eligibilities for children of low-income working parents. • Bridge cultural/literacy gaps. • Develop evening English as a Second Language (ESL) classes for the parents, coordinated by one teacher at the school, a local social service agency, and volunteers from the local university. • Start monthly cultural programs organized by the school Parent-Teacher Association to showcase all of the cultures at the school and facilitate more communication among the parents. • Create information tools that can be used by people with low health literacy to gain information on com- mon childhood illnesses; health promotion and dis- ease prevention actions; and new skills the families can use, even with limited resources, to navigate the U.S. health-care system. Offer to share these infor- mation tools with the local primary care clinics. • Communicate with the clinics about the need to provide required translation services either with trained, certified volunteers including university students, or with a telephone translation service. With the assistance and support of the community, Emily and the planning group were ready to design actions to implement some of these changes. Emily received two neighborhood development grants to help cover program implementation. The next steps in the process included looking for sustainable funding for an ongoing school health program aimed at reduc- ing the gap in access to care. 7711_Ch07_157-190 23/08/19 10:23 AM Page 163 Public Health Organizations: Global to Local Universal Declaration of Human Rights The Universal Declaration of Human Rights, adopted by the General Assembly of the United Nations in 1948, con- tinues to provide the underlying framework for equity in health at the WHO and down through national- and state-level approaches to improving health equity. The Declaration consists of 30 articles that serve as a standard of achievement for all nations to measure compliance with human rights and fundamental freedoms. Article 25 states, “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widow- hood, old age, or other lack of livelihood in circumstances beyond his control.”29 Articles 22 to 27 are most specific to equity in health care, examining economic, social, and cultural rights (Box 7-1). In 1978, at the International Conference on Primary Care, the Alma-Ata Declaration affirmed these human rights (see Chapter 15). The goal was to see the provision of primary health care to every individual by the year 2000, thus achieving the goal of health care for all. The second section of the Alma-Ata Declaration stated, “The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially, and eco- nomically unacceptable and is, therefore, of common 164 U N I T I I n Community Health Across Populations: Public Health Issues Article 22 Everyone, as a member of society, has the right to social security and is entitled to realization, through national effort and international co-operation and in accordance with the organization and resources of each State, of the economic, social, and cultural rights indispensable for his dignity and the free development of his personality. Article 23 1. Everyone has the right to work, to free choice of employment, to just and favorable conditions of work, and to protection against unemployment. 2. Everyone, without any discrimination, has the right to equal pay for equal work. 3. Everyone who works has the right to just and favorable remuneration ensuring for himself and his family an existence worthy of human dignity, and supplemented, if necessary, by other means of social protection. 4. Everyone has the right to form and to join trade unions for the protection of his interests. Article 24 Everyone has the right to rest and leisure, including reason- able limitation of working hours and periodic holidays with pay. Article 25 1. Everyone has the right to a standard of living adequate for the health and well-being of himself and of his fam- ily, including food, clothing, housing, and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age, or other lack of livelihood in circumstances beyond his control. 2. Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection. Article 26 1. Everyone has the right to education. Education shall be free, at least in the elementary and fundamental stages. Elementary education shall be compulsory. Technical and professional education shall be made generally available and higher education shall be equally accessible to all on the basis of merit. 2. Education shall be directed to the full development of the human personality and to the strengthening of respect for human rights and fundamental freedoms. It shall promote understanding, tolerance and friendship among all nations, racial or religious groups, and shall further the activities of the United Nations for the maintenance of peace. 3. Parents have a prior right to choose the kind of educa- tion that shall be given to their children. Article 27 1. Everyone has the right freely to participate in the cultural life of the community, to enjoy the arts, and to share in scientific advancement and its benefits. 2. Everyone has the right to the protection of the moral and material interests resulting from any scientific, literary, or artistic production of which he is the author. BOX 7–1 n The Universal Declaration of Human Rights, WHO 1948 Source: (29) 7711_Ch07_157-190 23/08/19 10:23 AM Page 164 concern to all countries.”30 In the 21st century, the WHO continues to advocate for reducing health inequity based on the concept that health is a fundamental human right.10 United States Healthy People 2020 stated that the impact of social and physical determinants of health “… determinants affect a wide range of health, functioning, and quality of life out- comes.” They provided a number of examples (Box 7-2).19 As noted earlier, Healthy People 2030’s foundational principles include “Achieving health and well-being requires eliminating health disparities, achieving health equity, and attaining health literacy”.17 Along with Healthy People, a number of U.S. national-level organizations have placed health equity as a priority. The Centers for Disease Control and Preven- tion (CDC) not only tracks disparity in health outcomes but also provides detailed information on evidenced- based resources to states and local governments. Every few years, they release a report on programs aimed at reducing health disparity.31 The U.S. Office of Minority Health (OMH) was created to address disparity and inequity in health among racial and ethnic minorities including Native Americans on reservations. The OMH provides funding for assessment, research, education, and intervention with public and private collaborative partners as suggested by the summit.32 In 2008, the OMH generated a logic model specific to improving ethnic and minority health that continues to describe what the OMH does (Fig. 7-5) (see Chapter 5).32,33 The model provides guidance to health-care providers, policy mak- ers, community stakeholders, and researchers to move the process along in a unified way.32 The goal is to create interventions that change outcomes and decrease racial and ethnic disparities. The five purposes of the model are to: 1. Provide policy makers and others concerned with health disparities a better appreciation of the issues 2. Better understand the interrelationship of all the variables 3. Provide a research format and direction for data input 4. Give building blocks to the community stakeholders so they can contribute input and improve structure 5. Improve the systematic planning of data collection, interventions, and evaluation33,34 State and Local Public Health Organizations At the state and local level, public health departments include minority and ethnic health as part of their mis- sion, and they are often the organizations that implement evidenced-based programs aimed at reducing disparity and promoting health equity as evidenced by the CDC’s Racial and Ethnic Approaches to Community Health (REACH) program.35 The REACH program also funds tribes, universities, and community-based organizations to develop and implement health programs aimed at reducing health disparities. Funded programs have in- cluded a wide range of health issues including improving physical activity, increasing access to healthy foods, and increasing breastfeeding. Vulnerability at the Population Level Social determinants of health, including economic deter- minants, environmental determinants, social capital, and health system determinants, are associated with the de- gree of vulnerability experienced by different populations. Thus, individual risk factors combine with community and population factors to influence the vulnerability of at-risk groups. These at-risk groups who experience vulnerability due to challenges related to the social deter- minants of health include those experiencing homeless- ness, migrants, immigrants, asylees, those with a history of incarceration, and members of Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) community. Develop- mental stages also contribute to vulnerability for older adults (Chapter 19) and children (Chapters 17 and 18) C H A P T E R 7 n Health Disparities and Vulnerable Populations 165 • Access to parks and safe sidewalks for walking is associated with physical activity in adults. • Education is associated with longer life expectancy and improved health and quality of life. • Health-promoting behaviors like getting regular physical activity, not smoking, and going for routine checkups and recommended screenings can have a positive impact on health. • Discrimination, stigma, or unfair treatment in the workplace can have a profound impact on health; discrimination can increase blood pressure, heart rate, and stress, as well as undermine self-esteem and self-efficacy. • Family and community rejection, including bullying, of lesbian, gay, bisexual, and transgender youth can have serious and long-term health impacts including depression, use of illegal drugs, and suicidal behavior. BOX 7–2 n Healthy People: Examples of the Impact of Social and Physical Determinants of Health Source (19) 7711_Ch07_157-190 23/08/19 10:23 AM Page 165 166 U N I T I I n Community Health Across Populations: Public Health Issues 1. Racial/Ethnic Minority Health Status Issues (i.e., preventable morbidity & premature mortality) 2. Racial/Ethnic Health Disparities 3. Need for a Systems Approach Long-Term Problems 1. Individual Level: • Knowledge • Attitudes • Skills • Behaviors • Biological/Genetic Risks 2. Environmental/Community Level: • Physical Environment • Social Environment • Community Values • Community Assets • Community Involvement • Economic Barriers 3. Systems Level: • Components and Resources • Coordination and Collaboration • Leadership and Commitment • User-Centered Design • Science and Knowledge 1. Individual Level: • Efforts to Increase Knowledge • Efforts to Promote Attitudes Conductive to Good Health • Efforts to Build Skills • Efforts to Promote Healthy Behaviors • Efforts to Address Biological or Genetic Risks 2. Environmental/Community Level: • Efforts to Increase Knowledge • Efforts Aimed at the Social Environment • Efforts to Address Economic Barriers 3. Systems Level: • Efforts to Strengthen Components and Resources • Efforts to Promote Coordination and Collaboration • Efforts to Foster Leadership and Commitment • Efforts to Promote User-Centered Design to Address R/E Minority Needs Through • R/E Minority Participation • Health Care Access/Coverage • Culturally and Linguistically Appropriate Service • Workforce Diversity • Racial/Ethnic Data Collection • Efforts to Improve Science and Knowledge 1. Individual Level: E.g., • Increased awareness/knowledge about disease prevention or risk reduction • Increased health care provider skills in providing culturally & linguistically appropriate services • Increased patient adherence to prescribed treatment regimens • Reduced morbidity & mortality 2. Environmental/Community Level: E.g., • Decreased exposure to risks in the physical environment • Increased public awareness about racial/ethnic health disparities • Increased health care access & appropriate utilization • Increased plans & policies that promote health & well-being at the local, state, & national levels • Reduced morbidity & mortality 3. Systems Level: E.g., • Increased inputs & other resources for racial/ethnic minority health-/health disparities-related priorities • Increased partnerships & collaborations for greater effectiveness & efficiency • Increased strategic planning, with goals & objectives, evaluation, & performance monitoring • Increased system design characteristics to minimize barriers for minority users • Increased knowledge development/science base about “what works” 1. Increased quality and years of healthy life for racial/ethnic minorities 2. Reduced and, ultimately, eliminated racial/ethnic health disparities 3. Systems approach to racial/ethnic minority health improvement and health disparities reduction A Strategic Framework For Improving Racial/Ethnic (R/E) Minority Health & Eliminating R/E Health Disparities Contributing Factors Strategies and Practices Outcomes and Impacts Long-Term Objectives and Goals Office of Minority Health Figure 7-5 Logic Model of a strategic framework for improving health disparities. 7711_Ch07_157-190 23/08/19 10:23 AM Page 166 especially vulnerable to adverse health consequences such as increased mortality and morbidity due to communi- cable diseases, injury, environmental exposure to toxins, and during disasters. Experiencing marginalization, stigma, racism, and discrimination increases vulnerability when coupled with the social determinants of health of poverty, education, and place. Poverty Economic factors are, perhaps, the most important factor influencing the health status of an individual or group. Lower socioeconomic status is associated with increased vulnerability. Socioeconomic status (SES) is a composite measure of the interrelated concepts of income, educa- tion, and occupation. With higher levels of education, a person is more likely to secure a better job, which in turn provides a higher rate of pay. By contrast, a person who does not earn a high school diploma has more difficulty finding a job that pays a living wage (a wage that provides access to the means of a healthy living, e.g., housing, food, and health care). Therefore, individuals at a lower SES level have increased vulnerability to poor health because of lack of economic resources. When household income falls below the economic threshold considered to be adequate to support the number of persons in the household, the members of that household are considered to be living in poverty. There are multiple aspects to defining this poverty threshold and the applications of this threshold to de- termine poverty rates. In the United States, the poverty threshold is the measurement used by the U.S. Bureau of the Census to calculate all official poverty population statistics. The poverty threshold is a yearly determina- tion of a standard of living below which a family has the lack of goods and services commonly taken for granted by mainstream society.36 The census bureau adjusts the threshold based on family size and other demographic variables. For example, in 2017, the threshold for a single person under the age of 65 was $12,752, and for a household of five with three children under the age of 18, the threshold was $29,253.36 With very few adapta- tions, the U.S. government’s measurement of poverty has remained unchanged for 40 years, although the basis on which the initial calculations were made has shifted. For example, the percentage of income spent on food has decreased, and the percentage spent on such cate- gories as transportation, health care, and childcare have increased. There are also considerable variances among costs in different parts of the United States and between urban and rural areas (see Chapter 16). These variances are not considered in the current poverty threshold. The poverty threshold is primarily used for statistical purposes, so a consistent method of measurement is used at the national level. The poverty guidelines are another federal measure (see Table 7-1). These guidelines simplify the poverty thresholds and are used for administrative purposes such as determining who is eligible for federal programs aimed at aiding those living in poverty.37 Both poverty guidelines and poverty thresholds are established on a yearly basis and are issued by the U.S. Department of Health and Human Services.36,37 In 2016, the median household income was $59,039, up slightly from 2015. The 2016 U.S. poverty rate remained higher than in 2000 (12.7% versus 11.1%) but had improved from 2012 when it was 15.0%. This translated to 40.6 million people living in poverty in 2016.38 This is not the highest percentage, as more than 20% lived in poverty in the early 1960s. The War on Poverty, under the Johnson administration, decreased the poverty rate to 11.1% in 1973. Unfortunately, the number rose again in the 1980s and has since fluctuated based on economic growth and recession, even with mul- tiple programs directed at decreasing poverty in the United States. When considering the influence of SES on health, it becomes clear that health-care providers must focus their efforts on improving not just health outcomes but also social determinants of health such as educational and employment opportunities. C H A P T E R 7 n Health Disparities and Vulnerable Populations 167 TABLE 7–1 n The 2018 Poverty Guidelines for the 48 Contiguous States and the District of Columbia Persons in Family/Household Poverty Guideline For families/households with more than 8 persons, add $4,320 for each additional person. 1 $12,140 2 $16,460 3 $20,780 4 $25,100 5 $29,420 6 $33,740 7 $38,060 8 $42,380 Source: (38) 7711_Ch07_157-190 23/08/19 10:23 AM Page 167 Social Capital and Vulnerability Social capital is a term that has numerous definitions in the literature. The central point of social capital is the benefits that occur through social networks. One example is that persons often secure a job based on whom they know rather than what they know. Social capital usually refers to a person’s or a community’s capacity to obtain support from the social connections available to the person or community. Social capital resides in the quantity and quality of interpersonal ties among people and communities.39 These relationships represent a resource (capital) that can be drawn upon during challenging times. Social capital is reflected in the institutions, organizations, and informal practices of giving that people create to share resources and build attachments with others. The values and norms of a community influence the health, well-being, and vul- nerability of individuals and populations. Community- level attributes such as social stability, recognition and valuing of diversity, safety, good working relation- ships, and a cohesive community provide a supportive environment in which to live, thereby reducing a per- son’s potential risk for poor health. These ties may be with family, friends, or colleagues, as well as with various community institutions and agencies. When a person or group has reduced social capital, he or she is at greater risk for vulnerability at all times but especially when faced with a challenge. A good example of community-level social capital is the case of the community referred to as Little Italy in Baltimore, Maryland. The neighborhood located east of downtown Baltimore experienced a number of assaults and robberies. The community already had a long- standing community committee. The committee called a meeting and invited the Baltimore police and their state representative to attend. Because of the relation- ships this community had built over time with the city of Baltimore and their state representative, they were able to obtain heightened police presence in the com- munity. The members of the community also banded together and began to pool their resources so that they could obtain further security for the community. As a result, the number of assaults and robberies fell. The community had developed strong social capital over time by building a sense of pride in the community among residents, the support among community busi- nesses, and the ability to gain the attention of lawmakers and the city police department. In addition, the commu- nity came together for one assault victim who had sus- tained serious injuries and raised funds to help cover his hospital expenses. An individual may have social attachments with other individuals within their community yet remain vulnerable because of a lack of social capital. For exam- ple, during Hurricane Maria in Puerto Rico, many of the individuals who were most vulnerable lacked connec- tions with individuals or agencies that could assist them with evacuation during the disaster. Although these individuals and families no doubt had social connec- tions with supportive family and friends, many of those same individuals lacked the capacity to provide needed support for evacuation in the form of money, trans- portation, and shelter. Multiple Determinants of Vulnerability To reduce vulnerability, it is necessary to examine the root causes in a comprehensive manner. Approaches to understanding vulnerability from the lens of individual- level determinants of health can result in a failure to assess the effect that larger social influences have on the individual or population. Conversely, approaches to vul- nerability that focus entirely on the social determinants of health at the population level could result in a failure to recognize the manifestation of these influences on in- dividuals and families. Using a multiple determinants of 168 U N I T I I n Community Health Across Populations: Public Health Issues n CULTURAL CONTEXT A person’s cultural identity provides a sense of con- nection to a community of individuals who share a culture. This can lead to an increase in social capital and often improved health. By contrast, those sepa- rated from their cultural group may experience increased isolation and thus increased vulnerability. For example, one set of researchers found that the isolation of men who sought same-sex relationships in Indonesia was associated with an increased vulnera- bility to HIV infections among participants in the study due to prohibitive cultural perspectives and norms with respect to homosexuality.40 In a 2004 editorial in the American Journal of Public Health, Thomas, Fine, and Ibrahim stated: “Efforts to eliminate health dispari- ties must be informed by the influence of culture on the attitudes, beliefs, and practices of not only minor- ity populations but also public health policymakers and the health professionals responsible for the delivery of medical services and public health interven- tions designed to close the health gap.”41 Addressing disparity in vulnerable populations requires not only understanding the cultural context of the community and the population needing care but also the cultural perspectives of those providing the care. 7711_Ch07_157-190 23/08/19 10:23 AM Page 168 vulnerability approach acknowledges the overlap of risk across many of the determinants of health at the population and individual level that results in increased vulnerability. That is, the more risk factors for poor health that a person or group has distributed across the individual and societal levels, the more likely it is that the person or group will be vulnerable. In particular, mar- ginalization, racism, discrimination, and stigma of a pop- ulation can result in increased vulnerability. Marginalization Marginalization is a social process through which a person or group is on the periphery of society based on identity, associations, experiences, or environment.42 To marginalize someone is to treat the person as though she is of little or no consequence or is unimportant. The marginalization of certain groups conveys the idea that individuals in those groups do not matter or are of little concern to the rest of society. Often, group differences, such as gender, ethnicity or race, education or income, geographical location, or sexual preference contribute to marginalization. Women, racial and ethnic minorities, and persons living in poverty are examples of groups that have a long history of marginalization within our society. Marginalization limits an individual’s or a group’s op- portunities for establishing beneficial relationships nec- essary for accessing health-care services. In addition, those who are marginalized can experience heightened levels of stress and despair related to their sense of powerlessness.43 Racism and Discrimination According to the Merriam-Webster online dictionary, racism is defined as “A belief that race is the primary determinant of human traits and capacities and that racial differences produce an inherent superiority of a particular race.”44 Discrimination occurs when one group gives un- just or prejudicial treatment to another group based on his or her race, ethnicity, gender, SES, or other group membership. Discrimination can occur at the individual, institutional, or structural level (see Box 7-3).45 Over time, a causal link between racial discrimination and increased risk for morbidity and mortality has emerged demon- strating a negative impact on both mental and physical health.46,47 Stigma Stigma is defined by the online Merriam-Webster dic- tionary as “a mark of shame or discredit”.48 Stigmatized individuals either possess, or are believed to possess, some attribute that is not valued in a particular social context. For example, being diagnosed with a mental health disorder (see Chapter 10) or a substance use disorder (see Chapter 11) can result in being stigmatized in a demeaning way and seen as less than. Members of vulnerable populations who are stigmatized experience loss of status within society, which can then result in discrimination. This discriminatory treatment leads to further stigma and further loss of status, thus perpet- uating a cycle that enhances vulnerability and marginal- ization that is, once again, beyond the control of the individual. Ethical Issues The majority of the literature on ethics and health care with vulnerable populations revolves around the inclu- sion of vulnerable populations in research. Health-care research focused on vulnerable populations includes par- ticipants who are at greatest risk for coercion and may not be able to give informed consent. These groups in- clude prisoners, pregnant women, children, those who are mentally incapacitated, refugees, the poor, older adults, sexual minorities, and persons with a substance use disorder.49 From a public health perspective, the issue of ethics and vulnerability extends beyond the ethical concerns of including participants in health-care re- search. Identifying a group as vulnerable must be done in a way that avoids paternalism and stereotyping. Vul- nerability does not mean that an individual or group is “less than” but rather acknowledges the increased risk C H A P T E R 7 n Health Disparities and Vulnerable Populations 169 • Individual discrimination refers to the behavior of individual members of one race/ethnic/gender group intended to have a differential and/or harmful effect on the members of another race/ethnic/gender group. • Institutional discrimination, on the other hand, is quite different because it refers to the policies of the dominant race/ethnic/gender institutions and the behavior of individuals who control these institutions and implement policies intended to have a differential and/or harmful effect on minority race/ethnic/gender groups. • Finally, structural discrimination refers to the policies of dominant race/ethnic/gender institutions and the behavior of the individuals who implement these policies and control these institutions, which are race/ ethnic/gender neutral in intent but which have a differential and/or harmful effect on minority race/ ethnic/gender groups. BOX 7–3 n Levels of Discrimination Source: (45) 7711_Ch07_157-190 23/08/19 10:23 AM Page 169 for adverse health outcomes and provides a means to ad- dress health inequity. Nursing care of vulnerable populations uses a frame- work of cultural competence, social justice, and human rights. The ethical code of nursing states that all indi- viduals, families, groups, and communities will receive equal nursing care.50 Nurses who demonstrate compe- tence with advocacy for social justice and protection of human rights are better able to address the social inequities of vulnerable populations. There is always a tension between availability of scarce resources and the perceived worthiness of the individual receiving these resources. Experiencing Homelessness Although not a disease, homelessness kills. Globally, per- sons experiencing homelessness often lack the resources needed for basic needs such as shelter, clothing, and food. If they experience a health issue, they may have limited access to health-care insurance, leaving the hos- pital emergency department (ED) as the primary acces- sible source of health care for homeless adults.51 Often health needs are complex and include both mental and physical health issues, and there is limited evidence on the effectiveness of interventions aimed at improving their health.52,53,54 Persons experiencing homelessness have a shorter life span.54 Viewed through the lens of social determinants of health, the relationship between homelessness and poorer health in this population is a consequence of adverse social and economic conditions. This situation leads to later diagnosis of disease and fewer resources for treating physical and mental health issues, which in turn leads to higher morbidity and mortality.54 Thus addressing social issues such as housing and access to primary care could counter the enormous economic costs of hospital care for people who are experiencing homelessness.54 Who exactly experiences homelessness? Is it someone who lives on the street or someone who lives in a shelter? What about someone sleeping on the couch of a friend or family member? To answer these questions, the U.S. government has a two-part definition of homelessness. According to The McKinney-Vento Homeless Assistance Act of 2009 that was reauthorized in 2015, someone who is homeless meets one or both of the following criteria:55 • One who lacks a fixed, regular, and adequate night- time residence • One who lives in a supervised shelter or institution designed for temporary residence, or one who lives in a place that is not normally used as accommoda- tion for people Using this definition of homelessness, a person who lives on the street, in a shelter, or is couch-surfing is ex- periencing homelessness. If a person moves from home to home constantly, then that person is lacking a fixed and/or regular nighttime residence and therefore is homeless. There are then clearly different types or levels of homelessness. Just as we separate prevention into three levels—primary, secondary, and tertiary—the standard for defining the degree of homelessness is to place those experiencing homelessness into three groups:56 • Primary homelessness includes everyone who is living without adequate shelter—those living in vehicles, surviving on the streets, staying in parks, or squatting in abandoned buildings. • Secondary homelessness includes those who are staying in a temporary form of housing because they have nowhere else to go—those living with friends or family, or in shelters. • Tertiary homelessness includes those who rent single rooms on a long-term basis without security of a fixed or permanent residence.56 Time periods provide another way of understanding homelessness. According to the National Coalition on the Homeless, there are three types of homelessness – chronic, transitional, and episodic. Those experiencing chronic homelessness are more likely to require shelter on a long- term basis, are chronically unemployed, older, and more apt to have physical and/or mental health issues. Persons experiencing transitional homelessness require shelter for a shorter period, are younger, and are more likely to ex- perience homelessness due to a catastrophic event. Those experiencing episodic homelessness are also younger, are in and out of the shelter system, are more likely to be chronically unemployed, and have medical and/or mental health issues.57 Persons Experiencing Homelessness Obtaining estimates of the number of persons who expe- rience homelessness is a challenge because of the difficulty in collecting the data. One way to get an estimate of how many people experience homelessness is to determine the number of persons experiencing homelessness on a given night. This is called a point in time estimate of homeless- ness, because a single night, or one point in time, was used to determine prevalence. In 2017, HUD found 553,742 individuals to be homeless on a single night. Less than a 170 U N I T I I n Community Health Across Populations: Public Health Issues 7711_Ch07_157-190 23/08/19 10:23 AM Page 170 fifth were chronically homeless (95,419). According to the report, a little under 112,000 had severe mental illness and little less than 90,000 had chronic substance use issues. About 7% were veterans. Based on racial categories, almost half of those tracked in this report (47%) were African American though only 13.4% of the U.S. popula- tion is African American.58 Estimating the prevalence is also done by the type of homelessness (primary, secondary, or tertiary) or the different populations experiencing homelessness. Certain segments of the population are at greater risk for experiencing homelessness. For example, families, single youths, and single adults do not experience the same rates of homelessness. There are also differences based on geography, with 50% of persons experiencing home- lessness residing in one of five states: California, New York, Florida, Texas, and Washington.57 Warmer climates make it easier to deal with issues related to weather. In the general population, using data from the 2017 Housing and Urban Development (HUD) report, less than 2% are experiencing homelessness.58 However, the HUD data does not necessarily include persons dou- bling up with friends and neighbors. Single or solitary adults, mostly males, are more likely to experience primary homelessness than those who are either solitary youths or in families. Homeless families are more likely to experience secondary homelessness than primary homelessness, as are solitary youths. Most cities responded that this was likely the result of the policies in place to protect families with children from experiencing homelessness, including policies that made it more diffi- cult to evict families who had fallen behind on their rent. Homelessness is not just a big city problem; rural homelessness does exist. Estimating how many people ex- perience homelessness in a rural setting is difficult because estimates such as that reported by HUD (Table 7-2) rely on counts of persons using services. Persons experiencing homelessness in rural areas have access to fewer rural serv- ice sites. In addition, there are a limited number of re- searchers working in rural communities.57 In comparison with urban homeless populations, the rural homeless are more likely to be white, female, married, homeless for the first time, to have jobs, and to be homeless for a shorter period of time.57 Impact on Health Adults experiencing homelessness are faced with an excess disease burden, a shorter life expectancy, limited access to care, and consumption of significantly more health-care resources when she or he does finally receive care.59-61 Establishing current prevalence of communi- cable and noncommunicable disease presents a challenge due to the lack of regular surveillance and the transient nature of the population. Available data underlines the fact that those experiencing homelessness have a higher rate of disease compared with the general U.S. population.60-62 According to the National Alliance to End Homelessness, those experiencing homelessness are three to six times more likely to have diabetes, HIV/ AIDs, cardiovascular disease, and/or a substance use dis- order.61 Between 25% to 33% of homeless persons have mental health issues, including schizophrenia, depres- sion, and bipolar disorder compared with 6% of the gen- eral population that experience the same severe mental health issues.62 A person experiencing homelessness is much more likely to arrive at the hospital in an ambu- lance, be uninsured, be admitted, and is also more likely to have a longer stay.60 The living conditions of those experiencing primary homelessness are not optimal. If a patient who is currently C H A P T E R 7 n Health Disparities and Vulnerable Populations 171 TABLE 7–2 n Prevalence of Homelessness by Race in 2017 Emergency Shelter Transitional Housing Unsheltered Total African American White Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other Race TOTAL 128,721 106,543 2,571 6,228 2,807 15,560 262,430 38,768 47,946 1,132 2,496 1,678 6,417 98,437 57,448 106,490 3,057 8072 4,040 13,768 192,875 224,937 260,979 6,760 16,796 8,525 35,745 553,742 Source: (58) 7711_Ch07_157-190 23/08/19 10:23 AM Page 171 homeless is admitted to the hospital for surgery, it will be much more difficult for that patient to keep an incision infection-free postdischarge than it will be for someone who is living in a place suitable for human shelter. Second, transportation costs make it difficult for a patient experi- encing homelessness to receive follow-up care and testing. Third, the nutritional intake of a homeless patient is irregular and less healthy than that of the general popu- lation, making diet instructions hard to follow, which may be further impacted by poor dental care. There are other complicating factors that are easily overlooked. For example, where can a diabetic homeless patient store insulin? How does such a patient keep a medication from being stolen? 172 U N I T I I n Community Health Across Populations: Public Health Issues l APPLYING PUBLIC HEALTH SCIENCE The Case of the Rubbermaid Storage Box Public Health Science Topics Covered: • Community assessment • Community diagnosis • Organization and management • Community partnerships While in graduate school pursuing a degree as an advanced public health nurse (APHN), Adele was asked to supervise a group of undergraduate nursing students assigned to take weekly blood pressure readings at a local homeless shelter, the City Gospel Mission. This faith-based nondenominational mission was located in downtown Cincinnati and provided multiple services including meals and shelter beds but did not offer health care. From her first trip to the City Gospel Mission, Adele felt compelled to reach out to this vulnerable population. Adele recognized that these men had very few options for health care, and she wanted to offer more than blood pressure screenings. As part of her practicum experience, she went to the mission on a weekly basis to provide nursing assessments, health education, and nursing care. She began to interact more with the men when they came to the clinic and worked with them to help identify their health needs and, in some cases, offer referrals. All of her supplies, including her blood pressure cuff and a glucometer, fit into a Rubbermaid storage box, which she left at the shelter. Although she was providing some assistance, she knew these men needed more. When she ap- proached her faculty preceptor, she was encouraged to apply the health planning process, do a focused assessment that would help her to understand whether there was a need for expanding the care, and consider developing the model of a nurse-managed clinic if there was a need. The faculty member explained that the assessment could provide the data she needed to develop a plan to address the health needs of the men she was seeing. In conducting part of their assessment, Adele and a fellow APHN student asked key informants, homeless men at the mission, where they sought health care. They all mentioned the ED at a nearby major urban medical center. The students’ assessment at the med- ical center focused on identifying the costs associated with nonurgent ED care for patients experiencing homelessness. The students presented the findings to the hospital performance improvement committee. The committee agreed that an intervention aimed at providing nonurgent care to homeless men outside the ED would result in a cost benefit to the hospital, and that a nurse-managed clinic model had the poten- tial to meet that need. After Adele graduated, she no longer had time to continue to provide even the small amount of nursing care she had offered at the mission. Having established a need, Adele together with her faculty preceptor sought sources of possible funding for expanding Adele’s practicum experience to establish a permanent nurse-managed clinic at the City Gospel Mission. The success of this project depended on the application of public health science and the public health competencies that Adele had acquired. First, a team was formed that included Adele, two faculty members from the Univer- sity of Cincinnati College of Nursing, the chief nursing officer from the hospital, and the director of the City Gospel Mission. The next step was to flesh out the initial assessment conducted by Adele and her fellow student. Adele’s assessment of ED use by the homeless was crucial information for the potential cost/benefit of the clinic. However, to help understand the breadth of the problem, further assessment was done using aggre- gate data from the City Gospel Mission on the number of potential clients for the clinic as well as secondary analysis of available data on the prevalence of primary homelessness in the city of Cincinnati. These data pro- vided a clear picture of the need for the clinic. The final step was to develop the program expanding on Adele’s Rubbermaid container of supplies to include a more comprehensive nurse-managed clinic model. The team chose a nurse-managed clinic model that would link with other resources in the city. Thus, 7711_Ch07_157-190 23/08/19 10:23 AM Page 172 C H A P T E R 7 n Health Disparities and Vulnerable Populations 173 patients of the clinic would receive nursing assess- ments, health education, and nursing care under the direction of Adele and be referred to other clinics for more complex medical problems. To do this, the project needed start-up funds to provide supplies, equipment, a method to keep clinic medical records, and to conduct an evaluation. The first grant application was not funded. The team took the grant reviews, refined the application, and submitted it to another funding agency. They were successful this time in obtaining a 2-year start-up grant. The grant application succeeded based on three key elements: (1) a clear delineation of the need for the clinic; (2) evidence of sustainability of the clinic once the funding was exhausted; and (3) a clear plan to evaluate the effectiveness of the clinic. Sustainability refers to the ability of a program to be maintained once the funding period has been completed. In this case, the three organizations that supported the grant—the college, the hospital, and the shelter—all committed to maintaining the clinic if the evaluation demonstrated that it was effective. The college com- mitted to sending students to the clinic for clinical experiences, and the hospital agreed to be the “owner” of the clinic, that is, staff would maintain the medical records and provide salary support for Adele to continue her work at the clinic. City Gospel Mission agreed to continue to provide the space and utilities for the clinic. The homeless men also became partners, offering suggestions about time, location, and some of the health needs they would like to see met. They also saw a role in helping with the running of the clinic. After 2 years of clinic implementation, the evalua- tion team demonstrated that the clinic had indeed improved health outcomes. One of the faculty mem- bers from the college conducted the evaluation. Atten- dees at the clinic were asked to complete a survey the first day they used the clinic and at least 2 months after they had begun to use the clinic. Forty-five homeless adults completed both a baseline survey and a survey after starting care at the clinic. There was a significant increase in the percentage of participants who were very satisfied in relation to perceived quality and avail- ability of health care. In addition, there was a significant improvement in health-related quality of life in relation to mental health, physical problems, and vitality.63 Adele’s story is true. Although the grant ended in 2006, the nurse-managed clinic was still operating in 2018. The City Gospel Mission had built a new facility and included a clinic for the nurses. They continue to see 30 or more persons a night. The clinic is staffed by volunteer nurses, nursing students, and, of course, Adele, who provides nursing care, as well as extra emotional support to her patients. The important issue here is that Adele alone with her Rubbermaid container was not enough. Adele took her enthusiasm and concern for a vulnerable population and built a team. The use of solid public health approaches re- sulted in organizational commitment. Addressing the health-care challenges for those who are vulnerable requires this approach and can be successfully initiated, implemented, and sustained by nurses. Interventions and Services for Persons Experiencing Homelessness Even in the best of circumstances, health-care providers experience problems in an acute care setting in helping any patient manage personal health for the long term. For example, sometimes it is difficult to ensure that, after discharge, patients will follow up on time with their health-care providers. Other times, patients may not take their medicines as prescribed, which makes it even more difficult to ensure that conditions are treated in the best way possible. In primary care, patients might not get rec- ommended testing because of embarrassment (e.g., colonoscopy) or because of costs associated with that testing. Each of these problems is magnified for patients who are also experiencing homelessness. Shelter Housing is the biggest need of the homeless. Simply pro- viding housing can improve the health of the homeless and reduce the number of hospital visits and hospital ad- missions.59, 60 Homeless shelters provide an immediate and temporary solution, usually for a stipulated and limited amount of time (e.g., 3 months) for an individual or a family. It is a safe and warm place to sleep and, in areas of the United States when the winter weather is more severe, an essential service. Shelters are frequently sponsored by nonprofit organizations that have religious and/or government sponsorship. Most shelters limit their service to certain groups of people, frequently not allowing any alcohol or illegal drugs, and have in place strict rules about there being no violence in the shelter. Many provide separate space or facilities for adolescents and families with children. Most shelters open late in the afternoon and close early in the morning, leaving the person staying at the shelter on the street for the daylight hours. Usually, shelters offer their service free of charge, 7711_Ch07_157-190 23/08/19 10:23 AM Page 173 and some will provide an evening meal for those staying at the shelter. Some communities supplement their night shelters with day shelters where people can go during the time the night shelters are closed. These facilities usually have an array of social services to help with permanent housing, job placements, mental health care and services for those with addictions, and job training. There may also be showers, laundry facilities, used clothing avail- able, as well as other amenities to help individuals and families secure more permanent housing. A step above the shelters is the more permanent tran- sitional housing, which is affordable due to significant sub- sidies, but again, there is usually a time limit (6 months to 2 years). People who agree to live in transitional housing usually must participate in programs that provide coun- seling, job searches, and job and educational training. Peo- ple are taught skills on how to maintain more permanent housing and manage their money. Permanent affordable housing is the long-term solu- tion. If the rent is subsidized based on the resident’s income, the person is usually allowed to stay as long as he or she remains in the low-income bracket. Permanent supportive housing combines this housing assistance with services for homeless persons with disabilities. Usually, they serve individuals and members of that household who have serious mental illnesses, chronic substance abuse problems, physical disabilities, or AIDS and related diseases. People may receive these services either at the housing site or through partnering agencies. Preventing homelessness is a cost-effective interven- tion. Funds can be used to pay expenses and resolve sit- uations in certain circumstances so that individuals and households can avoid homelessness, receive support services to help them pay for the cost of their housing, and develop skills and employment to avoid a recurrence of the problem. Moving people rapidly into permanent housing has also been shown to be cost effective and is the goal now of several nongovernmental organizations. Food When families and individuals live in poverty, they fre- quently have to make impossible choices between paying the rent, buying food, or buying essential medications. This can lead to homelessness and decreased ability to provide adequate food. Homelessness and hunger are in- separably linked. Those experiencing homelessness often experience food insecurity. The United Nations World Food Summit in 1996 defined food security as existing “when all people at all times have access to sufficient, safe, nutritious food to maintain a healthy and active life.”64 This definition of food security usually includes both physical and economic access to food that meets people’s dietary needs as well as their food preferences. In 2017, in the United States, 15.1% of households experienced food insecurity at some time during the year.65 The rate was higher (18.1%) in households with children.65 Non- profit organizations frequently help to provide food se- curity through private donations to food pantries, food banks, and soup kitchens. Health Care Steps are being taken to help address some of the barriers the homeless face in trying to attain health care, espe- cially access to health care. In many cities, health-care services are provided at places frequented by those expe- riencing homelessness, for example, soup kitchens and shelters. Outreach workers often go to the locations where the homeless are and tell them about the availabil- ity of different health-care resources. Some communities have mobile medical units that can travel to the patients’ locations. Some of these mobile medical units are very specialized (such as only providing dental care), and others provide primary care and referral services. Policy The housing-first model promotes providing immediate housing with supportive services and is gaining traction nationally. The underlying premise of housing-first is that obtaining health, security, and wellness is best achieved by first providing housing without other prerequisites.66 Sup- portive housing is effective for those who have had a long history of homelessness, for homeless veterans, and for those who are homeless with mental health and addiction problems.66 Preventing families from becoming homeless, along with very rapid rehousing if the family does become homeless, is also effective policy. Preventing individuals with disabilities from becoming homeless is also effective and requires the collaboration of health-care providers, social workers, and individuals who monitor subsidized supportive housing. Providing more and better mental health services, effective services to individuals who have suffered domestic violence, and creating additional addic- tion treatment centers also will have an impact on prevent- ing homelessness and will provide the additional support services necessary for individuals to keep their housing. Immigrants, Migrants, Refugees, and Asylees In the United States, migrants, immigrants, refugees, and asylees are often grouped together as one population, even though they are distinctly different populations. 174 U N I T I I n Community Health Across Populations: Public Health Issues 7711_Ch07_157-190 23/08/19 10:23 AM Page 174 They are distinct, though sometimes overlapping, popu- lations with different risk factors for adverse health outcomes and different barriers to achieving optimal health. The recent political debate over whether to admit immigrants or grant asylum highlights the importance of understanding the differences among these popula- tions as well as understanding how membership in one of these groups increases vulnerability in different ways. Immigrants Immigrant as defined by the Merriam-Webster diction- ary is a person who comes to a country to take up permanent residence.67 In the glossary of terms on the U.S. Department of Homeland Security (DHS) Web site, a reader looking up the term immigrant is referred to “Permanent Resident Alien.” A permanent resident alien is “An alien admitted to the United States as a law- ful permanent resident”68 such as a person who is not a citizen but who entered the country with a valid visa, or obtained a work permit, as well as permission to stay indefinitely. Illegal alien is a term sometimes used to describe those who enter a country without proper permission and with the intent of becoming permanent residents. For example, under the definition of perma- nent resident alien in the DHS glossary of terms is this qualifier: “… however, the Immigration and Nationality Act (INA) broadly defines an immigrant as any alien in the United States, except one legally admitted under spe- cific nonimmigrant categories (INA section 101(a)(15)). An illegal alien who entered the United States without inspection, for example, would be strictly defined as an immigrant under the INA but is not a permanent resi- dent alien.”68 Other terms in use include undocumented workers and undocumented immigrants based on a con- cern over possible stigma associated with the use of the term illegal alien. These two terms are not listed in the DHS glossary. (See the DHS Web site for more detail on the different categories of immigrants and different types of visas.) Migrant Workers The term migrant worker is used to describe those who move from place to place to get work and who often work in another country that is not their own.69,70 Globally, there are approximately 32 million migrants (3.1% of the global population).70 Across the globe, migrant workers are at increased risk for exploitation because of limited social protection, inequalities in the labor market, and increased risk for human trafficking.71 Migrant workers are at greater risk for experiencing modern slavery. Modern slavery includes the selling of people in public markets; women forced into marriage to provide labor; and forced work inside factories or fish- ing boats where salaries are withheld, or under threats of violence, that is, labor extracted through force, coercion, or threats.71 The Walk Free foundation and the Interna- tional Labour Organization developed the Global Slavery Index to help address the gap in knowledge related to the extent of modern slavery. They reported that, in 2016, there were 40.3 million persons living in modern slavery, 24.9 million were in forced labor, and 15.4 million were living in a forced marriage. Regions with a high level of modern slavery include Africa and Asia. However, data from Arab states in the Middle East were not avail- able, countries that host 17.6 million migrant workers.72 Modern slavery is also a concern in the U.S., with a par- ticular focus on sex trafficking, forced labor, bonded labor, child labor, and domestic servitude (see Box 7-4).73 Migrant Agricultural Workers in the U.S. In the U.S., migrant agricultural workers provide much of the labor in the agricultural industry, with an esti- mated 2.5 to 3 million migratory and seasonal agricul- tural workers in the United States.73, 74 Not all migrant C H A P T E R 7 n Health Disparities and Vulnerable Populations 175 “Trafficking in persons,” “human trafficking,” and “modern slavery” are used as umbrella terms to refer to both sex trafficking and compelled labor. The Trafficking Victims Protection Act of 2000 (Pub. L. 106-386), as amended (TVPA), and the Protocol to Prevent, Suppress, and Punish Trafficking in Persons, Especially Women and Children, supplementing the United Nations Convention against Transnational Organized Crime (the Palermo Protocol) describe this as compelled service using a num- ber of different terms, including involuntary servitude, slavery or practices similar to slavery, debt bondage, and forced labor. Human trafficking can include, but does not require, movement. People may be considered trafficking victims regardless of whether they were born into a state of servitude, were exploited in their home town, were transported to the exploitative situation, previously consented to work for a trafficker, or participated in a crime as a direct result of being trafficked. At the heart of this phenomenon is the traffickers’ aim to exploit and enslave their victims and the myriad coercive and decep- tive practices they use to do so. BOX 7–4 n U.S. Department of State’s Answer to the Question “What is Modern Slavery?” Source: (73) 7711_Ch07_157-190 23/08/19 10:23 AM Page 175 agricultural workers are immigrants. In the 2018 report by the National Center for Farm Worker Health, 47% of crop workers were unauthorized, 31% were citi- zens, 22% had work visas, and 73% were foreign born.74 Under Title 29 of the U.S. Code, “A migrant agricultural worker is a person employed in agricultural work of a seasonal or other temporary nature who is required to be absent overnight from his or her permanent place of residence. Exceptions are immediate family members of an agricultural employer or a farm labor contractor, and temporary H-2A foreign workers. (H-2A temporary foreign workers are nonimmigrant aliens authorized to work in agricultural employment in the United States for a specified time period, normally less than 1 year.)”75 In 2018, farmers and agricultural businesses that relied heavily on migrant workers blamed severe shortages of labor on the tightening of immigration laws in the U.S.76,77 Because migrant workers move around or are fre- quently away from their permanent place of residence, establishing residency for benefits (e.g., federal assis- tance through food stamps) is often difficult for this group. Most of these workers have no access to workers’ compensation or disability compensation. Many mi- grant farm workers employed in planting and harvesting follow the crops for jobs. For example, major agricul- tural work starts in California, Texas, and Florida. These starting points result in three streams of workers: the western stream from California to Washington State, the midwestern stream from Texas to all the midwestern states, and the eastern stream from Florida through Ohio to Maine (Fig. 7-6). These streams represent how migrant workers follow the jobs, especially in agricul- ture, where the time to harvest crops changes with the seasons. In the past few years, these streams have been less distinct.74 176 U N I T I I n Community Health Across Populations: Public Health Issues WA OR CA NV MT ID WY UT AZ CO NM TX ND SD NE KS OK MO AR MN WI IL IA TN LA AL MA MS FL KY ID MI OH GA SC NC WV VA MD DE CT NJ NY PA NH ME VT RI PR Major Migratory Streams for Farmworkers in the United States West Coast Stream Midwestern Stream East Coast Stream Figure 7-6 Migratory patterns of migrant farm workers. (Copyright (c) 1985–2002 National Center for Farm Worker Health, Inc. Used with permission. Retrieved from http://www.ncfh.org/) 7711_Ch07_157-190 23/08/19 10:23 AM Page 176 This group is particularly vulnerable for multiple reasons. In 2017, only 31% of migrant agricultural work- ers reported that they could speak English well and 27% could not speak English at all.74 In relation to health care, more than a third were uninsured (36.3%) and 63.5% lived below the poverty level.78 Impact on Health Poor, substandard housing is frequently a part of the life of a migrant or seasonal farm worker. If a person has to continually move to find work, it is more likely that the person moving will not have long-term or stable housing, putting him or her into one of the groups of tertiary, sec- ondary, or possibly even primary homelessness. The health of migrant workers reflects their poverty and poor living situations, making them vulnerable to conditions no longer thought of as being prevalent in the United States. Most foreign workers are from Mexico78 and have a higher incidence of tuberculosis, other communicable diseases, and poor nutrition in addition to having daily exposure to the dangerous occupation of farming and to pesticides. The workers live in crowded housing and working condi- tions, making them six times more likely to develop tuberculosis when compared with other workers.78 Intervention and Services for Migrant Workers Despite efforts at the federal level to help with building housing, substandard housing continues to be an issue for migrant workers.79,80 There is the option of housing C H A P T E R 7 n Health Disparities and Vulnerable Populations 177 l APPLYING PUBLIC HEALTH SCIENCE The Case of the Wandering Diabetic Public Health Science Topics Covered: • Focused community assessment • Partnership building • Advocacy Sara, a nurse at the local nurse-managed clinic run by the hospital, met Manuel and listened to his story. He told Sara he had lived in 12 states, following the jobs. He had dropped out of high school to help raise his siblings, and with the tough economy and his lack of education he couldn’t find anything except seasonal and other temporary work. This meant he held many differ- ent jobs as he traveled from place to place to find work. He worked as a ranch hand, did construction work, and followed the promise of riches to the oil fields of North Dakota. When the oil fields started letting workers go, there were few other jobs available. He returned to his home base in New Mexico and slept on friends’ couches for the first few months he was in town. After 4 months, he had worn out his welcome. Finally, Manuel found a job as an agricultural worker that had a workers’ tent city where he could live. Manuel came to the clinic because he was a type 1 diabetic, and with the lack of reliable refrigeration, he was no longer able to store his insulin and hoped that Sara had some ideas about where he could store it. He also had sores on his feet that worried him. He told Sara that many people in the tent city had limited re- sources, minimal electricity, and only a central water spigot that served as the main source of water for the workers and their children. After assessing her patient, Sara wondered if the lack of refrigeration and sanitation concerns were part of the underlying health problems being experienced by Manuel and some of her other patients. She started by gathering data about the tent city and its residents. She investigated the unmet health needs of this group of people and examined the impact of the squalid living conditions using a qualitative survey of the residents (see Chapter 4). Many of the respondents to the sur- vey stated that they had recently experienced infec- tions. Others had noncommunicable diseases that they were unable to manage properly. Based on this preliminary assessment, Sara collabo- rated with other health partners to come up with solutions. She contacted her colleagues at the hospital, including the diabetes management experts and com- municable disease experts. She also contacted the local health department to request assistance in examining options for this group. Next, she formed a coalition with her colleagues and other agencies, and used this coalition to inform policy makers about the situation at the tent city. By doing so, she advocated for the health of her patients. Sara applied for a grant to extend the clinic services to include a weekly outreach clinic at the tent city. She also found a local company to donate a generator so that Steven and other residents would have electricity for refrigeration to safely store their medications. Sara used a public health approach to the problem. She gathered data to examine the problem and applied her problem-solving skills in helping a population. She worked with the public health department and the hospital to evaluate the outreach program so that they would have evidence to share that would help other free clinics and public health departments that were trying to solve the same problem. 7711_Ch07_157-190 23/08/19 10:23 AM Page 177 located on the farm, but that generally means lower wages because housing rent is removed from the base salary, and there’s no guarantee that the housing will be adequate. The off-the-farm option usually consists of very makeshift shelters, not close to any basic infra- structure, and with limited or absent water access and sanitation. Farm workers, as a vulnerable population (low liter- acy levels, different culture and language, poverty), have difficulty accessing health care, paying for health care, and participating in prevention activities. Migrant farmers usually work for an hourly wage or per item harvested or planted, and do not have the luxury of sick time or paid time to visit a health-care provider. Ac- cording to the National Center for Farm Worker Health, migrant workers are faced with numerous bar- riers related to accessing adequate health care. These include the cost of coverage, lack of health-care providers in the area, and lack of transportation to health-care services.78 Another issue is the cultural and language barrier that prevents workers from knowing about accessible services.74, 78 Children of migrant workers are especially susceptible to unmet health needs. More than half (57%) of migrant workers are parents. In addition, an estimated 300,000 to 500,000 children under the age of 18 are engaged in agricultural work. Not only do children of migrant work- ers have less access to care, their mothers are often ex- posed to toxic pesticides during pregnancy. More than one half have unmet medical needs.81 Policy At the global level, goal 10 of the United Nations’ Sus- tainable Development Goals includes as one of the tar- gets: “Facilitate orderly, safe, regular, and responsible migration and mobility of people, including through the implementation of planned and well-managed migration policies”.82 In the U.S., the Immigration and Nationality Act (INA), protects immigrant and workers’ against dis- crimination. The law specifically prohibits “1) citizenship status discrimination in hiring, firing, or recruitment or referral for a fee; 2) national origin discrimination in hir- ing, firing, or recruitment or referral for a fee; 3) unfair documentary practices during the employment eligibility verification, Form I-9 and E-Verify; and 4) retaliation or intimidation.”83 The Affordable Care Act (ACA) does not directly ben- efit migrant workers, especially those who are undocu- mented. Employers with 50 or more employees are mandated to provide health-care insurance. Because farms use seasonal workers, the ACA uses a different formula. If the farm employs on average more than 50 full-time seasonal workers for fewer than 121 days, then the farm is not required to provide health-care cov- erage. In addition, workers who are undocumented are not required to purchase individual health-care insur- ance. This may leave a segment of the workforce unin- sured. In some cases, large farms are establishing clinics. Many migrant workers currently pay for health care out of pocket. Thus, further policy may be needed to cover the cost of health care to this population. Refugees and Asylees The 1980 Refugee Act in the United States, which is still in effect, defines a refugee as “a person outside of his or her country of nationality who is unable or unwilling to return because of persecution or a well-founded fear of persecution.”84 This definition is based on a United Nations 1951 Convention that states, “any person who, owing to a well-founded fear of being persecuted for rea- sons of race, religion, nationality, membership in a par- ticular social group, or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who not having a nationality and being out- side the country of his former habitual residence as a re- sult of such events, is unable or, owing such fear, is unwilling to return to it.”85 Refugees and asylees seeking resettlement in the United States constitute a special type of immigrant. An asylee is also a person “who is unable or unwilling to re- turn to his or her country of nationality because of per- secution or a well-founded fear of persecution on account of race, religion nationality, membership in a particular social group, of political opinion.”86 The dis- tinction between the two is that a person asking to re- ceive refugee status is outside the United States and seeking to enter, whereas an asylee is a person already re- siding in the United States when applying for asylum.86 Other terms used to describe forcibly displaced persons include internally displaced persons, stateless persons, and returnees (Box 7-5).87 The challenges facing refugees are the subsequent political issues around who should and who should not be allowed to seek asylum, with po- litical parties taking sides. Refugees Seeking Asylum In 2017, 68.5 million persons worldwide were forced from their homes by disasters, conflict, and persecution, up from 43.3 million in 2010. According to the UN HCR, every 20 minutes “… people leave everything behind to escape war, persecution, or terror.”88 Of these, 25.4 million 178 U N I T I I n Community Health Across Populations: Public Health Issues 7711_Ch07_157-190 23/08/19 10:23 AM Page 178 were refugees and 3.1 million were seeking asylum. More than half (57%) were from three countries, South Sudan, Afghanistan, and Syria. Turkey accepted the highest number of refugees (Table 7-3).88 In the U.S., the Trump administration announced in September of 2018 that the maximum number of refugees the U.S. would accept in 2019 would be dropped from 45,000 (the cap in 2018) to 30,000, the lowest num- ber in decades. Given the total number of refugees world- wide (25.4 million), this represents only 0.12% of refugees worldwide. Despite the existing cap of 45,000, only 19,899 refugees were admitted into the U.S. between October 2017 and the end of August 2018.89 Refugees seeking asylum are often in a position of in- security and unknown outcomes, many remaining in refugee camps for several years as the problems resolve in their own country. There currently are three sugges- tions for a permanent solution to the temporary refugee settlements. The preferred solution is for the refugees and asylees to be repatriated, returning to their home country when it is once again safe. However, this must be volun- tary and currently is occurring less frequently. If they can’t go home, there are two other options—they can stay in the host country, which most host countries do not want, or request resettlement to a third country.88 Impact on Health Refugees victimized by war and/or political repression, famine, or natural disasters frequently experience food insecurity, poor sanitation, exposure to multiple com- municable diseases, violence, and mental health issues with limited medical care both while fleeing their country of origin and while in refugee settlement camps in the host country. Many live in refugee camps, some for sev- eral years, with a major impact on their health. Those liv- ing in refugee camps are at greater risk for a number of health issues including chronic disease90, intimate part- ner violence,91 and poor sanitary conditions.92 Children in refugee camps are at increased risk for stunted growth due to chronic malnutrition.93 Mental health poses a significant health risk for refugees. Post-traumatic stress disorder (PTSD) and de- pression are common diagnoses among those in the re- settlement programs who have had severe exposure to violence.94-96 Silove, Ventevogel, and Rees presented an ecological model related to the mental health risk factors associated with migration including events prior to mi- gration, the stresses that occur during migration, and C H A P T E R 7 n Health Disparities and Vulnerable Populations 179 Refugees A refugee is someone who fled his or her home and country owing to “a well-founded fear of persecution be- cause of his/her race, religion, nationality, membership in a particular social group, or political opinion”, according to the United Nations 1951 Refugee Convention. Many refugees are in exile to escape the effects of natural or human-made disasters. Asylum Seekers Asylum seekers say they are refugees and have fled their homes as refugees do, but their claim to refugee status is not yet definitively evaluated in the country to which they fled. Internally Displaced Persons Internally Displaced Persons (IDPs) are people who have not crossed an international border but have moved to a different region than the one they call home within their own country. Stateless Persons Stateless persons do not have a recognized nationality and do not belong to any country. Statelessness situations are usually caused by discrimination against certain groups. Their lack of identification—a citizenship certificate—can exclude them from access to important government services, including health care, education, or employment. Returnees Returnees are former refugees who return to their own countries or regions of origin after time in exile. Returnees need continuous support and reintegration assistance to ensure that they can rebuild their lives at home. BOX 7–5 n Types of Forcibly Displaced Persons Source: (87) TABLE 7–3 n Refugees Accepted by Country Country Turkey Pakistan Lebanon Islamic Republic of Iran Germany Bangladesh Sudan Source: (88) Approximate Number of Refugees Hosted 3.5 million 1.4 million 998,900 979,000 970,400 932,200 906,600 7711_Ch07_157-190 23/08/19 10:23 AM Page 179 events that occur during the resettlement phase. They state that these events represent a “… dynamic inter-relationship of past traumatic experiences, ongoing daily stressors, and the background disruptions of core psychosocial systems, the scope extending beyond the individual to the conjugal couple and the family.”96 Intervention and Services The U.S. Public Health Service requires a health screen- ing for all immigrants and refugees prior to departure from their country of origin or their host countries. Refugees can be kept from immigrating if they have un- treated communicable disease, an untreated substance abuse disorder, or a mental illness that causes them to respond violently. If the refugee agrees to treatment, then he or she can be reconsidered for immigration.97 Upon arrival, refugees are eligible for 8 months of Med- icaid or Refugee Medical Assistance (RMA).98 During this 8-month period, refugees need to complete re- quired health screenings, begin to understand the health-care system, begin to learn English, and seek out and secure paid employment. After the 8-month period is over, many are then eligible for expanded health in- surance options under the ACA.98 They are also en- couraged to apply if eligible for other subsidy programs, such as Supplemental Security Income, for which they are entitled in their status as a refugee. Based on current global trends, the refugee issue con- stitutes a complex crisis. Politically, countries struggle with whether to accept refugees while millions continue to flee conflict and violence. Unaccompanied children and orphans further complicate the crisis. Central to the crisis is the ongoing short- and long-term consequences on the physical and mental health of the refugees. Health- care professionals continue to provide a central role in addressing the adverse effect of migration on populations seeking work, asylum, and resettlement because it is the nurses, physicians, and other health-care providers who provide health screening and treatment, and contribute to overall planning for the care of these extremely vulner- able populations. Incarcerated and Correctional Populations According to the U.S. Department of Justice, the incar- cerated population includes persons living under the jurisdiction of state or federal prisons, and in the custody of local jails. The correctional population includes the incarcerated population as well as persons living in the community while supervised on probation or parole.99 According to global data the U.S. has the highest incarceration rate in the world. In 2017, the U.S. incar- ceration rate was 655 inmates per 100,000 people compared to 77 per 100,000 in Germany.100 This is an alarming statistic for the sheer numbers, but equally important because once individuals have a history of incarceration, they have limited opportunities for employment, education, housing, and a stable family life. This in turn has significant impact on health.101 Persons Experiencing Incarceration Based on the U.S. Department of Justice data in 2016, a total of 2,162,400 persons were incarcerated in the U.S., out of an estimated 6,613,500 persons supervised by U.S. adult correctional systems or approximately 1 in 38 adults age 18 or older in the United States.102 Overall the jail incarceration rate in the U.S. was 860 prison or jail inmates for every 100,000 adults ages 18 and older, down from 1,000 per 100,000 in 2006 to 2008.103 African Americans were disproportionately repre- sented in this population with an incarceration rate among Non-Hispanic black adults 3.5 times higher than non-Hispanic white adults (599 per 100,000 versus 171 per 100,000, respecively).103, 104 However, looking at trends over the past decade, there has been a drop in the incarceration rate for African American men (9.8%) and women (30.7%) while at the same time there has been an increase in incarceration rate for white men (8.5%) and women (47.1%). The incarceration rate for Latino men declined 2.2% and rose 23.3% for Latina women.104 The U.S., even in states with more progressive approaches to incarceration, has a higher rate of incar- ceration than almost all other countries.105 However, many of the issues related to incarceration remain the same across countries. Issues include the debate related to punishment versus rehabilitation and what constitutes progressive reform related to imprisonment. Impact on Health Under the 1976 U.S. Supreme Court ruling Estelle v. Gamble, states are compelled to provide a constitution- ally adequate level of medical care for those who are incarcerated or care that generally meets a “community standard.”106 As the cost of health care increases, the cost to the state prison system increases as well. Not only does incarceration itself increase a person’s vulnerability, vul- nerable subpopulations are over-represented in prisons and jails. This translates into a greater need for health care. For example, the prevalence of hepatitis C is higher 180 U N I T I I n Community Health Across Populations: Public Health Issues 7711_Ch07_157-190 23/08/19 10:23 AM Page 180 in prisons.107 In addition there is an increasing preva- lence of noncommunicable diseases, and a high preva- lence of mental health and substance use disorders.101 The increase in the number of incarcerated older adults presents an emerging challenge for the correctional sys- tem due to a higher prevalence of noncommunicable dis- eases as well as cognitive disorders such as Alzheimer’s disease.108 The health needs of the incarcerated and correc- tional population reflect the health needs of the other populations they represent—in general, a vulnerable population of poverty with limited access to health care, low education levels, at-risk drug and alcohol use, men- tal health issues, and communicable disease such as hepatitis and HIV. All of these problems are amplified in prison. The stresses of prison life, poor diet, and frequently less than adequate medical care often exac- erbate noncommunicable conditions such as diabetes and hypertension. Men and women who are incarcerated or in the cor- rectional system experience higher rates of comorbidities of substance use and psychiatric disorders. These psychi- atric diagnoses include major depressive disorder, anti- social personality disorder, anxiety, PTSD, borderline personality disorders, and eating disorders. In one study, incarcerated women with a history of at-risk drug and alcohol use were nearly twice as likely to have affective disorder, a major depressive disorder, PTSD, or border- line personality disorder as women in the community.101 With 2.4 million schoolchildren having an incarcerated parent, there is also a collateral impact on families, in- cluding both significant economic effects and major mental health effects on the children.109 Policy Approaching the issue of incarceration requires imple- menting policy across the continuum of upstream, mid- stream, and downstream. An example of upstream policy is working with high-risk youth at the community level to promote education, provide opportunity for advance- ment, and prevent incarceration. Examples of midstream policies include providing alternatives to jail and prison for minor offenses, promoting education through these alternative sentencing options, providing treatment for mental health and substance use disorders, and providing opportunities for employment. This requires a cultural shift from zero tolerance to a broader concept of early re- habilitation and remediation efforts outside of the jail or prison to help prevent later, more serious crimes. Down- stream interventions provided within the context of re- habilitation rather than punishment have the potential to help vulnerable populations obtain access to education and behavioral health services with the intention of improving their opportunities of gainful employment on release. C H A P T E R 7 n Health Disparities and Vulnerable Populations 181 n EVIDENCE-BASED PRACTICE Use of Agonist Treatment for Persons Experiencing Incarceration In the U.S., more than half of persons incarcerated in state prisons and more than 60% of those incarcerated in jails meet the criteria for a substance abuse disorder.1 Yet few prisons or jails provide treatment for Opioid Use Disorder (OUD) to their inmates.2 Practice Statement: During incarceration persons with an OUD should be offered medication-assisted treatment (MAT), the gold standard for treatment of an OUD (Chapter 11). Targeted Outcome: All persons incarcerated in jails or prisons diagnosed with an OUD will be provided with MAT as well as direct links to providers of MAT in their community on release. Supporting Evidence: The effectiveness of MAT to treat OUDs in the general population is well documented.3 There is emerging evidence that MAT delivered to persons while incarcerated can result in better outcomes. In one study conducted in Britain, “… prison-based opioid substitution ther- apy was associated with a 75% reduction in all-cause mortality and an 85% reduction in fatal drug-related poisoning in the first month after release.”4 Recommended Approaches: MAT can be delivered using three different medications. Methadone and buprenorphine work as opioid agonists and thus suppress and reduce cravings for the abused drug. Naltrexone is an opioid antagonist that works in the brain to prevent opiate effects (e.g., feelings of well-being, pain relief) as well as the desire to take opiates. Choosing which medication to administer is done on a case-by-case basis (see Chapter 11). In addition to the administration of MAT, during the period of time a person is incar- cerated additional psychosocial treatment should be provided, as well as a warm handoff at the time of release. That is, the person should not only be told where to obtain a continuation of MAT but have a firm appointment and evidence that they have any needed transportation assistance to make their first appointment at the clinic, primary care office, or treatment facility. 7711_Ch07_157-190 23/08/19 10:23 AM Page 181 Lesbian, Gay, Bisexual, Transgender, Queer+ According to the WHO, persons who do not conform to established gender norms often face stigma, discrimina- tory practices, and/or social exclusion. This can adversely affect health through increased susceptibility to diseases as well as their mental and physical health. It can also re- sult in decreased access to health services, all of which can result in poorer health outcomes.110 In the U.S. and in other high-income countries, LGBTQ+ persons have experienced growing inclusion into the mainstream of society as evidenced by the increasing recognition of LGBTQ+ marriages. Despite this growing acceptance, those who identify as LGBTQ+ continue to experience discrimination from friends, family, and others, with in- creased risk for adverse health outcomes and becoming victims of violence. From a public health perspective, LGBTQ+ persons’ risk for poorer health outcomes re- quires action at the population level. However, before health-care professionals can address the health-care needs of this population, they must first understand the underlying social constructs associated with the LGBTQ+ community. The traditional social construct focuses on the char- acteristics of women and men including the “… norms, roles, and relationships of and between groups of women and men.”110 Moving away from this traditional con- struct is the presentation of gender identification and sexual orientation occurring across a continuum rather than in the more traditional binary model of female or male. This continuum includes persons who identify as straight (cisgender), gay, lesbian, bisexual, transgender, agender, or other gender-based terms (LGBTQ+) (see Box 7-6).111 Understanding these terms requires shifting from only a biological approach to a broader under- standing of how we view ourselves. As depicted in the graphic, Gender Bread Person, this involves an intricate interplay of our gender identity, our gender expression, and who we wish to be with sexually and romantically (see Fig. 7-7). This not only includes gender identity but also gender expression, our biological sex, as well as who we are sexually attracted to and who we are romantically attached to. For example, a cisgender person identifies 182 U N I T I I n Community Health Across Populations: Public Health Issues References 1. Bronson, J., & Stroop, J. (2017, June). Drug use, de- pendence, and abuse among state prisoners and jail inmates, 2007-2009. U.S. Department of Justice Special Report. Retrieved from https://www.bjs.gov/ content/pub/pdf/dudaspji0709 2. Lopez, G. (2018, Mar 26). How America’s prisons are fueling the opioid epidemic. Vox. Retrieved from https://www.vox.com/policy-and-politics/2018/3/13/ 17020002/prison-opioid-epidemic-medications- addiction 3. Substance Abuse and Mental Health Services Admin- istration. (2015). Medication and counseling treatment. Retrieved from https://www.samhsa.gov/medication- assisted-treatment/treatment#medications-used- in-mat 4. Hedrich, D., Alves, P., Farrell, M., Stöver, H., Møller, L., & Mayet, S. (2012). The effectiveness of opioid maintenance treatment in prison settings: A systematic review. Addiction, 107(3), 501–517. https://doi-org.ezp.welch.jhmi.edu/10.1111/ j.1360-0443.2011.03676.x Asexual: The lack of a sexual attraction or desire for other people. Androgynous: Identifying and/or presenting as neither distinguishably masculine nor feminine. Bisexual: A person emotionally, romantically, or sexually attracted to more than one sex, gender, or gender identity although not necessarily simultaneously, in the same way, or to the same degree. Cisgender: A term used to describe someone whose gender identity aligns with the sex assigned to them at birth. Gay: A person who is emotionally, romantically, or sexually attracted to members of the same gender. Gender fluid: A person who does not identify with a single fixed gender and expresses a fluid or unfixed gender identity. Genderqueer: A term for people who reject notions of static categories of gender and embrace a fluidity of gender identity and often, although not always, sexual orientation. Lesbian: A woman who is emotionally, romantically, or sexually attracted to other women. Queer: A term people often use to express fluid identi- ties and orientations. Often used interchangeably with “LGBTQ.” Transgender: An umbrella term for people whose gender identity and/or expression is different from cultural and social expectations based on the sex they were assigned at birth. BOX 7–6 n Gender Identity Terms Source: (111) 7711_Ch07_157-190 23/08/19 10:23 AM Page 182 with the gender they were assigned to at birth, they express themselves in that gender, and they are sexually and romantically attracted to cisgender persons assigned to a different gender at birth. The challenge for health-care providers is to provide an opportunity for patients to share their identity in relation to gender and sexual orientation in a way that is accepting. In 2011, the Joint Commission, the primary accreditation body for health-care facilities, stated that “Admitting, registration, and all other patient forms should provide options that are inclusive of LGBTQ+ pa- tients and families, and should allow LGBTQ+ patients to self-identify if they choose to do so.”112 Yet most health admission and assessment documents continue to use the binary approach of male or female. In addition, few medical schools or nursing schools include essential content related to caring for LGBTQ+ persons in their curriculum.113 Another problem is the lack of data on LGBTQ+ per- sons due to how health surveys ask the gender question. To address this, HP 2020 included two measurable objectives under the new topic of Lesbian, Gay, Bisexual, and Transgender Health with targets for increasing the number of population-based data systems that include questions related to sexual orientation and gender iden- tity at the state and national level.114 C H A P T E R 7 n Health Disparities and Vulnerable Populations 183 Figure 7-7 Gender Bread Person. (Artist Sam Killerman, uncopyrighted. Retrieved from http://itspronouncedmetrosexual.com/ genderbread-person/) n HEALTHY PEOPLE Lesbian, Gay, Bisexual, and Transgender Health Goal: Improve the health, safety, and well-being of lesbian, gay, bisexual, and transgender (LGBT) individuals. Overview: LGBT individuals encompass all races and ethnicities, religions, and social classes. Sexual orientation and gender identity questions are not asked on most national or state surveys, making it difficult to estimate the number of LGBT individuals and their health needs.114 7711_Ch07_157-190 23/08/19 10:23 AM Page 183 LGBTQ+ and Health According to a Gallup poll, in 2017, 4.5% of Americans identified as LGBTQ+ with 5.1% of women identifying as LGBTQ+ and 3.9% of men. This reflects an increase mostly in millennials.116 Persons who identify as LGBTQ+ reflect a diverse population across all racial and ethnic groups.117 They are also at increased risk for poorer health compared to their heterosexual peers. Some of these differences are attributable to differences in sexual behavior, but the underlying issues for those who identify as LGBTQ+ “… are associated with social and structural inequities, such as the stigma and discrim- ination that LGBTQ+ populations experience”.117 They are at increased risk for communicable diseases, suicide, mental health issues, and substance use disorders often linked to discrimination and social isolation.117 Another health issue for the LGBTQ+ community is the increased risk of being a victim of violence, specifi- cally hate crimes. Persons who identify as LGBTQ+ are more apt to be victims of hate crimes than any other minority group.118 The Orlando, Florida, mass shooting in 2016 highlighted the violence attached to these hate crimes. Adolescents and adults also experience partner violence.119,120 Park and Mykhyalyshyn explained that, as LGBTQ+ persons become more an accepted part of American society, those opposed to this community become more radicalized and less tolerant.118 Providing appropriate care to persons based on how they identify themselves in relation to gender is an im- portant first step. Health-care delivery to all persons must occur within the context of the person. For nurses, this begins with a clear understanding of the complexity of gender identity, gender expression, and sexual orien- tation. From a public health perspective, it requires ad- vocating for policies that support a more inclusive approach to health care across the continuum of gender. It also requires policies aimed at reducing hate crimes, stigma, and social isolation, the main drivers of disparity in health for those who identify as LGBTQ+. At-Risk LGBTQ+ Groups Civil rights expansions, most notably the U.S. Supreme Court decision in Obergefell vs. Hodges (5/15/15), which established the right to gay marriage in all 50 states, has encouraged more openness and societal acceptance of LGBTQ+ individuals and families. However, despite much research, landmark legal rulings, and the increasing willingness of individuals to publicly identify themselves as LGBTQ+, homophobia and its resulting behaviors of discrimination, violence, and shunning remain promi- nent in all areas of our society. Three subgroups of the LGBTQ+ community are especially vulnerable and face daunting barriers to leading a physically and emotionally healthy life: transgender youth, LGBTQ+ elders, and gay/bisexual men and women with HIV/AIDS. Transgender youth include an increasing number of very young children (ages 3 years and older) who are expressing gender nonconforming identities (gender dysphoria). Parents of these young children find them- selves searching for medical assistance and support as they navigate uncharted territory. These children are also vulnerable to bullying and societal/familial denial of their expressed gender, circumstances that can lead to depres- sion, anxiety, and other problems that can inhibit a healthy social and physical development. Medical sup- port may not be readily available outside of large metro- politan areas, and local community and educational support are often scarce. Older transgender youth are among our most vulnerable population groups. They are at high risk for family rejection, homelessness, substance use, risky sexual behavior, depression and suicide, as well as targets of sexual violence.121 LBGTQ+ elders face a variety of challenges as they grow older. Like their non-gay counterparts, they often feel socially isolated and less able to provide for them- selves or live independently. However, having experi- enced the depths of homophobia in their earlier years, the rejection of family and being “in the closet” at work and in their community, LGBTQ+ elders tend to be mis- trustful of mainstream medical and social services. Fear- ing discrimination and rejection, they are often wary of sharing their sexual orientation with their medical and social service providers, or even seeking out such services when needed. Many have already experienced insensi- tivity and discrimination by health care and social service providers in their younger years.122 Gay/bisexual men and women with HIV/AIDS con- tinue to be marginalized in our society for several reasons. 184 U N I T I I n Community Health Across Populations: Public Health Issues Midcourse Review: Of the two measurable objectives, objective one (Increase the number of population-based data systems used to monitor Healthy People 2020 objectives that include in their core a standardized set of questions that identify lesbian, gay, bisexual, and transgender populations) showed improvement. Objective two (Increase the number of states, territories, and the District of Columbia that include questions that identify sexual orientation and gender identity on state level surveys or data systems) had little or no improvement.115 7711_Ch07_157-190 23/08/19 10:23 AM Page 184 The stigmas of HIV/AIDS and homophobia have not diminished in many rural areas and among some ethnic, cultural, and religious groups. This reality leads many LGBT+ people with HIV/AIDS to avoid accessing med- ical and social services for fear that their health status will be discovered and result in family rejection and discrim- ination in employment and housing.123,124 Interventions and Policy In October 2009, the Matthew Shepard and James Byrd, Jr., Hate Crimes Prevention Act was signed into law and makes hate crimes based on sexual orientation, among other offenses, federal crimes in the United States.125 For the parents of children who express a nonconforming gender identity, there is often confusion and a sense of being an inadequate parent. Unless the family lives near a large urban area, it is unlikely that parents will have access to the medical care, psychosocial services, and educational resources that they and their child will need. This lack of resources is currently being filled by online groups and Web sites, sites where parents and children can search for information and connect with other fam- ilies. One potential resource for parents is the school nurse (see Chapter 18). Fortunately, there is a growing awareness in the medical/academic community to provide accurate infor- mation to families and their local health providers, as well as a growing number of clinics and clinicians trained to provide services to transgendered youth and their families. The American Psychological Association has published “Guidelines for Psychological Practice with Transgender and Gender Nonconforming People”,126 a comprehensive guide for those professionals working with transgendered people of all ages. In addition, many urban university medical centers and hospitals are estab- lishing clinics and programs for transgendered and gender nonconforming children and young adults. Medical issues aligned with transgendered youth and children who express a nonconforming gender identity include pharmacologic therapies to address body image issues, depression, anxiety, and suicidal ideations. Social and psychological therapies can address social function- ing, peer issues, school adjustment, and family issues as they arise. The availability of these resources is vital to the healthy development of these children in all areas of functioning. For LGBTQ+ older adults, their invisibility to main- stream elder service providers and medical personnel in many settings significantly diminishes their quality of life.127 Additionally, the lack of training for staff and res- idents in most long-term care settings such as assisted living complexes and nursing homes leave LGBTQ+ older adults open to psychological and physical abuse, which can lead to depression and self-isolation. For LGBTQ+ older adults living at home but in need of assistance in a variety of areas, the same problem arises with home care services. Staff may not be trained to respect the individual’s LGBTQ+ identity and her/his relationships with others.127,128 Understanding the needs of LGBTQ+ older adults is an essential skill for nurses who provide care and begins with not assuming a patient’s sexual orientation is het- erosexual, and/or dismissing the relationship between two partners. Nurses in all settings need to be under- standing of the discrimination and abuse LGBTQ+ older adults may have encountered in their lives and provide a supportive, affirming environment for the patients.128 Gay/bisexual men and women with HIV/AIDS pres- ent a variety of serious medical problems and psycholog- ical issues. Despite the many advances in medical care for people with HIV, there are significant disparities in how these new therapies are utilized in geographic and racial areas. In 2016, the CDC predicted that, if current rates continue, one in two African American gay and bi- sexual men will be infected with HIV.129 These statistics clearly demonstrate the need for more comprehensive measures to address the issues of poverty, race, and class inherent in the health care of gay/bisexual men and women with HIV/AIDS. Community-based organizations can be supportive of LGBTQ+ people and can influence the general commu- nity to provide a more inclusive environment. Public campaigns are a way to reach a large number of people with messages challenging homophobia. Schools also can educate young people, confronting widely accepted prej- udices. This might include specific curriculum and action against bullying, creating a school environment wherein all students feel comfortable. Political leaders, police de- partments, health services, broadcasters, and employers can all positively influence the way that the LGBTQ+ population is treated. n Summary Points • Health disparity and vulnerability reflect a complex intersection of risk factors at the individual, commu- nity, national, and global levels. • Social forces such as discrimination and stigma lead to the marginalization of certain segments of our so- ciety, resulting in increased levels of marginalization overall. 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U.S. Department of Justice Bureau of Justice Statistics (n.d.). Total Correctional Population. Retrieved from https://www. bjs.gov/index.cfm?tid=11&ty=t. 100. Gramlich, J. (2018, May 2). America's incarceration rate is at a two-decade low. Pew Research Center. Retrieved from https://www.pewresearch.org/fact-tank/2018/ 05/02/americas-incarceration-rate-is-at-a-two-decade- low/. 101. Centers for Disease Control and Prevention. (2014). Correctional Health. Retrieved from https://www.cdc.gov/ correctionalhealth/default.htm. 102. Kaeble, D., & Cowhig, M. (2018). Correctional populations in the United States, 2016. U.S. Department of Justice Office of Justice Programs Bureau of Justice Statistics Bulletin. Retrieved from https://www.bjs.gov/content/pub/pdf/ cpus16 . 103. Zeng, Z., (2018, Feb 22). Jail inmates in 2016. Office of Justice Program, Justice Bureau of Statistics. Retrieved from https://www.bjs.gov/index.cfm?ty=pbdetail&iid=6186. 104. Love, D. (2018, Feb 12). Black incarceration rates are drop- ping while white rates rise, but what’s really behind this sur- prising trend? Atlantic Black Star. Retrieved from https:// atlantablackstar.com/2018/02/17/black-incarceration- rates-dropping-white-rates-rises-whats-really-behind- surprising-trend/. 105. Wagner, P., & Sawyer, W. (2018). States of Incarceration: The Global Context 2018. Prison Policy Initiative. Retrieved from https://www.prisonpolicy.org/global/2018.html. 106. Estelle v. Gambelle, 429 U.S. 97. (1976). Retrieved from http://caselaw.lp.findlaw.com/cgi-bin/getcase.pl?court= US&vol=429&invol=97. 107. Larney, S., Zaller, N.D., Dumont, D.M., Willcock, A., & Degenhardt, L. (2016). A systematic review and meta- analysis of racial and ethnic disparities in hepatitis C anti- body prevalence in United States correctional populations. Annals of Epidemiology, 26(8), 570–578.e2. https:// doi-org.ezp.welch.jhmi.edu/10.1016/j.annepidem. 2016.06.013. 108. Skarupski, K.A., Gross, A., Schrack, J.A., Deal, J.A., & Eber, G.B. (2018). The health of America’s aging prison population. Epidemiologic Reviews, 40(1), 157–165. https://doi-org.ezp.welch.jhmi.edu/10.1093/epirev/ mxx020. 109. Turney, K., & Goodsell, R. (2018). Parental incarceration and children’s wellbeing. Future of Children, 28(1), 147–164. Retrieved from http://search.ebscohost.com.ezp. welch.jhmi.edu/login.aspx?direct=true&db=rzh&AN= 129524480&site=ehost-live&scope=site. 110. World Health Organization. (2018). Gender equity and human rights: Gender. Retrieved from http://www.who.int/ gender-equity-rights/understanding/gender-definition/en/. 111. Human Rights Campaign. (2018). Glossary of terms. Retrieved from https://www.hrc.org/resources/glossary- of-terms. 112. The Joint Commission. (2011). Advancing effective commu- nication, cultural competence, and patient- and family centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide. Oak Brook, IL: Author. Retrieved from https://www.jointcommission.org/assets/ 1/18/LGBTFieldGuide . 113. Bonvicini, K.A. (2017). LGBT healthcare disparities: What progress have we made? Patient Education & Counseling, 100(12), 2357–2361. https://doi-org.ezp.welch.jhmi.edu/ 10.1016/j.pec.2017.06.003. C H A P T E R 7 n Health Disparities and Vulnerable Populations 189 7711_Ch07_157-190 23/08/19 10:23 AM Page 189 114. Healthy People 2020. (2018). Lesbian, gay, bisexual, and trans- gender health. Retrieved from https://www.healthypeople. gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and- transgender-health/objectives. 115. National Center for Health Statistics. (2016). Chapter 25, Lesbian, gay, bisexual and transgender health: Healthy People 2020 midcourse review. Hyattsville, MD: Author. Retrieved from https://www.cdc.gov/nchs/data/ hpdata2020/HP2020MCR-C25-LGBT . 116. Newport, F. (2018, May 22). In U.S., estimate of LGBT population rises to 4.5%. Gallup: Politics. Retrieved from https://news.gallup.com/poll/234863/estimate-lgbt- population-rises.aspx. 117. Centers for Disease Control and Prevention. (2014). Lesbian, gay, bisexual, and transgender health. Retrieved from https://www.cdc.gov/lgbthealth/about.htm. 118. Park, Y., & Mykhyalyshyn, I. (2016, June 16). L.G.B.T. people are more likely to be targets of hate crimes than any other minority group. New York Times. Retrieved from https://nyti.ms/2jSzpDG. 119. Langenderfer-Magruder, L., Walls, N.E., Whitfield, D., Brown, S., & Barrett, C. (2016). Partner violence victimiza- tion among lesbian, gay, bisexual, transgender, and queer youth: Associations among risk factors. Child & Adolescent Social Work Journal, 33(1), 55–68. https:// doi-org.ezp.welch.jhmi.edu/10.1007/s10560-015-0402-8. 120. Langenderfer-Magruder, L., Whitfield, D.L., Walls, N.E., Kattari, S.K., & Ramos, D. (2016). Experiences of intimate partner violence and subsequent police reporting among lesbian, gay, bisexual, transgender, and queer adults in Colorado. Journal of Interpersonal Violence, 31(5), 855–871. https://doi-org.ezp.welch.jhmi.edu/10.1177/ 0886260514556767. 121. Heina, L.C., Stokes, F., Smith-Greenberg, C., Saewycd, E.M. (2018). Policy brief: Protecting vulnerable LGBTQ youth and advocating for ethical health care. Nursing Outlook, 66, 505-507. 122. Clay, R. (2014). Double-whammy discrimination. American Psychological Association, Monitor on Psychology, 45(10), 46. 123. Perez-Brumer, A., Nunn, A., Hsiang, E., Oldenburg, C., Bender, M., Beauchamps, L., Mena, L., MacCarthy, S. (2018). We don’t treat your kind: Assessing HIV health needs holistically among transgender people in Jackson, Mississippi. PLoS One, 1;13(11), e0202389. doi:10.1371/ journal.pone.0202389. 124. Bauermeister, J.A., Muessig, K.E., Flores, D.D., LeGrand, S., Choi, S., Dong, W., Harper G.W., Hightow-Weidman, L.B. (2018). Stigma diminishes the protective effect of social support on psychological distress among young black men who have sex with men. AIDS Education and Prevention, 30(5), 406-418. doi: 10.1521/aeap.2018.30.5.406. 125. United States Department of Justice. (2015). Matthew Shepard and James Byrd, Jr., Hate Crimes Prevention Act. Retrieved from https://www.justice.gov/crt/matthew- shepard-and-james-byrd-jr-hate-crimes-prevention- act-2009-0. 126. American Psychiatric Association. (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70, 832–864. http://dx.doi.org/10.1037/a0039906 Retrieved from https://www.apa.org/practice/guidelines/ transgender . 127. Fredriksen-Goldsen, K.I., Kim, H.-J., Shiu, C., & Bryan, A.E.B. (2017). Chronic health conditions and key health indicators among lesbian, gay, and bisexual older U.S. adults, 2013-2014. American Journal of Public Health, 107(8), 1332–1338. doi:10.2105/AJPH.2017.303922. 128. Muraco, A., & Fredriksen-Goldsen, K.I. (2014). The highs and lows of caregiving for chronically ill lesbian, gay, and bisexual elders. Journal of Gerontological Social Work, 57(2–4), 251–272. doi:10.1080/01634372.2013.860652. 129. Centers for Disease Control and Prevention. (2016). HIV Surveillance Report, 2015; vol. 27. Retrieved from http://www.cdc.gov/hiv/library/reports/hiv-surveillance. html. 190 U N I T I I n Community Health Across Populations: Public Health Issues 7711_Ch07_157-190 23/08/19 10:23 AM Page 190 191 Chapter 8 Communicable Diseases Michael Sanchez and Christine Savage LEARNING OUTCOMES After reading this chapter, the student will be able to: KEY TERMS 1. Apply the cycle of transmission to specific communicable diseases. 2. Describe the steps in an outbreak investigation. 3. Investigate the role of culture and environment in the management of an epidemic. 4. Discuss current issues related to emerging communicable diseases. 5. Describe the role of the nurse in the prevention and treatment of hospital- and community-acquired infections. Active immunity Agent Antigenicity Attack rate Carrier Case fatality rate Cellular immunity Chronic carrier Colonization Common source Community immunity Continuous source Convalescent carrier Endemic Environment Epidemic Epidemic curve Epidemic threshold Generation time Herd immunity Host Humoral immunity Immunity Inapparent carrier Incubating carrier Index case Infectivity Inherent resistance Intermittent source Outbreak investigation Pandemic Passive immunity Pathogen Pathogenic Pathogenicity Point source Reservoir Resistance Secondary attack rate Secondary case Sexually transmitted disease Susceptibility Toxigenicity Vaccine Vector Virulence n Introduction Communicable diseases (CDs) make national headlines on a regular basis. There was an outbreak of Zika virus that placed fetuses at risk for adverse outcomes. In the U.S., there were 116 live infants with Zika-related birth defects and 9 pregnancy losses due to Zika-related defects.1 In May 2018, an Ebola outbreak in the Democratic Republic of Congo in a less remote area brought concerns of a wider outbreak.2 In June of 2018, an outbreak of Salmonella Adelaide infec- tions related to pre-cut melon affected 60 people in 5 states.3 These headlines demonstrate the very real threat of CDs in today’s world as a result of both acute outbreaks and the long-term adverse effects of chronic infection. CDs have plagued humankind throughout recorded history. As recently as the first part of the last century, CDs were the leading causes of death. In the 1950s and 1960s, chickenpox, measles, and mumps were endemic in school-age children. With the advent of antibiotics and vaccines, CDs were no longer the primary killer of humans with a resulting increase in life expectancy. In the 1980s, the effectiveness of vaccines and antibiotics led some health-care providers to predict that CDs would be eliminated in many sections of the world, especially after the successful eradication of smallpox worldwide.4 While these pronouncements were being made, a new CD emerged, AIDS caused by HIV. During this period, other diseases emerged such as those caused by the Ebola fam- ily of viruses and the Zika virus. At the same time the predicted decline in the incidence of other CDs, such as tuberculosis (TB), did not occur. In the 21st century, CDs are a main reason for mor- bidity and mortality in the United States and the world. In the United States, acute respiratory infections, includ- ing influenza and pneumonia, are listed in the top 10 leading causes of death.5 In low-income countries, 5 of 7711_Ch08_191-217 21/08/19 11:02 AM Page 191 the 10 top leading causes of death are related to CD.6 For lower-middle-income countries, 3 of the top 10 leading causes of death are related to CDs. For upper-middle- income countries and high-income countries, acute res- piratory diseases are the only CDs on the list of the top 10 causes of death (Table 8-1).6 A major responsibility of public health officials from the local to the global level is to conduct surveillance to deter- mine whether there is a CD epidemic that threatens the health of populations. The surveillance in turn can help de- termine what if any action will be necessary to stop an epi- demic. The term epidemic is the combination of two Greek terms, epi (upon) and demos (people), and has the same roots as the term epidemiology (see Chapter 3). At first the term epidemic was used to describe a collection of illnesses based on their characteristics such as diarrhea or cough, but with the arrival of the Black Death (bubonic plague) in Europe, the word was used to describe the increased oc- currence of a single disease.7 In the 21st century, the term epidemic is used when there is a significant increase in number of cases than would normally occur. Endemic refers to the usual number of cases of a disease that occur within a population. At the other end of the spectrum, pandemic describes epidemics occurring across the globe. Communicable Diseases and Nursing Practice CDs are a public health issue and an important concern for nurses working in the community and in acute care settings. Nurses are confronted with CDs on a constant 192 U N I T I I n Community Health Across Populations: Public Health Issues TABLE 8–1 n Top 10 Leading Causes of Death by Level of Income Lower Middle Upper Middle High Cause of Death Low Income Income Income Income Lower respiratory disease Diarrheal diseases Ischemic heart diseases HIV/AIDS Stroke Malaria Tuberculosis Preterm birth complications Birth asphyxia and birth trauma Road Injury Chronic obstructive pulmonary disease Diabetes mellitus Cirrhosis of the liver Trachea, bronchus, and lung cancers Alzheimer’s disease and other dementias Liver cancer Stomach cancer Colon and rectal cancers Kidney diseases Breast Cancer Number 1 Number 2 Number 3 Number 4 Number 5 Number 6 Number 7 Number 8 Number 9 Number 10 Number 6 Number 1 Number 2 Number 5 Number 8 Number 4 Number 3 Number 7 Number 9 Number 10 Number 6 Number 1 Number 2 Number 8 Number 3 Number 7 Number 4 Number 5 Number 9 Number 10 Number 3 Number 6 Number 1 Number 2 Number 5 Number 8 Number 10 Number 4 Number 7 Number 9 (See WHO; http://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death for updates.) Source: (6) 7711_Ch08_191-217 21/08/19 11:02 AM Page 192 basis. Nurses provide care to patients with a CD and also must incorporate preventive measures in their practice, such as the use of personal protective equipment (PPE) and proper cleaning of patient areas to prevent transmis- sion of these diseases to themselves, co-workers, and other patients. These practices protect individuals and populations. For the practicing nurse, an understanding of CDs at both an individual level and a population level is essential. If the nurse only focuses on caring for the pa- tient with a CD without considering the implications for the population, the care falls short and potentially en- dangers others. The key to all these activities is to understand the in- fectious agents that cause disease, the environment rele- vant to the transmission of disease from one person to another, and who is at risk for becoming infected. Pro- fessional nurses back up their interventions related to the prevention and treatment of CDs with knowledge of the public health science behind these interventions. In the same way that nurses do not dispense medications without understanding the pharmacokinetics behind the medications, nurses cannot intervene in relation to CDs without understanding the science behind these diseases. Public health science provides the basis for understand- ing how CDs have an impact on the health of humans. Professional nurses armed with scientific knowledge re- lated to infectious agents can intervene in ways that reduce the risk for not only their individual patients and them- selves but also for the larger population they serve, with prevention the primary goal. Communicable Disease and the Burden of Disease Twenty-first-century improvements in technology and transportation have brought populations closer together and eliminated geographical barriers to transmission of disease. This increases the possibility of spreading CDs that in the past may have been contained in one geo- graphical area. This chapter provides an overview of the CDs that are leading causes of death with a focus on in- cidence and prevalence in the United States. Infectious Respiratory Disease Many agents are associated with respiratory disease (Box 8-1). These diseases are either bacterial or viral. Many of these diseases can be prevented through vacci- nation. Children are required to receive vaccination for many CDs before attending public schools, such as vaccines for prevention of chickenpox, diphtheria, and rubella. A new policy for most health-care settings is to require that all employees receive an annual flu vaccine. Because of vaccination programs across the United States and other countries, the incidence of many communi- cable respiratory diseases is declining. Despite these advances, respiratory disease caused by infectious agents continues to be a significant public health issue. Some of these diseases are seasonal, for example, in- fluenza (flu). Many have a higher morbidity and mor- tality rate in vulnerable populations, such as older adults and children. Influenza, or flu, is a communicable respiratory dis- ease and is a major public health concern. Flu is seasonal, with a peak in early December and a peak in February. Because of the higher mortality rate in vulnerable popu- lations such as children, older adults, and those who are already ill, many hospitals require that all employees re- ceive a flu vaccination. The CDC publishes a report titled FluView that follows trends in flu across the year. Trends in flu vary from year to year. In 2009–2010, there was a pandemic outbreak of H1N1 influenza that peaked ear- lier in October, which resulted in an estimated midrange of 61 million cases, 240,000 hospitalizations, and 12,470 deaths. Then the following 2011–2012 flu season was the mildest season on record.8 In 2015-2016 H1N1 re- emerged as the predominant virus for the season.9 Unlike the 2009-2010 season, the peak month for flu activity was January (Fig. 8-1). 10 Malaria Malaria is a subtropical disease caused by a parasite, the intraerythrocytic protozoa of the genus Plasmodium transmitted through the bite of an infected female C H A P T E R 8 n Communicable Diseases 193 Chickenpox Diphtheria Group A Streptococcus Haemophilus influenzae type b Influenza Legionnaire’s disease Measles (rubeola) Mumps Pneumococcal meningitis German measles (rubella) Tuberculosis Whooping cough (pertussis) Anthrax Hantavirus pulmonary syndrome Plague BOX 8–1 n Respiratory Communicable Diseases that Can Infect the Respiratory System 7711_Ch08_191-217 21/08/19 11:02 AM Page 193 Anopheles gambiae mosquito, often referred to as the “malaria vector”.11 About half of the world’s population is at risk for malaria. According to the World Health Or- ganization (WHO), in 2016, an estimated 445,000 deaths, mostly African children, were caused by malaria.12 The estimated number of cases in 2016 was 216 million worldwide, an increase of 5 million from the year prior.12 By comparison, in 2014, in the United States, there were 1,724 cases of malaria with 5 fatalities.13 Malarial infec- tions in the United States are primarily the result of ex- posure that occurred during travel abroad. In addition, these travelers had not adhered to recommended malaria prophylaxis. Malaria is a preventable disease, and much is being done globally to eradicate it. Globally, the eco- nomic and social burdens affect both individuals and governments including the cost of care, lost work, and burial expenses. Direct costs (for example, illness, treat- ment, premature death) have been estimated to be at least U.S. $12 billion per year.14 Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) HIV impairs and destroys the immune cells in the infected person’s body, affecting the ability to fight off infection. A person infected with HIV may not develop AIDS until 10 to 15 years after the initial infection.15 HIV/AIDS status is classified across five stages: 0, 1, 2, 3, unknown. A negative HIV test within 6 months of the first HIV infection diag- nosis is stage 0 and remains 0 until 6 months after diag- nosis. If a stage-3-defining opportunistic illness has been diagnosed, the stage is 3 (Box 8-2). Otherwise, the stage is determined by the CD4 test immunologic criteria based on the CDC case definition guidelines.15 According to UNAIDS, HIV has killed 35 million people over the past 3 decades, and, in 2016, an estimated 36.7 million people were living with HIV/AIDS worldwide, with 1.8 million new cases in 2016.16 In the United States, an estimated 1.1 million people are living with HIV/AIDS. In 2016, in the U.S., 39,782 persons were newly diagnosed with HIV/AIDS, and nearly 15% of those infected with HIV are unaware they are infected.17,18 In the U.S., the prevalence of HIV and AIDS is higher among persons in the 25- to 44-year-old age group, those who are African American and Hispanic, and in men. Racial disparity is especially apparent in children, with 80% of all pediatric cases being African American or His- panic.17,18 HIV infection is also on the rise among older adults because of increased longevity of those living with HIV as well as an increase in risky behaviors in this age group.19 Certain behaviors increase the risk for transmis- sion of HIV, including men having sex with men, those engaging in injection drug use, and those engaging in un- protected sex. There is also variation in the distribution of cases geographically. The South has the highest num- ber of people living with HIV, whereas the highest rates of new infections occurred in California, Florida, Texas, New York, and Georgia.20 Healthy People (HP) has a specific topic related to HIV/AIDS.21 The objectives related to the topic not only address disparity but also prevention, screening, and treatment. 194 U N I T I I n Community Health Across Populations: Public Health Issues Peak Month of Flu Activity 1982–1983 through 2015–2016 Octo be r Nov em be r Dec em be r Ja nu ar y Fe br ua ry M ar ch Apr il M ay 16 1 1 7 5 14 6 0 0 14 12 10 8 6 4 2 Figure 8-1 Peak flu activity. (Data source reference 10.) HIV infection is classified as stage 3 (AIDS) when the immune system of a person infected with HIV becomes severely compromised (measured by CD4 cell count) and/or the person becomes ill with an opportunistic infection. In the absence of treatment, AIDS usually develops 8 to 10 years after initial HIV infection; with early HIV diagnosis and treatment, this may be delayed by many years. BOX 8–2 n CDC: Definition of Stage Three HIV Infection/AIDS n HEALTHY PEOPLE HIV Goal: Prevent human immunodeficiency virus (HIV) infection and related illness and death. Overview: HIV infections in the United States con- tinue to be a major public health crisis. An estimated 1.2 million Americans are living with HIV, and 1 out of 8 people with HIV do not know they have it. Although recent data show that annual HIV infections declined 7711_Ch08_191-217 21/08/19 11:02 AM Page 194 UNAIDS 909090 Along with the HP goals related to HIV/AIDS are the 2014 UNAIDS goals related to the AIDS epidemic titled UN AIDS 909090: An ambitious treatment target to help end the AIDS epidemic. They have since published a midcourse review as well. The three main goals by 2020 were: • 90% of all people living with HIV will know their HIV status. • 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy. C H A P T E R 8 n Communicable Diseases 195 Little or no change Improving Met or exceeded 30% 50% 20% Healthy People 2020 Midcourse Review: HIV Figure 8-2 Healthy People 2020 Midcourse Review: HIV. (Data source reference 22.) 18% in the U.S. from 2008 to 2014, HIV continues to spread. In 2010, the White House released a National HIV/AIDS Strategy. The National HIV/AIDS Strategy was updated to 2020 (NHAS 2020) in July 2015. The strategy includes three primary goals: 1. Reducing new HIV infections. 2. Increasing access to care and improving health outcomes for people living with HIV. 3. Reducing HIV-related disparities and health inequities.22 Midcourse Review: Of the 27 objectives under the topic of HIV in Heathy People 2020, 11 were measura- ble. Of these, two exceeded or met targeted goals, five were improving, three had little or no change, and one was baseline only (Fig. 8-2). For persons aged 13 or older, there was no change in the number of new infections.23 • 90% of all people receiving antiretroviral therapy will have viral suppression.24 Midcourse Review 2016: • 70% of all people living with HIV knew their HIV status. • 77% of all people with diagnosed HIV infection were on sustained antiretroviral therapy. • 82% of all persons on treatment were virally suppressed.25 Diarrheal Disease Diarrhea is defined by the WHO as the passage of three or more loose or liquid stools per day. There are approx- imately 2 billion cases of diarrheal disease worldwide each year.26 In low-income countries, it is a leading cause of death among children. In 2017, the WHO esti- mated that 525,000 deaths in children under the age of 5 were caused by diarrhea.27 The most common route for transmission of diarrheal disease is the fecal-oral route. Good hand hygiene, especially hand washing, and soap alone can reduce the incidence of diarrheal disease by as much as 48%.28 Efficient sanitary systems and safe drinking water also play a huge role in preventing diar- rheal diseases. Pathogens that cause diarrheal disease include viruses, bacteria, and protozoa. Transmission is usually waterborne (e.g., cholera), foodborne (e.g., Escherichia coli [E. coli]), or through person-to-person contact; pathogens can infect the small bowel, the colon, or both.29 Worldwide, rotavirus is the most common cause of diarrheal disease among children, accounting for al- most 40% of all cases of infant diarrhea and is responsi- ble for a half million deaths in children under 5 years old.26 Until recently, infections with rotavirus among children under the age of 5 resulted in up to 70,000 hos- pitalizations and 60 deaths annually. In 2006, a vaccine was introduced that has helped reduce the incidence of this disease. There are now two vaccines available for use with infants. Since the introduction of these vaccines, the incidence of rotavirus-associated diarrheal infec- tions in children has declined.30 Emerging and Re-emerging Communicable Diseases The WHO defines an emerging disease as “one that has appeared in a population for the first time, or that may have existed previously but is rapidly increasing in inci- dence or geographic range.”31 Through public health efforts, some CDs are close to eradication, for example, polio mellitus and dracunculiasis (guinea worm disease), 7711_Ch08_191-217 21/08/19 11:02 AM Page 195 or have been eradicated, as in the case of smallpox. Yet, at the same time, new CDs have emerged such as severe acute respiratory syndrome (SARS), West Nile virus, and the Zika virus. Other diseases, such as malaria, TB, and bacterial pneumonias, are reemerging in forms that are resistant to drug treatments, for example, multidrug- resistant tuberculosis (MDRTB).33 New diseases are emerging at a rate of one per year. In the 21st century, emerging CDs continue to make global headlines such as the Zika virus. Response to such diseases results in a bur- den on the economic, social, and health-care systems of countries. Pandemics such as the SARS outbreak and epi- demics within countries such as the West Nile virus epi- demic in the summer of 2012 required a coordinated early response across political entities such as countries or states. Tuberculosis TB is an infectious disease caused by the Mycobacterium tuberculosis. It has been called many names, including white death, the great white plague, and consumption. The word consumption is even found in the Bible. It wasn’t until the end of the 19th century that the disease received the name tuberculosis after the agent that caused the dis- ease was identified. In 1889, the National Tuberculosis Association (now the National Lung Association) real- ized that TB was preventable and not inherited. Since that time, prevention efforts have resulted in a steady downward trend in the incidence and prevalence of TB, so much so that 100 years later, in 1998, a TB elimination project was initiated in the United States with the target date of 2010 for TB elimination. Although this has not occurred, the downward trend in TB incidence and prevalence is encouraging. The WHO End Strategy and the United Nations’ Sustainable development goals also have the goal of ending the global TB epidemic. These organizations aim to have a 90% reduction in TB deaths and 80% reduction in TB incidence.34,35 In the U.S., continued efforts are needed to address the disparity in incidence between U.S.-born and foreign-born individ- uals as well as between whites and minorities.35 Back in 1988, infection control experts were optimistic that the elimination of TB was a realistic goal. Unfortu- nately, at the same time, reports began to emerge of hospital-acquired MDRTB outbreaks. Between 1988 and 1992, five clusters of TB cases appeared in six hospitals. Four occurred in New York City, one in Florida, and one in New York State. What stood out about these cases was that the agent M. tuberculosis had mutated (changed) and was now resistant to drugs used to treat active TB. Sur- veillance was initiated that identified more patients who met the case definition of MDRTB. Upon investigation, some issues emerged. First, most of the patients were also infected with HIV. With HIV, TB does not always present in a classic manner, and diagnosis was delayed in these cases. In addition, recognition of drug resistance was hampered by the length of time it took to complete the drug susceptibility tests. The case fatality rate (CFR) was high. A CFR is determined by taking the number of fatal cases and dividing it by the total number of cases. Within 16 weeks of diagnosis, 72% to 89% of patients had died.36 Since that time, dramatic changes have taken place in acute care settings including strict Occupational Health and Safety Administration (OSHA) guidelines. Globally, in 2015, there were 10.4 million new cases of TB and 1.4 million TB deaths in HIV-negative per- sons, and an additional 0.4 million deaths due to HIV- associated TB.34 In 2015, in the United States, there were 9,577 reported cases of TB with an incidence rate of 3.0 per 100,000. Overall, both the prevalence and incidence of TB are decreasing, albeit at a slow rate of 3% per year.37 It was estimated that the rate of decline would need to accelerate to a 4%-5% annual decline to achieve the End TB Strategy by 2020. The number of new cases in 2015 in the United States was the lowest since 1953. However, the national goal to eliminate TB (less than 0.1 case per 100,000 population) was not met.37 The story of TB rates in the United States illustrates the importance of following trends of CDs. As men- tioned earlier, many CDs must be reported to the health department. This information is electronically forwarded from all 50 states and the District of Columbia to the CDC. The CDC follows these trends of data over time. On the surface, this is a simple process in that the total number of cases is followed by year. However, just know- ing the number of cases does not provide the CDC with additional information needed to protect the health of the public. Through careful surveillance of TB, the CDC can determine who is at greatest risk based on numerous factors including race, age, geographical location, and place of birth. The CDC can then examine whether the goal of eliminating TB is being met, and if not, where it needs to concentrate its efforts to meet the goal. 196 U N I T I I n Community Health Across Populations: Public Health Issues w SOLVING THE MYSTERY The Case of the Wandering Patient In February 2002, a 42-year-old man with HIV and schizophrenia was admitted twice to one hospital for fever and unproductive cough. Chest radiographs were read as normal, and a sputum culture was negative for M. tuberculosis. In April, he was admitted to another 7711_Ch08_191-217 21/08/19 11:02 AM Page 196 Infectious Agents and the Cycle of Transmission Public health departments are charged with protecting the population at large from the spread of infection. This requires understanding the cycle of infection. The key components of the cycle of infection begin with the epi- demiological triangle, which includes the three main con- structs needed for disease to occur in humans: the agent, the environment, and the host (see Chapter 3, Fig. 3-2). In CDs, the epidemiological triangle is expanded to help understand the cycle of transmission of the infectious agent from the reservoir to the host (Fig. 8-3). Agent Characteristics The term agent or pathogen refers to the infectious or- ganism that causes the disease such as a virus or bacteria. Knowledge of agent characteristics begins with a review of the six general categories of pathogens based on the biological properties of the pathogens (Table 8-2). The C H A P T E R 8 n Communicable Diseases 197 hospital with similar symptoms, treated with antibiotics, and released. Three days later he was readmitted and treated for suspected pneumonia. However, his stool culture came back positive for M. tuberculosis. A subse- quent acid-fast bacillus (AFB) smear test was 4+, indi- cating that he was highly infectious. Although he was placed in isolation, he continued to have contact with other patients and hospital personnel because of a lack of vigilance on the part of the staff to observe strict iso- lation procedures, with serious consequences.38 The investigation into this case started with identify- ing the index case, that is, the first case identified in a particular outbreak. Because the normal mode of transmission is airborne from person to person, identi- fying the index patient provides the investigators with the starting point for their investigation. The investiga- tors working on this case identified this 42-year-old man as the index case. Their next step was to identify secondary cases, that is, patients who were diagnosed with active TB and who had contact with the index patient. Five secondary cases were identified; one had diabetes and HIV, one had diabetes, two had end-stage renal disease, and one was a phlebotomist. The first two steps of the investiga- tion were now complete, identifying the index patient and secondary patients, but the investigation did not stop there. Because the index patient’s sputum came back with a 4+ AFB smear, there was a high level of in- fectivity, that is, anyone who came in contact with the patient was probably exposed to a high level of the M. tuberculosis bacillus. If that were the case, then everyone who came in contact with the patient would be at risk. The next step in the investigation was to identify all contacts. With some agents, once humans are infected the incubation period prior to the occurrence of symp- toms is short and can last less than a week. In others, it might be a little longer and last up to 3 months, as with syphilis. With TB, a person can become infected and show no sign of disease for decades. This is known as latent TB. The investigators identified a total of 1,045 contacts, both patients and employees of the hospital. They were able to test close to two-thirds of all these contacts. Eleven percent of the tested employees tested positive, and 23% of the tested patients tested positive. Those who tested positive were provided appropriate interventions to prevent development of the disease.38 This case illustrates the challenges faced in identi- fying the presence of an active infection and the urgency of taking measures to prevent further spread of the infection. The investigation focused on three stages: (1) identification of the index patient; (2) find- ing secondary cases; and (3) investigation of contacts. The report included recommendations for hospital in- fection control programs. The patient had been placed in isolation, and the investigators established that the isolation room was in accordance with appropriate isolation procedures. However, the patient came into contact with other patients, so the possibility is raised that the patient did not remain in his room.38 This case highlights the issue of isolation procedures in health-care agencies (see Chapter 14). The type of isolation is based on the cycle of transmission. Nurses are required to institute appropriate isolation proce- dures based on the known or suspected agent. These procedures are public health interventions aimed at preventing the spread of disease in three populations (other patients, employees, and community visitors). For airborne agents such as the bacterium that causes TB, isolation procedures involve preventing the spread of the agent through the hospital ventilation system, thus the need for negative pressure rooms. A negative pres- sure room is used in hospitals when respiratory isola- tion is needed. The ventilation system uses negative pressure so that air can come into the room but does not go back out into the building and is instead venti- lated to the outside. Choosing the right level of isola- tion requires knowing how the agent is transmitted to humans (person-to-person, airborne, etc.). 7711_Ch08_191-217 21/08/19 11:02 AM Page 197 categories include bacteria, rickettsia, viruses, mycoses (fungi), protozoa, and helminths. Also grouped with these agents are arthropods, parasitic insects that in themselves do not cause disease but transmit disease (e.g., ticks, fleas, and mosquitoes). This category also in- cludes head, body, and pubic lice, though only body lice are known to transmit disease. The other two types of lice are included, because scratching from lice can result in a secondary bacterial infection of the skin and because lice are transmitted from human to human. Once the class of the pathogen is known, the specific characteristics of the category provide further necessary information. For example, if the pathogen is a helminth, it is a parasitic worm. This relates directly to the biolog- ical characteristics of the group of pathogens. Knowing the class of pathogen can help with the care of the indi- vidual patient. For example, because general antibiotics work with bacteria but not with viruses, knowing the 198 U N I T I I n Community Health Across Populations: Public Health Issues Reservoir Portal of Entry Etiological Agent Susceptible Host Portal of Exit Mode of Transmission Figure 8-3 The cycle of communicable disease transmission. TABLE 8–2 n Types of Infectious Agents Category Type of Agent Examples of Diseases Bacteria Rickettsia Viruses Mycoses Protozoa Helminths Anthropods Microorganism, unicellular Either gram-positive or gram-negative Though in a separate class, they are a genus of bacteria that grows in cells. They are structurally similar to gram-negative bacteria A submicroscopic organism with a protein coat that are a piece of genetic material (RNA or DNA) are microorganisms. They are unable to grow or reproduce outside a host cell. A disease caused by fungi Single-celled animals such as flagellates, amoeboids, sporozoans, and ciliates Parasitic worm-like organisms that feed off living hosts Insects that act as vectors and transmit the agent from its reservoir to its host. Bacterial meningitis Anthrax Bubonic plague Tuberculosis Streptococcal infections Typhus Rocky Mountain spotted fever HIV Common cold Influenza Candida Histoplasmosis Fungal meningitis Malaria Giardia Toxoplasmosis Trichomoniasis Hookworm Pinworm Trichinosis Malaria Dengue fever Lyme disease Bubonic plague Source: Friss, R.H., & Sellers, T.A. (2014). Epidemiology for public health practice, (5th ed.) Burlington, MA: Jones & Bartlett. 7711_Ch08_191-217 21/08/19 11:02 AM Page 198 class of the pathogen can help to determine whether the patient should receive an antibiotic or an antiviral. In addition to the class of the agent, other character- istics of the agent are helpful to understand. The first characteristic is the infectivity of the agent. This reflects the capacity of an agent to enter and multiply in the host. Some agents have low infectivity, meaning either they have a decreased capacity to enter a human host and/or they have a decreased capacity to multiply once they are in the human host. The next characteristic of an agent is its pathogenicity, which is the capacity of the agent to cause disease in the human host. Not all infectious agents have the same capability to cause disease. Toxigenicity is another key issue with an infectious agent and reflects the pathogen’s ability to release tox- ins that contribute to disease within the human host. Not all agents release toxins. There is also variability among agents in relation to their resistance to survive environmental conditions. For example, HIV survives for only a short time outside its host (the human body), whereas anthrax can survive for decades in the soil or in warehouses where untreated animal hides have been processed. Another important characteristic of the agent is virulence, which is defined as the ability of the pathogen to cause disease. Finally, agents differ on antigenicity, that is the ability of the agent to produce antibodies in the human host. For example, prior to the arrival of vaccines, parents attempted to expose their children to infectious parotitis (mumps). Because a case of mumps usually results in the development of antibodies, the par- ents hoped their children would develop immunity to mumps during childhood because the disease can cause serious complications in adults. Thus, mumps virus has a high level of antigencity. Environmental Characteristics Reservoir The environment refers to the conditions external to the host and the agent associated with the transmission of the agent. The first of these is the reservoir, or where the agent resides. For most CDs, the reservoir is a human (the agent resides in an infected human). An- other common reservoir is animals, and these CDs are known as zoological diseases (e.g., Lyme disease and anthrax). For Lyme disease, the agent is a spirochete, Borrelia burgdorferi, and the reservoir is both animals and humans. For anthrax, the reservoir is also animals, including elephants, hippopotami, cattle, sheep, and goats; in spore form, the reservoir is soil exposed to the feces of these animals. Reservoirs also include water (waterborne diseases), food (foodborne diseases), and the air (airborne diseases). The human reservoir can be a person who is acutely ill or someone who is a carrier, that is, a human who is infected but who has no outward signs of disease. There are four main types of carriers: an incubating carrier, an inapparent carrier, a convalescent carrier, and a chronic carrier. An incubating carrier is someone who has been infected but has not yet shown signs of the disease. An inapparent carrier is someone who is infected but does not develop the disease, yet continues to shed the agent, such as Typhoid Mary (Box 8-3). A convalescent carrier is a person who is infected but who no longer shows signs of acute disease. The chronic carrier remains infected with the agent with no sign of disease for a long period of time. Mode of Transmission The next consideration is the mode of transmission, the method through which the agent leaves its reservoir and enters its host. Transmission can occur through water, food, air, vectors, fomites, unprotected sexual contact, or penetrating trauma (Table 8-3). Vectors are usually C H A P T E R 8 n Communicable Diseases 199 Mary Mallon worked as a cook and had no idea that she was an inapparent carrier of typhus. She was the first identified “healthy carrier” of typhoid fever in the United States. She worked in several households between 1900 and 1907. During that time, members in each household came down with typhus. She even nursed those who were sick, continuing to spread the disease. Although public health officials explained to her the reason she needed to be quarantined, she did not believe that she could spread the disease. Because of her disbelief, she escaped from her quarantine and went back to working as a cook. When she was once again apprehended, she was taken to North Brother Island near New York City and remained there for 3 years. She was released when she promised not to work as a cook. She worked as a laundress for a period of time, but the wages were low, so she changed her name and once again took a job as a cook, this time at New York’s Sloane Hospital for Women. She infected 25 people and one died. She was apprehended again by authorities and spent the rest of her life on North Brother Island. Her name has become synonymous with the healthy carrier of disease. BOX 8–3 n Typhoid Mary Source: Leavitt, J.W. (1996). Typhoid Mary: Captive to the public’s health. Boston, MA: Beacon Press. For more information, watch the PBS special The Most Dangerous Woman in America: http://www.pbs.org/wgbh/nova/typhoid/ 7711_Ch08_191-217 21/08/19 11:02 AM Page 199 insects that carry the disease from the reservoir to hu- mans without becoming ill themselves. A fomite is an inanimate object. An infected host touches the object and sheds the agent onto the object. The agent is then trans- mitted to the next person who touches the object. Possi- ble fomite transmission of the cold or the flu virus is used by marketers to sell their disinfecting products. Life Cycle of an Infectious Agent The two aspects of the environment, reservoir and mode of transmission, are best illustrated through a review of the life cycle of an infectious agent. The life cycle provides essential information on the environment and how an agent goes from its normal reservoir to the host, known as the mode of transmission. Some agents have complex life cycles, such as the human hookworm (Ancylostoma duodenale or Necator americanus) (Fig. 8-4).39 For other agents the life cycle of the vector is more important than the agent’s own life cycle, as in the case of the agent re- sponsible for Lyme disease, B. burgdorferi. A vector transmits the agent without becoming infected itself. The reservoir for B. burgdorferi includes mice, squirrels, and other small animals. This is where the agent resides. The blacklegged tick then transmits the agent among these animals to humans by biting an animal infected with the agent (the reservoir) and then biting a human. The black- legged tick has a 2-year life cycle. This life cycle, rather than the life cycle of the agent, provides the environmen- tal information needed to develop prevention programs. The tick feeds on small animals in the larval and nymphal 200 U N I T I I n Community Health Across Populations: Public Health Issues TABLE 8–3 n Types of Transmission Examples of Breaking the Cycle Type of Transmission Examples of Transmission Fomite transmission: An inanimate object carries the pathogen from the reservoir to the host. Aerosol or airborne transmission: The agent is contained in aerosol droplets and is transferred from one human to another or animal to human. Oral transmission: The agent is transferred through food or water. Vector borne transmission: An insect acquires the agent from an animal and transmits it to another. Zoonotic transmission: The agent is transmitted directly from animals to humans. Person-to-person transmission: The agent is transmitted through direct contact between persons, usually through contact with mucous membranes, blood, or saliva. It also occurs through venereal and in utero routes. Transferring of viruses on the surface of inanimate objects such as a phone. Transferring of lice through exchange of clothing. Using a cutting board for meat products and then vegetables without cleaning the board in between use. Transferring of the agent through the air, usually after the human host expels droplets into the air by coughing or sneezing. Ingestion of food or water contaminated with the agent such as cholera in untreated water and E. coli through the ingestion of contaminated beef Fleas, ticks, and mosquitoes are common vectors of agents to humans. Dogs, sheep, pigs are common sources of direct transmission from animals to humans such as hookworm or rabies. Decontamination of the fomite through the use of disinfectants or proper cleaning. Use of negative pressure rooms in hospitals and personal protective equipment such as facemasks. Eradication of the agent through cleaning of the water supply, implementation of food processing regulations, proper cooking of foods, hand hygiene. Eradication of the vector such as control of mosquito breeding grounds, use of insect repellent, and mosquito netting. Vaccination of the animal. Vaccination such as the hepatitis B vaccine, use of personal protective equipment. 7711_Ch08_191-217 21/08/19 11:02 AM Page 200 stage and on deer in the adult stage. During the nymphal stage, the tick is most aggressive and more apt to bite the host. The tick’s life cycle explains what seasons of the year humans can become infected and clarifies the mode of transmission. The life cycle of the agent or the vector provides added information on the transmission of an infectious agent, including how the agent exits its reservoir (portal of exit), the mode of transmission (water, vector, fomite, etc.), and how the agent enters the host (the portal of entry). For example, the agent that causes TB, M. tuberculosis, primarily infects the lungs; thus, the portal of exit is coughing. The action of coughing expels the agent from the reservoir (human) into the air. The agent has now left its reservoir and is contained in the droplets expelled from the lungs. The mode of transmission is through the air, so TB is considered an airborne disease. The portal of entry for TB is almost always through the host’s res- piratory system (the host breathes in the droplets that contain the agent and inhales them into the lungs). Host Characteristics The final aspect of the cycle of transmission is the host. The host is the human who is at risk for disease due to exposure to the agent. The main characteristic is the sus- ceptibility of the host, that is, the likelihood of becoming infected with the agent. This is expressed in terms of the host’s immunity, or resistance to the disease. Immunity There are two types of immunity, humoral and cellular. Humoral immunity means that the host carries antibod- ies to the agent in the blood, and cellular immunity is specific to each type of cell. Immunity is passive or active. When a person has passive immunity, immunity is transferred from one individual to another. It can occur naturally or artificially and lasts for only a short time. Passage of immunity from the mother to her infant is an example of natural passive immunity. Artificial passive immunity involves the transfer of antibodies and can be done in various forms. Active immunity is acquired through exposure to the agent. It is long-lasting and can last for life, as when a person who had mumps as a child remains immune for the rest of his life. Inherent Resistance Another measure of the host’s level of susceptibility is in- herent resistance. This is the ability of the host to resist the disease independent of antibodies. It can be inherited or acquired and is often linked to health status and is tempo- rary rather than permanent. Even if exposed to the agent, the host does not become ill due to her own ability to resist the disease because of other factors that boost the body’s ability to resist the disease, such as adequate nutrition. Colonization Another host characteristic is colonization. In this case, a person is infected with the agent but has no signs of in- fection. This term is mentioned frequently in acute care settings in relation to multiple drug resistant agents such as methicillin-resistant Staphylococcus aureus. Patients are admitted with no signs of infection but are colonized with a serious multidrug-resistant pathogen. Colonized hosts are able to spread the disease despite not being ap- parently ill. Breaking the Chain of Infection When clinical signs and symptoms are present, the host is not only infected, but disease has now occurred. The cycle of transmission is complete. The agent has travelled from the reservoir to the new host and has caused dis- ease. For the nurse, understanding the cycle of transmis- sion for a specific pathogen can guide the type of intervention developed to break the chain of infection. Interventions can be aimed at any point in the cycle of transmission. For example, with the outbreak of the Zika virus in the summer of 2016, Florida attempted to break the cycle of infection by eradicating the vector, the Aedes aegypti mosquito, through application of pesticides. The use of mosquito nets in malaria-prone areas attempts to block the mode of transmission by placing a barrier between the portal of exit and the portal of entry. One of the key components in breaking the chain of transmission is to reduce the susceptibility of the host. C H A P T E R 8 n Communicable Diseases 201 = Infective Stage = Diagnostic Stage i d Adults in small intestine Eggs in feces Rhabditiform larva hatches Filariform larva Filariform larva penetrates skin http://www.dpd.cdc.gov/dpdx 5 1 2 3 4 i d Figure 8-4 Life cycle of the hookworm. 7711_Ch08_191-217 21/08/19 11:02 AM Page 201 the sudden increase in the incidence of a CD. Conducting an outbreak investigation requires solving the mystery, similar to what a detective does in solving a murder case. With CDs, though, solving the mystery always involves more than knowing “whodunit.” In the game Clue, the winning player announces their final conclusion that it was, for example, Mrs. White who did it in the parlor with the lead pipe, based on a process of elimination. Unlike Clue, a CD outbreak investigation requires much more. Investi- gators seek to identify who got sick, what made them sick, when they got sick, and at what point it happened. The public health team’s goal is to gather enough information so that measures can be put in place to halt the spread of disease. These facts are essential to determine what is the best action to take to break the chain of transmission and prevent further spread of the disease to uninfected mem- bers of the population. Public health science provides the guide for answering these questions (see Chapter 3). Some- times the investigation is completed more quickly, as in some foodborne disease outbreaks, but sometimes unrav- elling the mystery takes much more time and detective work, especially if the disease is an emerging disease, as was the case with HIV in the 1980s. This is primarily achieved through vaccination. Because of the importance of this approach, the HP topic related to CDs includes a strong focus on immunization. The first objective under this topic is to “reduce, eliminate, or maintain elimination of cases of vaccine-preventable disease” and has 10 vaccine-related targets, 4 of which have a target of total elimination (no cases). The four CDs targeted for elimination through vaccination include acute paralytic poliomyelitis, rubella, hepatitis B, and congenital rubella syndrome.40 Outbreak Investigation Despite efforts to prevent transmission of disease, out- breaks of infectious disease continue to occur. When they do, public health departments conduct outbreak investiga- tions. An outbreak investigation, related to CDs, involves conducting a systematic epidemiological investigation into 202 U N I T I I n Community Health Across Populations: Public Health Issues n HEALTHY PEOPLE Immunization and Communicable Diseases Goal: Increase immunization rates and reduce preventable CDs. Overview: The increase in life expectancy during the 20th century is largely a result of improvements in child survival associated with reductions in infectious disease mortality because of immunization.1 However, CDs remain a major cause of illness, disability, and death. Immunization recommendations in the United States currently target 17 vaccine-preventable diseases across the life span. HP 2020 goals for immunization and CDs are rooted in evidence-based clinical and community activities and services for the prevention and treatment of CDs. Objectives new to HP 2020 focused on tech- nological advancements and ensuring that states, local public health departments, and nongovernmental or- ganizations are strong partners in the attempt on the part of the United States to control the spread of CDs. Objectives for 2020 reflected a more mobile society and the fact that diseases do not stop at geopolitical borders. Awareness of disease, and completing preven- tion and treatment courses remain essential compo- nents for reducing infectious disease transmission.40 Midcourse Review: Of the 67 measurable objectives, 21 were met or exceeded targets, 26 were improving, 11 had little or no change, and 6 were worse (Fig. 8-5). Among the objectives that were getting worse were the number of U.S.-acquired cases of mumps, pertussis, and measles.41 16% 9% 39% 31% 3% 2% Healthy People 2020 Midcourse Review: Immunization and Infectious Diseases Getting worse Little or no change Improving Met or exceeded Base line Informational Figure 8-5 Healthy People 2020 Midcourse Review: Immunization and Infectious Disease. (Data source reference 41.) w SOLVING THE MYSTERY The Case of the Halloween Cider Public Health Science Topics Covered: • Epidemiology • Surveillance 7711_Ch08_191-217 21/08/19 11:02 AM Page 202 C H A P T E R 8 n Communicable Diseases 203 In this hypothetical case, Susan and Mary, the infec- tion control nurses in two hospitals located in the same county, noticed an increase in positive laboratory results for E. coli 0157:H7 infections in their patients. On Monday, the laboratory informed Mary that there were two patients with positive results for E. coli 0157:H7. Mary called Susan to see whether her hospi- tal had any cases. Susan called Mary back on Tuesday to report three cases; Mary had an additional seven cases. As required, they reported their findings to the county public health department. The public health nurse, Joe, asked them to join the investigation team. In any outbreak investigation, identifying the culprit, that is, the infectious agent responsible for causing the dis- ease, is crucial. Outbreak Investigation The first thing Joe did was to determine whether there was an epidemic. He accomplished this through a re- view of the 10 reported cases at the time of Susan and Mary’s first call. Most E. coli bacteria are harmless and are normal flora living in the intestines. However, Shiga toxin-producing E. coli (STEC) such as 0157:H7 are pathogenic; that is, they cause disease.42 There are federal health regulations that require that certain dis- eases are designated as notifiable. E. coli 0157:H7 is one of these diseases. For each notifiable disease, there is a CDC case definition.37,38 To begin the investigation, they used the CDC guide to define what constituted a case. Case identification provides the investigators with information needed to plot the outbreak and helps to determine whether there is a common source. Sometimes the agent is not known at the outset, so clinical parameters define a case until the pathogen is identified. When the pathogen is not known, a patient is considered a case if he or she manifests specific clini- cal symptoms such as fever, diarrhea, and vomiting, which the team determines based on review of the presenting cases. Because Mary and Susan had already identified the agent, a case was defined based on labo- ratory-confirmed E. coli 0157:H7. Much is known about the agent E. coli 0157:H7, which was isolated in the early 1980s, and there are specific guidelines for defin- ing a case (Box 8-4).43 In addition to the guidelines, the team included in the case definition the date on which symptoms first occurred. This helped to confirm that the case occurred within a similar time frame as the other cases. The team members also extended their search outside of the county to determine whether there were any cases that had occurred within the same time frame but diagnosed elsewhere. Because the team members knew the identity of the agent, they also knew the common reservoir and method of transmission. Because E. coli normally lives in the intestinal tracts of humans and animals, the usual route for transmission is the fecal-oral route. E. coli, therefore, is either water- or food- borne and has been traced in previous outbreaks to various types of produce, such as spinach, as well as meats, such as undercooked hamburger. Thus, the team must determine whether there was a common source of infection and whether it was foodborne or waterborne. A common source of infection occurs when the pathogen is transmitted from a single source, such as cantaloupes grown on a particular farm or hamburgers served at a particular restaurant. To help determine the severity of the outbreak, the team calculated the CFR using the total number of fatal cases divided by the total number of cases. In this outbreak, there was a total of 106 cases including 5 deaths. The CFR was 4.7%. Because of the CFR and the potential that this E. coli outbreak could be multistate, the county public health department Culture-independent diagnostic testing (CIDT), defined as the detection of antigen or nucleic acid sequences of the pathogen, is rapidly being adopted by clinical labora- tories. For Shiga toxin-producing Escherichia coli (STEC), these are generally PCR-based testing methods that do not require a stool culture and thus do not yield an isolate. Although concerted efforts are being made to ensure reflexive culture is performed at the clinical laboratory or the state public health laboratory, CIDT- positive reports are not always culture-confirmed. The current STEC case definition classifies a positive CIDT result detecting Shiga toxin, that is not culture-confirmed, as a suspect case. To prevent an increase in underreporting of STEC infection cases and to make case definitions for enteric bacterial pathogens more consistent, this position state- ment proposes that: 1. Detection of Shiga toxin, Shiga toxin genes, E. coli O157, or STEC/EHEC by CIDT with- out culture-confirmation in a clinically compatible person be classified as a probable STEC case. 2. Illnesses among persons who are epidemiologically linked to a confirmed or laboratory-diagnosed probable case will be classified as probable epidemiologically-linked cases. BOX 8–4 n Escherichia coli 0157:H7—CDC Clinical Description Source: (43) 7711_Ch08_191-217 21/08/19 11:02 AM Page 203 204 U N I T I I n Community Health Across Populations: Public Health Issues worked in collaboration with the state health depart- ment and the CDC to help locate cases outside the county. CFR = Number of fatal cases Total number of cases Once the team defined what constituted a case based on laboratory confirmation of infection with the agent, the members used basic epidemiology to help plan the next step. The team began to figure out the essential aspects of this potential outbreak and then plan the prevention efforts based on whether the inter- vention was aimed at the agent (eradicating the agent), the environment (interrupting transmission), or the host (reducing susceptibility). To do this, they collected further data on each of the cases, such as onset of symptoms, place of residence, and information about where they were and what they ate, starting with the maximum exposure date. Because the range of incuba- tion is 8 to 10 days, the team started with the day of onset of symptoms and worked backward to the maxi- mum date of exposure. For example, for case number one symptoms began on November 7. The team worked backward to October 28 and collected data on where the person was and what he or she ate. The team used the data to build an epidemic curve. An epidemic curve is constructed by plotting on a graph the number of cases (y-axis) based on the date of onset (x-axis). This requires making a graph that includes the number of new cases per day and month (Fig. 8-6). The graph helped determine how much time elapsed between exposure to the pathogen and the beginning of clinical symptoms. Because the incubation ranges from 8 to 10 days, the team could estimate what date(s) the exposure probably occurred. The epidemic curve also helped determine whether there was a point source, that is, the source of the exposure happened at one point in time; a continuous source, that is, the exposure is ongoing; or an intermittent source, that is, expo- sure comes and goes. After looking at the epidemic curve (see Fig. 8-5), Joe noted that after day 5 there was a decline in the number of cases, but there was a subsequent increase in cases on days 10 and 11. This represented a bimodal curve that could be a result of two different point sources or of possible household exposure, because E. coli can be transmitted from person to person. When the cases that occurred on the second curve were reviewed, all of them were family members of an earlier case. This led the P er ce nt ag e (% ) Day # New Cases # New Cases 1 2 3 4 5 6 7 8 9 10 11 12 13 14 30 20 15 5 25 10 0 Figure 8-6 Plotting the epidemic curve. team to conclude that there was a point source for the exposure. Because it appeared to be a point source, team members then examined all the cases to determine whether there was a common source, that is, some- thing that all of the cases ate, drank, or did that could have been contaminated with E. coli. The team also examined the data on where the patients were and whether there was a common restaurant or a food market where the people purchased food or drink. The team next needed to determine how the cases come in contact with the agent. To help with this process, the team mapped out the cycle of transmis- sion for E. coli 0157:H7. Mapping out this information helped the team’s investigation because members needed to know the most likely places where patients may have come in contact with E. coli. Knowing some- thing about the pathogen helped the team members develop a hypothesis for the source of the infection so they could begin to build an intervention to prevent further cases. Generating a hypothesis about the sources of in- fection is a key step in outbreak investigations. The team began by reviewing the sources of infection in prior E. coli 0157:H7 outbreaks. There was an out- break of E. coli 0157:H7 in Washington State in 1993 that resulted in 700 cases and 4 deaths. All of the fa- talities were children. In 1999, there was an outbreak 7711_Ch08_191-217 21/08/19 11:02 AM Page 204 Infectious Agents and Attack Rates The hypothetical Case of the Halloween Cider illustrates how humans become infected with an agent that can cause disease. A few other pieces of information are use- ful to have when conducting an outbreak investigation related to an infectious disease. First, transmission can occur from the reservoir directly or indirectly. Person- to-person contact is an example of direct transmission and occurs with sexually transmitted infections (STIs). Indirect transmission occurs when the agent leaves the C H A P T E R 8 n Communicable Diseases 205 at the Washington State Fair. A total of 781 people were infected, and 2 died.44 An outbreak in 2007 resulted in only 12 cases but caused the recall of 21.7 million pounds of ground beef and the closing of the Topps Meat Company.45 E. coli outbreaks contin- ued with one in 2018 linked to romaine lettuce that resulted in a nationwide alert to avoid eating any ro- maine lettuce.46 Based on these cases, the team mem- bers developed the hypothesis that the outbreak was foodborne and began by examining the data to deter- mine whether there were any commonalities among the cases. The data they examined included their sur- vey of all the patients who met the definition of being a case. The infection control nurses, Susan and Mary, interviewed patients still in the hospital, and Joe con- ducted phone interviews with those who were dis- charged or who were cared for at home. Based on information from the CDC, cases were located out- side the county and outside the state. The CDC and the state health department helped coordinate data collection for these cases. Based on the epidemic curve, the team narrowed the possible date of the initial exposure to a 5-day pe- riod that extended from October 28 to November 1. During that time, the county held a Halloween festival, and all of the primary cases had attended the festival. At the festival, there were multiple possible sources for exposure, including a petting zoo, the sale of apple cider from a local farm, a fresh fruit and salad stand, and a hamburger stand. With all the information gath- ered, the team then narrowed down possible sources based on the ones that the cases had in common. About half of the cases had gone to the petting zoo, a quarter of the cases had eaten fresh salads from the fruit and salad stand, and a third had consumed ham- burgers. In contrast, all but four of the cases reported drinking cider. The team then calculated relative risk (see Chapter 3) for the disease based on the possible exposure to hamburgers, petting zoo, and cider. Based on their survey, they found that approximately 95% of the cases reported consumption of the apple cider sold at the food stand next to the kiddy rides. They then questioned the vendor and found that the cider came from a local farmer who made the cider just for the fair. Management of the Epidemic Now that the team had identified the probable source of the outbreak, the team had to isolate the source. In some of the E. coli 0157:H7 outbreaks, isolating the source had proved to be problematic. For example, in the 2018 epidemic associated with the consumption of romaine lettuce, cases were dis- tributed across multiple states.46 In this hypothetical case, to manage the epidemic, the team located the farmer who supplied the cider to the stand at the fair. The cider was homemade and unpasteurized cider thus a possible source of E. coli 0157:H7. If the cider had come from a commercial enterprise, the health department would want to intervene and make sure no further sale of the cider occurred. In this case, the public health department questioned the farmer about further sale of the product and dis- covered that the farmer had a vegetable stand. The county public health department closed the stand and all of the cider the farmer had was destroyed. The public health department also alerted the public to the threat of infection for those who had consumed the cider so that they could be screened for possible infection and provided with treatment if needed. A public service announcement was released advising the public to destroy any cider that had been pur- chased from this farm. Managing an outbreak, especially in the case of a disease known to have an increased risk for mortality, requires prompt action on multiple levels. The key is to know how best to break the cycle of transmission. In this case, the reservoir was the target. The team focused on removal of the cider, the actual reservoir for the E. coli 0157:H7. The team also sought to elimi- nate further consumption of the Halloween cider. In this hypothetical case, a local intervention would work if the farmer who made the cider sold only to the ven- dor at the fair who then sold only single servings of the cider at the fair. Instead, the farmer owned a farm stand with cider products; therefore, a broader intervention was warranted. 7711_Ch08_191-217 21/08/19 11:02 AM Page 205 reservoir and is transferred to the human host through an indirect means such as a vector or in the case of fomite transmission. Once transmission has occurred, disease is not neces- sarily immediately apparent. As mentioned earlier, inap- parent infection is the subclinical phase during which there are no apparent clinical symptoms. From a public health perspective, it is often important to identify those with inapparent infection not only to provide early treat- ment, but also to stop the spread of infection, as you will see in the next case. To help understand how long this inapparent infection phase can last, it is important to know the incubation period. This is the time interval be- tween infection and the first clinical signs of disease. For E. coli, the incubation period is short, but for other pathogens, it can be quite long. For example, persons in- fected with TB during childhood may not develop the disease until later in life. As discussed in Chapter 3, time is a key issue in epi- demiology. With CDs, the incubation period for the pathogen is one example of time that must be considered when investigating an outbreak and planning prevention. Another factor to consider is the generation time, which is the interval between infection with the agent and the maximum time that the host is infectious, that is, the communicability of the host. Sometimes the incubation and generation time are the same. If that is the case, then when symptoms appear, the host can no longer transfer the agent to other hosts, but that is not always the case. Generation time helps when dealing with the spread of agents that have a large number of subclinical cases. Another issue related to infection at the population level is community or herd immunity. This refers to the immunity of a population to an agent. If a large por- tion of the population is immune (by vaccine or past infection), that can prevent the spread of the disease to persons in the population who do not have immunity. There is usually a threshold of immunity that needs to be achieved to establish herd immunity. In other words, a certain percentage of the population must be immune to achieve herd immunity to a specific agent. With herd immunity, even if a few members of the community become infected, the population as a whole is protected from an outbreak. In the hypothetical Case of the Halloween Cider, the team calculated a CFR. There are other rates that can be helpful in an investigation, including attack rate and sec- ondary attack rate. An attack rate is actually a type of incidence rate (see Chapter 3 for more in-depth discus- sion). It is calculated using the number of persons who are ill divided by the total number of the population, which includes persons who are ill plus those who are well. This is multiplied by a constant (usually 100) and expressed over a certain time period. The attack rate can be calcu- lated based on a particular risk factor. For example, sup- pose the team had narrowed down the possible risk factors at the county fair as the consumption of burgers at the burger stand, the petting zoo, and the cider. For each risk factor, the team would calculate a separate attack rate for those exposed to the risk factor and those not exposed. Group A could be those who drank the cider and group B could be those who did not drink the cider. Once these two attack rates are calculated, the difference between the two attack rates would be determined. This process would then be repeated for the burgers and the petting zoo (Box 8-5). The risk factor with the greatest difference in attack rates may be your common source for the outbreak. Another calculation useful in an outbreak investiga- tion is the secondary attack rate. This reflects the spread of disease from those who contracted the disease from the initial source to others usually within the same household or other unit where people come in close contact with others. The secondary attack rate is calculated by dividing the number of new cases in a particular group minus the initial case(s) by the number of susceptible persons in the group minus the initial case(s) (see Box 8-5). Sexually Transmitted and Reproductive Tract Infections Not all CD outbreaks follow the course described in the Case of the Halloween Cider. In that case, the outbreak required public health officials to take action related to a 206 U N I T I I n Community Health Across Populations: Public Health Issues Attack Rate = ill × 100 during a time periodill + well Number of new cases in group – initial cases Secondary Attack Rate (%) = Number of susceptible persons in the group – initial cases × 100 BOX 8–5 n Rate Calculations 7711_Ch08_191-217 21/08/19 11:02 AM Page 206 food product and those who became ill were not aware of their risk. On the other hand, Sexually transmitted in- fections (STIs), also referred to as sexually transmitted diseases, are related to behavior. Much has been done to alert those who are sexually active to the risk involved in unprotected sexual activity. In HP, the topic “sexually transmitted disease” is a separate topic area from the topic “immunization and infectious diseases.” Specific diseases targeted in the objectives are chlamydia, pelvic inflammatory disease (PID), gonorrhea, syphilis, and human papillomavirus. Burden of Disease and Sexually Transmitted Infections STIs are caused by pathogens transmitted from human to human through sexual contact. The reservoir of the agent is the human body. These infections can cause se- rious illness and disability, and are preventable. There are three notifiable sexual infections that have federally funded control programs: chlamydia, gonorrhea, and syphilis.49 The incidence rate of chlamydia (agent: Chlamydia trachomatis) has increased from 160.2 per 100,000 in 1990 to 497 per 100,000 in 2016 with the rate in women double the rate in men.50 Chlamydia is associated with PID and can be passed on to the infant during delivery. The agent Chlamydia trachomatis is a bacterium and is treatable with antibiotics. Unfortunately, for many women there are no symptoms, and often the infection goes undiagnosed. If the infection is not treated and PID develops, women can experience complications such as infertility, ectopic pregnancy, and chronic pelvic pain. As this is a treatable infection public health efforts focus on screening and early treatment, as well as education and promotion of condom use during intercourse. Another serious STI is gonorrhea (Neisseria gonor- rhoeae). After chlamydia, it is the most commonly re- ported STI in the United States. At the end of the 20th century, the incidence rate fell 75% from 1975 to 1997 and reached a historic low in 2009 with a national rate of 98.1 cases per 100,000. However, in 2016 there was an 18.5% increase from 2015 with a total of 468,514 cases of gonorrhea (a rate of 145.8 per 100,000).51 Like chlamy- dia, it is a major cause of PID, infertility, and ectopic pregnancies. Also, like chlamydia, the infection is treat- able, but serious health consequences occur if it is un- treated. In addition, there is now widespread resistance to a class of antibiotics used to treat gonorrhea, the fluo- roquinolones, resulting in a change in CDC guidelines for the treatment of gonorrhea with cephalosporins.52 C H A P T E R 8 n Communicable Diseases 207 n HEALTHY PEOPLE Sexually Transmitted Diseases Goal: Promote healthy sexual behaviors, strengthen community capacity, and increase access to quality services to prevent STDs and their complications. Overview: Sexually transmitted diseases (STDs) refer to more than 25 infectious organisms transmitted primarily through sexual activity. STD prevention is an essential primary care strategy for improving reproductive health. Despite their burdens, costs, and complications, and the fact that they are largely preventable, STDs remain a significant public health problem in the United States. This problem is largely unrecognized by the public, policy makers, and health-care providers. STDs cause many harmful, often irreversible, and costly clinical complications, such as: • Reproductive health problems • Fetal and perinatal health problems • Cancer • Facilitation of the sexual transmission of HIV infection47 Midcourse Review: Of the 14 measurable objectives, 4 were met or exceeded targets, 4 were improving, 3 had little or no change, and 3 were worse (Fig. 8-7). Among the objectives that were getting worse were the number of new cases of primary and secondary syphilis among males and the number of new cases of gonorrhea among males.48 50% 14% 14% 11% 11% Healthy People 2020 Midcourse Review: Sexually Transmitted Diseases Measurable Getting worse Little or no change Improving Met or exceeded Figure 8-7 Healthy People 2020 Midcourse Review: Sexually Transmitted Diseases. (Data source reference 48.) 7711_Ch08_191-217 21/08/19 11:02 AM Page 207 The third STI under national surveillance is syphilis, a genital ulcerative disease caused by the bac- terium Treponema pallidum. Syphilis has four stages: primary, secondary, tertiary, and latent. The primary stage occurs between 10 and 90 days following infec- tion, and is evidenced by a sore, or multiple sores, at the site where the bacterium entered the infected per- son. The sore or chancre often heals without treatment. If there is no treatment, then the infection enters the secondary stage. During the secondary stage, the per- son develops a skin rash and mucous membrane le- sions can occur while the chancre is healing or shortly thereafter. It can be accompanied by various other symptoms such as fever or swollen lymph nodes, or the symptoms may be so mild that they are not noticed. These symptoms will also resolve with or without treat- ment. However, if no treatment is given it can progress to the latent stage of syphilis, which is a period of time when there are no symptoms of the infection and can last for years. The tertiary stage does not occur in all cases of untreated syphilis, but a person with tertiary syphilis can experience adverse effects on numerous internal organs, including the brain, resulting in paral- ysis and dementia. Historical examples of people with late-stage syphilis include Al Capone and King George III of England, who was on the throne at the time of the American Revolution. In 2017 there were a total of 30,644 cases of both pri- mary and secondary syphilis reported in the United States, a rate of 9.5 cases per 100,000 population, up from 8.6 per 100,000 in 2016. In 2017, in the U.S., the rate in men was 10 times higher than in women (16.9 cases per 100,000 males vs. 2.3 cases per 100,000 females) with men accounting for 87.7% of primary and secondary syphilis cases. Men who have sex with men accounted for 57% of the cases. The rate of congenital syphilis increased in 2017 to 23.3 cases per 100,000 live births, a 43.8% in- crease from 2016 (16.2 cases per 100,000 live births) and a 153.3% increase from to 2013 (9.2 cases per 100,000 live births).53 Risk Factors The main risk factor for STIs is unprotected sexual contact. The pathogens responsible for STIs are transmitted through the exchange of bodily fluids. Some groups are more at risk than others based on gender, ethnicity, and socioeconomic status. As noted earlier, men accounted for almost 90% of all cases, and men who have sex with men accounted for more than half the cases. (Fig. 8-8).54 There was also a difference in the number of syphilis cases among racial groups. For example, according to the CDC in 2017, the rate of reported primary and secondary syphilis increased across all racial ethnic groups with the highest preva- lence rate in blacks with 24.2 cases per 100,000 popu- lation, up from 23.1. For whites the rate increased from 4.1 to 5.94 cases per 100,000.53,55 The disparity in rates of STIs across ethnic and socioeconomic status has been well documented over the past decades.56,57 For example, although blacks represent only 13% of the population, rates of gonorrhea among blacks was 8.6 times higher than the rates among whites.51 This may be due in part to socioeconomic factors. For example, those with less health insurance coverage are more apt to seek care at public health clin- ics. Although STIs are reportable infections, compli- ance with this law for reporting cases is higher in public clinics than it is in private physicians’ offices. Access to care may also prevent early diagnosis and treatment.56,57 208 U N I T I I n Community Health Across Populations: Public Health Issues Syphilis Cases by Gender and Sexual Partner 52% 12% 15% 0% 15% 6% Men who have sex with men only (n = 15,953) Men who have sex with men and women (n = 1,783) Men who have sex with women only (n = 4,548) Men without data on sex of sex partners (n = 4,601) Women (n = 3,722) Cases with unknown sex (n = 37) Figure 8-8 Syphilis cases by gender and sexual partner. (Data source reference 54.) 7711_Ch08_191-217 21/08/19 11:02 AM Page 208 C H A P T E R 8 n Communicable Diseases 209 l APPLYING PUBLIC HEALTH SCIENCE The Case of Syphilis in Baltimore City Public Health Science Topics Covered: • Health planning • Community assessment The Baltimore Syphilis Elimination Project provides an excellent example of how a collaborative effort between a public health department and health care providers, including nurses, can result in a reduction in disease. The project began due to a 40% increase in prevalence of syphilis in Baltimore City that prompted an assessment of the data related to the new syphilis cases and the implementation of a population-level in- tervention.58 Because syphilis is a notifiable disease, all diagnosed cases in Baltimore are reported to the local public health department, which in turn reports the cases to the state health department. This information is then reported to the CDC. The case of syphilis in Baltimore City helps to illustrate the differences be- tween a public health response to a foodborne infec- tious disease outbreak and an increase in new cases of an STI. The first step for the team in Baltimore City was to determine whether the increase in cases was an epi- demic. An excess of cases above the endemic levels in a specific community or region is considered an epi- demic. To decide whether there is a need for action, public health officials examine the increase in cases to determine whether the increase has reached an epi- demic threshold, that is, the number of cases above the endemic rate associated with an increased risk for spread of the disease. The epidemic threshold is used to make decisions about whether to alert the public about a possible epidemic. Epidemic thresholds differ from disease to disease, and the methods for determin- ing the threshold can also vary. These calculations re- quire a sophisticated approach, but they help guide public health officials in deciding when an epidemic alert is needed.59,60 The choice of an epidemic thresh- old usually reflects the number of cases that exceeds a certain number per 100,000 population over a specified time period. Because the term epidemic is emotionally charged, public health officials use it with caution. When a general public alert is needed, the epidemic threshold can help the public health officials either as- sure the public that there is not an epidemic or alert the public to a real risk. Next, it is important to determine the type of epi- demic related to the specific mode of transmission. The Case of the Halloween Cider fits the description of a common-source epidemic as do other water- and foodborne infections. There can also be a vector-borne epidemic such as the Zika epidemic, which was spread by mosquitos. In the case of syphilis, the disease has been endemic in the human population for thousands of years. Therefore, unlike an E. coli outbreak, the in- crease in syphilis cases in Baltimore City did not reflect a national epidemic or a pandemic but rather a specific increase in one particular geographical area. In this case, once the public health officials realized there was a dramatic increase in the number of cases, they first defined what constituted a case. They looked at the cases based on demographics and found that the increase was occurring mainly in the Hispanic popula- tion. In that population, the incidence rate had in- creased by 73% compared with a 40% increase for the population in general. Another interesting detail also emerged in their review of cases. They found that the majority of all Hispanic cases were primary cases.58 Health Planning Now the team was ready for action. Instead of a na- tional media campaign and product recall as in the case of an E. coli 0157:H7 or Salmonella outbreak, a local pro- gram was put together, the Syphilis Elimination Project, an excellent example of how to plan a health program (see Chapter 5). It is also a good example of incorporat- ing both a primary and a secondary approach to preven- tion. In addition, they developed a prevention program that targeted a population at increased risk with a selected level of prevention (see Chapter 2). The Syphilis Elimination Project had two goals. The first goal focused on knowledge, awareness, and de- creasing incidence of syphilis in the Baltimore City His- panic community, and the second was to get those with syphilis into treatment. Under the first goal, the objective was to increase the number of Hispanics tested for syphilis by 50% from baseline.58 This is an example of case finding. Case finding comes under the umbrella of secondary prevention. The purpose of find- ing cases is to identify those who are infected and get them into treatment. In STIs, the reservoir is humans. If there is an effective treatment for the disease, it is pos- sible to eliminate the agent in the reservoir. Early treat- ment for the disease from a population perspective is therefore both a primary and a secondary prevention measure. Through case finding, public health officials can intervene in relation to the agent’s reservoir. For the Baltimore City Syphilis Elimination Project, there were specific challenges related to culture, stigma, 7711_Ch08_191-217 21/08/19 11:02 AM Page 209 Emerging Sexually Transmitted Infections Gonorrhea and syphilis are mentioned throughout his- tory, whereas other STIs are new arrivals. In 1981, a new STI emerged that grabbed the attention of the world— HIV. Unlike gonorrhea and syphilis, there currently is no cure for this infection. When it was first identified, those with the infection had few treatment options and the CFR was high. Over the years, science has developed successful treatments, and the diagnosis of HIV infection is no longer a death sentence in the United States. At the end of 2015, it was estimated by the CDC that 1.1 million people aged 13 and older were living with HIV infection in the United States. This estimate included more than 162,500 (15%) persons with undiagnosed infection.61 The emergence of this STI changed how nurses pro- vide care. Unlike other STIs, this virus could be trans- mitted through exposure to other bodily fluids, including blood. In the late 1980s, when surveillance data indicated that health-care workers were at increased risk for HIV infection through exposure to blood and other bodily se- cretions, a legal approach was taken to prevent the spread of this disease in health-care workers. OSHA put into law the requirement that health-care workers use PPE. As al- ways, the prevention measures taken were based on the mode of transmission and targeted a population at risk for becoming infected. Following the institution of this law, the incidence rate of HIV in health-care workers with no other risk factors dropped dramatically. The use of PPEs has become routine in all health-care settings. This dramatic change in hospital-based infections con- trol created as dramatic a shift in care as hand hygiene did after the discovery that germs cause disease (see Chapter 1). HIV/AIDS is a pandemic and has had a severe impact on certain portions of the globe, especially in developing countries where access to treatment is limited. Once again, disparity exists related to this STI because of so- cioeconomic status, culture, and governmental support of prevention efforts. This infection is an example of the emerging diseases affecting the United States and world as a whole. 210 U N I T I I n Community Health Across Populations: Public Health Issues and access to the population. Before the team members initiated their project, they had to address these chal- lenges. In addition, skills related to cultural competency were needed to develop a program that would be ac- cepted by the intended recipients. The team members combined their efforts at case finding with a multi- method patient education campaign. Bilingual outreach workers conducted street outreach by providing educa- tion on syphilis in bars, stores, and on the street. Because there is no known method of reducing our biological susceptibility to syphilis, the Elimination Project could not reduce biological susceptibility of the host. Instead, they developed a culturally relevant edu- cational program that provided the population at risk, Hispanics living in Baltimore City, with behavioral strategies to reduce their chances of becoming infected. When there are no means available to reduce the biological susceptibility of the host, the focus of pri- mary prevention in CD becomes both the mode of transmission and the portal of entry. Through educa- tion, it is hoped that those who are not infected be- come educated on how the disease is transmitted and how it enters the body so that they can implement ef- fective strategies to prevent becoming infected. In this case, an additional challenge was to reach the popula- tion most at risk, because the project fit the definition of a selective prevention program (see Chapter 2). The Syphilis Elimination Project team members had done their homework on who was getting infected, and they had a good grasp of where this selected population resided. They designed a program that incorporated cultural and geographical issues related to the popula- tion. They used bilingual outreach workers who con- ducted their educational interventions during the evening hours and in the early mornings in high-traffic areas. They chose these times to try to reach the most people by targeting working and partying hours. By the end of 10 weeks they had met their first goal, with 2,825 Hispanics having received patient education and health information materials. Thus, by taking into con- sideration the role of culture and the importance of engaging the community, the project was successful in primary prevention (providing education to those not yet infected). They were also able to meet their second goal, screening (secondary prevention) and identifying those in need of treatment. Because the cases that were identified through screening were almost all pri- mary infections, few needed tertiary interventions, that is, treatment of clinical disease as seen in secondary and latent syphilis. n CULTURAL CONTEXT Prevention of Sexually Transmitted Infections Due to the mode of transmission, STIs bring additional challenges to prevention efforts. Changing risky behav- iors in general can be difficult but addressing sexual behaviors may be tied to feelings of shame, guilt, or 7711_Ch08_191-217 21/08/19 11:02 AM Page 210 Communicable Diseases and Communicability Not all diseases caused by an infection are communi- cable. Understanding the difference between an agent that infects humans and causes disease, and the com- municability of the agent is based on the transmission of the infection from one person to another. A person may become infected with a pathogen, but no public health response is required to prevent further transmis- sion of the agent to other persons, because the agent is not actually communicable. One example that helps il- lustrate the difference between the agent and the threat of transmission from one person to another is the Case of the Flesh-Eating Bug. C H A P T E R 8 n Communicable Diseases 211 powerlessness, and that can present barriers to the nurse wishing to intervene. The Syphilis Elimination Project demonstrates that these barriers can be over- come, especially if a population approach is taken that includes consideration of the culture of the target pop- ulation and that includes that population in the design, implementation, and evaluation of the intervention. However, stigma continues to present a barrier to health-care providers attempting to care for persons with an STI. One group of researchers in Uganda con- cluded stigma associated with HIV resulted in poor communication between HIV clients and providers about childbearing.62 In other cases, the loosening of cultural norms around sexual behaviors may actually increase the risk of contracting an STI. For example, a group of nurses working to address the rise in STIs in Thailand noted that the increase in tourism, the adopt- ing of western culture, and the loosening of cultural norms has coincided with the increase in the demand for entertainment and sex business by tourists includ- ing sex shows and sexually provocative performances.63 w SOLVING THE MYSTERY The Case of the Flesh-Eating Bug Public Health Science Topics Covered: • Epidemiology • Surveillance On June 20, 2006, David Walton, a leading econo- mist in the United Kingdom, was admitted to Chel- tenham General Hospital complaining of fever and stomach pain. Within 24 hours, he was dead. According to one physician, the infection “seemed to spread be- fore our eyes, down the thigh, growing towards the shoulder and chest”.64 In another case, a 3-year-old girl, Isabel Maude, was brought to the emergency room with high fever, nau- sea, and vomiting. Her parents explained that their daughter had recently come down with chickenpox. The physician reviewed the care of chickenpox with the parents and sent the child home. The symptoms worsened, and the child was readmitted to the pedi- atric intensive care unit because of organ failure. The first physician had missed the diagnosis based on the recent history of chickenpox. The child actually had a much more serious infectious disease. She eventually recovered after a 2-month stay at the hospital.65 The case would have turned out differently if the health- care provider who first saw the little girl had asked more questions. The health-care providers failed to solve the mystery when they first saw the girl. They did not go beyond the obvious clinical conclusion that this was chickenpox and ask what else might be going on. A third case related to this same infectious disease occurred in Lanarkshire, England. Between December 24, 2008, and January 3, 2008, two persons with a history of intravenous (IV) drug use died of the flesh-eating bug. There was one other confirmed case and one suspected case. These deaths prompted a public health announcement from the public health authorities in Lanarkshire. The first two cases did not result in a pub- lic health alert. This third case did, but it was different from the other CD investigations reviewed in this chapter. In the Case of the Halloween Cider and in the syphilis epidemic in Baltimore City among Hispanics, the infection occurred within a population. The hypo- thetical E. coli outbreak took place at a fair, and anyone who attended that fair and drank the unpasteurized cider was at risk for becoming infected. In Baltimore City, an increase in the incidence rate for an STI occurred within a specific ethnic population with less access to care and less awareness about their risk for infection. In both cases, interventions were aimed at reducing the incidence rates within a population. The cases also differed on the CFR. In the first case, though the CFR is low for many E. coli outbreaks, many of those deaths are in children and older adults, and occur soon after infection. In the second case, the period between infection and death in untreated cases can be as long as 20 years. Therefore, the urgency related to an E. coli outbreak is fueled not only by the need to decrease illness but also by the importance of 7711_Ch08_191-217 21/08/19 11:02 AM Page 211 212 U N I T I I n Community Health Across Populations: Public Health Issues decreasing the risk of mortality, especially in children. In this case, the case of the flesh-eating bug, although the virulence of the disease was extreme, the disease was not spreading to the general public. One group of persons appeared to be at greater risk.66 One of the issues in CDs is separating the agent from the disease or diseases caused by the agent. In the case of the “flesh-eating bug,” the agent can cause rapid death in some cases and no illness at all in other cases. In addition, the disease is linked to more than one agent. This is where the cycle of transmission gets in- teresting. Although the specific agent may differ, the portal of entry is the same; bacteria are introduced through an opening in the skin. In some cases, the in- troduced bacteria are those that are often found on the skin or in the throat.67 This was not the case with the men who had a history of IV drug use. Therefore, although the disease was the same and the portal of entry was the same, the reservoir differed. This then has implications for the decision of whether or not to proceed with a public health alert. In relation to E. coli 0157:H7, the primary concern was to deal with an out- break. In the case of the “flesh-eating bug”, only one of the scenarios given earlier resulted in a public health initiative similar that in E. coli outbreaks. To answer the question about whether a public health alert is needed, it helps to go back to the lessons learned in the Case of the Halloween Cider. In that case, the team conducted an assessment to determine whether this was a common source of outbreak. Based on the agent, the team members rightly suspected that this was a foodborne outbreak. In the three scenarios presented related to the “flesh-eating bug”, the first two cases represented an isolated incident. No new cases were admitted to the hospital. Knowing the usual portal of entry of an agent that causes this disease low- ered the public health concern that others were at risk. However, in the third case there were three more cases in rapid succession. The one thing the patients had in common was IV heroin drug use. This raised the potential threat to the health of persons who were IV drug users of heroin, not the public in general. One reason for the public health response was the virulence of the “flesh-eating bug”. When it enters the body through a wound, the agents associated with the “flesh-eating bug” have a very high level of viru- lence; that is, the severity of the disease produced by the agent and the CFR were high. In the United States, the CFR for this disease ranges from 20 to 30 per 100 cases.67 However, not all persons exposed to agents that cause this disease become ill. Bacteria that cause this disease include S. aureus, Clostridium perfrin- gens, Bacteroides fragilis, Aeromonas hydrophila, and others. Again, the presence of the agent is not what is important but rather the portal of entry. The agent itself can be present on the skin or in the throat and cause no disease or mild disease with a very low CFR. However, when introduced to the host through a wound, the disease agent causes changes. The formal name for this infectious disease is necrotizing fasciitis (NF). One of the known agents responsible for this dis- ease is group A (-hemolytic streptococci (GABHS). In the throat, GABHS can cause mild illness, but when in- troduced into the human body through a break in the skin, NF can result. This leads us back to the issue of the infectivity of the agent. From one perspective, the infectivity is low because there must be an opening in the skin for the agent to enter and cause disease. Therefore, the CDC does not recommend antibiotic prophylaxis in all per- sons exposed to the patient, unless there are certain other risk factors present. However, from another perspective, the infectivity of the agent is a key issue. Once the agent has entered the host through a break in the skin, it can rapidly multiply in the host, resulting in what is reflected in the quote that the infection “seemed to spread before our eyes, down the thigh, growing towards the shoulder and chest”.64 For the first two cases, no public health alerts were made, but in the third case there was reason to believe that it was actually a common source outbreak. All of the cases had a history of heroin IV drug use. Although there were only four cases and two deaths, the viru- lence of the agent prompted action. In addition, a simi- lar outbreak a few years earlier in the United Kingdom had resulted in 43 deaths. What the public health offi- cials discovered was each of the cases had injected heroin that had been contaminated with the causative agent that was in spore form. They had a common source outbreak. This discovery led to a selective pre- vention effort that targeted those at risk, persons en- gaged in current IV drug use. Their efforts included alerting emergency departments. This part of their alert focused on case finding and early treatment. The three examples of NF provided here illustrate that not all CDs require an immediate public health response and that various issues come into play when making these decisions. Key issues include the viru- lence of the agent or agents causing the disease, whether or not there is a common source for the 7711_Ch08_191-217 21/08/19 11:02 AM Page 212 Controlling Communicable Diseases In all the cases presented here, the main focus is to con- trol the spread of disease. There are three main ap- proaches: (1) changing the environment; (2) inactivating the agent; and (3) increasing host resistance. Changing the environment can involve altering or eliminating the reservoir, controlling the vector, applying personal meas- ures of hygiene, and using aseptic technique. Nurses en- gage in these measures regularly in patient care settings through their own use of proper hygiene and aseptic technique. In this way, they help reduce the occurrence of healthcare-acquired infections. Public health officials actively engage in these measures on a regular basis through general community-level sanitation measures related to water, food, and sewerage. They also actively participate in vector control. Communities at risk for mosquito-borne diseases have mosquito control pro- grams aimed at eliminating the breeding grounds of the insects. This may include the use of insecticides or the draining of swampy areas. Inactivating the agent includes the use of physical and chemical agents. Pasteurization of cider uses heat to in- activate infectious agents such as E. coli 0157:H7. One of the main issues with transmission of E. coli 0157:H7 through beef products is the failure to properly cook the beef at a high enough temperature to inactivate the agent. Cold is also used to inactivate agents in food products. The advent of refrigeration greatly reduced the spread of foodborne diseases. There are specific guidelines related to adequate refrigeration of foods to prevent the growth of bacteria that can cause disease. Chemical methods in- volve the use of chemicals to control agents such as the chlorination of water or the use of disinfects to clean po- tentially infected areas or items. Finally, breaking the cycle of transmission can be accomplished through increasing host resistance. As mentioned above, resistance can be active or passive. Eradication of smallpox was accomplished through the use of vaccines. This was a global campaign launched in 1967. At that time, smallpox had a CFR of 24% and left most of the survivors either scarred or blind. Once a per- son had the disease, there was no known treatment. However, since the late 1700s, it was known that inocu- lation with cowpox protected against the disease. The global effort to increase host resistance was successful and in 1977 the last documented case occurred. The use of vaccines to increase host resistance has dramatically changed the impact of CDs on populations, especially children. Vaccine refers to the immunizing agent used to increase the host’s resistance to viral, rickettsial, and bacterial diseases.68 They can be killed, modified, or changed into a variant form of the agent. In the United States, children routinely receive a series of vaccines that protect against measles, mumps, diphtheria, po- liomyelitis, and rubella.69 Recently, there has been con- troversy over the potential risk of autism related to childhood vaccinations despite the lack of scientific evi- dence to support the link. The CDC has put together a guide for parents on the use of vaccines.70 The use of vac- cines is a good example of evidence-based practice, be- cause all vaccines go through a vigorous process to establish safety and effectiveness prior to being used.69 C H A P T E R 8 n Communicable Diseases 213 n CELLULAR TO GLOBAL Using the WHO definition, CDs begin with a pathogen: Infectious diseases are caused by pathogenic microorganisms, such as bacteria, viruses, parasites, or fungi; the diseases can be spread, directly or indirectly, from one person to another. Zoonotic diseases are infec- tious diseases of animals that can cause disease when transmitted to humans.71 Addressing CD requires action at the population level, with the WHO providing a central leadership role through their emergency preparedness program. Their stated vision: An integrated global alert and response system for epidemics and other public health emergencies based on strong national public health sys- tems and capacity and an effective international system for coordinated response. In the first 6 months of 2018, the WHO responded to the following outbreaks: Ebola in the Democratic Republic of Congo, Measles in Japan, Rift Valley Fever in Kenya, Middle East Res- piratory Syndrome Coronavirus in Saudi Arabi, and Cholera in Cameroon. Preventing and responding quickly to CD outbreaks requires the ability to treat at the cellular level and implement actions at the national and global level to reduce the impact of CDs.72 outbreak, and whether the public health alert will reduce the occurrence of more cases as well as pro- mote early detection and treatment. Of interest in the second case, the disease resulted in the parents of the child developing an organization, Isabel Health- care, that provides a diagnosis system that prompts health-care providers to reach a timely diagnosis, thus preventing the delay in treatment experienced by their daughter.65 7711_Ch08_191-217 21/08/19 11:02 AM Page 213 n Summary Points • CDs are significant health issues that place populations at risk for increased morbidity and mortality. • Preventing the transmission of disease requires an understanding of the cycle of transmission. • Specific actions taken by nurses and other health- care providers at the population level include: • Participating in an outbreak investigation • Instituting appropriate isolation within an acute care setting • Screening patients or aggregates for an infectious disease • Developing and implementing a community outreach program to educate the public on a specific disease • Vaccination is an important public health interven- tion aimed at reduction of the transmission of infec- tious agents. 214 U N I T I I n Community Health Across Populations: Public Health Issues n EVIDENCE-BASED PRACTICE Vaccination Recommendations During Childhood Practice Statement: Vaccination is recommended by the CDC for all children as outlined on the CDC’s Web site for parents related to vaccination.70 Targeted Outcome: Decrease in incidence of vaccine preventable diseases in children. Evidence to Support: Childhood vaccinations have been part of pediatric care for more than 70 years with a significant reduction of childhood CDs. Recommended Approaches: Vaccines are held to the highest standard of safety. The United States cur- rently has the safest, most effective vaccine supply in history. Years of testing are required by law before a vaccine can be licensed. Once in use, vaccines are continually monitored for safety and efficacy. Immu- nizations, like any medication, can cause adverse events. However, a decision not to immunize a child also involves risk. It is a decision to put the child and others who come into contact with him or her at risk of contracting a disease that could be dangerous or deadly. Consider measles. One out of 30 children with measles develops pneumonia. For every 1,000 children who get the disease, 1 or 2 will die of it. Thanks to vaccines, we have fewer cases of measles in the United States today. However, the disease is ex- tremely contagious, and each year dozens of cases are imported from abroad into the United States, threat- ening the health of people who have not been vacci- nated and those for whom the vaccine was not effective.73 The CDC and the Food and Drug Admin- istration continually work to make already safe vac- cines even safer.69 In the rare event that a child is injured by a vaccine, he or she may be compensated through the National Vaccine Injury Compensation Program (VICP).74 Vaccines are used to increase host resistance to other diseases. These include influenza, pneumonia, and tetanus. Health-care workers are immunized for hepatitis B. In some countries, a tuberculosis vaccina- tion program is in effect for all members of the popu- lation. Several factors influence the decisions of public health agencies to make vaccines mandatory and how much protection will be provided by vac- cines. First, vaccines are given when the risk to the population is high. For example, hepatitis B is not given to the general public because the risk is low. Health-care providers are at higher risk from their exposure to blood and bodily fluids; thus, health-care workers providing direct care to patients are re- quired to be vaccinated for hepatitis B. For most of the childhood diseases, the risk is high for all chil- dren, so vaccination is often required prior to enrollment in schools, and health departments have active outreach programs for all the children in the population. The vaccine for TB is not used universally in all countries. In a country such as India, where the prevalence of TB is high, the vaccine is used to pre- vent childhood TB. However, in the United States it is not recommended because of the low risk of infec- tion related to receiving the vaccine and the variabil- ity of effectiveness of the vaccine against adult pulmonary TB.75 Vaccines continue to be a major prevention tool in public health. Science continues to work at develop- ing new vaccines such as a possible vaccine against HIV. In addition to the development and testing of vaccines, continued efforts are needed to implement effective vaccination programs. Not all persons at risk for increased morbidity and mortality related to influenza and pneumonia get vaccinated. There continues to be negative press related to the side effects of vaccines. However, without vaccines, smallpox eradication would not have happened. Altering the environment, inactivating the agent, and increasing the resistance of the host are all powerful tools that nurses can use to decrease the incidence of CDs. 7711_Ch08_191-217 21/08/19 11:02 AM Page 214 REFERENCES 1. Centers for Disease Control and Prevention. (2018). Out- comes of pregnancies with laboratory evidence of possible Zika virus infection, 2015-2018. Retrieved from https://www.cdc. gov/pregnancy/zika/data/pregnancy-outcomes.html. 2. Centers for Disease Control and Prevention. (2018). 2018 Democratic Republic of the Congo, Bikoro. Retrieved from https://www.cdc.gov/vhf/ebola/outbreaks/drc/2018-may. html. 3. Centers for Disease Control and Prevention. (2018). Multi- state outbreak of Salmonella Adelaide infections linked to pre-cut melon. Retrieved from https://www.cdc.gov/ salmonella/adelaide-06-18/index.html. 4. World Health Organization. (2018). Smallpox. Retrieved from http://www.who.int/csr/disease/smallpox/en/. 5. Centers for Disease Control and Prevention, National Center for Health Statistics. (2018). Leading causes of death. Retrieved from https://www.cdc.gov/nchs/fastats/leading- causes-of-death.htm. 6. World Health Organization. (2018). The top ten causes of death. Retrieved from http://www.who.int/mediacentre/ factsheets/fs310/en/index1.html. 7. Martin, P.M.V., & Martin-Granel, E. (2006). 2,500-year evolution of the term epidemic. Emerging Infectious Diseases, 12(6), 976-980. 8. Centers for Disease Control and Prevention. (2012). 2011–2012 flu season draws to a close. Retrieved from http:// www.cdc.gov/flu/spotlights/2011-2012-flu-season-wrapup. htm. 9. Centers for Disease Control and Prevention. (2017). Summary of the 2015-2016 influenza season. Retrieved from https://www.cdc.gov/flu/about/season/flu-season- 2015-2016.htm. 10. Centers for Disease Control and Prevention. (2018). Influenza (Flu): The flu season. Retrieved from https:// www.cdc.gov/flu/about/season/flu-season.htm. 11. World Health Organization. (2017). Key points: World malaria report 2017. Retrieved March 21, 2018, from http:// www.who.int/malaria/media/world-malaria-report-2017/en/ 12. World Health Organization. (2017). World malaria report 2017. Geneva Switzerland: Author. 13. Mace, K.E., & Arguin, P.M. (2017). Malaria surveillance — United States, 2014. MMWR Surveill Summ, 66(ss-21) Retrieved from https://www.cdc.gov/mmwr/volumes/ 66/ss/ss6612a1.htm. 14. Centers for Disease Control and Prevention. (2018). Malaria’s impact worldwide. Retrieved from https://www. cdc.gov/malaria/malaria_worldwide/impact.html#. 15. Centers for Disease Control and Prevention. (2016). Terms, definitions, and calculations used in CDC HIV surveillance publications. Retrieved from https://www.cdc.gov/hiv/ statistics/surveillance/terms.html. 16. UNAIDS. (2017). FACT SHEET – WORLD AIDS DAY 2017. Retrieved from http://www.unaids.org/sites/default/files/ media_asset/UNAIDS_FactSheet_en . 17. Centers for Disease Control and Prevention. (2017). HIV/AIDS basic statistics. Retrieved from https://www. cdc.gov/hiv/basics/statistics.html. 18. Dailey, A.F., Hoots, B.E., Hall, H.I., Song, R., Hayes, D., Fulton, P., Prejean, J., Hernandez, A.L., Koenig, L.J., Valleroy, L.A. (2017). Vital signs: human immunodeficiency virus testing and diagnosis delays — United States. Morbidity and Mortality Weekly Report, 66, 1-7. 19. Centers for Disease Control and Prevention. (2018). HIV/AIDS: HIV among people aged 50 and over. Retrieved from https://www.cdc.gov/hiv/group/age/olderamericans/ index.html. 20. Centers for Disease Control and Prevention. (2018). HIV in the United States by Geography. Retrieved from HIV in the United States by Geography at https://www.cdc.gov/hiv/pdf/ statistics/cdc-hiv-geographic-distribution 21. U.S. Department of Health and Human Services. (2018). Healthy People 2020 topics and objectives—HIV. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives 2020/overview.aspx?topicId=22. 22. U.S. Department of Health and Human Services. (2017). NATIONAL HIV/AIDS STRATEGY: UPDATED TO 2020 • 2017 PROGRESS REPORT. Retrieved from https://files.hiv. gov/s3fs-public/NHAS_Progress_Report_2017 . 23. U.S. Department of Health and Human Services. (2017). Healthy People Midcourse Review Chapter 20: HIV. Retrieved from https://www.cdc.gov/nchs/data/hpdata 2020/HP2020MCR-C22-HIV . 24. UNAIDS. (2014). 90-90-90 An ambitious treatment target to help end the AIDS epidemic. Retrieved from http://www. unaids.org/sites/default/files/media_asset/90-90-90_en . C H A P T E R 8 n Communicable Diseases 215 t CASE STUDY The Measles Epidemic Learning Outcomes By the end of this case study, the student will be able to: • Gain understanding of the investigation of an epidemic. • Describe appropriate prevention measures. • Apply the cycle of transmission to individual infectious agents. In 2016, there were 86 cases; in 2017, there were 118 cases; and from January 1 to April 25, there were 63 confirmed cases of measles reported to the CDC with the majority unvaccinated.76 Starting with the current year, plot the number of cases of measles for the past decade then answer the following questions: 1. What would represent an endemic incidence rate, and at what point would the CDC decide there was an epidemic that required action? 2. What is the mode of transmission for the agent? 3. In 2018, the CDC identified lack of immunization as the key issue. Using the epidemiological triangle, is the appropriate prevention approach related to the agent, the environment, and/or the host? 7711_Ch08_191-217 21/08/19 11:02 AM Page 215 25. UNAIDS. (2017). Ending AIDS: Progress towards the 90-90-90 targets. Retrieved from http://www.unaids.org/ sites/default/files/media_asset/Global_AIDS_update_ 2017_en . 26. World Health Organization. (2015). Diarrhoea. Retrieved from http://www.who.int/topics/diarrhoea/en/. 27. World Health Organization. (2017). Diarrhoeal disease. Retrieved March 20, 2018, from http://www.who.int/en/ news-room/fact-sheets/detail/diarrhoeal-disease. 28. Centers for Disease Control and Prevention. (2015). Diarrheal disease in less developed countries. Retrieved from http://www.cdc.gov/healthywater/hygiene/ldc/diarrheal_ diseases.html. 29. Centers for Disease Control and Prevention. (2018). Rotavirus. Retrieved from http://www.cdc.gov/rotavirus/ index.html. 30. Tate, J.E., Burton, A.H., Boschi-Pinto, C., Parashar, U.D., World Health Organization–Coordinated Global Rotavirus Surveillance Network. (2016). Global, regional, and national estimates of rotavirus mortality in children< 5 years of age, 2000–2013. Clinical Infectious Diseases, 62(suppl_2), S96-S105. doi: 10.1093/cid/civ1013. 31. World Health Organization. (2018). Emerging disease. Retrieved from http://www.searo.who.int/topics/emerging_ diseases/en/. 32. National Center for Emerging and Zoonotic Infectious Diseases. (2018). About the National Center for Emerging and Zoonotic Infectious Diseases. Retrieved from http:// www.cdc.gov/ncezid/. 33. Centers for Disease Control and Prevention. (2018). Tuberculosis: Multidrug-Resistant Tuberculosis (MDR TB). Retrieved from https://www.cdc.gov/tb/publications/ factsheets/drtb/mdrtb.htm. 34. World Health Organization. (2016). Global tuberculosis report 2016. Retrieved from http://apps.who.int/iris/ bitstream/handle/10665/250441/9789241565394-eng. pdf;jsessionid=ACA0E2B6D09D5A5E5E78593A6EE3816 A?sequence=1. 35. LoBue, P.A., & Mermin, J.H. (2017). Latent tuberculosis infection: The final frontier of tuberculosis elimination in the USA. The Lancet Infectious Diseases, 17(10), e327-e333. 36. Centers for Disease Control and Prevention. (1991). Tuberculosis outbreak among HIV-infected persons. JAMA, 266(15), 2058, 2061. 37. Centers for Disease Control and Prevention. (2016). Reported tuberculosis in the United States, 2015. Atlanta, GA: U.S. Department of Health and Human Services. 38. Tipple, M.A., Heirendt, W., Metchock, B., Ijaz, K, & McElroy, P.D. (2004). Tuberculosis outbreak in a commu- nity hospital—District of Columbia, 2002. Morbidity and Mortality Weekly Report, 53(10), 214–216. 39. Centers for Disease Control and Prevention. (2013). Life cycle of the hookworm. Retrieved from https://www. cdc.gov/parasites/hookworm/biology.html. 40. Healthy People 2020. (2018). Immunization and communica- ble diseases. Retrieved from http://www.healthypeople.gov/ 2020/topicsobjectives2020/overview.aspx?topicid=23 41. Healthy People 2020. (2017). Healthy People 2020 Midcourse Review Chapter 23: Immunization and communicable diseases. Retrieved from https://www.cdc.gov/nchs/data/ hpdata2020/HP2020MCR-C23-IID . 42. Centers for Disease Control and Prevention. (2018). Escherichia coli. Retrieved from http://www.cdc.gov/ ecoli/general/index.html. 43. Council of State and Territorial Epidemiologists. (2017). Public health reporting and national notification for Shiga Toxin-Producing Escherichia coli (STEC). Retrieved from https://c.ymcdn.com/sites/www.cste.org/resource/resmgr/ 2017PS/2017PSFinal/17-ID-10 . 44. Rangel, J.M., Sparling, P.H., Crowe, C., Griffin, P.M., & Swerd- low, D.L. (2005). Epidemiology of Escherichia coli 0157:H7 out- breaks 1982–2002. Emerging Infectious Disease, 11(4), 603–609. 45. Centers for Disease Control and Prevention. (2007). Multistate outbreak of E. coli 0157 infections linked to Topp’s brand ground beef patties. Retrieved from http:// www.cdc.gov/ecoli/2007/october/100207.html. 46. Centers for Disease Control and Prevention. (2018). Multistate outbreak of E. coli O157:H7 infections linked to romaine lettuce. Retrieved from https://www.cdc.gov/ ecoli/2018/o157h7-04-18/index.html. 47. U.S. Department of Health and Human Services. (2018). Healthy People 2020. Topic—sexually transmitted diseases. Retrieved from http://www.healthypeople.gov/2020/ topicsobjectives2020/overview.aspx?topicid=37. 48. U.S. Department of Health and Human Services. (2017). Healthy People 2020 Midcourse review Chapter 37: sexually transmitted disease. Retrieved from https://www.cdc.gov/ nchs/data/hpdata2020/HP2020MCR-C37-STD . 49. Centers for Disease Control and Prevention. (2017). 2016 sexually transmitted disease surveillance. Retrieved from https://www.cdc.gov/std/stats16/natoverview.htm. 50. Centers for Disease Control and Prevention. (2016). Sexually transmitted disease surveillance: Chlamydia 2016. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved from https://www.cdc.gov/std/stats16/chlamydia.htm. 51. Centers for Disease Control and Prevention. (2016). Sexually transmitted disease surveillance: Gonorrhea 2016. Atlanta, GA: U.S. Department of Health and Human Services. Re- trieved from https://www.cdc.gov/std/stats16/gonorrhea.htm. 52. Centers for Disease Control and Prevention. (2017). Gonorrhea treatment and care. Retrieved from https:// www.cdc.gov/std/gonorrhea/treatment.htm. 53. Centers for Disease Control and Prevention. (2017). Sexually transmitted diseases surveillance: Syphilis 2017. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved from https://www.cdc.gov/std/stats17/syphilis.htm. 54. Centers for Disease Control and Prevention. (2017). Syphilis statistics. Retrieved from https://www.cdc.gov/std/stats17/ figures/39.htm. 55. Centers for Disease Control and Prevention. (2017). Syphilis. Retrieved from https://www.cdc.gov/std/stats16/Syphilis.htm. 56. Hogben, M., & Leichliter, J.S. (2008). Social determinants and sexually transmitted disease disparities. Sexually Transmitted Disease, 35, S13-S18. 57. Chesson, H.W., Kent, C.K., Owusu-Edusei, K., Jr., et al. (2012). Disparities in sexually transmitted disease rates across the “eight Americas”. Sexually Transmitted Disease, 39, 458-464. 58. Endyke-Doran, C., Gonzalez, R.M., Trujillo, M., Solera, A., Vigilance, P.N., Edwards, L.A., & Groves, S.L. (2006). The Syphilis Elimination Project: Targeting the Hispanic commu- nity of Baltimore City. Public Health Nursing, 24(1), 40–47. 216 U N I T I I n Community Health Across Populations: Public Health Issues 7711_Ch08_191-217 21/08/19 11:02 AM Page 216 59. Martin P.M.V., & Martin-Granel, E. (2006). 2,500-year evolution of the term epidemic. Emerging Infectious Diseases, 12(6), 976–980. 60. Green, M.S., Swartz, T., Mayshar, E., Lev, E.B., Leventhal, A. Slater, P.E., & Shemer, J. (2002). When is an epidemic an epidemic? Israel Medical Association Journal, 4, 3–6. 61. Centers for Disease Control and Prevention. (2017). HIV/AIDS. Atlanta, GA: U.S. Department of Health and Human Services Retrieved from https://www.cdc.gov/hiv/ basics/statistics.html. 62. Beyeza-Kashesya, J., Wanyenze, R.K., Goggin, K., Finocchario- Kessler, S., Woldetsadik, M.A., Mindry, D., ... Wagner, G.J. (2018). Stigma gets in my way: Factors affecting client- provider communication regarding childbearing among people living with HIV in Uganda. PLoS One, Open Access. https://doi.org/10.1371/journal.pone.0192902. 63. Praditporn, P., & Wilawan, M. (2016). Challenges in the prevention of HIV among Thai homosexual males in the era of diversity and freedom of culture. Australian Nursing & Midwifery Journal, 24(5), 41. 64. Koster, O. (2007). Flesh-eating bug killed top economist in 24 hours. Mail Online. Retrieved from http://www.dailymail. co.uk/news/article-428234/Flesh-eating-bug-killed-economist- 24hours.html. 65. Isabel. (2018). Isabel’s story. Retrieved from https:// symptomchecker.isabelhealthcare.com/about-isabel- symptom-checker. 66. Waldron, C., Solon, J.G., O’Gorman, J., Humphreys, H., Burke, J.P., McNamara, D.A. (2015). Necrotizing fasciitis: The need for urgent surgical intervention and the impact of intravenous drug use. Surgeon, 13(4), 194-9. doi: 10.1016/ j.surge.2014.01.005. 67. Centers for Disease Control and Prevention. (2017). Necrotizing fasciitis. Retrieved from https://www.cdc. gov/features/necrotizingfasciitis/index.html. 68. U.S. Department of Health and Human Services, Vaccines.gov. (n.d.). Glossary of terms. Retrieved from http://www.vaccines.gov/more_info/glossary/index.html. 69. Centers for Disease Control and Prevention. (2017). Vaccine safety. Retrieved from https://www.cdc.gov/vaccinesafety/ index.html. 70. Centers for Disease Control and Prevention. (2017). For parents: Vaccines for your children. Retrieved from https:// www.cdc.gov/vaccines/parents/vaccine-decision/index.html. 71. World Health Organization. (2018). Infectious diseases. Retrieved fromhttp://www.who.int/topics/infectious_ diseases/en/. 72. World Health Organization. (2018). Emergency preparedness, response. Retrieved from http://www.who.int/csr/en/. 73. Centers for Disease Control and Prevention. (2018). Measles (rubeola). Retrieved from http://www.cdc.gov/measles/. 74. Health Resources and Services Administration. (n.d.). National Vaccine Injury Compensation Program. Retrieved from http://www.hrsa.gov/vaccinecompensation/index.html. 75. Centers for Disease Control and Prevention. (2018). Fact sheet: BCG vaccine. Retrieved from http://www.cdc.gov/tb/ pubs/tbfactsheets/BCG.htm. 76. Centers for Disease Control and Prevention. (2018). Measles cases and outbreaks. Retrieved from https://www.cdc.gov/ measles/cases-outbreaks.html. C H A P T E R 8 n Communicable Diseases 217 7711_Ch08_191-217 21/08/19 11:02 AM Page 217 Chapter 9 Noncommunicable Diseases Christine Savage LEARNING OUTCOMES After reading the chapter, the student will be able to: KEY TERMS 1. Describe the impact of noncommunicable diseases on the health of a population. 2. Define the burden of noncommunicable diseases using current epidemiological frameworks. 3. Describe the risk factor at the individual and population levels related to development of a noncommunicable disease. 4. Apply current evidence-based population interventions to the prevention of noncommunicable diseases. Burden of disease Chronic disease Chronic disease self-management Cultural shift Disability-adjusted life years (DALY) Health-adjusted life expectancy (HALE) Health-related quality of life (HRQoL) Human genome epidemiology Human genomics Life expectancy Monogenetic Noncommunicable disease (NCD) Polygenetic Premature death Years of productive life lost (YPLL) n Introduction In contrast with communicable diseases, a noncommu- nicable disease (NCD) is a disease that is not passed from one person to the next through direct or indirect means and is not associated with an infectious agent. The broader term, chronic disease, refers to either communicable dis- eases such as AIDS, or NCDs such as diabetes that have a long duration and usually slow progression, require med- ical attention over time, and/or limit the ability to perform activities of daily living (ADLs).1 According to the World Health Organization (WHO) there are four main cate- gories of NCDs: cardiovascular diseases (CVD), cancers, chronic respiratory diseases (CRD), and diabetes.1 The news and talk shows constantly reference our risk for NCDs and encourage us to engage in healthy behav- iors. We are told to eat healthfully, engage in regular ex- ercise, and avoid unhealthful behaviors such as tobacco use, overeating, and risky use of alcohol and drugs. For those of us who are currently healthy, it is easy to assume that NCDs do not affect us directly. The truth is that the burden of disease associated with NCDs affects us all. NCDs decrease our community’s ability to reach optimal productivity and health, and contribute to the increasing cost of health care. If we solely focus on combating NCDs on the individual level after disease has occurred, we are doomed to failure in the long run. Many risk factors that contribute to the development of NCDs, such as expo- sure to secondary smoke in public places, are beyond the ability of an individual to control or modify. True change requires a population-level approach that encompasses interventions that require action at the individual, family, and community level. Nurses in all settings play an im- portant role in prevention of NCDs across the contin- uum of prevention through primary-, secondary-, and tertiary-level interventions. Noncommunicable Chronic Diseases The majority of NCDs cannot be prevented or cured through vaccination or medication; rather, they require maintaining a healthy lifestyle, early diagnosis and 218 7711_Ch09_218-238 23/08/19 10:33 AM Page 218 treatment, and long-term management. Annually, a total of 40 million people die from a NCD, approxi- mately 70% of all deaths globally.2,3 In the United States, preventing NCDs is a major priority as reflected in many of the Healthy People (HP) objectives.4 The majority of NCDs could be prevented through a reduc- tion in behavioral risks such as tobacco use, sedentary lifestyle, harmful alcohol use, and an increase in health- ful eating.2 Health-care providers, including nurses, typically care for those with NCDs on an individual basis, often during an acute phase of the disease or at the end stages of disease. More recently, especially with the imple- mentation of the Affordable Care Act, the care of NCDs is moving away from an acute care model to a chronic care model in which the disease is managed over time and the focus is decreasing morbidity and mortality associated with NCDs through an integrated care delivery model (Fig. 9-1).5 This model requires health-care providers to reframe the care provided from the treatment of acute phases of an NCD within an acute care setting to long-term management in the community. Care of an existing NCD should be provided within a secondary and tertiary prevention framework that focuses on early detection and treat- ment as well as a long-term plan of care aimed at re- ducing morbidity and mortality (see Chapter 2). To accomplish this, nurses must use not only their knowl- edge of the pathophysiology of an NCD but an under- standing of the public health issues associated with the disease. All nurses have a role to play in reducing the burden of disease related to NCDs in populations they serve. Nurses across settings and specialties become part of national and global efforts aimed at reducing the toll that chronic diseases take on the health of not only individuals but also of populations. C H A P T E R 9 n Noncommunicable Diseases 219 ProductiveProductive InteractionsInteractions Delivery System Design Organization of Health Care Health Systems Improved Outcomes Prepared, Proactive Practice Team Productive Interactions Informed, Activated Patient The Chronic Care Model Resources and Policies Community Self- Management Support Decision Support Clinical Information Systems Figure 9-1 The Chronic Care Model. (Developed by the MacColl Institute, ®American College of Physicians-ASIM Journals and Books.) n CELLULAR TO GLOBAL Chronic noncommunicable disease occurs at the cel- lular level for an individual, yet management of a NCD over time requires an understanding not only of the risk factors across the continuum of cellular to global but also of the resources needed to provide care to those with NCDs. There is also a need for commu- nity and global level interventions aimed at reducing morbidity and mortality associated with NCDs. Build- ing on the chronic disease care model that focuses on care of individuals and families is the wider scope of factors that contribute to the morbidity and mortality associated with NCDs. The WHO acknowledges that action to reduce the burden of disease associated with NCDs includes “… a comprehensive approach … requiring all sectors, including health, finance, trans- port, education, agriculture, planning and others, to collaborate to reduce the risks associated with NCDs, and promote interventions to prevent and control them.”2 Prevention of NCDs and care for in- dividuals with NCDs occurs within the context of the community where they live. 7711_Ch09_218-238 23/08/19 10:33 AM Page 219 Burden of Disease NCDs add significantly to the overall burden of disease for a population. The burden of disease uses the disability- adjusted-life-year (DALY) measure to determine the extent of the burden a disease has on a population (see later).6 Knowing about the burden of disease associated with a specific disease helps in understanding the impact the disease has on the population or community. Esti- mating the burden of a disease can help a community prioritize health promotion and prevention efforts by targeting those diseases that account for the greatest bur- den to the community. Determining the burden of dis- ease involves calculating not only the cost of treatment but also the social and economic impacts. Analysis of the burden of a disease allows for the assessment of the com- parative importance of a disease, injury, or risk factor. This assessment takes into account how much the dis- ease, injury, or risk factor contributes to overall disability and premature death in the population. For example, if in Berryton, a hypothetical U.S. town of 8,000 adults, the prevalence of type 2 diabetes rose from 160 (2%) to 800 (10%) cases, the impact on the town would involve more than the cost to treat the indi- viduals with the disease. Let’s add another aspect to this town. It is a rural farming community recently hit with a shortage of migrant farm workers resulting in an in- ability to harvest all of the tomatoes, the town’s main crop. The new cases are occurring for the most part in 35- to 45-year-old males, and the closest medical center is 100 miles from the town. With a depressed economy, rural setting, and reduced access to care, the potential for adverse consequences and premature death associated with diabetes is increased. This could result in a decrease in the number of able-bodied people to work on the farms, further depressing the economy. Thus, the impact of an NCD extends beyond individuals and their fami- lies. For this community, the disease contributed to re- duced productivity and adversely affected the economic viability of the town. Life Expectancy Estimating the health of a population is calculated based on a number of measures. First, mortality rates are used to estimate the life expectancy of a group of people. Life expectancy is defined as the number of years a person could be expected to live based on the current mortality rates in a specific setting, usually a country. There is great variability across countries in life expectancy, especially between developed and developing countries. For exam- ple, the estimated life expectancy in the United States for 2017 was 80 years and in Afghanistan it was 51.7 years.7 Life expectancy is a valuable tool, but it fails to capture the burden of ill health caused by NCDs. To help ad- just for these factors, public health officials use the healthy life expectancy measure. Health-adjusted life expectancy (HALE) reflects the average number of years that a person can expect to live in good health by adjust- ing for disease and/or injury. The WHO uses HALEs to measure the average level of health in countries and re- gions by evaluating population-specific prevalence of dis- ease and injury as well as severity distribution of health states.8 As a result of problems with comparable health state prevalence data, the WHO uses a four-stage strategy to compute HALE (Box 9-1). This allows the WHO to estimate HALE for countries across the globe. Epidemi- ologists compute the HALE for a chronic disease using data related to age, the number of survivors, and the number of years lived. Premature Death NCDs often lead to premature death, that is, a death that occurs earlier than the standard life expectancy. For those who die prior to reaching the age they would be ex- pected to live, their death is defined as premature. There- fore, premature death reflects the number of potential life years lost. Premature death is usually expressed as the 220 U N I T I I n Community Health Across Populations: Public Health Issues The World Health Organization uses death registration data that are reported annually to estimate HALE. This information is part of the WHO Global Burden of Disease (GBD) study. Other sources of data include the WHO Multi-Country Survey Study (MCSS) and World Health Survey (WHS). Information use includes estimates for the incidence, prevalence, duration, and years lived with disability for 135 major causes. However, compara- ble health state prevalence data are not available for all countries, so a four-stage strategy is used: • Data from the WHOGBD study are used to estimate severity-adjusted prevalence by age and sex for all countries. • Data from the WHOMCSS and WHS are used to make independent estimates of severity-adjusted prevalence by age and sex for survey countries. • Prevalence for all countries is calculated based on GBD, MCSS, and WHS estimates. • Life tables constructed by WHO are used to compute HALE for countries. BOX 9–1 n Application: Health-Adjusted Life Expectancy (HALE): Methods of Estimation Source: (8) 7711_Ch09_218-238 23/08/19 10:33 AM Page 220 years of potential life lost (YPLL). YPLL is calculated by subtracting the age at which a person dies from their expected life expectancy.10 For example, if a man died of a heart attack in the United States in 2011 at the age of 42, the YPLL would be 36 because the life expectancy in the United States was 78 years that year.11 By contrast, the YPLL for a man who died in a motor vehicle crash at the age of 21 would be 57. From a population perspective, premature death is calculated based on the number of potential life years lost prior to the life expectancy of the population per 100,000 persons—in other words, how many total years of useful life were not available to the population because of early death. If you calculated the YPLL for a 50-year-old man who died of a heart attack in Afghanistan in 2011, the YPLL would be 0 because the life expectancy for males was 49. Disability-Adjusted Life Years In addition to premature death, most NCDs lead to dis- ability that can affect an individual’s quality of life and productivity. For that reason, YPLL does not adequately capture the full burden of disease. A method for quanti- fying the burden of disease that takes into account both premature death and disability is called the disability- adjusted life year (DALY). This is defined as measure- ment of the gap that exists between the ideal health status of a disease- and disability-free population that lives to an advanced age.9 It is calculated using population-level data. One DALY represents 1 lost year of life. It is calcu- lated as a sum of the years of life lost (YLL) related to pre- mature death in the population plus the years lost to disability (YLD) related to the disease. To calculate the DALY, you start with the YLL. The YLL is the number of deaths multiplied by the standard life expectancy at the age at which death occurs. For this you need the number of deaths attributed to the disease or risk factor and the expectancy at age of death in years. YLL measures lost years of life due to deaths using an in- cidence perspective (number of new cases or deaths), this perspective is also taken to calculate the YLD. For an es- timation of the YLD for a particular cause in a particular time period, you take the incidence (number of new cases) during that time period and multiply it by the av- erage duration of the disease. To account for the variabil- ity of the severity of the disease, a weight factor is included that reflects the severity of the disease on a scale from 0 (perfect health) to 1 (dead). The basic formula for YLD requires multiplying the incidence times the dis- ability weight times the average duration of the disease until remission or death (Box 9-2).9 Noncommunicable Diseases in the United States NCDs are the number one cause of death and disability in the United States. The four common risk factors that account for much of the NCDs in our country are the same as the risk at the global level and are modifiable. These include (1) nutrition, (2) physical activity, (3) to- bacco use, and (4) alcohol use. One-fourth of all persons living in the United States with an NCD have one or more limitations in their daily activities.10 The first pro- posed goal of HP 2030 is to “Attain healthy, thriving lives and well-being, free of preventable disease, disability, in- jury, and premature death.”11 This requires prevention and early treatment of NCD. Healthy People includes multiple topics related to specific NCDs as well as the four common risk factors associated with development of NCDs. Diabetes is an example of a topic for HP 2020 re- lated to NCD that will continue to be a focus of HP 2030. According to the American Diabetes Associa- tion, in 2015 more than 30 million people, almost 10% of the population of the U.S., had diabetes with 7.2 million undiagnosed and was the seventh leading cause of death. The annual cost in 2017 was $327 billion USD. 11 C H A P T E R 9 n Noncommunicable Diseases 221 DALY = YLL (Years of Life Lost) + YLD (Years of Life Disabled) The basic formula for YLL is: YLL = N × L where: • N = number of deaths • L = standard life expectancy at age of death in years The basic formula for YLD is the following (again, without applying social preferences): YLD = I × DW × L where: • I = number of incident cases • DW = disability weight • L = average duration of the case until remission or death (years) BOX 9–2 n Application: Disability-Adjusted Life Year (DALY) calculation Source: (9) 7711_Ch09_218-238 23/08/19 10:33 AM Page 221 Leading Causes of Death and Disability According to the WHO, NCDs are not only costly but are common and often preventable causes of death and dis- ability.1 Seven of the top ten leading causes of death in the United States are NCDs including heart disease, cancer, chronic lower respiratory diseases, stroke (cerebrovascu- lar disease), Alzheimer’s disease, diabetes, nephritis, nephrotic syndrome, and nephrosis (Box 9-3).14 Under- standing NCDs from a public health perspective allows us to step back and examine the context of these diseases and the causal factors linked to the occurrence of disease. Heart Disease and Stroke In the U.S., CVD and stroke are the first and fifth leading causes of death.14 They are costly and widespread. One in every four deaths in the U.S. is attributable to CVD,15 and one in every 20 deaths is attributable to stroke.16 To- gether they account for close to one-third of all deaths in the United States.15, 16 Although rates for coronary heart disease have dropped over the last 3 decades, large re- gional variations in the burden associated with CVD exist across the U.S. with dietary risk exposures being the largest attributable risk factor related to CVD burden of disase.17,18 Other risk factors include high blood pressure, obesity, tobacco use, high cholesterol, and low levels of physical activity.18 Understanding the risk factors for CVD has come from public health science. Before World War II, hyper- tension was accepted as a part of the normal aging process and little was understood about how to treat it, never mind how to prevent it. As life expectancy im- proved, the prevalence of CVD grew. Because of this in- crease in prevalence, the National Heart Institute (now 222 U N I T I I n Community Health Across Populations: Public Health Issues n HEALTHY PEOPLE Noncommunicable Disease: Diabetes Goal: Reduce the disease burden of diabetes mellitus (DM) and improve the quality of life for all persons who have, or are at risk for, DM. Overview: DM occurs when the body cannot produce enough insulin or cannot respond appropriately to in- sulin. Insulin is a hormone that the body needs to ab- sorb and use glucose (sugar) as fuel for the body’s cells. Without a properly functioning insulin signaling system, blood glucose levels become elevated and other meta- bolic abnormalities occur, leading to the development of serious, disabling complications. Many forms of diabetes exist. The three common types of DM are: • Type 2 diabetes, which results from a combination of resistance to the action of insulin and insufficient in- sulin production • Type 1 diabetes, which results when the body loses its ability to produce insulin • Gestational diabetes, a common complication of pregnancy. Gestational diabetes can lead to perinatal complications in mother and child, and substantially increases the likelihood of cesarean section. Gesta- tional diabetes is also a risk factor for the mother and, later in life, the child’s subsequent development of type 2 diabetes after the affected pregnancy.12 Midcourse Review: Of the 20 objectives for this topic area, 2 were developmental and 18 were measurable. For 4 of the measurable objectives, the target was met or exceeded, and 1 was improving. For 10 there was little or no detectable change, and 1 objective was baseline only and 2 were informational (Fig. 9-2).13 22% 11% 6% 56% 5% Baseline only Target met or exceeded Little or no change Improving Informational Healthy People 2020 Midcourse Review: Diabetes Figure 9-2 Midcourse Review Diabetes. • Heart disease: 635,260 • Cancer: 598,038 • Accidents (unintentional injuries): 161,374 • Chronic lower respiratory diseases: 154,596 • Stroke (cerebrovascular diseases): 142,142 • Alzheimer’s disease: 116,103 • Diabetes: 80,058 • Influenza and pneumonia: 51,537 • Nephritis, nephrotic syndrome, and nephrosis: 50,046 • Intentional self-harm (suicide): 44,965 BOX 9–3 n Top 10 Leading Causes of Death, CDC 2017 Source: (14) 7711_Ch09_218-238 23/08/19 10:33 AM Page 222 known as the National Heart, Lung, and Blood Institute) initiated a longitudinal cohort study in 1948 (defined in Chapter 3) in Framingham, Massachusetts, which is still going on today.19 From the data collected over the past 6 decades, we now know a great deal about the risk fac- tors for CVD and stroke. Based on the findings from this study, both individual and population level interventions have been developed aimed at reducing risk and subse- quently reducing the prevalence of CVD. Cancer Although great strides have been made in the prevention and treatment of cancer, it is the second leading cause of death in the United States and the world.14,20, 21 In the U.S., cancer mortality rates rose over the 20th century but are now declining mostly due to the drop in tobacco use. In addition, public health efforts to promote in- creased screening for breast and colorectal cancer have resulted in a decrease in deaths because of early detection and screening, and the length of cancer survival has in- creased.20 Globally, cancer accounts for 1 in 6 deaths with 30% to 60% preventable.21 Tobacco use is the leading risk factor for cancer with Lung cancer the leading cause of cancer death in both men and women; 80% of all lung cancers result from smoking or exposure to secondhand smoke.21 Risk for cancer is a combination of behavioral, ge- netic, and environmental factors. For example, in breast cancer all three levels of risk apply. Family history, diet, exercise, reproductive history, and alcohol use have all been associated with increased risk for breast cancer (Fig. 9-3).22,23 An example of genetic risk is the harmful mutation of BRCA1 or BRCA2, tumor suppressor genes. Women who test positive for this gene mutation have an increased lifetime risk for developing breast and ovarian cancers.24 Chronic Lower Respiratory Disease According to the WHO, CRD includes chronic obstruc- tive pulmonary disease (COPD), asthma, occupational lung diseases, and pulmonary hypertension. One of the most common is COPD, which includes emphysema and chronic bronchitis. Although treatable, these diseases are not curable and 90% of the deaths attributable to CRD occur in middle-income and low-income countries.25 The major risk factor for COPD and other CRDs is tobacco use, and the causative link between the two is the abnormal inflammatory response of the lungs to the nox- ious particles or gases present in tobacco smoke. Other risk factors include exposure to air pollutants, chemical fumes, and dust from the environment or workplace.25 Globally, indoor air quality is thought to play a bigger role in the development of COPD.26 Diabetes Over the past few decades, great improvements have oc- curred in the management of diabetes and the reduction in complications such as blindness and diabetes-related end-stage renal disease. Despite these advances, diabetes remains a leading cause of death in the U.S. and globally. According to the WHO, 422 million adults worldwide have diabetes, representing an almost quadrupling inci- dence since 1980.27 Although the incidence of diabetes in the U.S. has de- clined since 2008, the prevalence of diabetes is growing. In 2015, a little over 9.4% of the U.S. population and 12.2% of adults had diabetes.28 Differences exist in age- adjusted prevalence based on ethnic group with 15.1% of Native Americans and 12.7% of African Americans com- pared to 7.4% of white non-Hispanic and 8.1% of Asians, which may reflect socioeconomic status rather than an underlying genetic risk factor.28 Two underlying factors that have contributed to the increase in the incidence of type 2 diabetes globally are changes in lifestyle, especially exercising and diet. In addition, improved treatment has resulted in a longer survival rate. Thus, an increased in- cidence combined with an increased survival rate has re- sulted in an overall increase in the prevalence of type 2 diabetes (see Fig. 3-7, Chapter 3).27 C H A P T E R 9 n Noncommunicable Diseases 223 Figure 9-3 Risk Factors for Breast Cancer. Family History Reproductive History Lifestyle Alcohol Use Age Estrogen 7711_Ch09_218-238 23/08/19 10:33 AM Page 223 Public health efforts are in full force in attempting to turn this trend around. The focus has been on behavioral change to reduce individual risk. The prevention or delay of the onset of type 2 diabetes can happen through a healthy lifestyle that includes making healthful changes to diet, increasing the level of physical activity, and main- taining a healthy weight.27, 29 These recommendations are based on solid epidemiological data related to risk, that is, persons who exercise regularly, eat healthy, and maintain a normal body mass index (BMI) are at a much lower risk for type 2 diabetes. Type 1 diabetes is another story. Less than 10% of persons with diabetes have type 1. It is usually diagnosed in childhood and is associated with genetic risk rather than behavioral risk. Risk Factors Risk for NCDs is complex and related to numerous fac- tors, individual behaviors, genetics, and environmental exposure as well as the larger socioeconomic context in which people live. To prevent NCDs, the epidemiologist explores factors that increase the risk of disease occur- ring. As explained in Chapter 3, two types of studies are often conducted to help determine what leads to devel- opment of disease: a case control study and a cohort study. Based on these studies, we can determine the rel- ative risk or the odds ratio of disease that can occur based on exposure to a risk factor. In chronic diseases, there are two major categories of risk that have received a great deal of attention nationally: lifestyle or behavioral risk factors and socioeconomic risk factors. 224 U N I T I I n Community Health Across Populations: Public Health Issues w SOLVING THE MYSTERY Applying Public Health Science: The Case of the Struggling Heart Patients Public Health Science Topics Covered: • Assessment • Program Planning and Evaluation • Building Partnerships In the Mississippi Delta, a section of western and northwestern Mississippi bordered by the Mississippi River and the Yazoo River, health-care providers were alarmed by the high rate of CVD in the Delta. According to the Mississippi State Health Depart- ment, residents of the Delta have the highest rates of stroke in Mississippi. In addition, the Delta and the state have the highest rates of obesity and CVD in the United States.30 This area of Mississippi is faced with serious socioeconomic risk factors including poverty and low educational attainment. The poverty rate for the Delta ranges from 30% to 40% compared to 22% for Mississippi and 15% nationally.30,31 The chal- lenge, then, was to develop a program to increase access to routine health screenings and improve on disease self-management. The Mississippi Department of Health, in partner- ship with the CDC, formed the Mississippi Delta Health Collaborative (MDHC) that included individu- als and groups across the community. They currently report progress in attaining their goal of reducing stroke and heart disease through three program areas: clinical, community, and faith-based. The clini- cal component has involved incorporating commu- nity health workers (CHWs) into the health-care team.30 Evidence has demonstrated the effectiveness of using community workers to address health needs in populations at risk. One of the challenges is to clarify the role of these workers.32 The most com- monly used definition is the one by the American Public Health Association: “A Community Health Worker (CHW) is a front line public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. A CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy.”33 The MDHC conducted an initial assessment and identified community assets including mayoral health councils, schools, and churches. Building on these as- sets, they partnered with the CDC and implemented the Clinical-Community Health Worker Initiative (CCHWI). The focus was to improve clinical outcomes for CVD through use of the ABCS— appropriate Aspirin use, A1c (hemoglobin control), Blood pressure control, Cholesterol management, and Smoking cessation.34 The CCHWI program uses a system in which referrals are made from multiple sources including health-care providers in federally qualified health centers (FQHCs) and rural clinics as well as referrals 7711_Ch09_218-238 23/08/19 10:33 AM Page 224 C H A P T E R 9 n Noncommunicable Diseases 225 based on elevated blood pressure readings ob- tained during from health screenings conducted in barbershops, churches, and other MDHC partner locations. A MDHC program manager and two regis- tered nurses provide oversight for the CHWs and are available for consultation.34 According to the CDC, a total of 8 CHWs visit patients throughout 17 of the 18 Delta counties. 34 CHWs follow the ABCS protocol during their visit (Box 9-4). As noted in Chapter 5, evaluation is a key compo- nent of health planning. For this program, evaluation demonstrated the benefits of using CHWs to help reduce the morbidity and mortality associated with CVD. According to the MDHC report they had seen 1,057 patients and found significant mean changes in both diastolic and systolic blood pressure readings indicating better controlled blood pressure. They established relationships with churches and barbershops. Of the 27 barbershops who joined the collaborative, 17 became smoke free. In the 77 churches that partnered with the collaborative, 73 congregational nurses and advocates were trained. They concluded their report with the following: “Every time a local barber identifies someone with high blood pressure, every time a church holds a wellness fair, every time a clinical CHW encourages her clients to get up and move, and every time some- one doesn’t light up a cigarette in public spaces, the Delta becomes a healthier place.”30 The Case of the Struggling Heart Patients illustrates the role that socioeconomic status plays in increasing risk for CVD as well as the importance of in- corporating community members into population-level programs to assure that the programs are relevant to the community, reflect an understanding of the cultural context of a community, and the power of bringing together multiple groups and individuals to address a serious health issue in the face of limited resources. Using CHWs, the program provided patients with members of their own community to help them self-manage their disease and address behavioral risk factors, specifically smoking and obesity. Once referrals are made, the CHWs follow-up with patients within 48 hours through face-to-face contact, phone calls, or mailings to establish and maintain linkages to health care, promote adherence to treatment proto- cols, and work toward improvement in the ABCS. Specif- ically, CHWs conduct home visits that last about 1 hour, where they: • Offer informal counseling on medication adherence, to- bacco cessation, healthy nutrition, and physical activity. • Encourage patients to use a primary care provider if screenings indicate the need. • Reduce barriers to health-care access by arranging transportation, assisting patients with scheduling appointments, and helping patients prepare for medical visits. • Contact clinical systems when patients have elevated blood pressures. • Use an online web-based portal to collect quantitative and qualitative information during the home visits as part of MDHC’s ongoing evaluation. BOX 9–4 n ABCS protocol Source: (30, 34) Behavioral Risk Factors The WHO posed a question: “Why treat people’s illnesses without changing what made them sick in the first place?”35 We must strive to understand what contributes to the occurrence of NCDs. In addition to environment, much attention has been given to the role of individual behaviors. The current focus is on healthy nutrition, adequate exercise, and avoidance of substance misuse, es- pecially tobacco and alcohol (see Chapter 11). The evalu- ation of risk factors has been the dominant paradigm of the late 20th century and through the first decade of the 21st century. Understanding risk factors requires an un- derstanding of public health science, especially epidemi- ology. Most of the studies that have established the link between a risk factor and a disease are based on case con- trol and cohort studies (see Chapter 3). Often, the explo- ration of risk factors begins with a basic community/ population assessment (see Chapter 4). Nutrition, Exercise, and Obesity More than a third of U.S. adults are obese (have a BMI greater than or equal to 30).36 Differences in prevalence exist in relation to racial/ethnic groups, an age-adjusted obesity rate of 48.1% in African Americans, 42.5% in Hispanic non-blacks, 34.5% of white non-Hispanic, and 11.7% in Asians.36 About 17% of children and adoles- cents are obese.37 It is well-known that obesity and over- weight increase the risk for NCDs, especially heart disease, type 2 diabetes, certain cancers, and stroke. The main risk factors associated with obesity are poor nutrition and lack of exercise, which reflect individual 7711_Ch09_218-238 23/08/19 10:33 AM Page 225 the air quality and alert residents when the air quality places a person at risk for health consequences (see Chapter 6). The environment plays a key role in under- standing the risk for NCDs and is best understood through the application of public health science methodologies. behaviors that are thought to be modifiable, that is, they can be changed with intervention. However, using the web of causation (see Chapter 3), these two risk factors are linked to numerous other factors at the population level, including changes in population behaviors, envi- ronmental factors, and socioeconomic factors. The risk factor model often fails to establish the complex link be- tween individual behaviors, population-level factors, and the development of NCDs. A good place to start when faced with a growing health problem such as obe- sity is to do a population-level focused assessment that allows for assessment of both the individual level and community level data. This type of assessment can help identify who is at greatest risk for obesity as well as the population-level factors that contribute to obesity. For example, the prevalence rate for obesity in Mississippi was higher than the national level.30 A more thorough population-level assessment can help the primary health network (PHN) develop an intervention that is cultur- ally relevant and takes into consideration barriers faced by the population. Environmental Risk Factors for Noncommunicable Disease It is also important to remember that environment plays a key role in the development of NCDs (see Chapter 6). Pollutants in the environment increase the risk for asthma, cardiovascular health problems, and cancer.38,39 These pollutants include those found in the air, the home, the water supply, and the ground. Since 1950, the United States has experienced drastic changes in the food supply, the built environment, increased population, and prolif- eration of environmental chemicals. The built environ- ment includes the structures that exist in our towns and cities such as buildings, roads, sewage systems, parks, and recreation facilities (see Chapter 6). In 1800, only 3% of the world’s population lived in an urban setting. In 2018, 55% of the population was urban, and the United Nations (UN) projected that, by 2050, 68% of the world’s popula- tion will be urban. The most urbanized region in the world is North America with 82% of the population living in an urban area. By contrast, 48% of the population in Africa lives in a rural setting, but this is changing, with most of the future urban growth projected by the UN to occur in Africa and Asia (see Chapter 16).40 The growth of cities reflects a growth in commerce, economic oppor- tunities, and opportunities for building social capital. However, it also increases issues related to environmental pollutants. For example, most of us are aware of the po- tential pollutants in the air. Local news stations report on 226 U N I T I I n Community Health Across Populations: Public Health Issues l APPLYING PUBLIC HEALTH SCIENCE The Case of the Growing Children Public Health Science Topics Covered: • Assessment • Program planning In Marksville County, a hypothetical county located in the state of Florida close to the Everglades, there was a growing concern among the citizens about the prevalence of obesity and overweight among the chil- dren as well as county adults. The issue arose at a city council meeting in Yonston, the only major city in the county. The mayor and city council charged the health officer with heading up a task force to address this issue and asked the task force members to concentrate on childhood obesity. The most obvious step in ad- dressing the issue was first to conduct an assessment. The county had a population of 10,576. The ethnic pro- file of the county was 5% Seminole Indians, 11% African American, 17%, Hispanic, 65% Caucasian, and 2% other races. Seventeen percent of the population was under the age of 18. The health officer knew that the first step would be to mobilize a broad band of stakehold- ers and community residents. Before doing so, the health officer decided to seek a commitment from a smaller group, the steering committee. After thinking about this in consultation with other people, the health officer chose the following people for the steering committee: the principal of the local high school, a university professor from the local nurs- ing school, the county political representative, CEO of the local hospital, two businesspeople, and the director of the Head Start program. The CEO talked with the nurse manager of the pediatric unit and asked her to represent him on the committee. Orientation meetings were held, and goals and objectives of the initiative were set. The overall goal was to conduct a community assessment focused on determining the extent of obe- sity and overweight in Marksville County, to examine trends of the epidemic, to identify resources for ad- dressing the issue, and to develop an action plan. An assessment related to a specific health issue helps bring about a greater understanding of the 7711_Ch09_218-238 23/08/19 10:33 AM Page 226 C H A P T E R 9 n Noncommunicable Diseases 227 factors influencing that health issue for that particular population. This committee conducted a focused as- sessment (see Chapter 4) related to obesity in chil- dren and adolescents. Overweight and obesity, which are determined by using weight and height to calcu- late a BMI, are growing public health problems for adults and children.37 An adult who has a BMI that ranges between 25.0 and 29.9 is considered over- weight. If the BMI is 30 or higher, then the person is considered obese. For children and adolescents, over- weight is often defined as at or above the 95th per- centile of the sex-specific BMI for age growth chart. Ranges above a normal weight have different labels: at risk for overweight and overweight.41 After establishing the steering committee, a larger coalition was formed to build the structure needed to conduct the assessment. Invitations were sent out to a broader constituency to develop a coalition to ad- dress the issue. Initially, the public was invited to a town hall meeting. The goal was to increase aware- ness about obesity and overweight within the commu- nity and to gain a commitment to get involved. They provided the community with the data on obesity in their county based on data from the Florida Depart- ment of Health. The committee then presented the community with the facts about why childhood obesity is an important public health issue for their county. They explained that obesity occurs when more calories are consumed than are expended. They further explained that they were tackling this problem because childhood obesity has both immediate and long-term health impacts. If the community did not act, they would be faced with sicker children as well as the long-term cost of caring for more adults with chronic diseases occurring at an ear- lier age. According to the CDC, 70% of obese youth have at least one risk factor for CVD, such as high cho- lesterol or hypertension. Obese children and adoles- cents are at greater risk for bone and joint problems. They also suffer from psychological problems because of social stigma and low self-esteem. As adults, they are at higher risk for CVD, type 2 diabetes, stroke, cancer, and osteoarthritis.37 The committee was able to grab the community’s attention when they gave the facts about type 2 dia- betes among the children of the county. Based on hos- pital discharge data from the county hospitals, 50 of their children were already being treated for type 2 diabetes with an overall prevalence rate of 2.8 per 1,000 children and adolescents, higher than the national prevalence of 1.7 per 1,000. The subpopulation most affected in their community was the Seminole Indians, with 14 Seminole children in their county diagnosed with type 2 diabetes, a prevalence rate of 4.9 per 1,000 children under the age of 18. Thus, 28% of the children diagnosed with type 2 diabetes in their county were Seminole Indians. With the support of the community, the committee added key members suggested by the community to help them complete a more in-depth assessment. They began by reviewing national statistics related to the prevalence of obesity/overweight in children and ado- lescents and comparing those rates with their own rates. They were able to find national reports on the extent of the problem as well as a national-level con- cern related to the problem. One of the objectives of HP is concerned with reducing the proportion of children and adolescents who are obese.42 n HEALTHY PEOPLE Nutrition and Weight Status HP 2020: Objective: Nutrition and weight status (NWS)—children and adolescents NWS-10: Reduce the proportion of children and adolescents who are considered obese NWS-10.1 Children aged 2 to 5 years NWS-10.2 Children aged 6 to 11 years NWS-10.3 Adolescents aged 12 to 19 years NWS-10.4 Children and adolescents aged 2 to 19 years HP 2020 Midcourse Review: Based on the data reported in the Healthy People Midcourse review, there was little or no detectable difference from baseline. Source: (42, 43) The team reviewed the National Center for Health Statistics Data Brief and found that the prevalence of obesity among children remained high.43 After further review they also discovered that, on the national level, the prevalence of obesity is higher in Native American children than the population as a whole.44 Another source of secondary data came from the Youth Risk Behavioral Surveillance System (YRBSS), which is a state-based health survey that annually collects infor- mation on health conditions, behaviors, preventive practices, and access to health care.45 It is used to monitor health problems in youth as well as healthy 7711_Ch09_218-238 23/08/19 10:33 AM Page 227 228 U N I T I I n Community Health Across Populations: Public Health Issues and unhealthy behaviors, including the prevalence of obesity among youth and young adults. They also located information on youth behaviors specific to Florida that was helpful in comparing the state statistics with national statistics.46 Based on their review of the YRBSS, they noticed that, not only were the health behaviors of individual students assessed, but environmental factors were in- cluded as well. The nurse manager of the pediatric unit at the community hospital remembered a discussion in a recent nursing practice committee meeting about the problem of only focusing on individual risk factors when examining a health problem. She went back to the literature and examined new developments in public health science and again reviewed the web of causation (see Chapter 3). She brought back to the committee her concerns about focusing on behavioral risk factors alone. She argued that the risk factor para- digm targets individual change only and ignores the dif- ference between individual risk factors and population risk factors; she encouraged the committee to take a macro-look at risk factors as well.47 The committee agreed to do this. Taking this broader view of risk related to healthy diet and exercise in children and adolescents, the com- mittee reviewed the importance of a healthy school environment that should include a focus on health education, healthy food availability, and physical education (PE). On the CDC’s Web site they found a model for schools to use to help prevent childhood obesity called the Whole School, Whole Community, Whole Child (WSCC) (Fig. 9-4).48 The four main components of this model were: (1) Physical education and physical activ- ity; (2) Nutrition environment and services; (3) School Figure 9-4 Whole School, Whole Community, Whole Child (WSCC). (From the CDC https://www.cdc.gov/healthyyouth/ wscc/) 7711_Ch09_218-238 23/08/19 10:33 AM Page 228 Tobacco Use In addition to nutrition and exercise, tobacco use is a major behavioral risk factor for chronic disease (see Chapter 11). The use of tobacco is strongly associated with increased risk for adverse health outcomes includ- ing cancer, pulmonary disease, and CVD. According to the CDC, approximately 90% of all lung cancer deaths in men and close to 80% of lung cancer deaths in women are directly related to tobacco smoking.50 Although to- bacco use has declined over time, in 2015, 15% of adults in the U.S. were current smokers and 1.1 billion people smoked tobacco worldwide with 80% of users living in low-income countries.51-53 The single most preventable cause of morbidity and mortality is the use of tobacco.51 Globally, tobacco use kills half of its users with an esti- mated 7 million people dying each year prematurely of diseases related to smoking.53 To address this major health issue, in 2000 Healthy People 2010 set an objective of reducing tobacco use to 12% of adults aged 18 or older (see Chapters 3 and 11). By 2016 this goal was met in only two states, California and Utah. The percentage of current smokers in the United States in 2016 by state ranged from 8% in Utah to 24.6% in Kentucky and 24.8% in West Virginia.54 There is strong evidence to support the benefit of smoking cessation. People who quit smoking have a lower risk of lung cancer than if they had continued to smoke.55,56 The challenge is that the use of tobacco is more than an individual issue and requires interventions at the population and community level. Both the WHO and the U.S. Department of Health and Human Services have presented population-level strategies aimed at re- ducing tobacco use. From a global perspective, the WHO initiated an international tobacco treaty in 2005. Based on a recent study, researchers concluded that there was a significant association between the demand-reduction measures included in the treaty and lower smoking prevalence. They concluded that there would be future reductions in tobacco-related morbidity and mortality. C H A P T E R 9 n Noncommunicable Diseases 229 health services to support physical, psychological, and emotional health; and (4) Family and community en- gagement. The committee now had some important data using secondary data sources from the national, state, and county level as well as a framework to help design a prevention program. They decided they were missing key information, especially the information found in the YRBSS, be- cause their analysis of county data was hampered by a small numbers problem; that is, there were not enough respondents in the national survey to make any conclusions. They decided to do their own survey of school-age children in the county as well as collect institution-level data on the schools in the county to determine what was being offered related to health education, PE, and nutrition. In addition, they col- lected data from the Head Start and the Women, Infants, and Children (WIC) programs. In looking at the data, a growing trend in the com- munity was noted from the 2015-2016 program year and the 2016-2017 program year. During the 2015- 2016 program year, 22% of children in Head Start and 18% of children in Early Head Start were identified as overweight. In the 2016-2017 program year, the per- cent for Early Head Start stayed the same but for Head Start it increased to 24%. In the two WIC programs in the county, 18% of children were identified as over- weight. These percentages were higher than the popu- lation of those under the age of 18 as a whole. These data on the under-5 age group illustrated the need to develop a program that extended beyond school-age children. Also, based on their earlier data, those at greatest risk for adverse consequences related to obesity were the Seminole Indian children. They also examined the school data and found that the county schools performed similarly to the rest of the state on the CDC indicators. Healthy nutrient and dietary behavior habits were taught at both the ele- mentary and high school levels, but they did not include key physical activity topics in these courses. Because of recent budgetary problems, PE was no longer offered in the schools, though they had an intramural sports program at the high school and middle school levels. The vending machines in the school did not sell healthy foods, and soft drinks were advertised in the school. Notably, the Pepsi Cola Company donated the new school football scoreboard. They also found that the school cafeteria prepared foods using a deep-fat fryer. Based on these findings, the committee began to put together action steps to address the issues specific to their community. They wanted to develop a broad pro- gram that would include children aged 5 and below as well as children and adolescents attending school. They also felt it was important to engage the Seminole Indian community in the planning to make sure that any inter- vention developed was culturally relevant. They started with the nine guidelines found on the CDC Web site.49 In this way, the schools became leaders in the fight against childhood obesity and in the promotion of a healthier lifestyle in their community. 7711_Ch09_218-238 23/08/19 10:33 AM Page 229 These findings demonstrate the value of implementing population-level interventions.57 Alcohol Use Alcohol use accounts for 5.1% of the global burden of disease and is a component cause of more than 200 dis- eases and injury conditions (see Chapter 11).58-60 Reduc- tion in the burden of disease associated with alcohol use requires a health-care workforce capable of implement- ing evidence-based interventions across the continuum of alcohol use and the life span. If health-care providers understand the continuum of alcohol use across the life span, including adverse alcohol-related health conse- quences for both the drinker and non-drinker, the scope of prevention and intervention efforts is greatly ex- panded. Although alcohol consumption is a socially ac- ceptable and normative practice in the United States, it has the potential to adversely affect health across the life span, including but not limited to injury, breast cancer, hypertension, stroke, liver disease, and brain damage.58,59 Genomics and Risk for Noncommunicable Disease Understanding risk for NCDs includes the genetic risk each person or group of genetically related persons has for dis- ease. Human genomics is the study of the genetic structure or genome of a living human. Evidence gathered through genomics clearly demonstrates that there is a genetic role in the major NCDs including cancer, diabetes, health dis- ease, and asthma.61,62 Genetic risk predisposes a person to disease independent of environmental and behavioral risks. Understanding genetic risks and identifying genetic muta- tions offer hope for both prevention and treatment of chronic disease. An example of genetic risk is the BRCA1 and BRCA2 gene mutations, known as tumor suppressors, which increase the risk for breast cancer.63 Persons who screen positive for BRCA1 and BRCA2 mutations can choose either to undergo prophylactic surgery (removal of both breasts) or to avoid known risk factors associated with the development of breast cancer.63 The WHO has a human genetics research project that is critically evaluating genetic research related to the four NCDs, cancer, asthma, diabetes, and CVDs, in the hopes of identifying strategies to control or prevent these diseases.61 The CDC has a dedicated site on human genomics and public health. The organization states that the study of the relationship among genes, environment, and be- haviors will help us understand why some people get sick and others do not.62 The role of family history in the de- velopment of disease is not a new concept, but the map- ping of the human genome has allowed scientists to identify the actual genes linked to the development of disease and thus increase the ability of researchers to de- velop and evaluate genetic screening and other interven- tions that can improve health and prevent disease. Despite the promise of genomics to help control NCDs, there are potential problems with reliance on ge- nomics to help solve the problem of these diseases. Most chronic diseases are not monogenetic; that is, the disease is linked to a single gene mutation such as cystic fibrosis. Only 2% of total diseases are monogenetic. All other dis- eases result from multifactorial causes and are polyge- netic, meaning multiple genes act together to cause the disease. Many diseases are experienced in the later years of life rather than early in life when genetic interventions are more apt to be beneficial. To further complicate the understanding of the role of genetics in the development of disease, Strohman pointed out in the early 1990s that slower genetic change fails to compensate for rapid en- vironmental change. He explained that “genes are regu- lated by cellular responses to the external world and that diseases are initiated by those responses.”64 In other words, our genetic makeup is not static and as we age will adapt to the environment we are exposed to. Thus, ge- netic risk is not a linear source of complex chronic dis- ease but is rather a dynamic process based on interaction between the gene and the environment. The question Strohman raised was whether genomic research should focus on genetic engineering that would fit the individual human organism to a hostile environment or on envi- ronmental engineering that would refit the environment to be consistent with the evolving human genome.64 Building on the complexity of the interaction between genetics and the environment described in detail by Strohman64 a new field is emerging, human genome epi- demiology. This field provides the scientific basis for the study of the distribution of gene variants, gene-disease as- sociations, and gene-environment and gene-gene inter- actions within and across populations. This allows public health scientists to estimate the absolute, relative, and at- tributable risks for disease based on genomic factors (see Chapter 3). Thus, the growing understanding of the human genome from a population perspective offers new essential information on the occurrence of chronic dis- ease based on population-level as well as individual risk. Disparity and Noncommunicable Disease Differences in socioeconomic status are a major contrib- utor to health status and risk for development of disease and thus a disparity in life expectancy.65 As defined in Chapter 7 disparity is a difference or inequality in some 230 U N I T I I n Community Health Across Populations: Public Health Issues 7711_Ch09_218-238 23/08/19 10:33 AM Page 230 aspect of health such as a disparity in the infant mortality rate between two groups. Disparity in morbidity and mortality statistics for NCD persists (see Chapter 7). For example, African Americans and persons living in the southeastern United States bear a statistically greater dis- ease burden related to stroke.66 The challenge is to un- derstand the upstream determinants of these disparities and to separate out biological causes from those related to the conditions of life, that is, the infrastructure of so- ciety and why society is set up as it is.65 Socioeconomic Risk for Noncommunicable Disease As demonstrated previously, the development of an NCD is multifactorial. In addition to the physical envi- ronment, behavior, and genetic risk, socioeconomic fac- tors play a role in determining who is at greater risk for developing an NCD. Health is remarkably sensitive to the social environment, and those who are less well-off are at greater risk for experiencing ill health. The term often used to describe these factors is the social determi- nants of health (see Chapter 7). According to the WHO, multiple factors contribute the differences in health sta- tus (Box 9-5) with poverty a major driving factor.67,68 The premise is that it does not make sense to treat people for disease without addressing the things that make them sick in the first place. Interventions aimed at reducing risk must consider the social determinants of health and the barriers that exist within a socioeconomic context that reduce the ability of individuals, families, and com- munities to experience a healthy lifestyle. Disparity in NCD rates between different populations is also linked to socioeconomic and geographical factors (see Chapter 7). As evidenced by regional disparity in the United States relative to prevalence rates of NCDs. For example, West Virginia has the highest prevalence rate of diabetes at 15% in 2016 (Table 9-1).69 These regional disparities reflect differences in socioeconomic factors and cultural lifestyle. Within states, disparity exists between counties and is often correlated with socioeconomic status, as exemplified by the difference in tobacco use and obesity rates. There is good news. There has been a narrowing of the gap in premature deaths between African Americans and whites in the United States. Researchers from the Uni- versity of Pittsburgh reported that between 1990 and 2014 African Americans had a 28% reduction in YLL compared to whites with a 4% reduction. The decline in heart disease and cancer death rates helped to account for the decline in YLL especially in African American adults aged 30 to 40.70 C H A P T E R 9 n Noncommunicable Diseases 231 Income and social status: Higher income and social sta- tus are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health. Education: Low education levels are linked with poor health, more stress, and lower self-confidence. Physical environment: Safe water and clean air, healthy workplaces, safe houses, communities and roads all contribute to good health. Employment and working conditions: People in employ- ment are healthier, particularly those who have more control over their working conditions Social support networks: Greater support from families, friends, and communities is linked to better health. Culture: Customs and traditions, and the beliefs of the family and community all affect health. Genetics: Inheritance plays a part in determining lifespan, healthiness, and the likelihood of developing certain illnesses. Personal behavior and coping skills: Balanced eating, keeping active, smoking, drinking, and how we deal with life’s stresses and challenges all affect health. Health services: Access and use of services that prevent and treat disease influences health. Gender: Men and women suffer from different types of diseases at different ages. BOX 9–5 n Social Determinants of Health Source: (67, 68) TABLE 9–1 n Top 10 Highest Rates of Type 2 Diabetes (2016) Rank State Diabetes Rate 1 2 3 4 5 6 7 8 9 10 Source: (69) West Virginia Alabama Mississippi Arkansas Kentucky South Carolina Tennessee Georgia Louisiana Oklahoma 15.0% ±0.9 14.6% ±1.0 13.6% ±1.1 13.5% ±1.4 13.1% ±0.9 13.0% ±0.8 12.7% ±1.0 12.1% ±1.0 12.1% ±1.2 12.0% ±0.9 7711_Ch09_218-238 23/08/19 10:33 AM Page 231 The relationship between socioeconomic status and prevalence of NCD presents an ethical dilemma for providers of health care (Box 9-6). A central risk factor for increased morbidity and mortality related to NCD is access to health care including preventive screening, early and ongoing treatment, and resources needed to manage care. In the United States, the Affordable Care Act (ACA) was designed to attempt to increase access to care. How- ever, for the most part, U.S. health care is based on a fee- for-service basis, and health-care providers are reimbursed based on the care they provide (see Chapter 21). For those who are unable to obtain adequate insurance or who do not have adequate transportation to services, care is often delayed until the disease has become advanced. For ex- ample, an insulin-dependent diabetic single man who is currently homeless faces daily challenges, which may in- clude maintaining an adequate diet when he is dependent on soup kitchens, checking his blood sugar when he does not have his own glucometer, obtaining insulin and in- sulin supplies, and storing those supplies in a safe place. By contrast, an insulin-dependent diabetic married man currently employed and domiciled has the financial means and the social support needed to meet those chal- lenges. For both men, diabetic care will continue for the rest of their lives. Prevention of morbidity and mortality related to their diagnosis requires careful self-management over time including monitoring of blood sugar, diet and exercise, foot care, adherence to medication regimens, and regular check-ups with their health-care provider. Is it ethical for those who have the financial means to have the resources needed to meet their ongoing daily health- care needs necessary for survival whereas those who do not have the financial means do not? Prevention Strategies for Noncommunicable Diseases Prevention and management of NCDs are global priori- ties.1 Prevention strategies extend across the continuum from primary to tertiary prevention (see Chapter 2). Pre- vention of NCD across all three levels occurs across many settings (see Chapters 13 to 20). Prevention efforts are often focused on reducing the individual risk factors mentioned earlier, but often the success of prevention ef- forts require multifaceted interventions at the individual, family, community, and policy levels. For the nurse, these efforts can seem overwhelming. At the individual and family levels, primary preven- tion focuses on behavioral change with a strong emphasis on healthy eating and exercise. These approaches not only provide information as to what constitutes a healthy lifestyle but also provide participants with strategies for making improvements in nutrition and physical activity and accessing the resources needed. The difficulty is that the populations at greatest risk for NCDs are those with limited access to the resources needed to maintain a healthy lifestyle. Thus, population-level primary preven- tion programs help to change barriers to a healthy lifestyle. For example, obtaining an adequate level of ex- ercise in an urban setting requires safe streets for walking and/or access to recreational activities. This requires ac- tion at the community and policy levels. Nurses, espe- cially those working in a public health role, can help facilitate community engagement in improving the safety of streets and improving access to healthy foods at rea- sonable prices. Secondary prevention efforts are also associated with reduced morbidity and mortality related to NCD, espe- cially screening (Chapter 2). Examples of screening pro- grams recommended by the CDC for the prevention of NCDs include mammograms and screening for colorec- tal cancer.71,72 Such programs result in the early detection of disease and thus in early treatment. Often the nurse provides care related to tertiary pre- vention efforts aimed at reducing the adverse conse- quences experienced by a person who has already been diagnosed with a disease. The goal is to reduce the mor- bidity and disability associated with the disease and to pre- vent premature death. During the course of the disease, there can be periods of acute illness that are usually shorter and often require admission to an acute care facility for care. Chapter 14 provides in-depth coverage of the role of public health science in the nursing care of patients during an acute phase of an NCD that requires interventions to 232 U N I T I I n Community Health Across Populations: Public Health Issues Critical ethical questions related to chronic disease health care include the following: • Is health care for the management of chronic diseases a right or a privilege? • Should government pay for medically necessary serv- ices when an individual cannot afford those services? • If yes, does this approach truly serve the greater good for the greater number? • If no, who should be responsible for paying for these services? • How does failure to provide services to those in need impact the community in general? BOX 9–6 n Ethics and Disparity Related to Chronic Diseases 7711_Ch09_218-238 23/08/19 10:33 AM Page 232 address an acute stage of an illness. Primary care settings provide care to help patients manage a chronic disease as well as care for milder acute phases of the disease (see Chapter 15). Two concepts grounded in public health pre- vention models and used in both acute care and primary care settings are health-related quality of life and chronic disease self-management. Health-Related Quality of Life Health-related quality of life is central to the overarching goals for HP. The primary goal is to attain and promote “a high quality of life for all people, across all life stages.”4 Health-related quality of life (HRQoL) is a multidimen- sional construct related to the desired physical and psychological health outcomes for most of the interven- tions that nurses provide to individuals and families. HRQoL is defined here as the self-perceived impact of physical and emotional health on quality of life, includ- ing the effects on general health, physical functioning, physical health and role, bodily pain, vitality, social functioning, emotional health and role, and mental health.73,74 The CDC has a whole Web site dedicated to HRQoL.74 Included on the Web page is the four- questions measure it uses for HRQoL that can easily be used in any health-care setting, and the evidence supports it as a reliable and valid measure of HRQoL. This healthy data measure not only can help in measuring an individ- ual’s HRQoL, but according to the CDC, it is also being used at the national and state levels to identify health dis- parities (see Chapter 7), to track population trends, and to build broad coalitions around a measure of population health. This measure is compatible with the WHO’s defi- nition of health (see Chapter 1).75 The CDC uses the Healthy Days measure in the Behavioral Risk Factor Surveillance system.73,76 Numerous studies have been conducted using HRQoL as a central measure.77,78 C H A P T E R 9 n Noncommunicable Diseases 233 n EVIDENCE-BASED PRACTICE Measuring Health-Related Quality of Life (HRQoL) Screening for HRQoL Practice Statement: The use of the HRQoL screen- ing tool can help health-care providers identify persons whose health is negatively impacting their quality of life and can provide a means to measure key health indica- tors for public health assessments. Targeted Outcome: Identify those in need of inter- ventions aimed at improving their quality of life and identifying vulnerable populations. Evidence to Support: The CDC’s 14-item HRQoL tool includes the standard four-item set of Healthy Days core questions and the Standard Activity Limita- tion and Healthy Days Symptoms modules. When used together, these measures make up the full CDC HRQoL-14 Measure. Public health departments have used the tool to identify vulnerable groups when con- ducting community assessments. The screening tool not only provides a method for assessing an individual’s HRQoL but also provides PHNs with a useful indicator of health at the population level. Recommended Approaches: The CDC HRQoL screening tool is used in community assessments and surveillance. A guide published in the late 1990s de- scribed the use of HRQoL as one of the main indica- tors for monitoring health in populations and evaluating outcomes, and is still recommended by the CDC. Ac- cording to the CDC, the following are the main rea- sons for measuring HRQoL: • HRQoL is related to both self-reported chronic diseases (diabetes, breast cancer, arthritis, and hyper- tension) and their risk factors (BMI, physical inactiv- ity, and smoking status). • Measuring HRQoL can help determine the burden of preventable disease, injuries, and disabilities, and can provide valuable new insights into the relationships between HRQoL and risk factors. • Measuring HRQoL will help monitor progress in achieving the nation’s health objectives. Sources Linde, L., Sørensen, J., Ostergaard, M., Hørslev- Petersen, K., & Hetland, M. (2008). Health-related quality of life: validity, reliability, and responsiveness of SF-36, EQ-15D, EQ-5D, RAQoL, and HAQ in patients with rheumatoid arthritis. Journal of Rheumatology, 35(8), 1528-1537. Andresen, E.M., Catlin, T.K., Wyrwich, K.W., & Jackson- Thompson, J. (2003). Retest reliability of surveillance questions on health-related quality of life. Journal of Epidemiology Community Health, 57(5), 339-343. Centers for Disease Control and Prevention. (2016). Health-related quality of life methods and measures. Retrieved from https://www.cdc.gov/hrqol/ measurement.htm. Ware, J.J., Kosinski, M., & Keller, S.D. (1996). A 12-item short-form health survey: Construction of scales and preliminary tests of reliability and validity. Medical Care, 34(3), 220-233. 7711_Ch09_218-238 23/08/19 10:33 AM Page 233 Chronic Disease Self-Management An evidence-based approach to improving HRQoL for persons with NCD is chronic disease self-management (CDSM). CDSM is an ongoing process by which indi- viduals with a chronic illness or condition engage in self- management of medications, symptoms, and promotion of their own health, and can be applied to both noncom- municable and communicable chronic disease.79 CDSM requires implementation of health-promotion and health protection strategies, which are fundamental concepts for nursing practice (Chapter 2). Extensive research ex- ists related to the efficacy of patient education programs for specific chronic diseases such as asthma and diabetes and has now shown effectiveness with diverse popula- tions and diseases.79-83 Evidence is accumulating that heterogeneous CDSM programs that include persons with different chronic diseases are effective, reduce emer- gency department usage and health distress, and tran- scend ethnic boundaries.81,83 Moreover, they apply to underserved populations who do not have regular health-care providers.80,84 CDSM has great potential for improving self-management of disease, health behaviors, health-care utilization, and health status. NCD prevention and reduction of risk factors that lead to NCDs continues as a focus in the development of the Healthy People 2030 framework and objectives.85 It is an issue across all health-care settings. Strategies for specific NCDs are discussed across the chapters in this text. The key is to remember that prevention efforts require interventions at all levels with the goal of not only reducing the prevalence of NCD but also of im- proving the overall HRQoL for individuals, families, and populations. 234 U N I T I I n Community Health Across Populations: Public Health Issues n CULTURAL CONTEXT Noncommunicable Diseases Culture plays a big part in the prevention and treat- ment of NCDs. For the most part, when culture is mentioned in conjunction with prevention of NCDs, the focus is on its role in relation to individual risk be- haviors such as food, nutrition, and exercise. Culture is also important in the development of education materi- als (Chapter 2). However, another issue in relation to culture and NCDs has to do with the cultural shifts that have occurred at the national level in relation to prevention. Cultural shifts occur over time because no culture is static. In the past 50 years, there have been cultural shifts in the United States in relation to risk behaviors associated with NCDs. A cultural shift is defined as a change in society’s dominant views, morals, and behav- iors. When applied to health, it represents a shift in how society views that issue and the risk factors asso- ciated with development of disease. For example, there has been a cultural shift in how society perceives drink- ing alcohol and driving; once this was viewed as a nor- mal behavior and now it is one that is not tolerated and results in criminal consequences. Another example is the shift in how we view the foods we eat. Some states have passed laws prohibiting the sale of large, sugary drinks or the use of deep-fat fryers in schools. A cultural shift changes the way organizations are struc- tured, the environment we live in, and the activities we participate in. Let’s examine a major cultural shift in the United States related to a major preventable risk factor associ- ated with the development of NCDs. In the 1950s, no one questioned a person’s right to smoke in public. Smoking occurred in all public places, including banks, hospitals, and restaurants. As the evidence grew that secondhand smoke affected the health of the non- smoker, public health policy initiatives were begun to reduce smoking in public places. In the beginning, sci- ence drove the change. Based on the evidence, public health policies were put in place that required restau- rants to designate no smoking sections, and employers constructed separate places for their workers to smoke, often referred to as “butt huts.” However, what began as evidence-based public health policy shifted to a social reality. As fewer people smoked, tolerance of smoking declined, and the culture shifted from viewing tobacco use in a positive manner to viewing it as a negative and unpleasant behavior. In the 1930s and 1940s, movie stars smoked on screen, and in the 1950s, cigarette ads depicted the male smoker as rugged and manly, as in the Marlboro Man. Today, most public spaces are smoke free. It is hard to deter- mine which comes first, the policy or the cultural shift. Often, one reflects the other. However, to be effec- tive, public polices need the support of the community. When the culture matches the policy, the policy is more apt to bring about change. Not only does the culture of groups play a role in individual behavior, but also the cultural norms of a population shift over time and can have a significant im- pact on health. Sometimes there are opposing cultural values in relation to a risk factor. For example, people may have differing views about the appropriateness of using public policy to restrict the ingredients that 7711_Ch09_218-238 23/08/19 10:33 AM Page 234 n Summary Points • NCDs contribute significantly to the overall burden of disease. • Seven out of the top ten leading causes of death in the United States are NCDs. • Risk for NCD is a combination of individual behaviors, the environment, genes, and socioeco- nomic factors. • Prevention occurs across the continuum, starting with primary prevention during the perinatal period through tertiary prevention measures such as chronic disease self-management programs. C H A P T E R 9 n Noncommunicable Diseases 235 restaurants put in foods. Understanding that cultural shifts occur over time related to reducing NCD is im- portant for the nurse who wishes to actively engage in prevention efforts. Nursing can play a role in helping the cultural shift along. As the largest segment of the health-care workforce, nurses can be in the forefront of positive cultural shifts related to prevention; the shift can happen at a more rapid pace and populations will get healthier. A world with reduced morbidity and mortality related to NCDs and improved HRQoL can happen, and nurses are major drivers of the shift to healthier living as part of our culture. t CASE STUDY Prevention of Chronic Obstructive Respiratory Disease (COPD) A group of nurses on a medical-surgical unit in a hospi- tal that serves an Appalachian community in Kentucky on the West Virginia border were growing frustrated with the continued readmission of persons with COPD. One of the nurses came across statistics on the age-adjusted death rate of COPD in Kentucky. It was 62.8 per 100,000 compared to other states such as Hawaii at 15.5 per 100,000. She also found that COPD death rates were highest in the states sur- rounding the Ohio and Mississippi Rivers.85 The nurses decided to put together a proposal related to the pre- vention of COPD. 1. Choose a primary, secondary, and/or tertiary pre- vention approach and support your decision. 2. Choose a target population based on age and level of intervention (primary, secondary, and tertiary). 3. Access information on the Huntington/Ashland area of West Virginia and Kentucky and see what can be learned about: a. Cultural considerations b. Possible partners for the intervention c. Possible barriers 4. Review the literature again for evidence-based inter- ventions relevant to your chosen population and prevention level. 5. Using Chapter 5 as a guide, draft a possible preven- tion intervention the nurses in the journal club could help initiate. REFERENCES 1. World Health Organization. (2018). Noncommunicable diseases. 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Retrieved from https://www.cdc.gov/copd/data.html. 238 U N I T I I n Community Health Across Populations: Public Health Issues 7711_Ch09_218-238 23/08/19 10:33 AM Page 238 239 Chapter 10 Mental Health Bryan R. Hansen and Christine Savage LEARNING OUTCOMES After reading the chapter, the student will be able to: KEY TERMS 1. Define the global burden of disease related to mental disorders using current epidemiological frameworks. 2. Apply the National Academy of Medicine framework related to prevention of mental health disorders. 3. Define the difference between behavioral, biological, environmental, and socioeconomic risk factors related to mental health disorders. 4. Apply current evidence-based population-level interventions to the prevention of mental disorders and the promotion of optimal mental health for communities and populations. 5. Describe systems approaches to the promotion of mental health and the prevention and treatment of mental health disorders. Any mental illness (AMI) Behavioral health Burden of disease Deinstitutionalization Emotional health Health-related quality of life (HRQoL) Indicated prevention Intersectoral strategies Major depressive disorder (MDD) Mental disorder Mental health Mental illness Protective factors Resilience Selective prevention Serious mental illness (SMI) Stigma Transinsitutionalization Universal prevention n Introduction Achieving optimal mental health is an essential compo- nent of programs aimed at improving the health of populations. Mental health is defined as mental and psychological well-being, which includes our emotional, psychological, and social well-being, and is essential to health overall.1,2 In 2005, the Institute of Medicine (IOM), now named the National Academy of Medicine, reported that mental or substance-use problems and disorders are the leading cause of combined disability and death for women and the second highest for men.3 Of the 10 lead- ing health indicator topics of Healthy People 2020 (HP 2020), four topics related directly to behavioral health: mental health, substance abuse, tobacco, and injury/ violence.4 These four topics come under the umbrella of the term behavioral health. Each of these interrelated issues has an impact on the health of individuals, families, and communities. Often mental illness, substance abuse, and/or intentional injury and violence co-occur. Thus, there is a logical and empirical connection among these health issues. Taken together, they make up the most serious and prevalent public health problems of our times. So that each aspect of behavioral health can be covered in depth, these four leading health indicator topics of health are covered in three separate chapters. Chapter 10 covers mental health and mental health disorders; Chapter 11 covers substance use including alcohol, tobacco, and other drugs; and Chapter 12 covers injury and violence. This chapter focuses on promotion of mental health, which is best defined by HP 2020 as “a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with chal- lenges.”4 The term emotional health is used interchange- ably with mental health and is defined the same way. HP also includes mental disorder and mental illness under the topic of mental health. Mental health reflects a positive state of health, whereas mental disorder refers to the diagnosable disorders that negatively affect the mental health of individuals and affect an individual’s 7711_Ch10_239-255 21/08/19 10:45 AM Page 239 ability to cope with everyday life. Mental illness is a term that refers to all mental disorders collectively. The terms mental disorder and mental illness are often used inter- changeably and are defined as “clusters of symptoms and signs associated with distress and disability (i.e., impair- ment of functioning), yet whose pathology and etiology are unknown.”1,4 Mental illnesses are disorders, not dis- eases. Disease is a term used when the pathology is known or can be detected, which is not the case with a mental health disorder. Diagnoses that come under the category of mental disorders include depression, anxiety disorders, bipolar disorder, and schizophrenia. Not all mental health disorders have the same etiology (cause) or require the same population-level interventions. Mental disorders can vary in severity from mild to severe. The term any mental illness (AMI) is defined as a mental, behavioral, or emotional disorder. AMI can vary in impact, ranging from no impairment to mild, moderate, and even severe impairment.5 The term serious mental illness (SMI) is used to refer to a diagnosable mental dis- order that severely disrupts a person’s ability to function socially, to obtain and maintain employment, to have adequate financial resources, and to access appropriate and adequate support or maintain family supports.5 SMI does not refer to any particular diagnosis; rather, it implies eligibility for specific kinds of support services. The mental disorders that can lead to SMI include major depression, schizophrenia, bipolar disorder, obsessive-compulsive disorder (OCD), panic disorder, post-traumatic stress disorder (PTSD), and borderline personality disorder. In contrast with mental disorders, mental health rep- resents a state of emotional well-being. Persons who are emotionally healthy are those who can meet the demands and stresses of everyday life and function in society. Mental health does not merely represent the absence of a mental disorder but rather the cognitive and emotional ability to deal with the ups and downs of life while con- tributing to society through work and play. Viewed from a population perspective, the health of a population re- flects not only the physical well-being of the members of the population or community but also their social and emotional well-being. Because of their overall impor- tance to health, mental health and mental disorders are included in the HP list of topics Optimal mental health is an essential component of healthy communities. The promotion of mental health involves interventions at the individual and community levels. At the individual level, promotion of optimal mental health requires not only the delivery of inter- ventions focused on behavioral change but also the availability of adequate systems for care of those with mental health disorders. At the community level, pro- motion of mental health requires an environment that encourages strong social networks and a safe place to work and live. Because of the importance of mental health, in 2012, the World Health Organization (WHO) issued a resolution on mental health that aims to reduce the global burden of mental disorders and improve the overall mental health of countries. This resolution in- cludes recognition of “the need for a comprehensive, coordinated response to addressing mental disorders from health and social sectors at the country level. The delegates recognized this includes approaches such as programs to reduce stigma and discrimination, reinte- gration of patients into workplace and society, support for care providers and families, and investment in men- tal health from the health budget.”6 240 U N I T I I n Community Health Across Populations: Public Health Issues n HEALTHY PEOPLE Mental Health Goal: Improve mental health through prevention and by ensuring access to appropriate, quality mental health services. Overview: Mental health is a state of successful performance of mental function resulting in produc- tive activities, fulfilling relationships with other peo- ple, and the ability to adapt to change and to cope with challenges. Mental health is essential to personal well-being, family and interpersonal relationships, and the ability to contribute to community or society. Mental disorders are health conditions characterized by alterations in thinking, mood, and/or behavior associated with distress and/or impaired functioning. Mental disorders contribute to a host of problems that may include disability, pain, or death. Mental illness is the term that refers collectively to all diagnosable mental disorders.4 n HEALTHY PEOPLE Objectives: Reduce the proportion of persons who experience major depressive episode (MDE) MHMD-4.1: Adolescents aged 12 to 17 years Baseline: 8.3% of adolescents aged 12 to 17 years experienced an MDR in 2008. Target: 7.4% Target-Setting Method: 10% improvement 7711_Ch10_239-255 21/08/19 10:45 AM Page 240 Epidemiology of Mental Disorders Tracking the prevalence of mental health disorders at the global level is challenging due to differences in tracking and the reliance on diagnoses that results in an underes- timation of disease. It is estimated that globally 1 billion people have a mental health disorder.7 In the United States, in 2018, an estimated 25% of adults reported hav- ing mental disorders within the previous year.8 The U.S. annual economic burden associated with SMI, including direct costs such as medical care, loss of earnings, and indirect costs such as disability, homelessness, incarcer- ation, and early mortality, have been estimated to exceed $317 billion.9 As reviewed in Chapter 9, the burden of disease is measured in years of life lost related to ill health and reflects the difference between total life expectancy and disability-adjusted life expectancy. Ex- amining the burden of disease related to mental disor- ders allows us to consider what impact mental disorders have on the population or community. The best place to start is to examine the prevalence of mental disorders across the life span from both a global and an interna- tional perspective. Surveillance of Mental Health Disorders Estimating the prevalence of mental disorders is chal- lenging because there has been no centralized method for conducting surveillance of mental health disorders in the United States or globally. The Centers for Disease Control and Prevention (CDC) compiles data from eight surveillance systems to identify gaps in surveillance and make recommendations for an improved method for collecting data on mental health disorders. This allows the CDC to address the broad spectrum of mental health using surveillance systems that, in many cases, do not focus specifically on mental health but include important indicators of mental health and mental health disorders. Through this process of examining data from all data sources, they were not only able to provide some esti- mates of prevalence of different mental disorders but also to help make recommendations about how to address the gaps in mental illness surveillance. The data sources included the Pregnancy Risk Assessment Monitoring System (PRAMS), National Nursing Home Survey, National Health Interview Survey, National Hospital Discharge Survey, National Health and Nutrition Exam- ination Survey, National Ambulatory Medical Care Sur- vey, National Hospital Ambulatory Medical Care Survey, and Behavioral Risk Factor Surveillance System.10 At the global level, the WHO has developed the World Mental Health Survey to help determine estimates of human capital costs and prevalence of mental disorders in a wide range of countries.11 Prevalence of Mental Health Disorders Mental health is an important part of overall health across the entire life span. Differences exist among age groups in relation to specific disorders. To understand the importance of the issue and to evaluate the effective- ness of interventions from a population perspective C H A P T E R 1 0 n Mental Health 241 Midcourse Review: In the 4 years from 2008 to 2012, the percentage of adolescents aged 12 to 17 reporting having had a major depressive episode (MDE) in the past 12 months increased about 10%, from 8.3% to 9.1%, moving away from the Healthy People 2020 target of 7.5%. See Figure 10-1. Data Source: National Survey on Drug and Health, SAMHSA Source: (4) Percentage of Adolescents Experiencing Major Depressive Episode in Previous 12 Months 10.0% Percentage of MDE HP 2020 Target 9.5% 9.0% 8.5% 8.0% 7.5% 7.0% 6.5% 6.0% 5.5% 5.0% 2008 2012 Figure 10-1 Percentage of Adolescents Experiencing Major Depressive Episode in Previous 12 months. (See reference [4].) 7711_Ch10_239-255 21/08/19 10:45 AM Page 241 requires knowledge of the prevalence of mental disorders within and across communities and populations. The 12-month prevalence is a measure that esti- mates the occurrence of a disorder within 1 year prior to assessment. In 2015, the 12-month prevalence of all mental disorders not including substance-use disor- ders in the U.S. was 4% and most prevalent in those aged 18-44.12 There are gender, ethnic, and age differences in the prevalence of SMI (Fig. 10-2).12 In 2015, the 12-month prevalence of any mental disorder was higher in females than in males.12 Those reporting two or more races had the highest prevalence of SMI, followed by American Indians/Alaska Natives.13 American Indians/Alaskan Natives also have a high rate of lifetime PTSD compared to other races.14 Children also experience mental disor- ders, with 49.5% of teens diagnosed with AMI between the ages of 13 and 18 years.12 Under the umbrella of SMI are specific diagnostic cat- egories that have been the focus of population level pre- vention efforts, especially major depressive disorder (MDD). MDD is a mood disorder that is diagnosed based on the occurrence of one or more major depressive episodes in the absence of a manic or hypomanic episode. In 2016, about 13%, or 3.1 million, of U.S. teens between 12 and 17 years had at least one episode of MDD in the previous 12 months, as did about 6.7%, or 16.2 million adults.15,16 For adults, it is most prevalent among those aged 18 to 25 years and is more prevalent in women than in men.16 Because of the high prevalence and the impact on health, HP 2020 includes reduction of the number of persons who experience an MDD as one of the mental health objectives. Over the beginning of this century, the morbidity and mortality rate associated with SMI increased, with 4.2% of all adults in the U.S. experiencing SMI in 2016. Persons diagnosed with an SMI died 10 to 20 years ear- lier than the general population. Part of this is attrib- uted to suicide and injury. The other contributing factor is the strong association among SMI, chronic dis- ease, and substance use.17–19 Persons with SMI are less likely to receive preventative screening and interven- tions, less likely to receive treatment for diagnosed co- morbidities, and more likely not to adhere to medical interventions, which exacerbates the disparity in mor- tality rates.20 242 U N I T I I n Community Health Across Populations: Public Health Issues 12% In 2015, 4.0% of adults aged 18 or older in the United States (an estimated 9.8 million adults) had a serious mental illness (SMI) in the past year. This percentage was not significantly different from the percentage in 2011 (3.9%). In 2015, the percentage of adults aged 18 or older in the United States with past year SMI was higher for females than for males. This percentage was higher than the national average for Whites, and for those aged 18–25 or aged 26–44. This percentage was lower than the national average for those who were Black, Native Hawaiian or other Pacific Islander, Asian, or Hispanic or Latino. This percentage was also lower than the national average for adults aged 65 or older. American Indian or Alaska Native non-Hispanic other Pacific Islander Estimate is significantly different from the estimate for males (p � .05) Estimate is significantly different from the national average (p � .05) Source SAMHSA, Center for Behavioral Health Statistics on Drug Use and Health, 2015 AI/AN = NH = OPI = # +10% 8% 6% 4% 2% 0% United States Male Female Gender Race/Ethnicity Age Group White, NH Black, NH AI/AN, NH Native Hawaiian or OPI, NH Asian, NH Hispanic or Latino 18–25 26–44 45–64 65 or older 4.0% 3.0% 5.0%# 4.5%+ 2.9%+ 6.3% 1.8%+ 1.7%+ 2.9%+ 5.0%+ 5.0%+ 4.0% 1.6%+ Past Year Serious Mental Illness (SMI) Among Adults Aged 18 or Older in the United States, by Gender, Race/Ethnicity, and Age Group (2015)11 Figure 10-2 Prevalence of serious mental illness among U.S. adults, 2015. (See reference 12.) 7711_Ch10_239-255 21/08/19 10:45 AM Page 242 Behavioral, Biological, Environmental, and Socioeconomic Risk Factors Numerous factors contribute to the development of mental disorders at both the individual and community levels, and must be considered when attempting to understand the etiology of mental disorders. There is interplay among the individual, the family, and the com- munity environment. From a public health perspective, improving the mental health of a population requires taking all these factors into account when developing interventions. Individual-Level Risk Factors for Mental Disorders At the individual level, both nature and nurture play roles; that is, genetics, family environment, and individ- ual behavior are associated with the risk of developing a mental disorder, along with socioeconomic factors and community environment. Therefore, it is difficult to define the exact etiology of most mental disorders; the precise cause is poorly understood. There are, however, specific factors that have been associated with the devel- opment of mental disorders (Box 10-1). Recent work has helped demonstrate the link between genotype and mental illness through an environmental pathway. For example, PTSD is moderately heritable, but environmen- tal factors play a large role in whether a person who has a susceptible genotype develops PTSD after severe trauma.21 Another issue related to the development of a mental disorder is the relationship between physiology and mental health. Conditions that affect brain chemistry, hormonal imbalances, or exposure in utero to viruses or toxins can increase the risk for development of a mental disorder.22 Physical trauma such as traumatic brain injury is also associated with an increased risk of developing a mental disorder.23 Individuals who have experienced malnutrition or low birth weight are also at higher risk for development of a mental disorder.24 Some medication side effects include depression, anxi- ety, or suicidal ideation. In addition, an interaction between medications can result in increased risk for depression and other mental health disorders. Also, persons with diseases that reduce their quality of life or terminal diseases such as cancer may experience mental health disorders.25 Conversely, there is evidence that mental disorders are themselves independent risk factors for cardiovascular disease, type 2 diabetes, and injuries.26 Family instability is a factor in the development of mental disorders, with a higher incidence rate in individ- uals raised in situations of abuse or neglect, including sexual abuse, or for those who have experienced exposure to traumatic events, including serious loss.24 In addition, children of parents with mental disorders are at increased risk for developing mental disorders themselves because of the negative impact a mental disorder has on parenting skills.27 Exposure to family stress because of poor financial situations, death, divorce, or unemployment is also asso- ciated with mental disorders.22 Along with family envi- ronment, individual characteristics can increase the risk for development of a mental disorder. For example, individuals with low self-esteem; those who are lonely, isolated, and/or have poor social skills; and those who have unhealthy thinking patterns are at higher risk. Some behaviors also increase the risk of mental disorders, or substance use disorders (Chapter 11).24 An emerging issue is the increased incidence of men- tal disorders in Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) adolescents (see Chapter 7). They are more likely to be depressed and anxious, and attempt C H A P T E R 1 0 n Mental Health 243 • Family history of mental disorders or history of being diagnosed with a mental disorder in the past • Traumatic events: military combat, assault, or witness to a violent crime • In utero exposure to viruses and toxins; poor nutrition • Cerebral injury: experiencing brain damage as a result of a serious injury such as a violent blow to the head, traumatic brain injury • Stressful life situations: financial problems, the death of a loved one, or marital problems and/or divorce • Social isolation: having few friends or few healthy relationships • Developmental delays • Substance use: illicit drugs, alcohol, medication side effects, and drug interactions • Poor health: living with a chronic medical condition such as cancer • History of being abused or neglected as a child • Low self-esteem, social isolation, poor social skills • Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) adolescents • Anxiety, depression, suicidal tendencies • Poverty and socioeconomic level • Rural versus urban populations • Lower education level • Dangerous communities, high crime rates BOX 10–1 n Risk Factors for Mental Illness 7711_Ch10_239-255 21/08/19 10:45 AM Page 243 and/or commit suicide because of insecurity and diffi- culty in negotiating their coming out, family disapproval, rejection, victimization, and chronic stress from stigma- tization.28 Thus, the development of a mental disorder is a complex combination of genetics, other physical dis- orders, and family environment. Community-Level Risk Factors for Mental Disorders The determinants of health also play a role in the devel- opment of mental disorders because the community environment plays a pivotal role. There is a clear inverse relationship between poverty and prevalence of mental disorders, with a greater prevalence of mental disorders in populations and communities experiencing social and economic disadvantages.29 Part of this risk is associated with a lower level of education, fewer job opportunities, and lower job satisfaction.29 Living in dangerous com- munities (Chapter 12), especially those with high crime rates, is another risk factor. Protective Factors: Building Resilience Although a risk-based approach is one strategy for addressing the prevention of mental disorders, an examination of protective factors is equally important. Understanding why some individuals can overcome adversity is a key component in the development of in- tervention programs focused on prevention of mental disorders. Protective factors are processes within individuals, families, or communities that exist, can be strengthened, or can be incorporated into interventions for purposes of building resilience. They are the supports and opportunities that buffer adversity.30 Resilience is an individual’s ability to access protective factors that exist at different levels to withstand chronic stress or re- cover from traumatic life events (Box 10-2).31 Individual strengths such as social competence, problem-solving ability, autonomy, and a sense of purpose show re- silience. Protective factors can reduce risk for mental health disorders and can promote optimal mental health. Understanding what factors help individuals, families, and communities reach optimal health, then, is as important as understanding the factors that in- crease the risk for developing a mental disorder. Both prevention and treatment interventions can build on these protective factors to help promote optimal mental health. Research on individual protective factors provides the foundation for supporting protective factors in preven- tion interventions. According to Harvard University’s Center on the Developing Child, “… the single most common factor for children who develop resilience is at least one stable and committed relationship with a supportive parent, caregiver, or other adult.”32 The use of resilience building in children exposed to adverse childhoods to reduce the potential of mental health diagnoses holds promise.33,34 More than 2 decades ago, the report from the Presi- dent’s New Freedom Commission on Mental Health was published, emphasizing that the transformation of the mental health delivery system depends on a focus on coping with challenges in life and building resilience.35 Interventions to promote resilience focus on a strengths- building approach. Because strengths recognized in re- silience are inherent psychological needs, humans are compelled to meet them throughout their lifetime, and the factors determining whether they do meet them are often dependent on the wider systems in which an individual interacts, including families, schools, and communities.31 A community can also be resilient.31 Similar to how resilience in an individual is defined, a resilient commu- nity is characterized by social competence, problem- solving, a sense of identity, and hope for the future. A resilient community has certain resources available that are important for human development. These resources include health care, childcare, housing, education, job training, employment, and recreation.31 A journal’s spe- cial edition addressed the factors that are important for communities to promote childhood resilience, including increasing the availability of programs that foster healthy parent-child interactions and increase parental social support.36 A community’s resilience contributes to an individ- ual’s capacity to develop resilience and whether a MHD is present or not. The community develops and nurtures resilience by valuing and providing the means of con- nectedness, by supporting and nurturing commitment 244 U N I T I I n Community Health Across Populations: Public Health Issues • Environmental capital: structural factors and features of the natural and built environments • Environment that enhance community capacity for well-being • Social capital: norms, networks and distribution of resources that enhance community trust, cohesion, influence, and cooperation for mutual benefit • Emotional and cognitive capital as resources that buffer stress and/or determine outcomes and contribute to individual resilience and capability BOX 10–2 n Protective Factors and Resilience Source: (32) 7711_Ch10_239-255 21/08/19 10:45 AM Page 244 and shared values where everyone participates in mean- ingful structure and role responsibilities, and by engaging in critical reflection and skill building that feeds back into the community. The ability of a community to build resilience is called community capacity.37 An example of community-level resilience is that of community members and organizations working in partnership with youths, families, and schools. A sense of connectedness can result when schools work in partnership with students, families, and community groups. An example of this connectedness is a program called Elev8 in Baltimore, Maryland, which is focused on improving educational and social outcomes for middle grade adolescents and their families in East Baltimore.38,39 “Each Elev8 Baltimore school is assigned a site manager and a family advocate responsible for collaborating with the principal and staff; building relationships with students and families; responding to the needs of students, parents and school staff; pro- moting the integration of learning, health and family support strategy; and developing a family engagement plan to facilitate connections among families, the school, and the broader community.”39 School connectedness is an example of a way to build community resilience. Such programs demonstrate that building resilience at the community level not only can improve the mental health of children and youth but also can have a positive impact on children’s behavioral and academic outcomes.40,38 The importance of inter- disciplinary programs that work together to build com- munity resilience is also increasingly recognized as an approach to address social determinants of health, inequities in education, and the urban environment overall.32,41 Some programs operate at the intersection of public health, education, and urban planning. Exam- ples have included the Obama administration’s Neigh- borhood Revitalization Initiative, which focused on standardized test scores and educational inequities, and the Choice Neighborhoods program, which is based on Hope VI, which targets severely distressed public hous- ing developments.42,43A focus in these programs is to develop community health centers and full-service com- munity schools, and to pursue community development for purposes of revitalizing neighborhoods.38 Cultural Context and Stigma Culture has tremendous influence on the meaning of mental illness for individuals, families, and communities. A culture’s deeply rooted beliefs and attitudes exert con- siderable influence on how mental illness is viewed by society, the individual with the illness, his family, and the community. It may be viewed as real or imagined, adap- tive or maladaptive, or as a valued distinction or inten- tional deviance from the norm. Beliefs and attitudes determine how likely it is that support will be available and whether a person with a mental health disorder will seek help or accept treatment.44–47 For example, studies of cross-cultural stigma have suggested that Latino groups may view taking psychoactive medications as a sign of weakness, preferring instead to be self-reliant, whereas some Asian groups may see mental health as emotional weakness that causes one to “lose face,” thus jeopardizing family lineage.47 C H A P T E R 1 0 n Mental Health 245 n CELLULAR TO GLOBAL The factors affecting mental health exist on a contin- uum from the cellular to the global. The interactions among an individual’s genetics, epigenetics, and the larger environment are myriad, predicting much of what we know about mental well-being. Although individuals may have a stronger genetic predisposition for certain types of mental illness, factors across the life span heavily influence its expression. Even beginning before birth, factors such as access to nutrients in utero and exposure to maternal trauma contribute to an individual’s mental health risk profile. As a person ages, employment opportunities and exposure to dis- ease also cumulatively affect mental health status. Even into older age, factors such as social integration and chronic illness continue to impact mental well-being. Thus, public health interventions to promote mental wellness must address all levels of this continuum.24 n CULTURAL CONTEXT Cultural Influences on Mental Health48 “People often think of mental health as a very per- sonal matter that has to do only with the individual. However, mental illnesses and mental health in general are affected by the combination of biological and ge- netic factors, psychology, and society. This intersec- tionality is important, but the heavy influence of societal factors often goes ignored. An interesting aspect of society is its diversity in cultures and back- grounds that affect an individual’s mental health related experiences … For instance, culture affects the way in which people describe their symptoms, such as whether they choose to describe emotional or physical symptoms. Essentially, it dictates whether people 7711_Ch10_239-255 21/08/19 10:45 AM Page 245 Stigma is one of the barriers to the treatment of men- tal health problems.48 Goffman’s classic definition views stigma as a combination of personal attributes and soci- etal stereotypes related to human characteristics viewed as unacceptable.49 Stigma refers to a trait or attribute of a person that results in the discrediting of that person. Stigma occurs when the person, rather than the trait or condition, is held responsible for the inability to per- form an action.50, 51 Cultural belief systems can produce stigma, the form of social disapproval that pervades the attitudes and actions of the community, the family, and even the individual. Stigma acts as a barrier to achieving health and well- being, and can greatly undermine a community’s efforts to capitalize on strengths. There is a growing awareness of disparities in access and use of mental health services among ethnic and racial minority populations. Treatment disparities among African American and Hispanic groups, for example, are especially acute. Although African Americans and Hispanics are more than 20% more likely to report psychological distress than non-Hispanic whites, African Americans are 15% less likely and Hispanics are half as likely as non-Hispanic whites to receive mental health care.52-55 There are many possible explanations for these disparities, including variations in expression of symptoms, bias or prejudice among providers, experiences of mistreatment, difficulties in accessing treatment, and stigma among various populations.56 These groups also have the highest numbers of people who lack insurance coverage.57 Stigma can cause individuals with mental illness to adopt a number of behaviors that serve to protect them from stigma but may result in failure to seek treat- ment (Box 10-3).56 The American Psychiatric Association (APA) has de- veloped strategies to address issues related to culture and stigma. These strategies address challenges related to the complexity of the issue, including illness progression, family history and cultural influences, impenetrable iso- lation reinforced by stigma, and multiple system failures. An example is the organization’s recommendations for providing culturally competent care for Asian Americans who may have a mental disorder (see Box 10-4).58 The term Asian refers to people whose country of origin is located in the Far East and includes people from South- east Asia, the Indian subcontinent, and the Pacific Islands. Providing care requires an understanding of the diversity of cultures as well as the possibility that present- ing symptoms may represent culture-bound syndromes that can affect Asian American populations.58 The importance of understanding culture and stigma is exemplified by the incident that occurred on April 16, 2007. Seung-hui Cho, aged 23 years and a senior at Virginia Polytechnic Institute and State University (Virginia Tech), wounded 25 people and killed 32 and then himself in a shooting rampage that lasted several hours. Cho was only 8 years old when his family arrived in the United States from South Korea. He was a shy child and apparently was bullied. His childhood years had been troubled, and in middle school, he was diagnosed with selective mutism, a severe anxiety disorder, and an MDD. He began to re- ceive treatment and therapy, which continued through his sophomore year in high school. During college, he was hospitalized for mental illness symptoms and offered treatment, which he declined.59, 60 The tragic shooting incident led campus police and state government officials to investigate and make recom- mendations. Due to this incident and others, colleges and universities across the nation have evaluated and revised safety and security plans, and strengthened campus men- tal health services.61 This case illustrates that a traumatic experience of this nature has a widespread impact on a community, with lasting psychological distress. Violent acts such as this; the Columbine High School shootings; the movie theater shootings in Aurora, Colorado; the shootings in Newtown, Connecticut; and the shootings in Parkland, Florida, are linked with mental disorders and social-identity threats.61 The high-profile case at Virginia Tech is an example of the impact that culture has on understanding the 246 U N I T I I n Community Health Across Populations: Public Health Issues selectively present symptoms in a ‘culturally appropri- ate’ way that won’t reflect badly on them … Every culture has its own way of making sense of the highly subjective experience that is an understanding of one’s mental health. Each has a prevailing attitude about whether mental illness is real or imagined, an illness of the mind or the body or both, who is at risk for it, what might cause it, and perhaps most importantly, the level of stigma surrounding it.” • Not telling other people about symptoms • Masking the symptoms • Normalizing mental health symptoms • Emphasizing somatic aspects • Refusing to seek treatment • Fearing rejection by family and friends • Concern about difficulty finding housing and employment • Being socially ostracized BOX 10–3 n Impact of Mental Health Stigma Source: (56) 7711_Ch10_239-255 21/08/19 10:45 AM Page 246 to optimize the mental health of individuals and com- munities. Promotion focuses on building communities with living conditions and environments that support mental health. Prevention focuses on implementing strategies that prevent mental disorders and providing early intervention and adequate treatment for those with mental disorders.64 Measure of Mental Health: Health-Related Quality of Life One way to assess mental health is to measure health- related quality of life (HRQoL). It is a marker not only of physical health but also of mental health. As noted in Chapter 9, HRQoL is central to the overarching goals for HP 2020. HRQoL as defined in Chapter 9 is the self-perceived impact of physical and emotional health on quality of life, including the effects on general health, physical functioning, physical health and role, bodily pain, vitality, social functioning, emotional health and role, and mental health.65,66 The HRQoL measure used by the CDC includes items specifically aimed at measuring C H A P T E R 1 0 n Mental Health 247 A Few Best Practices for Working with Asian Patients • Assess the language barrier. Ascertain whether the patient speaks English or not, their native dialect, and the degree of acculturation. • Ask about traditional beliefs as part of your cultural formulation. These may influence how the individual expresses mental distress, such as through somatic symptoms. For non-English speaking unacculturated individuals, particularly among the elderly, many hold traditional values and a concept of health and disease (e.g., Yin/Yang) that may influence the individual’s expression of mental distress such as through somatic symptoms. They may seek traditional healers such as acupuncturists and herbalists. Their ideas about bodily symptoms may affect drug compliance. • Many Asian immigrants view physicians and other providers as authority, so encourage patients’ participa- tion in their care. Taking blood pressure, checking pulse, and giving advice about diet and foods/use of herbal products can promote rapport. • Involve the family in health-care decisions. If interde- pendence among family members is valued, treat the family as a unit. • Familiarize yourself with ethnopsychopharmacological research. You may, for example, start with a lower pre- scribed dosage of psychotropic medications for Asians. • Prescribe cognitive behavioral therapy, where appropri- ate. Talking therapy is foreign to many Asians. If psy- chotherapy is indicated and involvement of the family is discouraged to maintain confidentiality, explain the rationale and procedure to both the patient and the family. • Allow sufficient time for interviews. Translation needs extra time, and it takes time for Asian patients to feel comfortable in sharing very intimate, personal informa- tion with outsiders. • Be attentive to comorbid medical problems. • Consider traditional interventions in addition to medication and, if indicated, diets, exercises, and other traditional methods (Tai Chi, breathing exercises) of stress-reduction and relaxation. • Ask detailed clinical history with open-ended questions first, and be attentive to nonverbal clues (facial expres- sion, tearing, etc.). Please refer to the APA Web site for further informa- tion on treating Asian patients and resources to help you provide culturally competent care: https://www. psychiatry.org/psychiatrists/cultural-competency/ treating-diverse-patient-populations/working-with- asian-american-patients. BOX 10–4 n APA Best Practices for Working with Asian American Patients Source: (58) expressions and presentation of mental disorders. Korean Americans make up 9% of the Asian population in America, up 41% from 2000. Of these, a little less than two-thirds are foreign born, but they rank 12th of all U.S. naturalizations since 2012 and fifth among Asians.62 Han and Pong (2015) reported that Asian American college students are unlikely to present to a health-care provider and complain of mental problems. Rather, their concerns are focused on schooling, and vocational or employment- related problems. Families are likely to insist that a family member suffering with mental problems should keep her or his problems hidden because of the shame it can bring on the family. By the time help is sought, the problems have often become severe.63 Prevention of Mental Disorders and Promotion of Mental Health Because mental health is not simply the absence of a mental disorder, prevention of mental disorders and pro- motion of mental health are key components of efforts 7711_Ch10_239-255 21/08/19 10:45 AM Page 247 emotional and mental health. It is a useful tool for the nurse who wishes to assess the level of mental health in a patient as well as a tool for assessing the overall mental health in a population. The tool is available on the CDC Web site and can be easily downloaded. National Academy of Medicine Model of Prevention In 1997, the IOM, now the National Academy of Medi- cine, reported that the primary, secondary, and tertiary continuum of prevention was confusing when applied to mental disorders and developed a new model that more clearly separates prevention from treatment.67 This framework, presented in Chapter 2 and again in Chapter 11, divides the prevention category into three levels developed specifically for behavioral health issues: (1) universal, (2) selective (also referred to as selected), and (3) indicated, with possible interventions at each level. Universal prevention refers to prevention interven- tions provided to the entire population, not just those who might be at risk. The interventions include but are not limited to public service announcements provided to the public at large through billboards, media messages (print and electronic), or general health education programs. Selective prevention includes interventions provided to specific subgroups who are known to be at high risk for mental disorders because of biological, psy- chological, social, or environmental factors but who have not yet been diagnosed with mental disorders. High-risk subgroups include but are not limited to those with a family history of mental disorders, with a history of ad- verse childhood events, or who are victims of violence. An example is counseling delivered to students at a school where violence has occurred, such as the extensive coun- seling required following the Parkland, Florida, shootings. Selective interventions include opportunities for learning strategies to prevent the development of a mental disorder as well as early warning signs to help individuals and families seek help early. Indicated prevention addresses specific subgroups at highest risk for development of a mental disorder or individuals who are showing early signs of a mental disorder. The purpose of indicated tech- niques is to delay or reduce the severity of a mental dis- order. At this level, there is less concern about community prevention and more emphasis on individuals who demonstrate early signs of mental disorders.67 Promotion of Mental Health and Policy The WHO strongly supports the implementation of strategies that will create healthful living conditions and environments that result in optimal mental health. The organization stated that mental health promotion depends on intersectoral strategies. These are defined as strategies that engage more than one sector of society with a shared interest such as governmental agencies, grass roots citizen groups, nonprofit groups, and/or businesses. Some strategies proposed by the WHO in- clude those that address needs of specific age groups, vulnerable populations, and women. Other strategies focus on the environment, such as the workplace, schools, housing, and community development. The WHO recommended that governments main- stream mental health promotion across policies and programs.64 The WHO warns against focusing only on mental disorder treatment and stresses that an up- stream approach (see Chapter 2) is vital to the health of communities. To support its efforts related to mental health im- provement, the WHO developed a model to guide its activities called the Mental Health Improvements for Nations’ Development (MIND) (Fig. 10-3). It includes four components: (1) Action in Countries, (2) Mental Health Policy, Planning & Service, (3) Mental Health, Human Rights & Legislation, and (4) Mental Health, Poverty & Development. This model demonstrates not only the need for intersectoral strategies but also for interrelationships between multiple factors that con- tribute to mental health.68 Secondary Prevention: Screening for Mental Disorders The focus of the National Academy of Medicine’s report Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series is the need for appropriate behavioral health treatment.69 The report has a strong emphasis on early identification and treatment. The model for secondary intervention in mental health is screening, brief intervention, and refer- ral for treatment (SBIRT), an approach also used in sec- ondary prevention programs related to at-risk alcohol use (Chapter 11). The Substance Abuse and Mental Health Service Administration (SAMHSA) issued a re- port on the use of screening for behavioral health that includes screening for depression and trauma/anxiety disorders. Although SAMHSA concludes that no evi- dence exists to support a comprehensive SBIRT pro- gram for these disorders, there is evidence that screening is effective.70 Reliable screening tools exist that have validity across the life span and across health-care settings. Tools differ based on the specific mental disorder being screened. The screening tools most often used in primary care are 248 U N I T I I n Community Health Across Populations: Public Health Issues 7711_Ch10_239-255 21/08/19 10:45 AM Page 248 for depression and anxiety disorders. Tools to screen for depression include the Patient Health Questionnaire 2 and the Center for Epidemiological Studies Depression Scale. Screening tools for anxiety disorders include the Brief Symptom Checklist-18 of the My Mood Monitor.70 The challenge is not only to screen but also to provide care to those who screen positive. Thus, universal screening for depression is only recommended in situa- tions in which accurate diagnosis and treatment are available.70 One approach related to screening and engagement into treatment for disorders is to integrate care for men- tal disorders within primary care settings. Because most people identified with mental disorders are seen in a primary care setting, integrating care within this setting is a logical approach. Without an integrated system, those who screen positive may not receive the care they need. Kroenke and Unutzer (2017) suggest there are six key components to successfully integrating mental health care into primary care settings (Box 10-5).71 C H A P T E R 1 0 n Mental Health 249 Mental Health, Poverty & Development Mental Health, Human Rights & Legislation Mental Health Policy, Planning & Service Development Action in Countries NATIONS’ DEVELOPMENT MENTAL HEALTH IMPROVEMENTS Figure 10-3 WHO Mental Health Improvements for Nations’ Development (MIND). (From World Health Organization. [2012]. Mental Health, MIND— mental health in development. Retrieved from http://www. who.int/mental_health/policy/en/index.html.) • Population-Based Care: Depends on systematic efforts to identify all patients with disease, provide treatment, and track outcomes. This may be difficult to do with current system of nonintegrated electronic health records. • Measurement-Based Care: Essential for public health surveillance, but most mental disorders depend on patient-reported outcomes (PROs). The ideal PRO is brief, self-reported, public domain, multipurpose, easy to score and interpret, and available in multiple lan- guages. Although a few scales meet these criteria, most do not. One that does meet most of these criteria is the Patient Health Questionnaire family of scales. • Treatment to Target: Requires regular monitoring of disorder severity and adjusting treatment based on monitored outcomes. Interventions must be evidence- based and, if patients are not improving as expected, there is a systematic protocol to incorporate measure- ment results in treatment changes. • Care Management: Dedicated clinician who follows patients with particular disorders in (a) practice(s). Also, maintains disease registry, provides disease-related education, tracks treatment adherence, and coordinates care. • Psychiatric Consultation: Accessible and dedicated psychi- atrist who can meet frequently with care manager and occasionally will also meet with patients. Can also facili- tate referrals and may be integrated by telepsychiatry. • Brief Psychological Therapies: Can be administered in primary care clinics or remotely by trained behavioral health specialists. Approaches include motivational interviewing, behavioral activation, and problem-solving treatment. BOX 10–5 n Six Key Components for Mental Health Care Integration into Primary Care Settings Source: (71) 7711_Ch10_239-255 21/08/19 10:45 AM Page 249 250 U N I T I I n Community Health Across Populations: Public Health Issues suicidal ideation, self-harm, and suicide attempts than their heterosexual, cisgender counterparts.72,73 As is recommended, when Enrico considered cultural risk factors as part of his suicide risk assessment, he discovered that one protective factor for Yuichi was that Asian adolescents had lower odds of suicidal ideation, planning, and self-harm when compared to white adolescents, despite the continuing issue of stigma that has not yet been eliminated in Japanese culture.73-75 Enrico discussed these findings with his colleagues and nursing supervisor. Given the sensitive nature of Yuichi’s disclosure, he cautioned the team that it was especially important they consider how to address Yuichi’s suggestion that he was considering suicide, while also not outing him to his parents against his will. Enrico pointed out to his colleagues that social support is critically important to the mental health of LGBTQ+ adolescents.76 He explained how he is concerned that if Yuichi is outed to his parents, he may lose a key com- ponent of his current social support network. The team discussed whether they had a duty to tell Yuichi’s par- ents about his sexual orientation and his thoughts about ending his life. One reference Enrico found provided support and guidance for the team’s conclusion.77 The team decided that they would only tell Yuichi’s parents that the team was concerned about Yuichi’s mental well-being and had requested a consult with a psychia- trist while he was still inpatient. The team also recom- mended that Yuichi follow up with counseling once he was discharged from the hospital. Following Yuichi’s discharge with this recommended plan, Enrico worked with the hospital policy committee to develop a new policy outlining the protocol for noti- fication of parents about sensitive issues regarding their children. He also worked with the policy committee to update the suicide risk assessment protocol to include a cultural component. Four months after Yuichi was discharged, he re- turned to the hospital to thank Enrico for his help. He told Enrico that the counselor his parents had found had been very helpful to him and that, with the coun- selor’s guidance, he had decided to wait until after his 18th birthday and his high school graduation before coming out to his parents. Yuichi did say, however, that he was feeling much better and more hopeful for the future. Enrico thanked him for coming in to update him and told Yuichi that his experience as a patient had helped the hospital create new policies to make things better for the patients who followed him. l APPLYING PUBLIC HEALTH SCIENCE The Case of Sadness Under the Rainbow Public Health Science Topics Covered: • Epidemiology • Surveillance • Program Planning Enrico, a nurse for 2 years, recently started working in a pediatric medical-surgical unit in a rural, critical access hospital. Last week, he was involved in the care of Yuichi, a 17-year-old male who was admit- ted for surgery to remove a ruptured appendix. As Enrico provided care to Yuichi on the third day after surgery, he noticed that Yuichi was withdrawn and quiet, rarely looking at Enrico or even appearing to notice his attempts to start a conversation. However, when Enrico brought in his afternoon pain medicine, Yuichi seemed to notice Enrico’s left wrist and bright- ened visibly. Enrico looked at his left wrist where he had a rainbow band on his wristwatch. Yuichi asked, “Why do you wear the rainbow watch?” Enrico considered carefully for a moment, then decided to disclose personal information because he felt this was the first time there was an opening to develop a therapeutic connection with Yuichi. Enrico disclosed he was gay and wore the wristband in solidarity with the LGBTQ+ community. Immediately, Yuichi, smiling shyly, visibly relaxed. He then told Enrico that he was also gay and had recently come out to his friends at school but was still in the closet to his parents and family. He told Enrico that his parents emigrated to the United States from Japan when he was a baby and are very conservative. He confessed that he has been very worried about how his parents will react to his coming out and has even been feeling like “being dead would be better than living like this, especially if they kick me out.” After Enrico had returned to the nurses’ station, he started to review the evidence about LGBTQ+ adolescents, mental health risks, and mental health interventions. Over the next day, Enrico found sev- eral journal articles and a book chapter that helped him to better understand the current evidence about the prevalence of and interventions for the mental health challenges of sexual and race/ethnic minority youths.72-77 Enrico learned that, among the many risk factors for suicide, LGBTQ+ youths have been reported to experience higher odds of sadness, 7711_Ch10_239-255 21/08/19 10:45 AM Page 250 Tertiary Prevention: Treatment for Mental Disorders At the individual level, a person diagnosed with a mental disorder must meet the clinical criteria for the diagnosis. Because there are no definitive diagnostic laboratory tests or scans useful for diagnosing mental disorders, experts in the field developed a manual, the Diagnostic and Statistical Manual of Mental Disorders (DSM), to guide diagnostic decision making and provide consis- tency and accuracy in diagnoses among clinicians. The newest revision of the manual, DSM-5, is organized so the chapters are based on underlying vulnerabilities as well as symptom characteristics. The goal of the DSM is to facilitate a more comprehensive approach to diag- nosis and treatment, and the DSM-5 represented a major change from earlier versions of the manual.78 Thus, at the individual level, experts re-examined diag- nostic criteria based on the best evidence in developing the DSM-5. Treatment of mental health usually focuses on the individual and can include many different treat- ment modalities. At the population level, tertiary treat- ment and policy are closely related with access to treatment as the central issue. Mental Health Policy Related to Treatment Access to treatment and the type of treatment available have been central issues since the end of World War II. Prevention at the population level related to treatment entails reduction of disparity in access to treatment, whereas promotion of mental health requires policies that will strengthen the mental health of populations.79 Historically, government policy focused on treatment of mental disorders and was influenced by underlying attitudes concerning mental disorders. In the latter half of the 20th century, policy changes were put in place that led to deinstitutionalization. Other events that influenced policy related to treatment include pharmacological ad- vances, for example, the introduction of drugs such as Thorazine, as well as a cultural change from focusing on treatment of those with mental disorders to improving mental health for all. C H A P T E R 1 0 n Mental Health 251 n EVIDENCE-BASED PRACTICE Screening for Suicide Risk Among Adolescents in Primary Care Practice Statement: Adolescents should be screened in primary care for suicide risk using a validated and reliable screening tool if there is reason to believe an adolescent is at elevated risk. Targeted Outcome: Identification of those at risk, initiation of prevention strategies, and, when indicated, referral to treatment Evidence to Support: The evidence for the effective- ness of screening for suicide risk in adolescents, as well as in adults and older adults, has been found to be incomplete by the U.S. Preventive Services Task Force (USPSTF).1 The American Academy of Pediatrics recommends that, if adolescents are screened for suicide risk, they should be asked directly about suici- dal ideation.2 There is some evidence that screening for suicide can detect adolescents who are at increased risk for suicide, but there is insufficient evidence yet to determine whether that identification translates to improved outcomes, such as decreased attempted and completed suicide rates.3 Recommended Approaches: Adolescents that have known risk factors for suicide, such as recent mental illness, increased substance use, or withdrawal from social support networks, should be screened by suicide assessment. Direct questioning regarding suicidal ideation should be used, such as asking, “Have you ever had thoughts about taking your own life or wishing you were dead?” Standardized assessments may be helpful, but most have been found to be too sensitive while lacking specificity in this population.1-3 If adolescents are positive for suicidal ideation, they should be referred for immediate psychiatric evaluation by hospitalization, transfer to an emergency department, or same-day appointment with a mental health provider.2 Sources: 1. LeFevre, M.L. (2014). Screening for suicide risk in adolescents, adults, and older adults in primary care: U.S. Preventive Services Task Force recommenda- tion statement. Annals of Internal Medicine, 160(10), 719-726. doi:10.7326/M14-0589. 2. Shain, B.N. (2007). Suicide and suicide attempts in adolescents. Pediatrics, 120(3), 669-676. doi:10.1542/ peds.105.4.871. 3. Kennebeck, S., & Bonin, L. (2017). Suicidal ideation and behavior in children and adolescents: Evaluation and management. UpToDate. Retrieved from https://www.uptodate.com/contents/suicidal- ideation-and-behavior-in-children-and-adolescents- evaluation-and-management. 7711_Ch10_239-255 21/08/19 10:45 AM Page 251 Supreme Court decisions also affected policy. For example, the “least restrictive alternative” principle in the ruling in Shelton v. Tucker (1960), which allowed invol- untary admission to a psychiatric facility only if there were no another alternative that would allow more freedom, and the ruling in O’Connor v. Donaldson (1975), which stated that mental patients who were not dangerous and involuntarily institutionalized had the right to be treated or discharged.80 These landmark decisions resulted in deinstitutionalization of those diagnosed with mental disorders from psychiatric hos- pitals to independent living arrangements, thus shifting the burden of treatment to the community. President John F. Kennedy signed the Community Mental Health Centers Act in 1963, which opened the way for a network of community mental health centers to provide compre- hensive services and continuity of care.81 Unfortunately, community facilities did not develop at the same pace as deinstitutionalization. In addition, insufficient planning for alternative facilities and services (medical and psychiatric care, social services, housing and nutrition, income and employment, and vocational and social rehabilitation) resulted in thousands of vulnerable and severely ill persons left behind to be- come imprisoned by poverty, neglect, victimization, substance abuse, and homelessness, all conditions that exacerbate psychiatric disorders.82,83 The term transin- stitutionalization began to appear in the literature in the 1980s and refers to the growing numbers of men- tally ill persons ending up on the streets, in jails and prisons, in nursing homes, boarding houses, and home- less shelters, and not in places of their own or in the hospital. Today, it is estimated that between 30% and 50% of persons in the United States who are homeless are also mentally ill.80, 83 The Mental Health Parity Act represents a step for- ward as the United States grapples with accepting treat- ment of mental illness as integral to promoting and ensuring a healthy public. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 was signed into law October 3, 2008, and mandates that group health plans of 50 or more persons, which cover mental health and substance-use disorders, must provide benefits equivalent to (or better than) those benefits provided for medical or surgical benefits. The Affordable Care Act of 2010 has also helped to fill in some of the gaps by requiring Medicaid and plans purchased by small businesses to include mental health and substance abuse coverage. However, significant gaps remain, and further work is needed to transform the delivery of health care to those with mental disorders. Attention is needed not only on parity of access but also on the ethics of providing treatment for mental disorders at parity with treatment for physical disorders. n Summary Points • Behavioral health is essential to overall health. • Behavioral health disorders will surpass all physical diseases as a major cause of disability worldwide. • Mental health, substance abuse, and violence are interconnected. • Mental health is the vehicle for developing meaning- ful relationships, sound thinking, skills for learning and communication, emotional maturity, resilience, and self-esteem. • Resilience is an individual’s ability to access protec- tive factors. • Risk factors and protective factors related to mental health outcomes occur at several levels: individual, family, social, and community. • Interventions occur at all levels, but societal inter- ventions are critical to transforming the mental health system. 252 U N I T I I n Community Health Across Populations: Public Health Issues t CASE STUDY Promoting Mental Health among Older Adults Learning Outcomes At the end of this case study, the student will be able to: • Apply demographic methods to determine the sever- ity of a problem at the population level. • Examine the role that members of the community play in addressing a population level health issue. • Discuss policy approaches to a population-level health problem. • Examine the evidence to support a population-based intervention. The nurses working for a primary health clinic were concerned about the increase in suicides among older adults in the clinic’s practice population. One of the nurses brought in an article about suicide risk among older adults.84 The nurses found the risk of suicide among older adults to be startling and decided to investigate what steps they might be able to take to address this type of situation in their own primary care clinic. One of the nurses stated they should not proceed without including members of the local 7711_Ch10_239-255 21/08/19 10:45 AM Page 252 REFERENCES 1. Mental Health.gov. (2017). What is mental health? Retrieved from https://www.mentalhealth.gov/basics/ what-is-mental-health. 2. World Health Organization. (2018). Mental health. Retrieved from http://www.who.int/mental_health/en/. 3. Institute of Medicine. (2005). Improving the quality of health care for mental and substance-use conditions: Quality chasm series. 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New York: Oxford University Press. 76. McDonald, K. (2018). Social support and mental health in LGBTQ adolescents: A review of the literature. Issues in Mental Health Nursing, 39(1), 1-14. doi:10.1080/ 01612840.2017.1398283. 77. Hyatt, J. (2015). Maintaining the privacy of a minor’s sexual orientation and gender identity in the medical environment. Journal of Healthcare Risk Management, 35(1), 31-36. doi:10.1002/jhrm.21176. 78. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA; American Psychiatric Association. 79. Thompson, J.W. (1994). Trends in the development of psychiatric services, 1844–1994. Hospital and Community Psychiatry, 45(10), 987-992. doi:10.1176/ps.45.10.987. 80. Krieg, R.G. (2001). An interdisciplinary look at the deinstitutionalization of the mentally ill. The Social Science Journal, 38(3), 367-380. Retrieved from http://www. accessmylibrary.com/article-1G1-78901856/interdisciplinary- look-deinstitutionalization-mentally.html. 81. Talbott, J.A. (1982). Twentieth-century developments in American psychiatry. Psychiatric Quarterly, 54(4), 207-219. doi:10.1007/bf01064816. 82. Reddi, V. (2005). Dorthea Lynde Dix (1802–1887). Center for Nursing Advocacy. Retrieved from http://www. nursingadvocacy.org/press/pioneers/dix.html. 83. Sisti, D.A., Segal, A.G., & Emanuel, E.J. (2015). Improving long-term psychiatric care: Bring back the asylum. JAMA, 313(3), 243-244. doi:10.1001/jama.2014.16088. 84. Jahn, D.R. (2017). Suicide risk in older adults: The role and responsibility of primary care. JCOM, 24(4). C H A P T E R 1 0 n Mental Health 255 7711_Ch10_239-255 21/08/19 10:45 AM Page 255 Chapter 11 Substance Use and the Health of Communities Michael Sanchez, Christine Savage, and Amanda Choflet LEARNING OUTCOMES After reading the chapter, the student will be able to: KEY TERMS 1. Describe the impact of substance use on the health of a population. 2. Define the burden of disease related to substance use using current epidemiological frameworks. 3. Apply current evidence-based population interventions to the prevention of harm associated with substance use across the continuum of use. 4. Describe population-level approaches to the prevention and treatment of substance use disorders. Abstinence At-risk substance use Binge drinking Blood alcohol level Duration Environmental tobacco smoke (ETS) Frequency Harmful use Low-risk use Heavy drinking Involuntary smoke exposure Moderate use Opioid epidemic Passive smoke exposure Pattern Physical dependence Psychological dependence Psychoactive substances Screening and Brief Intervention (SBI) Secondhand smoke exposure Stigma Substance use Substance use disorder Tolerance Quality Quantity Withdrawal n Introduction In 2017, media headlines blared alarming statistics on the opioid overdose epidemic in the U.S. In the fall of 2017, the president declared a national public health emergency, and states scrambled to both prevent at-risk opioid use and provide life-saving treatment for opioid overdoses.1 The recent opioid epidemic in the U.S. put a spotlight on the dangers associated with the use of psychoactive drugs and brought a media-driven public health response to substance use that had not occurred since perhaps the emergence of cocaine use and the media spotlight on “crack babies” in the 1980s. The number of states that have legalized marijuana for medical and/or recreational use is increasing, with a subsequent increase in current use. At the same time, federal efforts focus on continuing to criminalize the use of marijuana. Current use of marijuana in- creased from 6.2% in 2004 to 7.9% in 2017.2 In the past decade, the largest increase occurred among those 55 years of age or older with 1.1% reporting current use in 2004 and 6.1% reporting current use in 2014.3 Despite the recent focus on opioids, tobacco and alcohol, both legal substances, are leading causes of preventable deaths both globally and in the U.S.4,5,6,7 In 2017, based on the National Survey on Drug Use and Health, 87.1% of Americans aged 26 or older reported lifetime alcohol use. Of those aged 12-17 years old, 21.9% reported alcohol use within the past year, and 5.3% reported binge drinking.6 Although tobacco use has dropped over the past few decades, in 2017, 22.4% of those aged 18 or older reported past month tobacco use, and 62.7% reported lifetime use.2 With such a large pro- portion of the population using tobacco and/or alcohol, which are two leading causes of preventable death6,8,9, as well as the emerging issues such as the opioid epidemic and the emergence of legalized use of marijuana, it is important for nurses to have evidence-based knowledge and competency related to the prevention and treatment 256 7711_Ch11_256-282 23/08/19 10:37 AM Page 256 of at-risk substance use at the individual and community level. At-risk substance use, defined as use linked to ad- verse health consequences for individuals, families, and communities, occurs across the globe. From a public health perspective, the consequences go beyond the neg- ative impact on the health of the individual using the substance.8,9 Substance use increases the risk for injury, crime, and adverse health issues, and poses a risk for other individuals through environmental factors. For ex- ample, illicit drug use is linked to increased crime in a neighborhood, alcohol use while driving injures and kills drinkers and nondrinkers, and tobacco use pollutes the environment through the release of toxic chemicals. Sub- stance use is a major public health issue affecting all ages, populations, and countries.6,7,9 Substance use occurs within the social, cultural, and economic context of the community with different impacts at the national level. These differences can include quantity consumed, the type of substance consumed, and the cultural norms around consump- tion. In relation to the quantity consumed, the U.S. represents 4.8% of the global population, yet globally, in 2015, the U.S. accounted for 49% of all consumption of morphine, 29.8% of fentanyl consumption, and 69% of oxycodone.7, 10 Lower socioeconomic status is associated with an increased risk of alcohol-related harm due to increased vulnerability to alcohol based on nutritional and health status, as well as decreased access to care. The other economically associated issue is the quality of the alcohol, with a higher rate of alcohol- related deaths due to consumption of illegal alcohol that contains toxins.9 In addition, cultural differences exist around the use of substances. Cultural norms in some countries such as the U.S. and Russia include the acceptance of binge drinking, that is, consumption of more than the recom- mended limits of total alcohol during one episode of drinking. By contrast, in some countries, any consump- tion of alcohol can result in adverse social consequences. Finally, lack of economic resources within a country or community can reduce the ability to develop and/or enforce policies aimed at preventing at-risk substance use. These policies include ones designed to reduce dis- tribution of illicit substances, control distribution of legal substances, and provide programs aimed at preventing substance use-related harm. Advocating to prevent harm associated with substance use and to provide access to treatment for those with a substance use disorder (SUD) requires an understanding of the context in which sub- stance use occurs, the extent of the burden of disease, and evidence-based approaches that work across the contin- uum of use and life span. Substance Use and the Global Burden of Disease Substance use is a term used across the globe in reference to the use of psychoactive substances. These are chemical substances that have a pharmacological effect on the brain and central nervous system (CNS). The effects of these substances on an individual include altered mood, perception, and level of consciousness.6 The classes of psychoactive substances include stimulants, depressants, inhalants, dissociative anesthetics, narcotics, hallucino- gens, and cannabis (Table 11-1).11 Some are legal, such as alcohol and tobacco, whereas others are illegal (or illicit), such as heroin. Some are legal with a prescription, such as narcotics prescribed for pain. Although cannabis is still illegal at the federal level in the U.S., in a growing number of states, marijuana (cannabis) can be obtained with a prescription. In a growing number of U.S. states and some Western European countries, it is legal for recreational use. Understanding Substance Use and Risk Across the Continuum of Use and the Life Span Substance use includes four components: quantity, fre- quency, pattern, and duration.12 Assessment of these four components helps to determine the risk of adverse con- sequences. Consequences range from low to high risk with a diagnosis of an SUD at the high-risk end of the continuum (Fig. 11-1). Quantity is defined as the amount consumed, in other words, the dose. Frequency refers to how often the substance is consumed: daily, weekly, or monthly. The pattern of use refers to whether the use is consistent or occurs in an episodic manner, usually referred to as binging. Finally, duration of the use refers to how long over a lifetime the use has occurred. Another important factor is the quality of the sub- stance consumed.9 Quality reflects the process for the manufacturing of the substance consumed and whether the product might include toxins, other substances such as Fentanyl-laced heroin, or not reflect a consistent dose. This usually occurs when manufacturing of the substance is done through an illegal and/or unregulated process. This is most apt to occur when the substance itself is illegal or when it is legal, but there are inadequate regu- lations controlling manufacturing. Risk for harm associated with substance use occurs across the life span from fetal exposure to the last decades C H A P T E R 1 1 n Substance Use and the Health of Communities 257 7711_Ch11_256-282 23/08/19 10:37 AM Page 257 of life. Life span-associated risk for adverse conse- quences, both acute and chronic, differs based on human stages of development, ability to metabolize the sub- stance, and peer influence. Fetal exposure to alcohol can result in fetal alcohol spectrum disorders (FASD), which can occur due to fetal exposure to maternal alco- hol use, and it can include physical, behavioral, and/or learning problems.13 Based on findings from multiple studies on heavy alcohol use by adolescents, there is strong evidence of an association between alcohol use and adverse effects on the brain including brain devel- opment, brain functioning, and neuropsychological per- formance.14-17 For older adults, changes in the ability to metabolize alcohol, frailty, and other health issues in- crease the risk of alcohol-related acute adverse outcomes such as falls, interactions with other medications, and in- creased risk of intoxication.16 Duration of use over the lifetime can increase the risk for other health issues such as liver disease, cancer, and cardiovascular disease even in the absence of an SUD.8 258 U N I T I I n Community Health Across Populations: Public Health Issues TABLE 11–1 n Classes of Drugs Category Stimulants Narcotics Dissociative Anesthetics Depressants Inhalants Hallucinogens Cannabis Description Overstimulate the CNS resulting in accelerated heart rate, high blood pressure, and other symptoms related to stimulation of the CNS. Relieve pain and can result in a state of euphoria and other mood changes. Inhibit the body’s ability to perceive pain. Depress the CNS thus slowing down the brain and the body. Come from a wide range of chemicals inhaled producing mind-altering effects. Result in altered perception of reality. Result in a feeling of euphoria, and can include distorted perceptions, memory impairment, as well as difficulty thinking and solving problems. Examples Cocaine, amphetamines, methylphenidate, nicotine, methamphetamine, Ritalin, caffeine, and Methadrine Vicodin and OxyContin, opium, morphine, heroin, codeine, hydromorphone, meperidine, methadone, Darvon PCP Alcohol, barbiturates, and anti-anxiety tranquilizers (e.g., Valium, Librium, Xanax, Prozac, and Thorazine) Butyl nitrite, amyl nitrite gas used in some aerosol cans, gasoline and toluene vapors from correction fluid, glue, marking pens PCP, LSD, mescaline, peyote, psilocybin, ecstasy, PCE, and methamphetamine, and Cannabis Cannabinoids including marijuana, tetrahydrocannabinol, or THC; hashish; hashish oil; and synthetics like Dronabinol Source: (11) Substance Use Disorder Adverse Health Consequences Abstinence Low Risk Use Adolescent Young Adult Adult Older Adult At Risk Use Fetus Child Figure 11-1 Substance use across the continuum of use and the life span. 7711_Ch11_256-282 23/08/19 10:37 AM Page 258 Differences exist in the addictive properties of sub- stances, yet all have the potential to result in an SUD. Other factors that play a role in increasing the risk for substance use related adverse outcomes include genet- ics, the health of an individual, age, psychological is- sues, environment, cultural norms, exposure to stress, and access to social support.7,8,18 Prevention of harm associated with substance use requires much more than prevention of an SUD. It requires reframing our ap- proach to substance use from the cellular to the global level. Substance use places persons and communities at risk for adverse consequences that encompasses more than 200 diseases and injuries, as well as economic bur- dens to populations.8 A comparison of substance use across the life span from the cellular to global level helps to illustrate the variability of use. Alcohol is the most prevalent substance used worldwide. Globally, more than 50% of adults reported current use of alcohol. When broken down by gender, 65% of males and 45% of women re- port current alcohol use.6 In the U.S., the statistics are similar, with a little more than 50% of adults reporting current alcohol use. The second most prevalent sub- stance is tobacco with 19% of adults in the U.S. reporting current tobacco use.2 The World Health Organization (WHO) reported that, in 2008, 155 to 250 million people, or 3.5% to 5.7% of the global population used psychoactive substances other than alcohol and tobacco. The most commonly used substance after alcohol and to- bacco was cannabis.18,19 In 2017, the percent of adults 12 or older in the U.S. who reported current drug use was higher, at 11.2% of that portion of the population.2 The Global Burden of Disease Globally, the burden of disease (see Chapter 3) associated with alcohol use has risen over the past decade from 4.2% to 5.1%.9 A total of 3 million deaths every year are due to the harmful use of alcohol, which represents 5.3 % of all deaths in 2016.8 For young adults, the mortality risks are higher, with 25% of all deaths in persons aged 20 to 39 attributable to alcohol use.18 Estimates of the global burden of disease attributable to drug use is 0.8%, with opioid use the largest contributor.19 Tobacco contributes significantly to the global burden of disease, accounting for 1 in 10 deaths, killing more than 6 million people an- nually, almost double the number of deaths attributable to alcohol use.20 Taken together, alcohol, tobacco, and drug use contribute significantly to the burden of disease, with alcohol and tobacco as two of the three top leading causes of preventable death. Substance use is linked to a wide spectrum of adverse health consequences at the individual, family, and community levels (Table 11-2). Worldwide, tobacco and alcohol are among the top 10 risk factors for mortality, with tobacco being the number one risk factor in high-income countries.18-22 C H A P T E R 1 1 n Substance Use and the Health of Communities 259 n CULTURAL CONTEXT World Health Organization Report on Alcohol and Health: Culture and Context9 “The degree of risk for harm due to use of alcohol … varies with the physical and socioeconomic context in which a given drinking occasion and the ensuing hours take place. Moreover, the nature and extent of the harm that results from drinking can vary widely depending on the context. In some contexts, drinkers will be vulnerable to alcohol-related social harm, disease, injury, or even death if any volume of alcohol is consumed. This is the case, for instance, if a person drinks before driving a car or piloting an aeroplane [sic], when consuming alcohol can result in serious penalties and harm. Also, in many countries, there can be serious social or legal consequences for drinking at all, due to laws and regulations or cultural and religious norms, which can increase the vulnera- bility of drinkers to alcohol-related social harm.” Substance Use Disorders Use of alcohol, tobacco, and other drugs all have the potential to result in an SUD. A substance use disorder is “a maladaptive pattern of substance use leading to clinically significant impairment or distress” and can be diagnosed as moderate or severe.23 The broader term used to refer to SUDs is addiction, defined as meeting the criteria for an SUD. In recent years, the professional literature has moved away from the term addiction in an effort to view the full continuum of risk rather than dichotomize the problem into categorizing a person as addicted or not addicted, thus negating the full contin- uum of harm associated with substance use. The gold standard for diagnosing an SUD used by health-care providers in the U.S. is the Diagnostic and Statistical Manual of Mental Disorders (DSM). In 2015, new criteria were introduced that represented a radical change from the approach used in earlier editions of the DSM, which included two diagnoses: substance abuse and substance dependence. With the fifth edition of the manual, DSM-V, an SUD is presented as a continuum that uti- lizes severity, evidence of physiological dependence, and course of treatment to classify the disorder (Box 11-1).23 An SUD can be established with or without physiological 7711_Ch11_256-282 23/08/19 10:37 AM Page 259 dependence. Physiological dependence is defined as ev- idence of tolerance to or withdrawal from a foreign sub- stance. Tolerance involves an adaptation of the body to a drug that results in needing more of the drug to achieve a certain effect. If use of the drug is stopped abruptly, drug-specific physical and/or mental symptoms occur, also known as withdrawal.23 Physical dependence alone does not meet the criteria for a diagnosis of an SUD be- cause withdrawal can occur even with chronic use of a drug as prescribed.24 Thus, the terms substance abuse and substance dependence are not legitimate clinical terms. This also shifts the clinical picture away from pejorative language, such as abuser or addict, to a disease-oriented approach of a person with an SUD. For years, much of the focus related to substance use was on the treatment of those who met the criteria for an SUD. In other words, the focus was a downstream ap- proach (Chapter 2) with a simultaneous policy approach that focused on criminalization of certain substance use and control of access to legal psychoactive substances such as alcohol and tobacco. Over the past few decades, the global focus has shifted to include a broader up- stream approach. This new focus attempts to reduce harm at the population level through prevention of harmful substance use, reduction of harms associated with use and early treatment of SUDs, decriminalization of substance use, and broader policy initiatives.6,9 260 U N I T I I n Community Health Across Populations: Public Health Issues TABLE 11–2 n Adverse Consequences Related to Substance Use Level Individual Family Community Injury Increased risk for unintentional injury and suicide Increased risk for intentional and unintentional injury Increased risk for intentional and unintentional injury Environment Adverse effect on home environment (e.g., secondhand smoke in the home) • Secondhand smoke • Increased crime • Decreased property values Physical Health Increased risk for adverse health outcomes Increased risk for adverse health outcomes secondary to impaired family member Increased burden for cost of health care Psychosocial Health Negative impact on: • Mental health • Employment • Social networks Negative impact on: • Mental health • Employment • Social networks Negative impact on: • Community Social networks Source: (7-10) Severity Specifiers: Moderate: 2-3 criteria positive Severe: 4 or more criteria positive Specify If: With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present) Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 4 nor 5 is present) Course Specifiers (see text for definitions): Early Full Remission Early Partial Remission Sustained Full Remission Sustained Partial Remission On Agonist Therapy In a Controlled Environment BOX 11–1 n Diagnosis of Substance Use and Addictive Disorders Source: (23) n CELLULAR TO GLOBAL Alcohol provides an excellent example of the poten- tial adverse outcomes associated with use from the cellular to global level. At the cellular level, continued use of alcohol at higher than recommended levels can result in a toxic effect on cellular DNA, increasing the risk of developing cancer. Harm associated with use affects the family, the community, all the way up to global impacts on population health related to the burden of disease. In 2016, more than 3 million peo- ple died globally as a result of alcohol use, more than deaths associated with diseases such as tuberculosis, 7711_Ch11_256-282 23/08/19 10:37 AM Page 260 Measurement, Surveillance, and Risk Before developing interventions to help reduce the harm related to substance use, it is important to understand how surveillance of substance use and associated adverse health outcomes (see Chapter 3) is conducted in the U.S. and across the globe in relation to the prevalence of substance use and adverse health consequences asso- ciated with use. The first step in conducting surveillance is defining how substance use is measured. Across all substances, there is a classification of use that reflects the associated level of risk (Fig. 11-1). Because multiple terms are sometimes used, clarity is needed. The first term is abstinence, defined as no use of the substance. For alcohol, it is usually measured as two or fewer drinks in the past 12 months, and for tobacco and other drugs, it reflects no use at all in the past 12 months. Low-risk use or moderate use is use of the substance that places the user at little or no risk. For example, if a healthy person drinks at or below the recommended limits for alcohol consumption of no more than two drinks in one day for adult men (one drink for adult women) and no more than 14 drinks (7 drinks for women) in a week, they are considered low-risk.24 A number of terms are used to describe the next level of use including risky use, at-risk use, binge/heavy episodic use, harmful use, and nondependent heavy use. For example, at-risk use and harmful use are used interchangeably. For the purpose of this chapter, we will use the term at-risk use, defined as use associated with harm to the individual, family, and/or community.6,12,13 Moderate- or low-risk alcohol use is defined as no more than four drinks in one day for healthy adult men and no more than three in one day for healthy adult women and persons over the age of 65. At-risk alcohol use in- cludes heavy drinking and binge drinking. Heavy drinking is defined based on the number of drinks con- sumed during a week. For adult men, heavy drinking is 15 or more drinks in a week, and for women or adults over 65, it is 8 or more in a week. Binge (episodic heavy) drinking is defined as five or more drinks (four or more for women) consumed on a single drinking occasion and is associated with drinking that brings the blood alcohol level up to a blood alcohol concentration (BAC) of 0.08 grams percent or above.24 For substances other than alcohol, the distinction between low-risk use and risky use is less clearly defined. In general, any use of tobacco or illegal substances is con- sidered at-risk use. Use of psychoactive substances avail- able by prescription is termed risky use when the use is not in alignment with the prescription. At the end of the spectrum of risk is an SUD, as described earlier. For some substances or some situations, all use is seen as at-risk. For example, there is no level of low-risk use of substances during pregnancy including tobacco, alcohol, marijuana, and illegal drugs. When collecting individual substance use data, it is important to measure the four aspects of consumption of use: quantity, frequency, pattern, and duration. For alcohol use, quantity is measured as a standard drink, so the intake reflects the amount of alcohol (or dose) consumed rather than the amount of beverage con- sumed (Fig. 11-2). In the United States, a standard drink is 0.6 fluid ounces or 14 grams of pure alcohol. The amount of pure alcohol varies based on the type of beverage. For example, 12 ounces of beer or 5 ounces of wine represent one standard drink because they contain the same amount of pure alcohol.24 For some sub- stances, especially street drugs like heroin, quantity is hard to determine because there is no standard. Frequency is usually measured as number of times a week. Duration questions reflect how long over the life- time the substance has been used, and pattern is meas- ured based on whether the use is constant or varying. These terms are important not only when asking an in- dividual about substance use but also when measuring use at the population level. Surveillance related to substance use is conducted on a regular basis to help measure the prevalence of sub- stance use. How use is measured in these surveys helps public health officials determine the level of risk at the population level. Eleven different national surveillance surveys that involve the collection of data on substance use are listed on the Centers for Disease Control and Prevention (CDC) Web site, including the Behavioral Risk Factor Surveillance System (BRFSS), the National Survey on Drug Use and Health (NSDUH), and the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). This surveillance process C H A P T E R 1 1 n Substance Use and the Health of Communities 261 HIV/AIDs, and diabetes.9 The range of harm associ- ated with the use of alcohol extends across the full continuum of risk and requires not only mechanisms to care for individuals and families negatively affected by at-risk alcohol use but public health approaches at the local, state, national, and global level.8 The WHO’s global strategy is currently the most compre- hensive international policy document that provides guidance on reducing harmful alcohol use, which impacts many of the health-related targets of the Sustainable Development Goals.9 7711_Ch11_256-282 23/08/19 10:37 AM Page 261 provides information on the distribution of substance use and SUDs, as well as information on health-related consequences. Understanding the terms helps in the in- terpretation of the findings. For example, the report on binge drinking in the U.S. released by the CDC requires an understanding of what binge drinking is and is not.25 Models for Prevention and Treatment of Substance Use Disorders Prevention efforts related to substance use and adverse health consequences have shifted over the past 20 years from a narrow focus on the end of the continuum of use, an SUD, to a broader focus that includes the continuum of use across the life span. There are two models that guide prevention efforts: the harm reduction model and the Health and Medicine Division (HMD) of the National Academies of Sciences, Engineering and Medicine’s (formerly the Institute of Medicine [IOM]) prevention model presented in Chapter 2. Health and Medicine Division Prevention Model Prevention is aimed at promoting resilience. In 1997, the HMD of the National Academies of Sciences, Engineer- ing and Medicine identified the primary, secondary, and tertiary continuum of prevention as confusing and developed a new, simpler model that more clearly sepa- rates prevention from treatment.26 As explained in Chap- ter 2, this framework divides the prevention category into three levels—universal, selective, and indicated—and includes possible interventions at each level that can be applied easily to behavioral health issues. Universal Level of Prevention The universal level of prevention addresses identified populations regardless of identified risk. In the case of substance abuse prevention, older adults, pregnant women, and teenagers can be offered skills to allow the postponement of use of substances of abuse. Universal prevention techniques include: education regarding the effects of alcohol, tobacco, and other drugs on one’s own health, on the health of children, and the danger of fetal alcohol syndrome (FAS)/effects and risk factors; the dan- ger of using substances of abuse when using prescribed medication; and special education for older adults in an age-appropriate manner. It includes appropriate decision-making and social skills to empower partici- pants to make good decisions. Selective Level of Prevention With substance abuse, the selective level of prevention addresses specific subgroups known to be at risk for 262 U N I T I I n Community Health Across Populations: Public Health Issues Figure 11-2 Standard drink. (From NIH, National Institute on Alcohol Abuse and Alcoholism. [2018]. What is a stan- dard drink? Retrieved from https://www. niaaa.nih.gov/alcohol-health/overview- alcohol-consumption/what-standard- drink.) 7711_Ch11_256-282 23/08/19 10:37 AM Page 262 at-risk substance use by virtue of biological, psychologi- cal, social, or environmental factors. Whether or not in- dividual members of the specific subgroups are using alcohol, tobacco, or other drugs is not taken into con- sideration when applying selective interventions. What is important is that the subgroups are at higher risk for at-risk substance use than the general population. The selective interventions are tailored to specific character- istics of the subgroups such as age, gender, reproductive status, availability of drugs in the communities in which the members live, community attitudes toward sub- stance use, substance use by peers, family history of substance use, family attitudes, social problems, history of sexual abuse, and marginal or poor academic achieve- ment in school. Selective interventions include oppor- tunities for learning social skills that might delay initial use of alcohol, tobacco, and other drugs. After-school activities, services and resources available at community centers, classes on how to interview for a job, drug and alcohol education, role-playing, and self-esteem build- ing exercises and opportunities are examples of selective interventions. Indicated Level of Prevention The indicated level of prevention addresses specific subgroups at highest risk for development of an SUD or that are showing early signs of an SUD. These groups may appear to be experimenting with substances and, without aggressive preventative action, some members of the group will develop a full-fledged SUD. In addition to delaying initial substance use, the purpose of indi- cated techniques includes delaying or reducing the severity of an SUD. At this level, there is less concern about community prevention and more emphasis on those demonstrating early SUD. Indicated techniques might include continued alcohol and drug education, with specific attention to the consequences of continued use, and self-tests to determine the level of SUD a person might be experiencing, providing an opportunity for the early user to identify his or her risk factors and any signs or symptoms of SUD that might be present. Harm Reduction Model The harm reduction model is another model used in the prevention of adverse consequences associated with alcohol and drug use. Harm reduction refers to any pro- gram, policy, and/or intervention that seeks to reduce the harm related to alcohol and drug use or other high-risk behavior, rather than focusing solely on attainment of abstinence of the risky behavior at the individual level.27 Thus, it includes a wide spectrum of interventions from safer use (needle exchange programs) to abstinence. Thus, those engaged in at-risk use of substances who are not willing or able to engage in treatment that leads to abstinence are provided with options to minimize the harm associated with substance use. From a public health perspective, harm reduction is used to minimize the physical, emotional, social, and economic harm associated with substance use not only in relation to the individual but also to the larger population and the com- munity. The guiding principles of harm reduction are based on the assumption that interventions aimed at reduction of the adverse consequences associated with substance use should be free of judgment or blame.27 The Canadian Center for Substance Abuse proposed guiding principles for harm reduction (Box 11-2).28 The reduc- tion of the harm associated with substance abuse is a goal of Healthy People.29 C H A P T E R 1 1 n Substance Use and the Health of Communities 263 n HEALTHY PEOPLE AND SUBSTANCE USE Goal: Reduce substance abuse to protect the health, safety, and quality of life for all, especially children. Overview: Although progress has been made in substantially lowering rates of abuse of some sub- stances, the use of mind- and behavior-altering sub- stances continues to take a major toll on the health of individuals, families, and communities nationwide. Substance abuse—involving drugs, alcohol, or both—is associated with a range of destructive social conditions, including family disruptions, financial problems, lost productivity, failure in school, injuries, domestic vio- lence, child abuse, and crime. Moreover, both social attitudes and legal responses to the consumption of alcohol and illicit drugs make substance abuse one of the most complex public health issues. Midcourse Review: Of the 44 objectives for this topic area, 2 were developmental and 42 were measurable. For 10 of the measurable objectives, the target was met or exceeded, and 1 was improving. For 12 there was little or no detectable change and 9 were getting worse. Eight of the objectives were informational (Fig. 11-3). Source: (30) Alcohol Use Alcohol consumption is a socially acceptable and nor- mative practice in the U.S. As noted earlier, more than half (51.7%) of the U.S. population 12 years of age or 7711_Ch11_256-282 23/08/19 10:37 AM Page 263 For those between the ages of 18 and 25, 36.9% re- ported binge drinking and 9.6% reported heavy drink- ing.2 As noted earlier, alcohol accounts for 5.1% of the global burden of disease. According to the WHO, at- risk alcohol use is the third leading risk factor for poor health with approximately 3 million deaths each year associated with the at-risk use of alcohol. Worldwide, binge drinking is highest in middle to high per capita consumption countries and is higher for males than for females.2 Until recently, much of the focus in health care was on the person with an alcohol use disorder (AUD). Now, 264 U N I T I I n Community Health Across Populations: Public Health Issues 19% 2% 29% 21% 24% 5% Baseline only Informational Target met or exceeded Getting worse Little or no change Improving Healthy People 2020 Midcourse Review: Substance Abuse Figure 11-3 HP 2020 Midcourse Status of Objectives; Substance Abuse Objectives. (Data from National Center for Health Statistics. [2016]. Chapter 40, Substance Abuse in Healthy People 2020 Midcourse Review. Hyattsville, MD: National Center for Health Statistics.) Figure 11-4 Alcohol Use by Age Group. (Data from World Health Organization. [2017]. Global status report on alco- hol and health 2017. Geneva, Switzerland: WHO Press.) • Clients are responsive to culturally competent, non- judgmental services, delivered in a manner that demon- strates respect for individual dignity, personal strength, and self-determination. • Service providers are responsible to the wider community for delivering interventions that attempt to reduce the economic, social, and physical consequences of drug- and alcohol-related harm and harms associated with other behaviors or practices that put individuals at risk. • Because those engaged in unsafe health practices are often difficult to reach through traditional service venues, the service continuum must seek creative opportunities and develop new strategies to engage, motivate, and intervene with potential clients. • Comprehensive treatments need to include strategies that reduce harm for those clients who are unable or unwilling to modify their unsafe behavior. • Relapse or periods of return to unsafe health practices should not be equated with or conceptualized as “failure of treatment”. • Each program within a system of comprehensive services can be strengthened by working collaboratively with other programs in the system. • People change in incremental ways and must be offered a range of treatment outcomes in a continuum of care from reducing unsafe practices to abstaining from dangerous behavior. BOX 11–2 n Guiding Principles on Harm Reduction Source: (28, 29) older reported current use of alcohol. In the U.S., in 2016, nearly a quarter (24.5% up from 23.1% in 2010) of Americans age 12 and over reported binge (heavy episodic) alcohol use (five or more drinks on the same occasion at least once in the past 30 days for men and four or more drinks on the same occasion for women), and 6.1% reported heavy alcohol use (five for men and four for women or more drinks on the same occasion on at least five different days in the past 30 days) as depicted in Figure 11-4.2 80% 50% 40% 70% 60% 30% 20% 10% 0% Aged 12+ Aged 12–17 Aged 18–25 Aged 26+ Alcohol Use Lifetime alcohol use Current alcohol use Binge alcohol use Heavy alcohol use 7711_Ch11_256-282 23/08/19 10:37 AM Page 264 efforts are emerging to address at-risk alcohol use earlier to prevent acute and chronic harm associated with alcohol use. An AUD takes time to develop whereas one episode of heavy/at-risk alcohol use can lead to seri- ous adverse health consequences such as motor vehicle crashes, drowning, and alcohol poisoning. Health issues related to at-risk alcohol use occur across the life span beginning with fetal exposure to alcohol and can affect the nondrinker as well. For example, researchers looked at state data related to pediatric mortality in turn related to motor vehicle crashes and found that in 9% of the cases the operator was under the influence of alcohol.31 Overall, 16% of all pediatric and 29% of all motor vehicle-related deaths were due to alcohol.32 At-risk alcohol use increases the risk for adverse con- sequences both in the short and long term. Short-term or acute harms include injury, violence, interaction with medications, increased risk for unprotected sex, and other harms. Long-term or chronic harms include an increased risk for a number of cancers, cardiovascular disease, liver disease, dementia, and AUD.33,34 Thus harm associated with alcohol use as laid out by the WHO is not only due to the actual consumption of alcohol but is also due to societal and individual level vulnerability factors (Fig. 11-5).9 Timely prevention and early treatment is the key to saving lives, and the professional health-care workforce is the key to meeting national and global objectives related to reducing alcohol-related morbidity and mortality, and increasing the age and proportion of adolescents who remain alcohol-free. Because of the severity of consequences associated with at-risk alcohol use, prevention of adverse alcohol- related health consequences is a major public health issue across the life span. Since its inception, Healthy People has included prevention of adverse alcohol-related con- sequences related to at-risk use including reduction in motor vehicle crash deaths and injuries, alcohol-related hospital emergency department visits, alcohol-related violence, lost productivity related to alcohol use, and deaths of adolescents riding with a driver who has been using alcohol.35 Of the 21 main objectives listed under the substance abuse topic in HP 2020, 10 were specific to alcohol. The objectives included primary, secondary, and tertiary prevention. The objectives were grouped under three headings: policy and prevention, screening and treatment, and epidemiology and surveillance. HP 2020 also chose specific objectives under different topic areas as leading health indicators (see Chapter 1). For substance abuse, two leading health indicators were chosen, one related to adolescent use and the other to binge drinking in adults. Although use among adolescents dropped, the target for binge drinking among adults was not met. C H A P T E R 1 1 n Substance Use and the Health of Communities 265 Figure 11-5 WHO Concep- tual causal model of alcohol consumption and health out- comes. (Data from World Health Organization. [2017]. Global sta- tus report on alcohol and health 2017. Geneva, Switzerland: WHO Press.) Alcohol Production, Distribution, Regulation Drinking Context Culture Level of Development Mortality by Case Socioeconomic Consequences Harm to Others Health Outcomes Chronic/Acute Volume/Patterns Socioeconomic Status Familial Factors Gender Age Societal Vulnerability Factors Alcohol Consumption Individual Vulnerability Factors n HEALTHY PEOPLE AND ALCOHOL USE Healthy People Leading Health Indicator relevant to alcohol use reduction Targeted Topic: Substance use Specific Objective: SA 14-3 Objective: Reduce the proportion of persons engaging in binge drinking during the past 30 days – adults aged 18 or older Baseline: 26.9% of adults aged 18 years and over re- ported that they engaged in binge drinking during the past 30 days in 2008 Target: 24.4% Progress: The percentage of adults aged 18 and older who had engaged in binge drinking in the past 30 days has remained the same, measuring 27.1% in 2012 and 26.9% in 2015.34,36 7711_Ch11_256-282 23/08/19 10:37 AM Page 265 Consequences of Alcohol Use Alcohol is a causal factor in 200 types of diseases and in- juries9 and as noted earlier accounts for 5.1% of all deaths worldwide.6 The underlying pathophysiology reflects that alcohol use can result in multi-organ toxicity, and toxicity in one organ system affects other systems.4,8 Damage occurs not only in the liver and brain but also in the gastrointestinal (intestinal mucosa), endocrine (pancreas), and other organ systems, including the im- mune and cardiovascular systems.37 Acetaldehyde, the primary metabolic product of ethanol, is thought to be the instrumental toxin in developing alcohol-related dis- ease. For example, long-term exposure to alcohol results in alteration of cellular DNA, thus increasing the risk for cancer.38,39 In addition to physical problems, there are many psy- chosocial consequences associated with alcohol use for individuals and their families.40 These can include legal problems such as traffic violations, driving while intoxi- cated, and public intoxication. Early employment prob- lems can include lateness, frequent absences, an inability to concentrate on the job, and decreased competency, which can eventually lead to on-the-job accidents and injury, or loss of employment leading to chronic unem- ployment. It does not take a great deal of exposure to problem drinking for the family to also manifest dys- function. Family conflict, erratic child discipline, neglect of responsibilities, and social isolation can progress to di- vorce, spousal abuse, and child abuse or neglect. Other problems associated with at-risk alcohol use include in- jury (Chapter 12) and psychiatric illness (Chapter 10).9,40 Comorbidity of psychiatric illness and alcohol use is also common with evidence that alcohol is a causal factor for depression.41,42 Alcohol and Vulnerable Populations Across the Life Span Alcohol use can affect vulnerable populations interacting with their environment at key points over the life span (see Fig. 11-1). For the fetus exposed to alcohol, there is the risk of FASD, often characterized by prenatal or post- natal growth deficiency, certain facial features, and CNS structure or function changes.43,44 Alcohol is a leading teratogen, and it is estimated that the ratio of school chil- dren who were born with FASD is 1 in 20.44 Globally, ap- proximately 8 in every 1,000 live births (0.8%) had FASD, and a little under 8% of women who used alcohol during pregnancy delivered a child with FASD.43 The vulnerable time periods following pregnancy are those of childhood and early adolescence followed by early adulthood. Adolescence is a time often marked by willingness to take risks and experiment with alcohol, which can extend into early adulthood.45 In 2017, among young adults aged 18 to 25, the rate of binge drinking was 39% compared to 24.9% for all persons aged 12 and older.2 This underlines the need to begin primary pre- vention with children prior to the age of 12. The signifi- cance of focusing on children is twofold. First, children who initiate drinking before the age of 15 are five times more likely report a diagnosis of an AUD than persons who first used alcohol after the age of 20.46 In addition, the brain is developing during adolescence. The lack of executive functioning among this age group may inhibit good decision making, and unique characteristics in the adolescent brain may increase the reaction to the reward- ing sensations of alcohol use.44,45 To address the issue, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) published a guide to screening and brief intervention for youth. The guide uses an approach to screening that includes asking adolescents about peer use as a marker of at-risk use. It also suggests different questions based on age. The guide stresses that health-care providers are in an ideal position to prevent use as well as to identify those who may be drinking. The age range covered in the guide is 9 to 15.46 The impor- tance of prevention within this age range is underlined by the fact that those who start drinking before the age of 15 are at greater risk of developing an AUD.47,48 Older adults are another group at particular risk of detrimental consequences of alcohol use (Chapter 19). For older adults who continue to drink heavily throughout their life, the cumulative effect of alcohol exposure may result in damage to cells, tissues, and organs.40,49 In addi- tion, there is the possibility that even low-risk alcohol use may place the older adult at a higher risk because of the increased potential for falls and the interaction of alcohol with prescriptive drugs for comorbid conditions.45,50 Screening Brief Intervention and Referral for Treatment Globally, screening for at-risk alcohol use is an essential component in the fight to prevent the harm related to alcohol use.51 In the past, screening tools were devel- oped to help identify those who may have an AUD, but screening tools now in use also help the health-care provider identify persons at risk for adverse conse- quences related to alcohol use across the continuum of use (see Fig. 11-1).51 More recently, acute care settings are adopting a universal approach to screening for alcohol use.52-55 266 U N I T I I n Community Health Across Populations: Public Health Issues 7711_Ch11_256-282 23/08/19 10:37 AM Page 266 C H A P T E R 1 1 n Substance Use and the Health of Communities 267 l APPLYING PUBLIC HEALTH SCIENCE The Case of the Drinking Oncology Patients Public Health Science Topics Covered: • Setting Assessment • Secondary data analysis • Screening Jane worked with lung, esophagus, and head and neck cancer patients in the radiation oncology clinic in an urban academic hospital on the east coast. After several alcohol- and drug-related incidents with her cancer patients, she became concerned that the hospi- tal was not doing enough to help cancer patients with risky alcohol and drug use. One patient in particular, who completed chemotherapy and radiation for a large neck tumor and subsequently died from alcohol with- drawal, motivated Jane to try to find some solutions. The doctors, nurses, and social workers were doing everything they knew to do for patients with alcohol- and drug-related problems but commented frequently that the advice they were giving to patients was contra- dictory and often insufficient. Jane asked around and convened a small team of doctors, nurses, social workers, clinical nurse specialists, and advance practice providers to develop an action plan for these patients. The first step was to consult the literature. Jane and her team knew there were recommendations for drug screening as it related to cancer pain management and started with big organizations, like the Oncology Nursing Society56 and the National Cancer Institute,57 to look for guidelines. She was right—these groups suggested basic practices, like routine urine drug test- ing and the use of validated instruments designed to screen for substance “abuse” potential. The use of words like “abuse” and “addiction” common in the cancer literature told Jane and her team that the thinking might be out of date. Jane knew it would be difficult to ask the oncology doctors and nurses to use a long, unfamiliar screening tool in routine practice, especially without identifying strategies to cope with substance use issues simultaneously. A PubMed review of the oncology literature wasn’t very helpful; beyond the basic recommendations that oncology providers keep the potential for substance abuse and addiction in mind when writing prescriptions for narcotics, there were no prospective trials testing screening tools or interventions specific to the cancer population. Jane was hopeful that the substance use literature would be more instructive, and she was right. Whereas many chronic pain and substance use studies specifically excluded cancer patients because of the complex na- ture of their pain issues, there were some important lessons to be gleaned from the literature. First of all, Jane and her team learned about validated screening tools that were easy to apply in the ambulatory clinics to help providers identify patients whose substance use might place them at risk, meaning drug and alcohol use that would place them at higher risk for unintended negative consequences. The team reached out to experts in the area affiliated with the hospital who confirmed that a new approach to the problem, framing it with the context of risk rather than assigning a label such as “addict”, would help reframe their approach to prevention of harm in their patients associated with substance use. The experts explained that nurses and doctors could be taught a quick and relatively easy intervention in the clinic to give practical and meaningful advice called a “brief intervention.” The Substance Abuse and Mental Health Services Administration (SAMHSA)58 recommends using screening, brief intervention, and referral to treatment (SBIRT) in primary care offices, emergency departments, and trauma centers. One example of this strategy was validated by a small study of upper aerodigestive cancer patients. Lopez-Pelayo et al. (2016) noted that patients who received direct feedback about alcohol risk from their head and neck surgeon after a diagnosis of cancer were much more likely to reduce their alcohol intake than those who did not.59 Several public health-orientated resources were available to help guide the implementation of this strat- egy of screening, and then using brief interventions in the clinic; examples include the WHO’s SBIRT guide60 and the CDC guide, Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use.61 For patients who needed more than brief advice to cut back on their drug and alcohol consumption, such as patients who might be at risk for alcohol withdrawal or patients who use illicit drugs daily, a referral to treatment or substance use specialists would be called for. The team met to review the literature and decided to implement an SBIRT program as a pilot project in one of the oncology clinics. Although there was no evidence that SBIRT had been previously attempted in an oncology clinic, there was good reason to believe it might be a good place to start. The technique had been 7711_Ch11_256-282 23/08/19 10:37 AM Page 267 268 U N I T I I n Community Health Across Populations: Public Health Issues shown to be effective in reducing alcohol consumption in different groups of primary care and emergency de- partment patients, both of whom are similar to oncol- ogy patients. First, the team met with colleagues from the psychia- try department to discuss the concept of motivational interviewing, an approach to patient care that encour- ages clinicians to partner with patients to make positive behavioral changes to enhance their health. Jane learned that motivational interviewing techniques were used when delivering an effective brief intervention. Experts from the psychiatry department agreed to work with Jane and her team to develop a short education pro- gram to introduce the idea of SBIRT and motivational interviewing to the clinicians in the department. A training program for nurses, residents, and other allied health professionals combined motivational inter- viewing skills with specific substance use in oncology patients training. The project team worked with the training facilitators to incorporate oncology-specific considerations into the curriculum. The training in- cluded two 2-hour sessions (four sessions total). Confirmation of fidelity to the process of screening, brief intervention, and referral to treatment was obtained using standardized patients and role playing. The project trainers created pre- and post-training assessment tools, which were used to evaluate the effectiveness of the training. The team next turned their attention to the elec- tronic health record. They understood from their col- leagues that the best way to implement valid screening tools would be to incorporate them into the patients’ electronic record. Working with the Information Technology (IT) department, they developed an elec- tronic documentation infrastructure using validated instruments for SBIRT and clinical decision support in patients’ electronic medical records. Electronic forms were developed for patients’ radiation oncology electronic health records (Mosaiq) that incorporated validated and reliable instruments for screening (the three-item Alcohol Use Disorders Identification Test-Consumption [AUDIT-C] and a single question drug screen).59-66 This approach allowed the popula- tion of patient data into patients’ medical records and into the data system that facilitated retrospective, aggregate data collection. The forms included a clinical decision support feature that totaled results from screenings and assessments. Finally, electronic “just in time” toolkits were in- stalled on every computer in the clinic to help clinicians find the information they needed to implement SBIRT at the moment they needed to use it. Toolkits for staff use contained resources for low-, moderate-, and high-risk patients. The low-risk toolkit included oncology-specific substance use handouts, copies of the screening tools, and a list of resources for self-referral. The moderate-risk toolkit included examples of brief intervention language and all resources available in the low-risk folder. The high-risk toolkit included a readi- ness for change ruler, a brief intervention script, refer- ral resources and instructions, oncology-specific fact sheet, tips for reducing substance use, and follow-up recommendations. The department tracked screening rates for all new patients, and Jane and her team discovered that clinicians were struggling with the three-question AUDIT-C screening tool. Fortunately, the team found that researchers were validating single-question alcohol and drug screening tools in other settings, which Jane believed would increase the screening rate in her department. After the initial 3-month implementation process using longer screening tools, the department converted to two one-item screening questions. They also knew that an oncology-specific guide or set of recommendations would be helpful in the future. Their experience taught them that specialties do not always communicate and providing specific recommen- dations for the cancer patient population would be essential. Policy Level Interventions to Reduce Alcohol-Related Harm The interest in developing and disseminating both evidence-based practices and policies to minimize the harms associated with alcohol misuse is widespread.8,9 From a policy perspective, the WHO has brought to- gether member states to come up with policy strategies. They have outlined 10 areas for national action and four at the global level (Box 11-3).68 In the U.S., alcohol poli- cies focus on five main areas. The first is regulation of the physical availability of alcohol (e.g., minimum age, restrictions on sites). Next is altering the drinking con- text (e.g., serving intoxicated clients). A third policy approach is limiting alcohol promotion, such as the ban on advertising hard liquor on TV. A fourth policy is deterrence though sanctions on drunk driving. The fifth approach is developing policies related to treatment and early intervention as evidenced by the policy on includ- ing Screening and Brief Intervention (SBI) on level one 7711_Ch11_256-282 23/08/19 10:37 AM Page 268 and level two trauma units. These policies can be enacted at the national, state, and local level, or may be instituted outside of the government. Tobacco Use According to the WHO, tobacco use accounts for more than 7 million deaths each year. Of these deaths, 6 mil- lion are linked to direct tobacco use and the rest are due to exposure to secondhand smoke.69 Tobacco is the num- ber one cause of preventable death in the U.S., causing approximately 480,000 deaths each year attributable to smoking, with 41,000 attributable to secondhand smoke exposure. In the U.S., tobacco use accounts for one out of every five deaths.70 It is the only legal product that causes the death of half of its regular users. More than one billion people use tobacco products worldwide.70 According to the U.S. Surgeon General’s 2014 report, The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, there is enough evidence to infer a causal relationship between cigarette smoking and a number of diseases and conditions, many of which were not, initially, seen as smoking-attributable diseases or conditions. The report documents the devas- tating effects and explains how tobacco causes disease.71 In addition, those who consume both alcohol and tobacco may be at greater risk for adverse health outcomes.72 Tobacco users are directly exposed through three routes: (1) smoking cigarettes, pipes, or cigars; (2) chew- ing smokeless tobacco; and (3) inhaling snuff. Tobacco use through any of these routes is a major public health issue for the entire community. Secondhand smoke exposure occurs when nonsmokers are exposed to a mixture of the smoke produced from the end of the cigarette, cigar, or pipe as well as the smoke exhaled by the smoker. Because exposure to secondhand smoke is an environmental issue, it is also referred to as environ- mental tobacco smoke (ETS) as well as involuntary or passive smoking. According to the American Cancer Society, ETS contains more than 7,000 chemicals, 70 of which cause cancer.73 Based on data from the National Drug Use and Health Survey for 2016, tobacco use within the previous year was higher among males (35.6%) compared to females (21.8%).2 Tobacco use was higher in the lesbian, gay, bisexual, transgender population; among those living below the poverty level; and among the disabled.74 The South and Midwest regions of the country also reported higher tobacco use.75 Tobacco use is more prevalent in persons with a mental health disorder at 36.5%.76 Differences exist in the prevalence of current tobacco use across ethnic groups, with American Indians/Alaska Natives having the highest prevalence of 42.6%, up from 35.8% in 2010, followed by Non-Hispanic whites (31.3%), African Americans (27.8%), Nonblack Hispanics (23.8%), Hawaiian/Pacific Islanders (26.1%), and Asians (15%).2 Globally, differences in the prevalence of tobacco use also exist among countries. Although tobacco use is declining in the U.S., it is increasing globally, especially in low-income countries. According to the WHO, “The tobacco epidemic is one of the biggest public health threats the world has ever faced.” 69 Almost 80% of smok- ers live in middle- or low-income countries.69 Tobacco product use in the U.S, which includes cigarettes, smokeless tobacco, cigars, and pipe tobacco, generally, is on the decline. In 2017, approximately 24% of adults were current consumers of tobacco products (used within the last 30 days). Youth cigarette use has also steadily declined. In 2017, 4.9% of those aged 12-17 were current cigarette smokers, compared with 5.3% in 2016.2 Tobacco use varies by state and region. The preva- lence of tobacco use ranges from 11.3% in Utah to 32% in West Virginia.75 Despite the decline in use, 44% of the 68 measurable objectives related to tobacco use in HP 2020 showed little or no detectable change and three were getting worse (Fig. 11-6). 77 C H A P T E R 1 1 n Substance Use and the Health of Communities 269 The 10 areas for national action are: 1. Leadership, awareness, and commitment 2. Health services’ response 3. Community action 4. Drunk-driving policies and countermeasures 5. Availability of alcohol 6. Marketing of alcoholic beverages 7. Pricing policies 8. Reducing the negative consequences of drinking and alcohol intoxication 9. Reducing the public health impact of illicit alcohol and informally produced alcohol 10. Monitoring and surveillance The four priority areas for global action are: 1. Public health advocacy and partnership 2. Technical support and capacity building 3. Production and dissemination of knowledge 4. Resource mobilization BOX 11–3 n World Health Organization Global Strategy to Reduce Harmful Alcohol Use Source: (9) 7711_Ch11_256-282 23/08/19 10:37 AM Page 269 Consequences of Tobacco Use The adverse health consequences experienced by to- bacco users include cardiovascular disease, cancer, chronic obstructive pulmonary disorders, adverse effects on the oral cavity and teeth, and adverse maternal and neonatal outcomes.70,72 For nonsmokers exposed to ETS, the adverse effects are similar but also include other serious health risks, especially in children, including in- creased risk for asthma, sudden infant death syndrome (SIDS), middle-ear infections, and lower respiratory tract infections.71,72 Vulnerable Populations Across the Life Span Those who are most vulnerable to the adverse effects of tobacco use are in many cases children of smokers. From conception, children of smokers are at higher risk. Mothers who smoke during pregnancy are more apt to have children who are small for their gestational age. In addition, fetal exposure to tobacco increases the risk for SIDS. Children exposed to ETS in their home have higher rates of asthma and upper respiratory infections.73 This fact has resulted in a public service announcement campaign from the CDC to inform the public of the risk. Another concern is that youth are the most vulnerable population for initiation of tobacco use. According to the National Cancer Institute, initiation of tobacco use be- gins for most smokers prior to the age of 18.79 Based on this, of the six objectives in HP 2020 related to tobacco, three were focused on adolescents. The tobacco use objective aimed at the reduction of the initiation of tobacco use among children, adolescents, and young adults has eight targets. For objectives centered around initiation of use of tobacco products in those aged 12 to 17, by 2017 there was a decline across all products exceeding the 2020 target.70 Screening and Treatment for Tobacco Use Like other substance use, screening for tobacco use in- cludes assessment of quantity and frequency. It is also standard to ask what type of tobacco is used and history of past use. Most current users of tobacco are daily users, thus the standard screening question asks the person if they use tobacco products, if so, how much on average 270 U N I T I I n Community Health Across Populations: Public Health Issues 12% 3% 37% 44% 4% Baseline only Target met or exceeded Getting worse Little or no change Improving Healthy People 2020 Midcourse Review: Tobacco Usen HEALTHY PEOPLE AND TOBACCO USE Goal: Reduce illness, disability, and death related to tobacco use and secondhand smoke exposure. Overview: Scientific knowledge about the health effects of tobacco use has increased greatly since the first Surgeon General’s report on tobacco was released in 1964.78 Midcourse Review: Of the 77 objectives in the Tobacco Use Topic Area, 9 were developmental and 68 were measurable. Eight objectives had met or exceeded their 2020 targets, 25 objectives were improving, 30 objectives had demonstrated little or no detectable change, 3 objectives were getting worse, and 2 objectives had baseline data only (Fig. 11-6).77 Adolescent tobacco use continued to decline from 26% in 2009 to 22.4 % in 2016.77 Healthy People Leading Health Indicator Relevant to Tobacco Use Reduction Objective: Reduce tobacco use by adolescents past month TU-2.1. Target: 21.0% Baseline: 26.0% of adolescents in grades 9 through 12 used cigarettes, chewing tobacco, snuff, or cigars in the past 30 days in 2009.30 Progress: The proportion of students in grades 9–12 who used tobacco products in the past 30 days de- creased from 26.0% in 2009 to 22.4% in 2013, moving toward the 2020 target.77 By 2017, prevalence of tobacco use in high school students dropped to 7.6%.70 In 2013, there were statistically significant disparities in the rates of adolescent tobacco use by sex, race, and ethnicity.74 By 2017, the gender gap had narrowed related to any tobacco use.70 Figure 11-6 HP 2020 Midcourse Status of the Tobacco Use Objectives. (Data from Source: [75]) 7711_Ch11_256-282 23/08/19 10:37 AM Page 270 per day. The key is how the question is framed. The question should be “Have you ever used tobacco?” rather than “Do you smoke cigarettes?” Because tobacco use includes smokeless tobacco, cigars, pipes, and other forms of inhaling tobacco, it is important to identify those with a history of tobacco use. A good screening tool is to use the single-question approach recom- mended by the National Institute on Drug Abuse (NIDA), which can be combined with screening for al- cohol, tobacco use, and other drug use by asking a single question related to at-risk use.80 Because any current use of tobacco is considered at-risk, if the person is a current tobacco user, the next step in the screening process is to determine the person’s readiness to quit. If they are, the next step is to assist the person. If they are not willing to quit, you can provide support to help motivate them to quit by offering information on smoking cessation. Finally, arrange for follow up. If the person is not a cur- rent tobacco user, it is important to determine if they are a former user of tobacco and if they are at risk for relapse. It is also important to determine if they are exposed to secondhand smoke.73 Smoking cessation can occur for some without any intervention. However, over the past 2 decades, strides have been made in the development of methods to as- sist those who wish to stop smoking. Most former smokers quit without using one of the treatments that scientific research has shown can work. According to the CDC, there are a number of evidence-based ap- proaches to smoking cessation. They include: brief help by a health-care provider; counseling, including indi- vidual, group, or telephone; behavioral therapies; mo- bile phone-assisted treatment; and medications.81 Medications used for smoking cessation include over- the-counter and prescription nicotine replacement products and prescription non-nicotine medications such as bupropion SR (Zyban®) and varenicline tartrate (Chantix®). A combination of some form of counseling and medication is more effective than using either one by itself.81,82,83 Policy Level Intervention to Reduce Tobacco-Related Harm: Local to Global There are a number of events in U.S. history that coin- cided with changes in the smoking behavior of the American public, many of them associated with policy. Tobacco use in the U.S. rose steadily from the great depression, through World War II, and then peaked during the 1960s and 1970s. The period from 1934 to the end of World War II (1945) saw a consistent, almost 300% increase in number of cigarettes consumed. Consumption dropped off again in the mid-1950s when the first evidence of the association of cancer and cigarette smoking was found. Both of those periods of reduced cigarette consumption were followed by a rebound to levels higher than they were before. In 1964, this phenomenon ceased.84 With the release of the first Surgeon General’s report on Smoking and Health, a period began of reduced cigarette consumption that has continued over the past 3 decades. In addition, the Federal Communication Commission (FCC) applied the Fair-Trade Act of 1949 to tobacco advertising. The point of this was to offer a no-cost opportunity to present health information that was directed toward smoking cessation. The application of the Fair-Trade Act would have given the same amount of time to the anti-smoking initiatives (at no cost) as was purchased by the cigarette industry for advertising. Application of the Fair-Trade Act seemed to be associated with a marked decrease in number of cigarettes smoked. Shortly following the ban on televi- sion advertising, however, the resulting elimination of free anti-smoking advertising, and the smoker’s rights movement in the 1970s, cigarette smoking increased again. The Great American Smoke Out of 1977 hosted by the American Cancer Society appears to be the beginning of a fairly consistent decline in cigarette con- sumption. This provided opportunities to encourage people to commit and quit smoking while increasing public awareness of harms associated with smoking. In the 1980s, nonsmokers’ rights movements began with eventual changes in policies related to smoking in public places, advertising restrictions, and increased taxes.84 Currently, global public health efforts include both individual and population-level strategies with the objective of reducing tobacco related harm. The WHO’s Report on the Global Health Epidemic 2017 uses the acronym MPOWER to lay out policy steps needed to reduce tobacco use and includes interventions at the in- dividual and the population level (Table 11-3).85 Since MPOWER was released, the number of countries that have implemented at least one of the recommended measures has risen from 42 to 121. Eight countries have implemented four or more of the measures. In tandem with adoption of these measures has been a global decline in current tobacco use globally from 24% in 2007 to 21% in 2015. One example of these types of population-level actions is smoke-free environments. Two cities in China, Shanghai and Shenzhen, instituted a smoking ban that included indoor public places, work- places, and public transport as well as many outdoor public places. These measures require support at the C H A P T E R 1 1 n Substance Use and the Health of Communities 271 7711_Ch11_256-282 23/08/19 10:37 AM Page 271 national level.85 In the U.S., the CDC has published Best Practices for Comprehensive Tobacco Control Pro- grams.86 The five areas presented by the CDC include state and community interventions, mass-reach health communication interventions, cessation interventions, surveillance and evaluation, and infrastructure, admin- istration, and management. Drug Use The opioid overdose epidemic brought the issue of drug use to the national forefront. In addition to opioid use, the use of stimulants such as methamphetamine and cocaine continues with subsequent adverse effects on individuals and communities, resulting in what has been called a public health crisis. Drug use affects individuals, families, and communities because it can cause serious health consequences, environmental pollution, increased crime, and, due to potential overdose, a significant increase in mortality.87 In 2017, it was estimated that a little more than 11% of Americans reported illicit drug use during the past 30 days, up from a little more than 8% in 2010.2 The most prevalent illicit drug used was marijuana (9.6%) followed by nonmedical use of psychotherapeutics (sedatives, painkillers, stimulants) (2.2%), cocaine (0.8%), and hallucinogens (0.5%).2 Males were more apt to report current illicit drug use. Illicit drug use varies across age groups with those 18 to 25 reporting the highest current use (24.2%).2 There was an overall decline in current il- licit drug use among 12 to 17-year-olds from a high of 11.6% in 2002 to 7.9% in 2017.2 Those aged 65 years or older reported the lowest use at 3%.2 However, current illicit drug use is higher among adults aged 50 to 59 with an increase from 2.7% in 2002 to 9.5% in 2009.2 It is worth noting that rates of illicit use may be higher and likely to be underreported due to the illegality of these substances. 272 U N I T I I n Community Health Across Populations: Public Health Issues TABLE 11–3 n World Health Organization MPOWER: Effective Tobacco Control Monitor Protect Offer Warn Enforce Raise Source: (84) Monitor tobacco use and prevention policies Protect people from tobacco smoke Offer help to quit tobacco use Warn about the dangers of tobacco Enforce bans on tobacco advertising, promotion and sponsorship Raise taxes on tobacco w SOLVING THE MYSTERY The Case of the Morgue Pile Up: New Hampshire and the Opioid Epidemic Public Health Science Topics Covered: • Epidemiology • Surveillance • Program Planning Up to this point, we have largely been talking about SUDs in relation to individuals or populations. The fact is, however, that substance abuse is a community- wide problem, affecting not just individuals but also the community and health-care providers confronted with the grim reality of the impact drug use has on a community. In 2018, New Hampshire led the nation in per capita overdose deaths.6,88 Reporter Katharine Seeley from the New York Times wondered why New Hampshire, one of the wealthier states in the country, was experiencing such a high prevalence of opioid use and subsequent high overdose mortality rate. She discovered a report that helped explain the multiple factors that contributed to the crisis.88 The two main factors were access to opioids and lack of access to treatment. On the supply and demand side, New Hampshire borders Massachusetts, which has a large illicit drug distribution network, making access to opioids easier. In addition, the state has higher rates of prescribing opioids. On the treatment side, there are limited resources for those in need of treatment. Barriers to treatment include lengthy waitlists and trouble navigating the system. There is also little fund- ing for treatment on the consumer and program side. There are also staffing shortages.88 Using the steps in program planning, the HotSpot report89 demonstrates completion of the first step in the process, assessment. Based on their assessment, they found that overdoses increased in New Hamp- shire by almost 1,600% from 2010 to 2015. Based on these statistics, a number of groups partnered to do a Rapid “HotSpot” study in two phases. Phase one was with stakeholders and phase two was a survey con- ducted with opioid users (n = 76) and with first re- sponders/emergency department personnel (n=36). 7711_Ch11_256-282 23/08/19 10:37 AM Page 272 C H A P T E R 1 1 n Substance Use and the Health of Communities 273 Based on data from this study, preliminary considerations for New Hampshire’s approach to tackling the opioid overdose crisis include: • Increase public health funds targeting substance use • Expand prevention programs in elementary and middle schools • Strengthen treatment to include broader availability, non-prohibitive cost, and inclusion of medication- assisted options and holistic approaches • Incentivize physicians to become buprenorphine- waivered providers • Assist physicians with prudent prescribing of opioids, educating patients, and alternatives to pain management • Support first responder and emergency department personnel with vicarious trauma associated with responding to overdoses • Initiate needle exchange programs • Collaborate with Massachusetts on addressing the manufacturing and trafficking of fentanyl and other opioids • Launch programming to dispel stigma and fear: • Educate consumers (e.g., Narcan and Good Samaritan Law) • Educate physicians and pharmacists (e.g., chronic disease management and value of Narcan) • Educate law enforcement (e.g., alternative approaches to punitive measures) • Educate the public (e.g., opioid crisis is not isolated to one demographic/area and breaking the intergen- erational cycle of addiction) BOX 11–4 n HotSpot Report: Understanding Opioid Overdoses in New Hampshire: Next Steps Source: (87) The collected data helped them identify the next steps in the process (Box 11-4). The challenge in the program planning part is to decide what recommendations to act on and what barriers may further impede the ability to act on those recommendations. One barrier is the culture of New Hampshire, the state whose motto is “live free or die” with an emphasis on self-sufficiency. For example, the state does not have laws that require using seat belts and allows liquor stores to be next to major highways. Other issues include the lack of health-care providers in the field of substance use and the lack of needle exchange programs. In alignment with the harm reduction recommenda- tion from the report, in 2017, two Dartmouth medical students opened a needle exchange program in a soup kitchen.90 The program uses a harm reduction model built on community partnerships including working with the fire chief, the police chief, the mayor, and community organizers such as Hope for Recovery within the county. The program is located in the Southwestern Shelter, across the street from a soup kitchen, and is open at the same time the kitchen is providing meals. The students distribute supplies such as clean needles and sharps containers for safe disposal. They also distribute naloxone and teach how to recognize signs of overdose and how to use naloxone. One of the recommendations listed in the HotSpot Report was to increase the number of health-care providers able to deliver medication-assisted treatment. Placing those with an opioid use disorder on a similar acting medication has been controversial, yet evidence points to this approach as more effective in reducing re- lapse than an abstinence-based approach. n EVIDENCE-BASED PRACTICE Medication Assisted Treatment (MAT) The use of medications to treat an SUD has been in practice for many decades. With the opioid epidemic, there has been an increased focus on using MAT in conjunction with other treatments as an effective treatment for both opioid use disorders and AUDs. The use of MAT has also increased as a means to treat a nicotine use disorder. Some medications, especially buprenorphine and methadone, opioid agonists, result in long term maintenance while other medications, such as those used to treat a nicotine use disorder are used with the ultimate goal of abstinence. Practice Statement: Increase availability of MAT to adults suffering from a SUD with FDA-approved effec- tive medications. Targeted Outcome: Reduction in health risks asso- ciated with substance use and to achieve abstinence from use. Supporting Evidence: For an opioid use disorder in adults, MAT has been shown to be effective not only in reducing overdose deaths but also improving social functioning, reducing the risk of transmitting 7711_Ch11_256-282 23/08/19 10:37 AM Page 273 In addition to opioids, methamphetamines (meth) have also negatively impacted communities. Persons who use meth present in a number of ways. They can appear euphoric, tremulous, anorexic, with dilated pupils, or with diaphoresis. Continued use results in weight loss, strong body odor, dry mouth, and tactile hallucinations that often take the form of imagined insects under the skin. These tactile hallucinations can result in infections and lesions on the skin where the user scratches or tries to remove the insects. In an attempt to relieve dry mouth, the user often drinks copious amounts of sugary beverages, which contributes to tooth decay in addition to other dental manifestations associated with methamphetamine use such as bruxism, gingival inflammation, decreased saliva production, and lower pH values.91 Long-term use can result in cachexia, alopecia, corneal ulcerations, repetitive behavior pat- terns, and severe mental illness symptoms. Harm done to the family is predictably similar to the harm done by the use of other substances. Meth is less expensive than cocaine or heroin, so it appeals to those in the lower so- cioeconomic groups, that is, those who can least afford it financially.92 Meth is easily manufactured, particularly in states lacking laws regulating the sale of the key components for manufacture. Interestingly, the early centers of man- ufacture were the farming communities of the Midwest and Western U.S. The ease with which meth is manufac- tured and its increasing popularity facilitated the spread of meth “labs” throughout the U.S. and Mexico. These labs can be located in homes, apartments, trailers, campers, caves, or any place of shelter.93 274 U N I T I I n Community Health Across Populations: Public Health Issues Mortality risk during and after opioid substitution treatment: Systematic review and meta-analysis of cohort studies. British Medical Journal, 26, 357:j1550. doi: 10.1136/bmj.j1550. 4. National Institute on Drug Abuse. (2017). Principles of adolescent substance use disorder treatment: A research-based guide. Retrieved from https://www. drugabuse.gov/publications/principles-adolescent- substance-use-disorder-treatment-research-based- guide/evidence-based-approaches-to-treating-adoles cent-substance-use-disorders/addiction-medications. 5. Vashishtha, D., Mittal, M.L., and Werb, D. (2017). The North American opioid epidemic: Current challenges and a call for treatment as prevention. Harm Reduction Journal, 14, 7. Retrieved from https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC5427522/ doi: 10.1186/s12954-017-0135-4. communicable disease, reducing criminal behavior, and for pregnant women improving neonatal out- comes.1 The two medications approved for use by the FDA are buprenorphine and methadone. Both medications are opioid agonists and long-acting medications, thus reducing cravings and likelihood of subsequent relapse; both medications exemplify a harm reduction approach. In addition, both medica- tions were associated with substantial reductions in mortality in people being treated for an opioid use disorder.2 For an AUD, acamprosate calcium, disulfi- ram, oral naltrexone, and extended-release injectable naltrexone are approved for use in the treatment and have established effectiveness.3 For nicotine use disorders, bupropion, nicotine replacement therapies (NRTs), and varenicline are approved for use and have established effectiveness.4 For other sub- stances such as cannabis, cocaine, or methampheta- mine, there are no FDA-approved medications to treat an SUD. There is insufficient evidence on the effectiveness of MAT with adolescents or the possible negative impact on the developing adolescent brain.5 Recommended Approaches: The use of MAT is seen as part of a more comprehensive treatment plan that includes behavioral treatment. Access to MAT is an issue especially with the opioid epidemic.4 Methadone clinics must comply with federal regulations. Physicians, nurse practitioners, and physician assistants who have completed the required training may now dispense Buprenorphine in primary care settings, yet few actu- ally complete training. Social stigma related to SUDs can also impact the ability to open methadone clinics or for practitioners to complete the training and work with patients with a SUD. References 1. Volkow, N.D., Frieden, T.R., Hyde, P.S., & Cha, S.S. (2014). Medication-assisted therapies — Tackling the opioid-overdose epidemic. New England Journal of Medicine, 370, 2063-2066. DOI: 10.1056/NEJMp1402780. 2. Substance Abuse and Mental Health Services Admin- istration and National Institute on Alcohol Abuse and Alcoholism. (2015). Medication for the treatment of alcohol use disorder: A brief guide. HHS Publication No. (SMA) 15-4907. Rockville, MD: Substance Abuse and Mental Health Services Administration. 3. Sordo, L., Barrio, G., Bravo, M.J., Indave, B.I., Degenhardt, L., ... Pastor-Barriuso, R. (2017). 7711_Ch11_256-282 23/08/19 10:37 AM Page 274 Some of the chemical components of meth are quite caustic in their own right. They can include pool acid/muriatic acid, lye, acetone, brake fluid, brake cleaner, iodine crystals, lithium metal/lithium batteries, lighter fluid, drain cleaners, cold medicine containing pseudoephedrine or ephedrine, ethyl ether (in engine starting fluid), anhydrous ammonia (stored in propane tanks or coolers), sodium metal, and red phosphorous. Often, manufacturers of meth are either careless or lack knowledge regarding the proper handling of the compo- nents, which often leads to fires and explosions.94 Some “superlabs” can manufacture up to 100 pounds of meth per day. For every pound of meth produced, there are 5 to 6 pounds of toxic waste produced as well. This is an environmental disaster in the making. The manufacturers of meth dispose of the waste in a number of ways; flushing down the toilet, pouring into drains, burying, and pouring on the ground.93 Unlike other illicit drugs, pollution of the environ- ment with a hazardous chemical is a major issue con- nected to the production of meth. The threat to the water supply, health of the soil, and people in the sur- rounding areas is clear. Toxic waste byproducts from meth production can be in suspension in the air and settle on furniture, carpeting, floors, tables, food, and toys, creating a serious threat to those who reside where the labs are located, especially children. Children in such environments not only suffer from neglect but also are exposed to hazardous materials.95 When a meth lab is seized by law enforcement officials, assuming welfare of the children and treatment and/or incarceration for the users/manufacturers is only the beginning. For first responders, there are occupational health hazards that need to be addressed. Hazmat teams must be summoned to decontaminate and clean up the area where the lab was located. This process usually costs thousands of dollars or more, depending on the size of the lab.93 Consequences of Drug Use The consequences of drug use for individuals vary based on the pharmacokinetics of the drug used. For example, cocaine is a stimulant; thus, while under the effect of the drug, the individual experiences a stimulation of the CNS. These effects include an increase in energy, a de- creased need for sleep, and increased mental alertness. It also has a stimulant effect on the cardiovascular system including constriction of the blood vessels, dilated pupils, and increased heart rate and blood pressure. Once the drug has left the system, the person experiences a rebound effect, an understimulation of the CNS that can result in depression and decreased energy.96 Persons who use drugs are at increased risk for comorbid mental disorders, sexually transmitted infections (STIs), and other adverse effects on health secondary to the use of the specific drug.97 Vulnerable Populations Across the Life Span As with alcohol and tobacco, the portions of the popula- tion most vulnerable to the effects of drugs are the fetus, youth, and the young adult. Use of drugs has been asso- ciated with adverse maternal and infant outcomes. The variation of the adverse effects again relates to the pharmacokinetics of the drug used. Adverse effects include prematurity, small for gestational age, neonatal withdrawal, and birth defects. In addition, women who use illegal drugs during pregnancy are at higher risk for poor nutrition, are more apt to engage in prenatal care later during the gestational period or not at all, and are at greater risk for STIs.98 For youth and the young adult, the focus is on prevention of use. In 2015, 10.1% of youth age 12 to 17 reported current use of an illicit drug. In young adults, the rate increased to a little over one-fifth (22.3%) of those ages 18 to 25 reporting current illicit drug use. Three of the HP 2020 objectives related to substance abuse focused on the adolescent, specifically increasing the proportion who report never using substances, who disapprove of substance use, and who perceive great risk associated with substance use.6 To address the issue of adolescent drug use, the NIDA published two guides, Principles of Substance Abuse Prevention in Early Childhood99 and Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide,100 both aimed at preventing drug use and providing guidance for providers to help adolescents identified with a drug use disorder. Issues associated with drug use in adolescents include not only social consequences but cognitive development.101 Researchers are beginning to identify possible adverse effects of marijuana on brain development.101, 102, 103 These findings underscore the need for prevention of drug use and the importance of screening and offering age appropriate treatment when indicated. Screening and Treatment for Drug Use A number of screening instruments are available to screen for drug use. One widely used is the Drug Abuse Screen- ing Test (DAST-10). It screens for drug use excluding alcoholic beverages. The DAST-10 has been shown to be reliable and valid with both English-speaking and Spanish-speaking populations, and with those individuals seeking treatment for Attention-Deficit/Hyperactivity C H A P T E R 1 1 n Substance Use and the Health of Communities 275 7711_Ch11_256-282 23/08/19 10:37 AM Page 275 Disorder (ADHD).104 Another tool is the NIDA ASSIST tool. It is available online and covers the different types of drugs of abuse.105, 106 As with alcohol and tobacco, there is a clinician’s guide that incorporates both screening and interven- tions.106 The guide gives the health-care provider an ex- cellent overview of interventions that can be instituted at the individual level including pharmacological ap- proaches, the use of self-help groups, and behavioral therapies. SAMHSA also recommends using the SBIRT framework to address drug use in the same way used for those with at-risk alcohol use.107 Policy Level Intervention to Reduce Drug Use–Related Harm Policy related to drug use has been a hot topic for decades. Most policy has focused on controlling drug use through criminal means. In the U.S., drug policy has come under the title of a “war on drugs” complete with a federal level drug “czar.” The Office of National Drug Control Policy (ONDCP) is the national level organization focused on drug policy. The purpose of the office is to “… reduce drug use and limit its consequences by leading and coordinating the develop- ment, implementation, and assessment of U.S. drug policy.” This office also provides administrative and financial support to special commissions at the federal level such as the President’s Commission on Combating Drug Addiction and the Opioid Crisis, established by Executive Order on March 29, 2017.108 Under President Obama, the focus of the ONDCP shifted from prosecu- tion to increasing access to treatment. Under President Trump, the focus has shifted back to a focus on crimi- nalization of drug use and a “just say no” approach to prevention. Substance Use and Communicable Diseases A prime example of how substance use contributes to the burden of disease is the association between sub- stance use and communicable diseases. This occurs across multiple levels starting with the increased the risk of transmission of a communicable disease down to the cellular level. Many communicable diseases such as hepatitis, HIV/AIDS, sexually transmitted infections, and tuber- culosis are associated with substance use. Since the beginning of the HIV epidemic, substance use and in- creased risk of transmission of HIV have been strongly correlated. In a landmark study, McKusick, Horstman, and Coates (1985) examined the relationship between sexual behavior and HIV.109 Subsequent research over the past 30 years has established that substance use often leads to impulsive behaviors, as a result of altered judgment, and engagement in high-risk sexual behavior (i.e., sexual intercourse without a condom, transactional sex, or sex-work) thus placing persons at risk for sexually transmitted infections. Other issues also contribute to an increased risk of poorer outcomes. People living with HIV and who have been diagnosed with an SUD are also less likely to be en- gaged in care, to be adherent to antiretroviral treatment, and to achieve viral suppression, and are thus more likely to spread HIV to others.110 Additionally, particular sub- stances such as methamphetamine have also been linked to increased HIV viral load in the brain as well as neuronal damage, which leads to the development of HIV-associated neurocognitive disorders (HAND).110,111 Substance Use and Stigma Substance use has a long history of being viewed from a moral standpoint. Moral views of substance use vary based on ethnic culture, social practices, the specific substance in question, and the gender of the substance user. Often the person who engages in risky substance use suffers stigma. Stigma is defined as a mark of dis- grace or reproach. The person who is suffering from stigma often experiences shame, which in turn impacts their engagement in treatment. Stigma has not always been experienced with sub- stance use if the use is seen as a social norm. For example, tobacco use was a culturally acceptable practice for men in the United States, especially during the early to mid- 20th century. However, women who smoked before World War II were perceived negatively. Many of the early tobacco ads aimed at getting women to smoke sug- gested that women should defy this moral stand and smoke. By the 1960s and early 1970s, some tobacco com- panies took this one step further and created a specific brand for women, such as Virginia Slims, and created ads that linked cigarette use to the feminist movement. By the 1990s, cigarette smoking shifted from acceptable social practice to a culturally reprehensible practice. The scientific evidence that ETS resulted in adverse effects for the nonsmoker, coupled with a growing intolerance of the odor of tobacco smoke in public places, resulted in bans against public smoking with a subsequent benefit to the population as a whole. But has this shift also resulted in a moral shunning of the tobacco user? 276 U N I T I I n Community Health Across Populations: Public Health Issues 7711_Ch11_256-282 23/08/19 10:37 AM Page 276 The stigma related to alcohol use has, for the most part, focused on risky use or those with an AUD. One exception is the temperance movement in the late 1800s and early 1900s that resulted in the passing of the 18th amendment in 1919. This amendment, also known as Prohibition, effectively turned alcohol into an illicit drug. It was repealed in 1933, and alcohol use once again became a socially acceptable and normative practice. However, the judgment that a person who had an AUD was morally reprehensible did not change. The stigma associated with being an “alcoholic” resulted in the creation of confiden- tiality as a core principle in 12 step programs. An example of a cultural shift related to alcohol use is the banning of drinking and driving. In the 1950s, the phrase “one for the road” was socially acceptable. Although law enforcement attempted to deal with drunk driving, it was hard to determine what constituted drunkenness. A number of events contributed to a cul- tural shift in our view of driving under the influence (DUI).112 These include the advent of the Mothers Against Drunk Driving movement, technological ad- vances in measuring BAC, and evidence related to what constituted impaired driving. A cultural shift began in relation to public tolerance of the drunk driver. Today, all states have laws that restrict impaired driving in some capacity. Most states have laws that stipulate a precise BAC that, when present, constitutes proof that the in- dividual is too impaired to drive. In addition, the law has evolved to the point that most states allow for proof of impairment through other means, such as specific field sobriety tests. All of these laws represent an attempt to discourage individuals from driving when they have been drinking or using drugs because it is often difficult for an individual to determine when they have had too much to drink. Stigma is a continuing concern for persons who engage in risky drug use, especially when it becomes a barrier to treatment.113-115 Stigma is pervasive in the general and medical community. Examples of stigma in the nursing literature can be found, including articles about pregnant women engaged in illicit drug use or nurses who may be impaired.115-119 Stigma arises from the perception that risky substance use is a personal choice and the consequences are self-inflicted. The ONDCP support of midstream interventions reflects a growing emphasis on educating the national population on the benefits of treatment and the potential cost of continuing to treat substance use from a legal “war on drugs” approach. In addition, people with a SUD often experience discrimination and health inequities that fur- ther impede access to quality health-care services.118,119 Improving care delivery to this population by imple- menting a patient-centered approach and harm reduc- tion interventions will address the issue of stigma and advance health outcomes.120 n Summary Points • At-risk substance use affects the overall health of the individual, family, and the community. • Substance use results in adverse consequences from the cellular to the global level. • Substance use varies across the life span with increased vulnerability for youth, young adults, and pregnant women. • Evidence-based practices exist in relation to preven- tion programs, screening, brief intervention, and treatment. • Substance use, especially use of tobacco and alcohol, are serious public health issues, and policy initiatives exist at the global, national, state, and local levels aimed at reducing the harm associated with at-risk substance use. • Cultural context for substance use has shifted over time, but stigma continues to be a barrier for entrance into treatment for the person with at-risk use or an SUD. C H A P T E R 1 1 n Substance Use and the Health of Communities 277 t CASE STUDY Implementing an Opioid Overdose Prevention Program Learning Outcomes • Apply program planning to the development and implementation of a health program. • Examine current standards of care related to opioid overdose treatment • Identify strategies for training the public in recogniz- ing opioid overdose and steps need to prevent over- dose death. You have been asked to work with a community group to address the opioid epidemic. You suggest implementing a program in your county based on the program implemented by the medical students at Dartmouth College that combined a clean needle exchange program with a program for distribution of Naloxone. • Outline the basic steps for building this program (see Chapters 4 and 5) and who you would involve in each step. 7711_Ch11_256-282 23/08/19 10:37 AM Page 277 REFERENCES 1. America’s Opioid Epidemic. (2017). CBS News. 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Retrieved from https://www.drugabuse.gov/publications/ principles-drug-addiction-treatment-research-based- guide-third-edition. 27. Institute of Medicine (IOM) Prevention Model. (1997). Drug abuse prevention: What works. Rockville, MD: National Institute of Drug Abuse, pp 10-15. 28. International Harm Reduction Association. (n.d.). What is harm reduction? Retrieved from https://www.hri.global/ files/2010/05/31/IHRA_HRStatement . 29. Beirness, D.J., Jesseman, R., Notaradrea, R., & Perron, M. (2008). Harm reduction, what’s in a name. Canadian Center 278 U N I T I I n Community Health Across Populations: Public Health Issues • Identify: • The main partners you would bring on board for the program. • At least one barrier to implementing the program and steps you would take to overcome the barrier. • Key data you will need to collect to evaluate the program. • What strategies would you use achieve sustainability? 7711_Ch11_256-282 23/08/19 10:38 AM Page 278 on Substance Abuse. 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Advancing patient-centered care for structurally vulnerable drug-using populations: A qualitative study of the perspectives of people who use drugs regarding the potential integration of harm reduction interventions into hospitals. Addiction, 111(4), 685-694. 282 U N I T I I n Community Health Across Populations: Public Health Issues 7711_Ch11_256-282 23/08/19 10:38 AM Page 282 283 n Introduction School shootings. Motor vehicle crashes. Suicide bombings. War. It seems almost daily these events end up in the headlines creating a stir on social media. Every one of them contributes to increased mortality and morbidity. How do we address injury and violence from a public health perspective? What are the implications for nursing? Injury, both intentional and unintentional, results in both long-term health consequences and in- creased risk for death, and is a major reason for an emergency department (ED) visit. Of the 136.9 million ED visits annually, 39 million (28%) are injury related.1 Overview of Injury Injury is a serious public health issue that kills more than 5 million people globally and causes harm to many more. Injury occurs as the result of a wide variety of events, including motor vehicle crashes (MVC), drowning, poisoning, falls, burns, assault, self-inflicted violence, or acts of war. According to the World Health Organization (WHO), 9% of global mortality is attributable to injury, which is 1.7 times the deaths attributable to AIDS/HIV, tuberculosis, and malaria combined.2 Globally, road injury was the 10th leading cause of death in lower-income countries and lower-middle- income countries, and the eighth leading cause of death in upper-middle-income countries.3 In the U.S., in 2016, unintentional injury (accidents) was the fourth leading cause of death, and intentional injury (suicide) was the 10th leading cause of death. In contrast to the U.S., injury is not one of the top 10 leading causes of death in other high-income countries.3,4 Unintentional injury disproportionately affects the young and the impoverished, and in the United States is the number one cause of death for those aged 1 to 44.5 In addition, intentional injury (suicide and homicide) were in the top five causes of death for those ages 10 to 44, and Chapter 12 Injury and Violence Christine Savage LEARNING OUTCOMES After reading the chapter, the student will be able to: KEY TERMS 1. Describe the impact of injury and violence on the health of a population. 2. Define the burden of disease related to injury and violence using current epidemiological frameworks. 3. Use appropriate frameworks in the assessment of injury and violence. 4. Understand the role of policy in injury and violence prevention. 5. Apply current evidence-based population interventions to the prevention of injury and violence. Acquaintance violence Alcohol-impaired driving Child maltreatment Collective violence Community violence Emotional abuse Emotional neglect Family violence Fire-related injury Haddon Matrix Injury Intentional injury Interpersonal violence Intimate partner violence Motor vehicle crashes (road traffic injuries) Physical abuse Physical neglect Physical violence Poison Post-traumatic stress disorder (PTSD) Psychological/emotional violence Road traffic injury (RTI) Self-directed violence Sexual abuse Sexual violence Stalking Stranger violence Suicide Threat of physical/sexual violence Unintentional injury Unintentional poisoning Violence War Youth violence 7711_Ch12_283-312 23/08/19 10:38 AM Page 283 homicide was the third leading cause of death for those aged 1 to 9.5 Injury not only affects the person who is injured but also can have an effect on family members, friends, coworkers, employers, and communities.6 Injury is a serious public health issue due to mortality, disability, health-care costs, and the need for emergency care. Types of Injuries An injury is damage or harm done to or suffered by a person or thing. There are two types of injury, uninten- tional and intentional.7 An unintentional injury is an injury to a person that occurs in a short period of time for which there is no predetermined intent to injure another or oneself.8 Unintentional injuries include motor vehicle traffic injuries, drowning, falls, poisoning, burns, and other injuries. Although the media use the term ac- cident when referring to unintentional injuries, these in- juries are often predictable and preventable, and not the result of random unavoidable accidental events. In the United States, unintentional injuries account for more than 146,000 deaths and more than 30 million ED visits annually. Among unintentional injuries, the highest number of deaths are related to poisonings followed by motor vehicle traffic deaths and falls (Box 12-1).9 The population most at risk is males under the age of 45. More than a third (37%) of all deaths for children aged 1 to 19 are related to injury, making it the leading cause of death in this age group. For infants under the age of 1 year and newborns, it is the fifth leading cause of death.10 Unintentional injuries not only contribute to premature death, but nonfatal injuries also have consequences that range from temporary pain to long-term disability, chronic pain, and a diminished health-related quality of life. Following a serious injury, a person often requires hospitalization and/or rehabilitation services. Intentional injuries are injuries that occur because of a deliberate act that causes harm either to the self or to others.11 Violence refers to physical force used to violate, damage, or abuse others or oneself. It is a broader term and is used in conjunction with intentional injury in the public health literature. According to the WHO, violence is among the leading causes of death for those aged 15 to 44 years.12 Violence constitutes a serious threat to a community and often occurs along with mental illness and/or substance use (Chapters 10 and 11). In 2016 in the United States, more than 19,000 people were victims of homicide and nearly 45,000 people died by suicide.13 Of the $671 billion price tag for injuries in the United States, suicide accounted for $50.8 billion and homicide for $26.4 billion.14 Types of Violence The WHO presented a topology that separates violence into two contexts, family violence and community violence, and three categories, self-inflicted violence, interpersonal violence, and collective violence. Self- inflicted violence is violence in which the perpetrator and victim are one and the same and includes suicide and self-inflicted injury. Interpersonal violence occurs between individuals and includes two different contexts in which the violence occurs. The first is family vio- lence, which includes intimate partner violence (IPV), child abuse/maltreatment, and elder abuse. The second is community violence, which occurs in the context of the community and includes acquaintance violence, violence between individuals who know each other, and stranger violence, violence that occurs between individuals who do not know each other. Collective violence occurs when a large group of people engage in violent behavior and covers various types of violent acts such as conflicts between nations and groups, terrorism instigated by groups or states, rape as a weapon of war, and gang warfare.12 Violent acts are broken out into four types of violence: (1) neglect, (2) psychological violence, (3) physical vio- lence, and (4) sexual assault. The topology proposed by the WHO helps demonstrate the context in which vio- lence occurs and the four types of violence that can occur (Fig. 12-1).12 Injury and violence are of major concern worldwide, and in the United States Healthy People 2020 (HP 2020) health topics included prevention of unintentional injury and violence. This topic area was included because of the mortality and disability associated with injury. Under 284 U N I T I I n Community Health Across Populations: Public Health Issues Unintentional injury deaths: 1. Poisoning 14.8 deaths per 100,000 population 2. Motor vehicle injury 11.7 deaths per 100,000 population 3. Falls 10.4 deaths per 100,000 population Intentional injury deaths: 1. Suicide 13.7 deaths per 100,000 population 2. Homicide 5.5 deaths per 100,000 population Note: Crude death rate for the U.S. in 2015 was 844 per 100,000 population BOX 12–1 n Top Three Causes of Unintentional Mortality and Intentional Mortality, All Ages, 2015 Source: (9) 7711_Ch12_283-312 23/08/19 10:38 AM Page 284 this topic, there were a total of 43 objectives: 28 related to unintentional injury and 15 related to violence.15 Surveillance of Injury and Violence Injury surveillance is conducted via various reporting mechanisms at the local, state, and national levels. In relation to unintentional injury, various tracking meth- ods exist. For example, motor vehicle traffic incidents are tracked through the department of motor vehicles, C H A P T E R 1 2 n Injury and Violence 285 Interpersonal Family/Partner Physical Sexual Psychological Deprivation or Neglect Child Partner Elder StrangerAcquaintance Community Figure 12-1 The topology of violence. (From the World Health Or- ganization, Violence Prevention Alliance. [2018]. Definition and typology of violence. Retrieved from http://www. who.int/violenceprevention/approach/ definition/en/) Figure 12-2 HP 2020 Injury and Violence Prevention Midcourse Review. n HEALTHY PEOPLE Injury and Violence Prevention Goal: Prevent unintentional injuries and violence and reduce their consequences Overview: Injuries and violence are widespread in society. Both unintentional injuries and those caused by acts of violence are among the top 15 killers for Americans of all ages.1 Many people accept them as accidents, acts of fate, or as part of life. However, most events resulting in injury, disability, or death are predictable and preventable. The Injury and Violence Prevention Objectives for 2020 represent a broad range of issues that, if adequately addressed, will improve the health of the nation.15 Midcourse Review: Of the 65 objectives, 1 was archived, 9 were developmental, and 55 were measurable. Of those that were measurable, 9 met or exceeded the goal, 11 were improving, 26 had little or no change from baseline, and 9 were getting worse (Fig. 12-2).16 17%16% 47% 20% Getting worse Little or no change Improving Met or exceeded Healthy People 2020 Midcourse Review: Injury and Violence Prevention department of transportation, and, for fatal motor vehi- cle incidents, through vital statistics. Some categories of injury, such as poisoning, are tracked through the department of public health. Some injuries are not rou- tinely tracked at the governmental level, such as injury due to falls, but are tracked by institutions for patient- related falls and through public health departments and child protective services for child-related falls. Tracking of intentional injury became more central- ized in 2002 when the Centers for Disease Control and Prevention (CDC) received funding to establish the National Violent Death Reporting System. This system collects data on violent deaths from various state-level databases to create an anonymous database that could 7711_Ch12_283-312 23/08/19 10:38 AM Page 285 help states develop programs and monitor outcomes. Sources of data include death certificates, police reports, medical examiner reports, and other available data.17 Thus, multiple sources of data can be used to examine the impact of injury at the population level. Determining Risk for Injury or Violence Tracking the incidence of injury is only one part of the puzzle. A key step in prevention of injury is to determine who is at greater risk for incurring an injury. The risk fac- tors for injury vary based on the type of injury but come under the same main categories as chronic disease, be- havioral, environmental, and socioeconomic risk factors. For example, in an MVC, several factors come into play. The behavioral level assessment includes evaluation of such issues as wearing seat belts, texting while driving, or driving under the influence of alcohol. In addition, en- vironmental factors such as weather conditions and traf- fic control may play a role. Socioeconomic factors also play a role; for example, those with fewer economic re- sources may have older cars that may not be adequately maintained, and poorer countries, states, or municipali- ties may not be able to maintain safe roads. Analysis of risk for a particular injury requires a complex evaluation of a number of factors. The Haddon Matrix A common method used to determine injury risk is the Haddon Matrix. This matrix was developed based on the epidemiological triangle (see Chapter 3) and incor- porates the three constructs in the triangle: (1) agent, (2) host, and (3) environment. It was designed by William Haddon, Jr., the first head of what is now the National Highway Traffic Safety Administration (NHTSA). The original purpose was to examine the problem of traffic safety.18 The Haddon Matrix has a minimum of 12 empty boxes to be filled in. The rows reflect the time around the event—”pre-event,” “event,” and “post-event”—and the columns are related to the host, agent, and environment (Fig. 12-3). Filling in the boxes provides a method of viewing the factors that contributed to the event and helps in the planning of injury interventions and preven- tion strategies. The matrix can also help set up the process for data collection. The process helps identify interventions that could occur at multiple points by preventing the injury (pre-event) or by mitigating the impact of the event (event or post-event). Although this matrix was originally developed for the evaluation of MVCs, it can be used for any category of injury. Because it uses a classic epidemiological frame- work, it has applicability across settings. For example, it could be useful in an acute care setting to evaluate patient falls. It also provides needed information to develop primary prevention strategies (prevention of the event) and mitigation of the impact of the event, both during the event and following the event (secondary and tertiary prevention). Figure 12-3 includes a blank Haddon Matrix and a partially filled-out matrix related to motor vehicle crashes (MVCs) that can be used with your own county or city data. If you continue filling out the partially com- pleted form, you can begin to identify areas where interventions could be developed at all three levels: pre- crash, crash, and following the crash. The first part of the matrix provides vital information on what con- tributes to the injury and the consequences of the injury, and the second dimension provides vital information to help planners compare possible interventions on a va- riety of dimensions. The matrix becomes three dimen- sional by adding decision criteria for each level and includes consideration of the effectiveness, cost, feasi- bility, and other identified criteria used to decide what would be the best intervention.18 This can help planners choose from a variety of possible interventions. Prevention of Injury and Violence Prevention of injury and violence is a major public health initiative. The CDC has a national center dedi- cated to injury prevention. The homepage for this center illustrates the current main areas for prevention including suicide, opioid overdose prevention, trau- matic brain injury, home and recreation safety, motor vehicle safety, and violence prevention. The injury center not only collects surveillance data on injury, it also provides leadership and funds research aimed at reducing injury.19 Nursing Role in Prevention Nurses play a key role in addressing the issue of injury and violence through the care they provide, the interven- tions they develop, and their active role in policy making. There is constant national attention from the media on injury issues that help raise awareness and, in many cases, result in policy-level interventions. For example, the issue of violence against women has received inter- national attention, especially with the #metoo move- ment. Nurses directly helped shape policy here in the United Sates to help prevent violence against women. For example, public health nurse researchers, such 286 U N I T I I n Community Health Across Populations: Public Health Issues 7711_Ch12_283-312 23/08/19 10:38 AM Page 286 Dr. Jacquelyn Campbell, and nursing organizations, especially the American Nurses Association (ANA), were actively involved in the passing of the 2013 Violence Against Women Act. Nurses also play a role on the front lines every day providing care for persons following in- jury, especially in trauma centers. Dr. Nancy Glass used results from her research to develop an evidence-based app, myPlan, that women can use to help prevent rela- tionship abuse.20 Nurses like Dr. Glass and Dr. Campbell have championed the cause of preventing violence against women not only here in the U.S. but globally. Other nursing organizations also focus on injury prevention. The Society of Trauma Nurses (STN) in- cludes injury prevention and education in its mission C H A P T E R 1 2 n Injury and Violence 287 Phases Host/Human Poor vision Texting/Cell phone Reaction time Alcohol Risk taking Driving experience Failed brakes Missing lights Narrow shoulders Rain storm Malfunctioning seat belts Failure to wear seat belt High susceptibility Alcohol Agent Vehicle/Equipment Physical Environment Social Environment Pre-Event Event Post-Event Phases Host/Human Agent Vehicle/Equipment Physical Environment Social Environment Pre-Event Event Post-Event Partially Filled-In Haddon Matrix: Analysis of a Motor Vehicle Crash Complete the matrix by filling in possible factors for agent and environment based on the time phases. Assess the contributing factors or characteristics from the perspective of: 1. Host/Human: What were the Host or Human Factors that contributed to the event? 2. Agent Vehicle/Equipment: What was the crash worthiness of the vehicle? 3. Physical Environment: What was the status of the roadway design or safety features? 4. Social Environment: For example, passage and enforcement of seat belt laws. Combine with time phases: 1. Pre-Event: What factors affect the host before the event occurs? 2. Event: What are factors related to the crash phase? 3. Post-Event: What are the factors related to the post-event crash phase? Figure 12-3 Twelve boxes of the Haddon Matrix. 7711_Ch12_283-312 23/08/19 10:38 AM Page 287 statement. It has an active committee dedicated to injury prevention.21 In line with the STN priorities, trauma nurses at Cincinnati Children’s Hospital Medical Center (CCHMC) initiated an injury prevention program. The nurses developed and implemented a child passenger safety program. The program was offered to low-income families and was conducted at 46 “fitting” stations located in the community, including fire stations and health departments, so that parents could receive help on car seat installation, which is “fitting” the seats into their cars. These nurses also initiated a bike safety program, conducted community health fairs, and participated in leadership of the Safe Kids Coalition. Because injury prevention is an essential component of what nurses provide to their communities, how would you begin? A good place to start is to examine the injury data related to the setting in which you work and the population for whom you care. If you work in the ED, you are most likely confronted with injury on a daily basis. As almost all injury is preventable, it is important to take an upstream approach while tending to the victims downstream, as did the nurses at CCHMC. To review from Chapter 2, the upstream metaphor in public health refers to the following: peo- ple are drowning in a river and rescue workers are pulling them out to save them from drowning. Pretty soon, the rescuers realize that, no matter how hard they work at pulling people out, more keep floating down- stream. They decide to walk upstream to find out why people are falling into the river in the first place. Effort is then put into fixing the problem upstream that is causing people to fall into the river. The problem for the individual nurse is that it feels as though there is no time to walk upstream. There are just too many patients coming for nursing care who have already fallen into the water. Luckily, the upstream ap- proach is done as a collaborative effort across disciplines and entities. Take, for example, the child safety initiative at CCHMC.22 The programs were offered in community settings and included nurses at the hospital, the public health department, the fire department, and the police department. The key is to have someone ask the question, “What is happening upstream?” and then have a team not only ready to find out but also committed to fixing the issues upstream. Policy Aimed at Prevention of Injury and Violence Many examples of policies aimed at preventing injury exist at the state and local levels. For example, most local municipalities require that a fence be placed around a swimming pool to prevent accidental drowning. Pedes- trian laws and signs at crosswalks are in place to prevent injury to pedestrians. The list is long and demonstrates that policy efforts are effective in reducing injury. Seat belt laws alone have resulted in a reduction in fatal motor vehicle injuries and death. Policies aimed at reducing violence often come through the judicial system. How- ever, other approaches are also effective, such as creating neighborhood watch groups, increasing lighting on streets at night, and reducing density of alcohol outlets. Policy initiatives often arise from the grassroots, and effectiveness is often contingent on neighborhood buy- in (Chapter 4). Epidemiology of Unintentional Injury: Motor Vehicle Crashes Motor vehicle crashes (MVCs) are a major public health concern worldwide, particularly for the young. An MVC is the collision of a motor vehicle with another vehicle, a stationary object, or a person that results in injury or death. The term crash has been substituted for the term accident because most MVCs are not random accidental events but are related to preventable causes. To help encompass the broader issue of road-related injury, the WHO uses the term road traffic injury (RTI). The WHO’s definition of an RTI is similar to the definition of an MVC, but it includes the term public road. Thus, its definition is an injury that occurs as the result of a collision on a public road with involvement of at least one vehicle.23,24 In the United States, for persons aged 15 to 24, MVCs are the leading cause of unintentional injury deaths.25 The annual number of MVC deaths in the U.S. is 32,000 and there are more than 2 million MVC-related nonfatal injuries.26 There has been a decline over time in MVC- related injury, which may reflect an increase in the use of seatbelts, car seats, and booster seats.26 Policy can help reduce MVC-related injury and death. For example, variation in alcohol-related MVC deaths are associated with alcohol policies.27 Risk Factors for Motor Vehicle Crashes As noted earlier, when considering motor vehicle traffic, a number of factors come into play. The behavioral level includes such issues as wearing seat belts, texting while driving, or driving under the influence of alcohol. In addition, environmental factors may play a role, for exam- ple, weather conditions and traffic control. Socioeconomic factors also play a role; for example, those with fewer 288 U N I T I I n Community Health Across Populations: Public Health Issues 7711_Ch12_283-312 23/08/19 10:38 AM Page 288 economic resources may have older cars that may not be adequately maintained, and poorer countries, states, or municipalities may not be able to maintain safe roads. The CDC uses data from the National Vital Statistics System (NVSS) to estimate the economic burden of both fatal and nonfatal injuries.28 The annual cost of medical care and productivity losses associated with injuries and deaths from MVCs exceeds $63 billion.29,30 Other sources of data that can help determine which risk fac- tors are associated with MVC injuries are the Fatality Analysis Reporting System (FARS) and the Behavioral Risk Factor Surveillance System (BRFSS).31 In one study, Beck, Downs, Stevens, and Sauber-Schatz ex- plored the underlying risk factors related to the higher MVC rate in rural areas versus urban areas. In 2015, al- though an estimated 19% of the U.S. population lived in rural areas, 57% of passenger-vehicle–occupant deaths occurred on rural roads, with a higher proportion of rural MVCs resulting in death. Based on their review of the data, they concluded that, because there was a lower rate of seat belt use in rural areas, efforts to reduce MVC mortality should focus on improving seat belt use in rural areas.31 Two major risk factors for MVCs are alcohol use and distracted driving. Alcohol-impaired driving is driving with a blood alcohol level at 0.08 or above, and laws have been enacted that make it illegal to drive impaired. Distracted driving is defined as diversion of attention from activities critical for safe driving. There are three main types of diversions: visual (taking your eyes off the road), manual (taking your hands off the wheel), or cognitive (taking your mind off of driving).32,33 Distrac- tion can include use of handheld devices, eating, driver drowsiness, and adjusting the radio, and in 2015, these accounted for 10% of fatal crashes and 15% of injury crashes.33,34 Speed is another major contributing factor to the severity of the injury associated with MVCs. Speed con- tributes more than any other factor because of its impact on reaction time, the amount of kinetic energy created, and ability to control the vehicle.35 Other contributing factors include weather, road conditions, and vehicle safety features.35 Once again, behavioral and environ- mental factors and socioeconomic status play roles. Other injury issues exist when the broader context of all RTIs is considered. Passengers and operators of other vehicles such as all-terrain vehicles, motorcycles, and bicycles are at risk for injury in the case of an RTI. Pedestrians are also at risk. Potential injuries in these circumstances are major public health issues, especially because of the high mortality rates associated with these types of injuries. The same risk factors apply across all RTIs. Prevention of Motor Vehicle Crashes Reduction in MVC-associated injury has, in part, occurred due to changes at the policy level. Laws related to the use of seat belts, car seats, booster seats, and handheld phones have helped reduce injury and mor- tality. A case in point is the issue of texting while driv- ing. Under the Haddon Matrix, this risk factor would come under the Host/Human column as a pre-crash factor (see Fig. 12-3). This risk factor came to the fore- front of media attention in 2009 based on data indicat- ing that an increasing number of motorists were texting while driving prior to an MVC. The CDC now includes texting as one of the examples of distracted driving often equated with driving while intoxicated. Response to this risk factor has been reflected in laws making texting while driving illegal. Much of the prevention efforts at the primary level in the United States have focused on reducing risky behav- iors such as alcohol-impaired driving and on increasing public education about the importance of using proper safety measures. Back in the late 1970s, hospitals enacted policies that all parents must have a car seat in place prior to taking their newborns home from the hospital. An- other approach has been to put in place a graduated driver licensing system aimed at reducing MVCs where teenagers are the drivers. Other prevention efforts are aimed at the environ- ment: improving roads, installing traffic lights, and installing pedestrian walkway signs. These types of pre- vention approaches are more difficult to put in place in low- and middle-income countries (LMICs) that lack the resources and that have not placed a strong emphasis on injury prevention.24 The WHO adopted a global plan for road safety for the decade 2011–2020. The plan has five pillars, or categories, of prevention efforts. These include: “1) building road safety management capacity; 2) im- proving the safety of road infrastructure and broader transport networks; 3) further developing the safety of vehicles; 4) enhancing the behavior of road users; and 5) improving post-crash care.”24 In the United States, there have been dramatic im- provements in post-crash care, resulting in a reduction in MVC-associated mortality and morbidity. Much of this is due to the development of Level I trauma units, use of flight teams to bring helicopters to the crash site and transport victims directly to a trauma center, and the de- velopment of interventions aimed at decreasing the time from initial trauma to initiation of treatment. Such efforts C H A P T E R 1 2 n Injury and Violence 289 7711_Ch12_283-312 23/08/19 10:38 AM Page 289 to improve post-crash care help reduce long-term disabil- ity and survival rate of injury associated with MVCs. Epidemiology of Unintentional Injury: Burn-Related Injuries Burn-related injuries include “… an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction, or contact with chemicals. Skin injuries due to ultraviolet radiation, radioactivity, electricity, or chemicals, as well as respira- tory damage resulting from smoke inhalation, are also considered to be burns.”36 Globally, the annual estimate of burn-related deaths from fires is 265,000. This figure does not include deaths that occur from burns that occurred due to scalding, electrical burns, and other non-fire-related forms of burns.36 More than 96% of the fatal burns occur in LMICs, with more than half occur- ring in Southeast Asia.36 Burns are among the most devastating of all injuries and are almost always prevent- able. They are difficult to treat even in high-income coun- tries and, with limited resources, even more difficult to treat in LMICs.37, 38 In the United States, an estimated 486,000 people received medical treatment for burns in 2016. Fires and smoke inhalation accounted for 3,275 deaths. Of those burned, 40,000 required hospitalization. Seventy- three percent of burn injuries occurred in the home. The 290 U N I T I I n Community Health Across Populations: Public Health Issues n HEALTHY PEOPLE Injury and Violence (IVP) Objective: IVP-13 IVP-13.1: Reduce MVC-related deaths: deaths per 100,000 population Baseline: 13.8 deaths per 100,000 population were caused by MVCs in 2007 (age adjusted to the year 2000 standard population) Target: 12.4 deaths per 100,000 population Target-Setting Method: 10% improvement15 Midcourse Review: “The age-adjusted rate of MVC deaths per 100,000 population declined from 13.8 in 2007 to 10.5 in 2013, exceeding the 2020 target. In 2013, 33 states and the District of Columbia had achieved the national 2020 target for MVC deaths. In 2013, there were statistically significant disparities by sex, race and ethnicity, and geographic location in the age-adjusted rate of MVC deaths.”16 Source: 15, 16 majority (68%) of those burned were male. According to the American Burn Association, one civilian death due to burns occurs every 2 hours and 41 minutes.39 More than 300 children and adolescents are treated in emer- gency rooms for burn-related injuries each day, and two of those die.40 Younger children are more likely to sustain injuries from scald burns caused by hot liquids or steam, whereas older children are more likely to sustain injuries from flame burns caused by direct contact with fire.40 How- ever, in LMICs, the epidemiology of pediatric burn injury is different from what it is in high-income coun- tries in that burn mortality is often higher. Burn mortal- ity among children is closely associated with maternal deprivation and varies by region and income level, with the highest mortality burden in Sub-Saharan Africa.41, 42 Risk Factors for Burn Injuries Using the epidemiological data, the associated risk fac- tors for burn injuries are influenced by behavioral, social, cultural, and economic factors. Women and children in LMICs are at greatest risk because they spend more time at home using open fires to cook food and heat water. In LMICs in colder climates, there is exposure to heaters and stoves to keep homes warm.42 Behavioral risk factors include alcohol use, tobacco use, history of seizures, and history of a psychiatric disorder. Environmental risk fac- tors include the safety of the built environment, popula- tion density, the work environment, and the natural environment. To address these risk factors, in 2008, the WHO published a burn prevention plan (see Box 12-2) that addresses the main risk factors for burns, and it is still relevant today.42,43 Prevention of Burn Injuries Prevention is an essential component in any burn man- agement program, especially with the high incidence in LMICs.41,42 As in all injuries, the main focus is on reduc- tion of risk. For burns, primary prevention focuses on environmental measures in the home and behavioral changes. In the United States, many of the public health interventions focus on children and on measures that can be taken to reduce risk. In LMICs, the challenge for prevention is greater, where there is less governmental emphasis on prevention of injury as well as limited re- sources.37,38,42 In the United States, policy has played a large role in reducing fire-related morbidity and mortality. In 1911, a devastating fire in the Triangle Shirtwaist factory in New York City took the lives of 146 garment workers, most of them women. Based on that event, laws were put in place 7711_Ch12_283-312 23/08/19 10:38 AM Page 290 to improve safety of the workplace. Another fire, the Coconut Grove fire that occurred in Boston in 1942, resulted in the deaths of 462 people, the deadliest night- club fire in U.S. history. The club was decorated in a South Pacific motif using decorations made of flammable materials that covered exit signs. The fire spread rapidly, engulfing the club within 5 minutes of the first flame. The main entrance was a single revolving door that quickly became jammed as panicked customers tried to escape. This fire resulted in the institution of fire code regula- tions that are in place today, such as restriction on the use of flammable materials as decorations and require- ments for clearly marked exit signs. It also resulted in the mandate that two regular doors equipped with panic bars flank all revolving doors. The next time you go through a revolving door, you will notice that this safety measure is always in place. Secondary prevention focuses on what to do in the event of a fire. Stop, Drop, and Roll is an example of a suc- cessful campaign to teach children, workers, and others what to do if their clothes or hair are on fire (Fig. 12-4). The purpose is to mitigate the extent of the burns by using a technique that is effective in extinguishing the flames. Strides have also been made in the management of burns, resulting in a worldwide decline in fire-related mortal- ity.42 Care of a fire-related injury must also consider the issues of disability, disfigurement, emotional impact, and pain. C H A P T E R 1 2 n Injury and Violence 291 Specific recommendations for individuals, communities, and public health officials to reduce burn risk: • Enclose fires and limit the height of open flames in domestic environments. • Promote safer cookstoves, fewer hazardous fuels, and educate regarding loose clothing. • Apply safety regulations to housing designs and materi- als and encourage home inspections. • Improve the design of cookstoves, particularly with re- gard to stability and prevention of access by children. • Lower the temperature in hot water taps. • Promote fire safety education and the use of smoke detectors, fire sprinklers, and fire-escape systems in homes. • Promote the introduction of and compliance with in- dustrial safety regulations, and the use of fire-retardant fabrics for children’s sleepwear. • Avoid smoking in bed and encourage the use of child-resistant lighters. • Promote legislation mandating the production of fire-safe cigarettes. • Improve treatment of epilepsy, particularly in develop- ing countries. • Encourage further development of burn-care systems, including the training of health-care providers in the appropriate triage and management of people with burns. • Support the development and distribution of fire-retardant aprons to be used while cooking around an open flame or kerosene stove. BOX 12–2 n A WHO Plan for Burn Prevention and Care Sources: (42, 43) w SOLVING THE MYSTERY The Case of the Exploding Barrel Public Health Science Topics Covered: • Assessment • Epidemiology • Health planning In May 2020, Ben Smith, RN, moved from a large metropolitan area to a rural region of the country. He took a job working in the ED in a regional medical center serving six counties. After working there for 2 months, he became concerned about the number of injuries from firecrackers that he saw, especially injuries to teenagers. His concern grew when two teenagers were admitted to the ED. They had sus- tained eventually fatal injuries after placing a 50-gallon metal barrel over a sparkler bomb. After this event, Ben approached his supervisor about his concerns, and the supervisor commented that this was something they saw every summer, especially in July. Ben wanted to know whether the number of injuries was up this year and whether their ED had been involved in any prevention efforts. His supervisor thought that was a good question and suggested that Ben look into the issue. Ben applied basic public health principles that he had learned in his undergraduate community health courses to begin investigating the problem. He began Stop Drop Roll Figure 12-4 Stop, Drop, and Roll. 7711_Ch12_283-312 23/08/19 10:38 AM Page 291 292 U N I T I I n Community Health Across Populations: Public Health Issues by reviewing their records for the number of fire- works-related injuries treated in the ED during the past 5 years, including age of the patient, month the injury occurred, and the severity of the injury based on triage level. This first phase of his investigation required a basic understanding of epidemiology (see Chapter 3), specifically how to calculate incidence rates, track the rates over time, and compare them with national rates. It also required basic community assessment skills. In this case, he did a focused assessment (see Chapter 4), that is, he started with a specific focus of fireworks- related injury. He found that the Consumer Product Safety Commission (CPSC) had a fireworks safety page and a three-step guide to fireworks safety.44 This helped guide his investigation because the site provided information on the most common risk factors, current laws and regulations, and possible solutions. Through a link to firework injury data available on the CPSC site, Ben found that in 2016 there were an estimated total of 11,100 injuries in the U.S that required medical treatment at an ED.45 Using 5 years of data from their own hospital, Ben found that the two deaths he had encountered in the ED were the only deaths in the past 5 years, but various fireworks-related injuries had been treated during that time period that were similar to national data; most of the injuries had occurred to the fingers, hands, and eyes, and the majority were burns. He cal- culated incidence rates for the entire population living in the region served by the medical center, using popu- lation estimates for each of the 5 years (Box 12-3). He then looked at the frequency of injuries based on sepa- rate age groups including children under the age of 5, children aged 6 to 12, youths aged 13 to 18, and adults over the age of 18, and for each county. Based on that information, he determined that the overall incidence rate for the five-county region was higher than the national rate. He also found that the injury rate had decreased in children under the age of 6 but had increased in those aged 6 to 18. Starting in 2014, the majority of cases were between the ages of 13 and 18. Ben then looked into community information that might help explain the decreased incidence rate in one age group and the increased rate in the other age group. After talking with his colleagues in the pediatric units, he discovered that the community had introduced a fire- works safety initiative with new parents in 2014. The health departments in all five counties had developed a brochure that was handed out at all the well-baby clinics and was provided to the pediatricians as well. For children less than 5 years of age, the prevention program from the public health departments appeared to have been effective. But why was the rate going up in the older children, especially among teenagers? Ben did some further research on the laws sur- rounding the sale of fireworks. He found that there was a wide variance in the state laws. The state in which he was working had strict laws that went beyond the Federal Hazardous Substances Act, which prohibits the sale of highly dangerous fireworks and the components used to make them. However, the region his hospital served was close to the border of another state that had more lax laws and allowed the sale of fireworks that were just under the legal limit of no more than 50 milligrams of explosive powder and no more than 130 milligrams of flash powder. In 2015, two new fireworks stores had opened right across the state border. This increased availability was a possible factor in the increased incidence. He then applied the Haddon Matrix to the problem. He started with the incident that had resulted in the death of the two teenagers and filled out the Haddon Matrix using factors related to the two boys, pre-event, event, and post-event. He accessed local news reports, police reports, and fire department reports on fire- works-related injuries and filled in the matrix. He found that the social environment pre-event played a The populations of the following five counties are consid- ered here when estimating injury rates: County Q 44,516 County R 42,316 County X 40,383 County Y 17,934 County Z 28,093 • The total population for the preceding counties in 2012 = 173,242. • The total number of ED visits for fireworks injuries = 25. • Rate of fireworks-related injury for the region = 12.9 per 100,000. • The 2012 population for the United States as a whole = 313,780,968. • The estimated number of ED visits in the United States for fireworks-related injury in 2012 = 9,300. • Rate of fireworks-related injury in the United States = 2.9 per 100,000. BOX 12–3 n Estimating Injury Rates 7711_Ch12_283-312 23/08/19 10:38 AM Page 292 C H A P T E R 1 2 n Injury and Violence 293 big role, with a growing peer-related interest in using more dramatic fireworks. He also found that most of the injuries were clustered in the counties closest to the state border. The Haddon Matrix assisted Ben in his assessment in another way. It helped him examine whether there were factors during the event or post-event that also influenced the outcome of the injury. The two counties that were closest to the state border were also far- thest from the regional medical center and were quite rural. For some of the events, the time for emergency personnel to arrive on the scene was 20 minutes or more. Transportation to the regional medical center averaged 25 minutes from the time the emergency personnel arrived on the scene to the time the victim arrived at the medical center. Following his assessment, Ben identified possible ac- tion that could be taken by the hospital in conjunction with the public health departments, the schools, the emergency providers, and other stakeholders to re- duce the number of these incidents. The actions he recommended included prevention at the three levels of pre-event (e.g., public service announcements on firework safety), event (e.g., increasing safety measures at the county firework displays, emergency personnel preparedness), and post-event (e.g., a formal process for the evaluation of each event to identify contributing factors at the individual and community level). In some cases, his information opened the door for a discussion on injury prevention in the region at a higher level. Ben felt that the post-event issue related to emergency response time was bigger than just the fireworks injury issue. Ben’s approach to a problem led to the develop- ment of a comprehensive fireworks prevention pro- gram spearheaded by the regional hospital that built on the work done with the preschool children. Ben now had baseline data to track the effectiveness of the inter- vention. Based on his work, the community put an injury prevention committee in place. Epidemiology of Unintentional Injury: Drowning Drowning is defined by the WHO as “… the process of experiencing respiratory impairment from submersion/ immersion in liquid.” The end result of drowning includes death, morbidity, or no morbidity.46 The WHO estimates that there are 3,536 deaths from drowning annually, or 10 per day. Drowning is among the top 10 leading causes of death in children and young adults globally. This holds true in the U.S., with 10 deaths asso- ciated with unintentional drowning per day. Children ages 1 to 4 have the highest drowning rates. Those who receive emergency care for nonfatal submersion fre- quently require a high level of hospitalization, and if they suffer brain damage, they can become a heavy burden to society.47 Risk Factors for Drowning We know that age is a risk factor for drowning. This is true in the U.S. and globally. Age plays a role for the older adult as their swimming ability declines. For young chil- dren, risk is tied to multiple issues. Their inquisitiveness and their lack of coordination make them susceptible to falls into bodies of water such as swimming pools, lakes, ponds, ditches of water, bathtubs, and buckets. Children aged 1 to 4 have the highest drowning rate. In the United States, young males are 10 times more likely to drown than young females, with 80% of all drowning victims being male.47 In the United States, the most common sites for drowning are home swimming pools. Drowning rates for all rural residents are three times higher than for urban residents with drowning usually occurring in open water such as ponds, rivers, irrigation canals, and lakes. Children usually die of drowning in sites where they are without adequate supervision.47 Another risk factor is hair or body entrapment in drains of pools or spas. There are multiple risk factors associated with drowning (Box 12-4) that help guide development of prevention programs including swimming lessons, use of barriers around swimming pools, increased supervi- sion especially of children, and use of life jackets. Alcohol also increases the risk of drowning among adolescents and adults due to impairment of balance, coordination, and judgment. These effects of alcohol increase with sun exposure and heat.47 What factors influence drowning risk? • Lack of swimming ability • Lack of barriers, such as pool fencing • Lack of close supervision • Location: people of different ages drown in different locations • Failure to wear life jacket • Alcohol use • Seizure disorders BOX 12–4 n Risk Factors for Drowning in the U.S. Source: (47) 7711_Ch12_283-312 23/08/19 10:38 AM Page 293 require medical attention.50 In the U.S., falls are the leading cause of nonfatal injury in children under 19 years of age. 51 Risk Factors for Falls in Children In the U.S., the majority of falls in children occur on the playground, from windows, from beds or other furniture, from baby carriers or with baby walkers/riders that allow an infant to independently move from place to place, including ride-on toys and circular walkers.51,52,53 Age, socioeconomic status, and gender play roles as well. The type of fall changes based on the age and stage of devel- opment of the child. When examining the contributing factors that increase the risk for falls in children, it is important to consider the evolving developmental stages of children and adolescents. These include the innate curiosity of children in relation to their surroundings and increasing levels of independence. In addition, other fac- tors include inadequate adult supervision, poverty, being a single parent, and hazardous environments.50 Fall risk increases once an infant becomes mobile. In mobile infants and toddlers, falls are usually from furniture or on the stairs. Preschool and school-age children are at risk for playground-related falls.51,52 As children enter middle school and engage in athletics, sports-related falls predominate. Window-related falls are perhaps the most dramatic, as underscored by Eric Clapton’s song “Tears in Heaven.” In 1991, his 4-year-old son Conor fell Not having the ability to swim is a significant risk fac- tor and is more common in females than males, and more common in African Americans than whites.47 The tragic event that occurred on the Red River near Shreveport highlights this issue when six teens from two African- American families drowned. One unknowingly stepped off the shallow edge and slipped into the deep river, and six more teens went in to rescue him. Only one made it back. None of them knew how to swim and neither did their parents, watching from the shore.48 In the United States, African-American children aged 5 to 19 are five times more likely to drown in swimming pools than white children.47 Thus, the fact that no one in a family knows how to swim increases the risk, because family members often are the only ones supervising children when they swim. Prevention of Drowning Prevention requires a concerted effort on the part of health-care providers, public health officials, and family members. The American Academy of Pediatrics (APA) policy statement issued in 2010 remains the standard for prevention. The policy is aimed at increasing the role that pediatricians can play in preventing drowning in children and serves as a guide to nurses. The policy statement focuses on prevention interventions aimed at both pri- mary and secondary levels of prevention. The scope is broad and includes supervising, learning to swim (both caretakers and children), and making changes to the environment such as installing fences and drain covers.49 The CDC breaks down primary prevention into the fol- lowing categories: barriers, supervision, learning to swim, life jacket use, and alcohol use.47 From a secondary pre- vention viewpoint, both the APA and CDC recommend learning cardiopulmonary resuscitation (CPR). The CDC also includes recommendations to help prevent drowning in natural bodies of water. There is a clear consensus on the actions that can be taken to prevent drowning and, in the event of a drowning, to provide early and effective treatment to prevent mortality (Box 12-5). Epidemiology of Unintentional Injury: Falls in Children The WHO defines a fall as “… an event which results in a person coming to rest inadvertently on the ground or floor or other lower level”.50 The two populations at greatest risk for fall-related injuries are children and older adults (see Chapter 19). Globally each year there are 646,000 fall-related deaths and 37.3 million falls that 294 U N I T I I n Community Health Across Populations: Public Health Issues Tips to help you stay safe in the water: • Pool fencing on all four sides at a 4-foot height would reduce drowning by 83%. • Supervise when in or around water. • Use the buddy system. • Seizure disorder safety. • Learn to swim. • Learn cardiopulmonary resuscitation (CPR). • Air-filled or foam toys are not safety devices. • Avoid alcohol. • Don’t let swimmers hyperventilate before swimming underwater or try to hold their breath for long periods of time. • Know how to prevent recreational water illnesses. • Know the local weather conditions and forecast before swimming or boating. • Do not use personal flotation devices, as they are not designed to keep people safe. BOX 12–5 n Primary Prevention for Drowning in the United States Sources: See reference (47). 7711_Ch12_283-312 23/08/19 10:39 AM Page 294 from a 53rd floor apartment window in New York City. Window falls occur most often in urban, low-income, and multidwelling settings. Prevention of Falls in Children Prevention efforts begin with home safety interventions. Parents are encouraged to put stair and window guards in place to prevent falls and, as with drowning preven- tion, maintain supervision of children in the home and on the playground.54 Product regulation has also played a role in increasing the safety of baby walkers and play- ground equipment. The U.S. Consumer Product Safety Commission has a playground equipment safety guide- line publication that clearly outlines how to prevent playground-related injury.55 Window guards, baby walkers, and other nursery products must meet product safety requirements. C H A P T E R 1 2 n Injury and Violence 295 n EVIDENCE-BASED PRACTICE Use of Window Guards Practice Statement: Window guards should be placed on all windows in multidwelling buildings. Targeted Outcome: Reduction in incidence of window-related falls in children Evidence to Support: The majority of the evidence is linked to surveillance data tracking the incidence of window-related falls in children before and after the enactment of window guard laws. In New York City, the incidence dropped 35% in the 2 years following the enactment of the requirement for window guards. Recommended Approaches: Legislative approaches that require landlords and owners of multidwelling buildings to install window guards, provide access to window guards for those who may not be able to purchase them, and distribute public information on preventing window-related falls in children (Box 12-6). Source: (56) Epidemiology of Unintentional Injury: Poisonings According to the CDC, “A poison is any substance, in- cluding medications, that is harmful to your body if too much is eaten, inhaled, injected, or absorbed through the skin. An unintentional poisoning occurs when a person taking or giving too much of a substance did not mean to cause harm.”57 Globally, more than 80% of all uninten- tional poisonings occur in LMICs with a resulting loss In 1976, the New York City Board of Health enacted leg- islation known as Health Code Section 131.15, the window guard law. It requires owners of multiple dwellings (build- ings of three or more apartments) to provide and prop- erly install approved window guards on all windows, including first floor bathroom and windows leading onto a balcony or terrace in an apartment where a child (or chil- dren) 10 years of age or younger reside and in each hall- way window, if any, in such buildings. The exceptions to this law are: • Windows that open onto fire escapes • A window on the first floor that is a required second- ary exit in a building in which there are fire escapes on the second floor and up If tenants or occupants want window guards for any reason, even if there are no resident children in the covered age category, they should request them in writing, and they may not be refused. Examples: • Grandparents who have visiting children • Parents who share intermittent custody • Occupants who provide childcare If required or requested and window guards have not been installed, if they appear to be insecure or improperly installed, or if there is more than 4.5 inches of open, unguarded space in the window opening, a complaint should be made immediately to 311. For more information on Window Guards, call 311. BOX 12–6 n New York City Window Guard Program Source: (56) of more than 10.7 million years of healthy life (disability- adjusted life years [DALYs]).57 In 2015, in the U.S., 47,478 persons died from uninten- tional poisoning, a mortality rate of 14.8 per 100,000.58 Most concerning has been the rise in drug poisoning mor- tality, attributable to the rise in opioid drug overdoses (see Chapter 11). From 1999 to 2016, for all ages, the mortality rate for drug poisoning rose from 6.1 to 19.8 per 100,000 (Fig. 12-5).59 However, for non-Hispanic whites, the rate for all ages went from 8.7 in 1999 to 48.7 per 100,000. For non-Hispanic white males aged 25-34 the rate rose from 12.2 to 68.4 per 100,000. By comparison, for non-Hispanic black males during the same time period, the rate rose from 12.2 to 27.2 per 100,000 (Fig. 12-6).59 The National Poison Data System, an electronic surveil- lance system documenting all calls made to poison centers across the United States, is a source for data to monitor poisonings. In 2016, analgesics (11.2%), household 7711_Ch12_283-312 23/08/19 10:39 AM Page 295 cleaning substances (7.54%), cosmetics/personal care products (7.20%), sedatives/hypnotics/antipsychotics (5.84%), and antidepressants (4.74%) were the top five poison exposures in the U.S.60 For children 5 years of age and under, the top five poison exposures were cosmetics/ personal care products (13.3%), household cleaning substances (11.1%), analgesics (9.21%), foreign bodies/ toys/miscellaneous (6.48%), and topical preparations (5.07%).61 From a global perspective, lead poisoning, especially in children, is a leading cause of poisoning. According to the WHO, 494,550 deaths annually are due to lead exposure. Furthermore, there is a loss of 9.3 mil- lion DALYs due to the long-term effects that exposure to lead has on health, with the highest burden occurring in LMICs.61 In the U.S., the Flint, Michigan, water crisis demonstrated the real threat of lead poisoning due to the built environment (see Chapter 6). Risk Factors for Unintentional Poisonings As noted earlier, there are differences in unintentional poisoning mortality rates based on demographic charac- teristics such as age, gender, and ethnicity. Children younger than 6 years of age account for most poisoning events (46%), followed by adults (39%) and teens (7%).62 The most common poisoning in adults age 20 or older was related to pain medication and, in children, the most common poisonings were related to cosmetics and per- sonal care products.62 A major issue related to children and poisoning is the home environment. Most childhood poisonings occur in the home.63,64 Children who live in older homes are at greater risk for lead poisoning as a result of the presence of lead-based paint or carbon monoxide poisoning from older heating systems. The other issue is ingestion of poi- sonous substances found in the home such as chemicals and medications. Prevention of Unintentional Poisoning With the predominant problem of overdose related to prescription medications, the most obvious approach to prevention is a focus on proper use and labeling of 296 U N I T I I n Community Health Across Populations: Public Health Issues Year D ea th s pe r 10 0, 00 0 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 19 99 0 2 4 6 8 10 12 14 16 13.4 14.4 11.8 11.110.610.210.2 9.69.18.98.88.2 7.36.96.4 5.8 4.6 4.13.9 Age-Adjusted Drug Overdose Death Rate per 100,000, 1999–2017 Figure 12-5 Age-Adjusted Drug Poisoning Rate U.S. 1999–2016. (Data from https://www.cdc. gov/nchs/data-visualization/drug-poisoning-mortality/) Figure 12-6 Age-adjusted drug poisoning by race. (Data from https://www.cdc.gov/nchs/data-visualization/ drug-poisoning-mortality/) 30 25 20 15 10 5 0 Year 1999 2003 2008 2011 2017 Non-Hispanic Black TotalHispanicNon-Hispanic White *per 100,000 population Age-Adjusted Death Rate* for Drug Poisoning by Race 7711_Ch12_283-312 23/08/19 10:39 AM Page 296 C H A P T E R 1 2 n Injury and Violence 297 medications, not sharing medications, proper storage of medications, and proper disposal of medications.63,64 Due to the opioid overdose epidemic, much of the focus has been on reducing prescription of opioids for the treatment of pain (see Chapter 11). With children at greatest risk, prevention efforts related to poisoning reduction in children are also important. The American Association of Poison Control Centers provides valuable guides to prevention that cover a wide range of potential poisons as well as environmental issues related to expo- sure.65 The United States Consumer Product Safety Commission also has a Web site that provides guidance for prevention and highlights current hazards such as single load liquid laundry packets and tiny button batteries. They also provide a link to recent recalls.66 Another major mechanism for prevention of morbidity and mortality is the network of poison control centers throughout the U.S. 65 Prevention efforts globally include efforts to reduce lead poisoning and poisoning from pesticides. The WHO has an International Program on Chemical Safety (IPCS). Their work includes promoting and establishing poison centers, providing information on poisoning, and developing peer-reviewed guidelines on the prevention and management of poisoning.67 Epidemiology of Self-Directed Violence: Suicide Self-directed violence (SDV), both fatal and nonfatal, is a serious public health issue and is defined as “… any- thing a person does intentionally that can cause injury to self, including death”.68 It includes suicide, defined as “death caused by self-directed injurious behavior with an intent to die as a result of the behavior.”69 Other suicidal acts include suicide attempt, defined as “a non- fatal, self-directed, potentially injurious behavior with an intent to die as a result of the behavior; might not result in injury”, and suicidal ideation, defined as “think- ing about, considering, or planning suicide.”69 SDV also includes non-suicidal acts such as cutting, head banging, self-biting, and self-scratching with some non-suicidal acts being unintentional and occurring in response to something environmental.68 Currently, due to a rise in the suicide rate, prevention of suicide has become a primary public health focus. In the U.S., there has been an alarming statistically significant rise in the suicide rate from 1999 to 2016 from 10.5 to 13.4 per 100,000. By 2016, suicide was the 10th leading cause of death in the U.S. Breaking it down by age group, suicide was the second leading cause of death for persons aged 10 to 34, and the fourth leading cause of death among persons aged 35 to 54.70 There were more than twice as many suicides (44,965) in the United States as there were homicides (19,362).70,71 The media helped focus national atten- tion on the problem, especially with the high-profile celebrity deaths in 2018 of Anthony Bourdain and Kate Spade. One of the frequently referenced risk factors for suicide has been a history of mental health problems, but in a recent study of state surveillance data, 54% of those who committed suicide in 27 states had no known mental health condition.71 Globally, suicide is the 17th leading cause of death ac- counting for 1.4% of all deaths with an annual suicide rate of 10.7 per 100,000. It is also the second leading cause of death worldwide for persons aged 15-29. Almost a third (30%) are due to ingestion of pesticides. The other two most common methods globally are death by use of a firearm and hanging.72 There is no clear pattern globally with socioeconomically diverse countries in the top five: Guyana, Lithuania, South Korea, Kazakhstan, and Sri Lanka.73 Overall, in 2016, 4% of the U.S. population reported suicidal ideation (Fig. 12-7), and 0.5% reported a suicide attempt. Women and young people are more likely to attempt suicide than men and older adults. For that same year, 1.3 million adults attempted suicide, and 1 million reported making suicide plans.70 Risk Factors for Suicide Although in the United States suicide has been viewed as a moral problem or a sign of personal weakness by some (see Chapter 10), the underlying risk factors are complex and often multifactoral.71 Based on an analysis of suicide surveillance data, half of all persons who die by suicide had not been diagnosed with mental health disorder at the time of death. This brings into question limiting pre- vention to persons with a known mental health disorder. Those with mental health disorders often have other risk factors as well such as job or relationship problems or physical health issues.71 According to the WHO, some suicides are an impulsive action in a time of crisis with the person losing the ability to cope with life stressors. Other triggers “… experiencing conflict, disaster, vio- lence, abuse, loss, or a sense of isolation are strongly associated with suicidal behavior.”72 In addition, specific groups that experience discrimination are at increased risk including refugees; migrants; indigenous peoples; prisoners; Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) persons; and prisoners.72 There are a 7711_Ch12_283-312 23/08/19 10:39 AM Page 297 298 U N I T I I n Community Health Across Populations: Public Health Issues 10% All other groups are non-Hispanic or Latino NH/OPI = Native Hawaiian/Other Pacific Islander AI/AN = American Indian or Alaska Native * ** *** 8% 6% 4% 2% 0% Overall Male Female Gender Race/Ethnicity Age Group Hispanic or Latino* White AsianBlack NH/ OPI** AI/AN*** 2 or more 18–25 26–49 50+ 4.0 4.0 4.1 3.5 2.5 7.5 4.3 3.9 2.3 3.5 8.8 4.2 2.4 Figure 12-7 Past Year Prevalence of Suicidal Thoughts Among U.S. Adults. (2016) (Data courtesy of SAMHSA; figure source https://www.nimh.nih.gov/health/statistics/suicide.shtml) n CULTURAL AWARENESS AND COMPETENCY AROUND SUICIDE PREVENTION Taking into account the cultural context of different communities is central to the building of effective suicide prevention programs as evidenced by the Substance Abuse and Mental Health Services Administration’s publication To Live to See the Great Day that Dawns: Preventing Suicide by American Indian and Alaska Native Youth and Young Adults – 2010. The publication utilizes culturally appropriate guidance to American Indian and Alaska Native communities drawing on cultural strengths and narratives to address suicide risk.75 According to the Indian Health Service, “Factors that protect AI/AN youth and young adults against suicidal behavior are a sense of belonging to one’s culture, a strong tribal/spiritual bond, the opportunity to discuss problems with family or friends, feeling connected to family, and positive emotional health.”76 Building a prevention program should not only address risk factors but build on cultural strengths within a community. Suicides are preventable. There are a number of meas- ures that can be taken at population, subpopulation, and individual levels to prevent suicide and suicide at- tempts. These include: • Reducing access to the means of suicide (e.g., pesticides, firearms, certain medications) • Reporting by media in a responsible way • Introducing alcohol policies to reduce the harmful use of alcohol • Early identification, treatment, and care of people with mental and substance use disorders, chronic pain, and acute emotional distress • Training of non-specialized health workers in the assessment and management of suicidal behavior • Follow-up care for people who attempted suicide and provision of community support BOX 12–7 n World Health Organization: Prevention of Suicide Source: (72) Veterans are another vulnerable group at higher risk for suicide in the U.S., especially those experiencing number of protective factors as well including both family and community support (Box 12-7). homelessness. The attempted suicide rate among vet- erans who are housed is 1.2% compared to 6.9% of those experiencing homelessness.77 The rate of suicidal ideation in the past 2 weeks is also higher among those experiencing homelessness (19.8% versus 7.4%). In Montana, between 2013 and 2016, veterans accounted for 20% of all suicides.78 Comparing suicide rates 7711_Ch12_283-312 23/08/19 10:39 AM Page 298 among veterans versus civilian populations is compli- cated, and recent statistics can be misleading because it is important to be clear about who is counted as a veteran. In addition, suicide rates for the general popu- lation includes adolescents to older adults. Thus, when comparing the suicide rate in veterans to the adult pop- ulation, it is important to use an age-adjusted rate as well as a clear definition of who is classified as a veteran. Place of residence also plays a role. Both veterans and non-veterans living in rural areas in Montana and in the U.S. are at increased risk for suicide.73,79 Also, states with stricter gun laws have lower suicide rates as well as states with gun seizure laws.80 Nevada, a state that put in place suicide prevention programs, has seen a drop in the sui- cide rate, although the rate remains high. Prevention of Suicide Prevention occurs from the individual to the policy level. As evidenced by the reduction of suicide rate in states with stricter gun control laws, upstream polices that address a risk factor, in this case easy access to guns, can help reduce the suicide rate. One set of authors recommended the use of the socioecological model (Chapter 2) in the development of suicide prevention programs using access to guns as the targeted risk factor. Using this approach, prevention occurs across the C H A P T E R 1 2 n Injury and Violence 299 continuum of societal, community, relationship, and individual interventions.81 Examples of societal ap- proaches include policy and system level strategies. Novel approaches such as social networking for youth are emerging to address specific populations within the context of their daily lives. This is an example of a rela- tionship approach.82 The Zero Suicide (ZS) model is an example of a health systems-level approach. ZS uses a multilevel approach to help implement evidence-based practices for suicide prevention in the behavioral health setting. The compo- nents of the program include four aspects of clinical care (Identify, Engage, Treat, and Transition) and three components on the administrative level (Lead, Train, and Improve).83 The CDC published a guide to suicide prevention programs that illustrates that multiple evidenced-based prevention programs exist.84 From a global perspective, prevention requires attention to the multiple factors that contribute to suicide (Table 12-1). Suicide was listed in HP 2020 under mental health rather than injury and violence.85 Given that approxi- mately 50% of persons who commit suicide in the U.S. had not been diagnosed with a mental health disorder,71 suicide is relevant to both the mental health topic and to the violence and injury topic in Healthy People 2030. TABLE 12–1 n Suicide: Risk Factors and Protective Factors Risk Factors • Family history of suicide • Family history of child maltreatment • Previous suicide attempt(s) • History of mental disorders, particularly clinical depression • History of alcohol and substance abuse • Feelings of hopelessness • Impulsive or aggressive tendencies • Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma) • Local epidemics of suicide • Isolation, a feeling of being cut off from other people • Barriers to accessing mental health treatment • Loss (relational, social, work, or financial) • Physical illness • Easy access to lethal methods • Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts Protective Factors • Effective clinical care for mental, physical, and substance abuse disorders • Easy access to a variety of clinical interventions and support for help seeking • Family and community support (connectedness) • Support from ongoing medical and mental health care relationships • Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes • Cultural and religious beliefs that discourage suicide and support instincts for self-preservation • Substance abuse disorders or suicidal thoughts Source: (74) 7711_Ch12_283-312 23/08/19 10:39 AM Page 299 Epidemiology of Violence Against Children and Women Violence against women and children occurs both within and outside of the family context. Family violence includes violence between intimate partners (IPV), maltreatment of children, and elder abuse. The context of the violence is the family and occurs between individ- uals. The victims and the perpetrators have an established family-based relationship and can include violence against children and women. Violence against children that occurs outside the family includes community-based violence (see later), bullying, and school-based violence (see Chapter 18). Violence against women other than IPV includes stalking and sexual assault by persons other than intimate partners. Child Maltreatment Child maltreatment is defined by the federal Keeping Children and Families Safe Act of 2003 (P.L. 108-36) as “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emo- tional harm, sexual abuse or exploitation” or “an act or failure to act which presents imminent risk or serious harm.”87 The WHO points out that maltreatment of a child can lead to serious adverse consequences both im- mediately and long term. Violence against children not only leads to death, serious injury, and potential disabil- ity but also causes stress that negatively impacts brain de- velopment with damage to the nervous and immune systems. Thus, victims of child maltreatment may have “… delayed cognitive development, poor school per- formance and dropout, mental health problems, suicide attempts, increased health-risk behaviors, revictimiza- tion, and the perpetration of violence.”88 300 U N I T I I n Community Health Across Populations: Public Health Issues n HEALTHY PEOPLE 2020 Mental Health and Mental Disorders: Mental Health Status Improvement Objective: MHMD-1 Reduce the suicide rate Baseline: 11.3 suicides per 100,000 population occurred in 2007 (age adjusted to the year 2000 stan- dard population) Target: 10.2 suicides per 100,000 population85 Midcourse Review: The objective, MHMD-1, wors- ened, with a significant increase in the suicide rate from baseline to 12.6 per 100,000 in 2013 moving away from the target of 10.2.86 In 2016, the rate continued to climb to 15.6 per 100,000.71 Child neglect is the most prevalent form of child mal- treatment and includes both physical neglect and emo- tional neglect. Physical neglect includes the withholding of food, shelter, clothing, and/or medical or dental care, whereas emotional neglect involves the omission of caring, nurturing, and acceptance. Emotional abuse is defined as extreme debasement of feelings, whereas physical abuse is nonaccidental physical harm such as bruising, bites, thermal burns or cigarette burns, severe fractures, and even death. Sexual abuse defined by the federal Child Abuse Prevention and Treatment Act87 and as amended by the Keeping Children and Families Safe Act of 2003 is “the employment, use, persuasion, induce- ment, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or the rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children.”87 At both the global level and in the U.S., one in four adults have a history of physical abuse as a child.89,90 The National Child Abuse and Neglect Data System is the surveillance system that monitors trends of child maltreatment by collecting child protective service re- ports from 50 states, Puerto Rico, and the District of Columbia.91 In 2016, in the U.S., child protective services received reports of 676,000 victims of child maltreatment of whom an estimated 1,750 died.91 Also in 2016, chil- dren younger than a year old had the highest rate of child maltreatment at 24.8 per 1,000. American Indian or Alaska Native children had the highest rate (14.2 per 1,000) followed by African-American children (13.9 per 1,000). The fatality rate was highest in African-American children at 4.65 per 100,000, which is twice as high as the rate for white children (2.10 per 100,000) and three times as high as Hispanic children (1.58 per 100,000).91 Be- cause these data represent only those cases reported to child protective services, the actual incidence may be higher. The estimated cost of child maltreatment in the U.S. is $124 billion each year.90 Risk Factors for Child Maltreatment Risk factors for childhood maltreatment include three levels of risk: individual, family, and community (Table 12-2).92 Parental socioeconomic factors play a role. For example, the level of mother’s education and poverty, and parental behavioral issues such as mental health disorders or substance use place a child at higher risk.90, 92,93 For some, a parent’s history of child 7711_Ch12_283-312 23/08/19 10:39 AM Page 300 C H A P T E R 1 2 n Injury and Violence 301 TABLE 12–2 n Child Maltreatment: Risk Factors and Protective Factors Risk Factors for Victimization Individual Risk Factors • Children younger than 4 years of age • Special needs that may increase caregiver burden (e.g., disabilities, mental health issues, and chronic physical illnesses) Risk Factors for Perpetration Individual Risk Factors • Parents’ lack of understanding of children’s needs, child development, and parenting skills • Parental history of child abuse and or neglect • Substance abuse and/or mental health issues including depression in the family • Parental characteristics such as young age, low education, single parenthood, large number of dependent children, and low income • Nonbiological, transient caregivers in the home (e.g., mother’s male partner) • Parental thoughts and emotions that tend to support or justify maltreatment behaviors Family Risk Factors • Social isolation • Family disorganization, dissolution, and violence, including intimate partner violence • Parenting stress, poor parent-child relationships, and negative interactions Community Risk Factors • Community violence • Concentrated neighborhood disadvantage (e.g., high poverty and residential instability, high unemployment rates, and high density of alcohol outlets), and poor social connections. Protective Factors Family Protective Factors • Supportive family environment and social networks • Concrete support for basic needs • Nurturing parenting skills • Stable family relationships • Household rules and child monitoring • Parental employment • Parental education • Adequate housing • Access to health care and social services • Caring adults outside the family who can serve as role models or mentors Community Protective Factors • Communities that support parents and take responsibility for preventing abuse Source: (90) abuse in the family of origin is significant,93 whereas for other families current substance abuse and/or men- tal health issues including depression in the family are predictors of child maltreatment.90,92 Other risk factors include parents’ lack of understanding of children’s needs, child development, and parenting skills, or parental thoughts and emotions that tend to support or justify maltreatment behaviors.90 Maternal IPV (see later) is another strong risk factor for child maltreat- ment.94 The presence of a nonbiological, transient care- giver in the home is another risk factor for sexual abuse in particular (e.g., mother’s male partner).90 Community-level risk factors include low socioeconomic status and living in an impoverished community.90,92 7711_Ch12_283-312 23/08/19 10:39 AM Page 301 A history of childhood maltreatment can lead to lifelong health issues in adults.90 Prevention of Child Maltreatment The focus of childhood maltreatment prevention pro- grams is often on parental education, support, and/or public awareness campaigns in an effort to strengthen the protective factors within the home and community (Table 12-3).92,95 Tertiary prevention is also important to prevent recurrence of abuse or to decrease impair- ment. Home visitation (see Chapter 17) in particular has been implemented for the prevention of child maltreat- ment. Focusing on selective protective factors is the focus of many of these programs. Protective factors for child maltreatment include nurturing parenting skills, pro- moting stable family relationships, promoting household rules and child monitoring, and assisting with parental employment, adequate housing, or access to health care and social services.95 Home visitation programs include the Nurse Family Partnership Model, which has under- gone rigorous evaluations and shows promise for the prevention of child maltreatment.96 Examples of other programs aimed at reinforcing protective factors in 302 U N I T I I n Community Health Across Populations: Public Health Issues TABLE 12–3 n Childhood Maltreatment Prevention Programs Strategy Teach safe and healthy relationship skills Engage influential adults and peers Disrupt the developmental pathways toward partner violence Create protective environments Strengthen economic supports for families Support survivors to increase safety and lessen harms Approach • Social-emotional learning programs for youth • Healthy relationship programs for couples • Men and boys as allies in prevention • Bystander empowerment and education • Family-based programs • Early childhood home visitation • Preschool enrichment with family engagement • Parenting skill and family relationship programs • Treatment for at-risk children, youth and families • Improve school climate and safety • Improve organizational policies and workplace climate • Modify the physical and social environments of neighborhoods • Strengthen household financial security • Strengthen work family supports • Victim-centered services • Housing programs • First responder and civil legal protections • Patient-centered approaches • Treatment and support for survivors of IPV Source: (112) families and communities include the Triple P program and Family Connections.97,98 Violence Against Women and Intimate Partner Violence Intimate partner violence is violence that occurs be- tween two people in an intimate relationship. It includes physical violence, sexual violence, and/or psychological/ emotional violence as well as threats of physical and/or sexual violence. It can occur between both heterosexual and same sex partners.99 Globally, more than one-third of women (38%) have experienced either physical and/or sexual violence with 30% of them experiencing IPV. In addition, 38% of all homicides of women are perpetrated by an intimate partner.100 Physical violence is the intentional use of physical force with the potential for causing death, disability, in- jury, or harm. Physical violence includes, but is not lim- ited to, scratching, pushing, shoving, throwing, grabbing, biting, choking, shaking, slapping, punching, burning, use of a weapon, and use of restraints or one’s body, size, or strength against another person. Sexual violence is divided into three categories: (1) use of physical force to 7711_Ch12_283-312 23/08/19 10:39 AM Page 302 compel a person to engage in a sexual act against his or her will, whether or not the act is completed; (2) at- tempted or completed sexual act involving a person who is unable to understand the nature or condition of the act, to decline participation, or to communicate unwillingness to engage in the sexual act (e.g., because of illness, disabil- ity, the influence of alcohol or other drugs, or because of intimidation or pressure); and (3) abusive sexual contact. Threat of physical or sexual violence is the use of words, gestures, or weapons to communicate the intent to cause death, disability, injury, or physical harm. Psychological/ emotional violence involves trauma to the victim caused by acts, threats of acts, or coercive tactics. Psychological/ emotional abuse can include, but is not limited to, humil- iating the victim, controlling what the victim can and cannot do, withholding information from the victim, de- liberately doing something to make the victim feel diminished or embarrassed, isolating the victim from friends and family, and denying the victim access to money or other basic resources. Stalking is defined as “… a pattern of harassing or threatening tactics used by a perpetrator that is both unwanted and causes fear or safety concerns in the victim.”101,102 About 1 in 4 American women and about 1 in 10 males reported a lifetime impact of contact sexual violence, physical violence, and/or stalking.102 Surveil- lance of IPV occurs through various databases. This abuse can start early in dating relationships.102 LGBTQ+ persons also experience IPV at levels equal to or higher than the heterosexual population.103 IPV has significant negative effects on health. These effects are both short- and long-term and include phys- ical, mental, sexual, and reproductive adverse health con- sequences for women and their children.100,104 There are also serious negative social and economic consequences for women, their families, and their communities.100,104 Abused women are also more likely to use medical serv- ices including outpatient primary care, EDs, and mental and substance abuse services.105 Femicide (Box 12-8) is the most extreme negative outcome.106 C H A P T E R 1 2 n Injury and Violence 303 n CULTURAL CONTEXT As part of a series on violence prevention, the WHO examined how cultural and social norms can encourage violence, including IPV. Some examples of cultural norms from different countries provided by the WHO include the following: “a man has a right to assert power over a woman and is socially superior (India, Nigeria, Ghana); a man has a right to ‘correct’ or disci- pline female behavior (India, Nigeria, China); a woman’s freedom should be restricted (Pakistan); and physical violence is an acceptable way to resolve conflicts within a relationship (South Africa, China).”107 Devia- tion from norms results in disgracing the entire family, which can then lead to honor killings such as the honor killing of a couple who married for love in Pakistan in 2018. The role culture plays in violence against women has been in the spotlight with calls to stand up against a cultural acceptance of men perpetuating violence against women, especially sexual violence. Thus, at the global level, a cultural shift is occurring to not only accept women who speak out and report perpetrators but also to make violence against women unacceptable. Time magazine choosing the founders of the #metoo movement as their Person of the Year in 2017 is evidence of the cultural shift. Femicide is the intentional murder of women. • Femicide is usually perpetrated by men, but sometimes female family members may be involved. • Femicide differs from male homicide in specific ways. For example, most cases of femicide are committed by partners or ex-partners, and involve ongoing abuse in the home, threats or intimidation, sexual violence, or situations where women have less power or fewer resources than their partner. BOX 12–8 n World Health Organization Definition of Femicide Source: (106) Risk Factors for Intimate Partner Violence Risk for IPV occurs at many levels. At the individual level, risk factors include female gender, young age, being un- married, being uninsured or on medical assistance, low income, and having a history of child maltreatment.100,108 In addition, at-risk alcohol use by either partner or both is associated with IPV perpetration.100,108 Other risk factors include low self-esteem, mental health problems, unemployment, or desire for power and control in rela- tionships.100,108 At the family level, exposure as an ado- lescent to severe IPV between caregivers increases the risk for relationship violence in early adulthood.100,108 At the community level, residence in an area characterized by poverty and social disadvantage as well as by an increased density of alcohol outlets are factors associated with IPV–related ED visits.100,108,109 7711_Ch12_283-312 23/08/19 10:39 AM Page 303 Epidemiology of Community Violence Community violence is an event that includes crime, weapons use, and violence or potential violence, and is perpetrated in a public place by individuals who do not have a relationship with the vicitms.116 Examples of com- munity violence include violent acts or victimization by strangers perpetrated by one or more individuals, sniper attacks, gang wars, and drive-by shootings.117 The impact of violence on a community is widespread. Exposure to the constant stress of living within an unsafe community takes its toll on all of its citizens. It can lead to a sense of isolation for older adults who limit their activity outside their home because of violence. It can lead to a lack of physical activity in children and families because parents are concerned about the safety of their children. It can lead to psychiatric sequelae because of the feelings of fear and stress.116,117 Community violence can also occur in towns and neighborhoods where violence is not the norm, such as the killing of 20 children and 6 adults at Sandy Hook Elementary School in Newtown, Connecticut; the killing of church members in South Carolina; or the school shootings in Parkland, Florida. These events sent shock waves through the nation and brought calls for stricter gun control laws. Understanding the causative factors behind community-level violence is complex and can include individual level factors such as a history of men- tal illness or terrorism, as was the case in the Boston Marathon bombing and the events on September 11, 2001. In 2016, in the U.S., 5.7 million people aged 12 or older experienced violent victimization at a rate of 21.2 per 1,000. The rate of violent victimization by a stranger was higher than the rate for IPV (8.2 per 1,000 versus 2.2 per 1,000).118,119 These statistics reflect actual reported events of violent crime. At the community level, violence not only affects the victim(s), it also affects those who witness the violence and can create a community-level reaction of concern for safety. For some communities, it is an unexpected event that takes a community unaware, and in others, the violence is part of everyday life. In the case of war, one expects to be exposed to death, trauma, and stress. Unfortunately, certain neighborhoods in our cities have often been compared to war zones where it is not uncommon to be exposed to severe violence on a regular basis. Exposure to community violence (i.e., seeing some- one shot; someone being stabbed, molested, raped, mugged, threatened with a knife, gun or weapon; or someone being beaten up or hurt) is often associated 304 U N I T I I n Community Health Across Populations: Public Health Issues The majority of studies have focused on risk factors in relation to the female victim. Globally, there is a lack of research related to the perpetrator. In addition, outside of the U.S., there is little research on the community level related to IPV.110 In a ground-breaking study by Camp- bell et al., risk factors for femicide included a history of prior abuse, a history of perpetrator unemployment, availability of guns, and presence of the victim’s child from another relationship in the home.111 Prevention of Intimate Partner Violence In 2017, the CDC published Preventing Intimate Partner Violence Across the Lifespan: A Technical Package of Programs, Policies, and Practices, an evidence-based re- view of prevention strategies across the continuum aimed at reducing IPV and reducing negative conse- quences in persons who have experienced IPV.112 The main categories of prevention include: (1) Teach safe and healthy relationship skills, (2) Engage influential adults and peers, (3) Disrupt the developmental pathways to- ward partner violence, (4) Create protective environ- ments, (5) Strengthen economic supports for families, and (6) Support survivors to increase safety and lessen harms. This broad overview of prevention requires promoting change at all levels of the socioecological model (Chapter 2): individual, relationship, community, and society. Examples of evidence-based prevention strategies presented in the CDC technical program package include early childhood visitation programs, organizational and workplace policies, and family-based programs.112 At the secondary prevention level, screening and re- ferral for treatment are two key steps for prevention of further IPV in women who have a history of prior IPV or are at risk for IPV.110 Nurses have advocated for universal screening for IPV.110,111,113 A number of screening tools are available, such as the DOVE tool de- veloped by a nurse and tailored for screening during a home visit. DOVE is an evidence-based screening tool developed to help identify women who may be at risk for perinatal IPV and includes steps for implementing interventions during a perinatal home visit aimed at re- ducing violence.114 Disclosure of IPV requires action by the provider, further assessment, appropriate referrals, and discussion of a safety plan. To help practitioners, the Agency for Healthcare Research and Quality re- viewed the evidence to support screening for IPV in women who did not have signs of abuse. Their fact sheet provides the evidence to support screening as well as for resources for implementing screening in health- care settings.115 7711_Ch12_283-312 23/08/19 10:39 AM Page 304 with psychiatric sequelae including post-traumatic stress disorder (PTSD).115,116 Post-traumatic stress disorder is a type of anxiety disorder in children and adults who witness horrific events. PTSD can develop in response to a variety of traumatic events such as witnessing a violent act or crime, experiencing a natural or unnatural disaster, and experiencing physical or sexual abuse.116 Other comorbid psychiatric symptoms include anxiety and major depressive episodes. Substance use and behavior problems are also seen in children exposed to violence.116 Risk and Protective Factors for Community Violence For the most part, economically depressed and disorgan- ized communities with fewer resources and an increased access to guns are at greater risk for community-level violence.120 Truly understanding risk and protective factors for community violence continues to be a challenge. Risk factors often not addressed include racism, discrimination, prisoner reentry, and other conditions of vulnerability and invisibility.121 Protective factors at the community level include norms supporting gender equity and robust economic/job opportunities in communities. A particular concern with violence in the community is youth violence, which occurs when youths hurt peers unrelated to them that they may or may not know well.122 Young people perpetrate violent acts at a higher rate than any other age group. The risk factors for youth violence occur at the individual, family, peer, and community level. They include low socioeconomic status, poor parental supervision, delinquent peers, and harsh par- enting. At the community level, risk factors for violence are similar and include living in disorganized communi- ties with fewer resources, lower socioeconomic status, and a higher rate of transiency.122 Promoting youth development is one strategy used to decrease youth violence within the community. This is based on the fact that social connectedness is a pro- tective factor inversely associated with rates of crime at the community level.122 Resilience is the ability to suc- cessfully adapt and function despite exposure to chronic stress and adversity. Resilience is achieved through sup- port from a family, school, or peer group. The CDC has published a guide to evidence-based programs aimed at reducing youth violence. The recommendations include six areas: (1) promote family environments that support healthy development, (2) provide quality education early in life, (3) strengthen youth skills, (4) connect youth to caring adults and activities, (5) create protective community environments, and (6) intervene to lessen harms and prevent future risk. This technical prevention package provides links to evidence-based programs, many of which can be implemented at the community level.123 Epidemiology of War: An Example of Collective Violence War as defined by the online Merriam Webster diction- ary is “a state of usually open and declared armed hostile conflict between states or nations.”124 This excludes individuals or families fighting, gangs fighting, and other smaller community entities. Traditional war is thought of as the fighting between two political states or coun- tries, but just as common is the fighting between two groups within a state (civil war) that are aspiring to be- come the political entity for the state. War is a violent way of determining who will govern. War and its vio- lence create serious social consequences that affect all the political communities involved. These consequences can be a result of a prolonged conflict, extreme aggres- sion, excessive mortality and morbidity, and/or high financial cost, all of which reduce resources for social needs. In their book On War and Public Health, Levy and Sidel write: War accounts for more death and disability than many major diseases combined. It destroys families, communities, and sometimes whole cultures. It directs scarce resources away from protection and promotion of health, medical care, and other human services. It destroys the infrastruc- ture that supports health. It limits human rights and con- tributes to social injustice. It leads many people to think that violence is the only way to resolve conflicts—a mindset that contributes to domestic violence, street crime, and other kinds of violence. And it contributes to the destruction of the environment and overuse of nonrenewable resources. In sum, war threatens much of the fabric of our civilization (p. 3, 138).125 War affects more than the combatants. In the 20th century, it was estimated that 136.5 to 148.5 million people died in war and conflict.126 However, the largest death toll comes not from the direct conflict but from both the short- and long-term residual effects of the war such as disease and malnutrition.127,128 Worldwide, in 2018, examples of ongoing wars in- cluded those in Afghanistan, Syria, Yemen, Somalia, and Myanmar. More than 40 wars (both between nations and civil wars) began in the 1990s compared with fewer than C H A P T E R 1 2 n Injury and Violence 305 7711_Ch12_283-312 23/08/19 10:39 AM Page 305 10 in the first decade of this century. There also were fewer deaths caused directly by war-related violence. For example, the number of all battle-related deaths in conflicts in 2016 was 87,432.129 One contributing factor to lower mortality is that the nature of war has changed. There are no longer huge armies in battle with massive human destruction. However, more countries have access to weapons of mass destruction, and the number of countries with active nuclear warheads has grown from two in the 1940s to nine by 2013. With the use of social media, there has also been more reporting of wars and their atrocities. The reporting occurs almost at the moment they occur. It makes the violence seem greater, because of the immediacy with which it is being reported. When traditional reporting by journalists is impeded, as occurred in the Syrian con- flict, social media has provided an alternative source of news for those inside and outside the country. Even with fewer wars and numbers of deaths, the war- related effects of current conflicts are enormous. There is an obvious breakdown in public health systems with the displacement of resources to war and away from health services including prevention services, increases in disease transmission, and other changes in the social systems that had previously kept the population healthy. There are many other examples of the destructiveness of war: the use of child soldiers resulting in severe physical and emotional abuse of the children, making it very difficult for them to reintegrate into civil society; the forced movements of refugees and displaced persons from their own homes to areas with decreased health and safety; and the increased acceptability of violence as a solution to problems. 306 U N I T I I n Community Health Across Populations: Public Health Issues section of the world flows over into other countries, especially with the current crisis related to war refugees coming into western countries and ensuing resistance from citizens of western countries to accept refugees (see Chapter 7). Hogopian argued that war should be reframed as a public health issue due to the serious consequences to the health of populations that result during war and its aftermath.130 White took a global view and proposed that collaboration among nations was essential in the prevention of war.131 Advances in treating injury resulting from war at the cellular level has improved survival rate for combatants, yet a global international approach may be needed to reduce the short- and long-term impacts on non- combatants including those who stay and those who are forced to seek refuge from a war zone. n CELLULAR TO GLOBAL The Impact of War Advances in health care have reduced the immediate impact of combat injuries, reducing mortality and long- term morbidity substantially in the time between the American Civil War and today. So, on the surface, it appears we have vastly improved our ability to address the impact of war on combatants at the cellular level. Taking the wider view of the impact of war on the communities where the conflict occurs demonstrates the more complex relationship between armed conflict and health not only due to injury but malnutrition, destruction of community infrastructure, housing, and access to clean water. On the psychological level, both combatants and non-combatants suffer from short- and long-term PTSD. On the global level, war in one Role of the Nurse in War Starting with primary prevention, the nurse can sup- port actions to prevent war. If war ensues, the nurse may try to minimize the effects of the war as part of secondary prevention. After the war is over, the nurse, at the tertiary level, may help treat the victims of the war and minimize the political, economic, social, and environmental destruction. Nurses can help in surveil- lance and documentation of what happens during the war and report it to the appropriate agencies, advocate for the use of nonviolence, advocate to minimize the re- sults of war, and work with the refugees and displaced persons from the war, either in the United States or in other countries, to improve their health and social rein- tegration into society. With additional training, nurses can provide the emergency relief frequently needed during and immediately at the end of the war. Nurses can also help document and understand the most ap- propriate interventions for refugees and displaced persons, which are frequently specific to the affected population. Using this additional information, the reintegration of individuals into post-war social systems can be facilitated. n Summary Points • Injury is a major public issue that includes both in- tentional and unintentional injury, most of which is preventable. • Risk factors associated with injury and violence are complex and include a combination of individual behaviors, environment, socioeconomic status, and culture. 7711_Ch12_283-312 23/08/19 10:39 AM Page 306 C H A P T E R 1 2 n Injury and Violence 307 t SUICIDE AND VULNERABLE POPULATIONS Learning Outcomes At the end of this case study, students will be able to: • Compare dependent rates (Chapter 3). • Compare the effectiveness of different approaches to prevention based on the target population. • Explain the role of health-care providers and key stakeholders in prevention program planning. • Discuss the benefits of incorporating cultural components into a health program. • Compare and contrast different levels of prevention as well as the applicability of the socioecological model when developing a health program. Suicide rates are rising in the U.S. with a rate of 15.6 per 100,000 in 2016, up from 11.3 per 100,000 in 2007. Split into teams and have each team choose a different specific subpopulation (e.g., adolescents, older adults, veterans). Subpopulations can be further divided based on demographic variables such as race and gender. Examine the most recent statistics on suicide rates in this population as well as the most recent sta- tistics at the national and global level. Then examine the current evidence-based approaches to prevention and decide on a specific prevention approach. As part of your assessment and program planning: 1. Compare the suicide rate in your chosen population with the suicide rate in the general population and decide if there is a significant difference. 2. Examine possible evidence-based approaches to sui- cide prevention within the context of a particular health-care setting (e.g., ED, primary care, public health department) and the chosen population. 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Retrieved from https://onsafety.cpsc.gov/blog/2017/06/27/ fireworks-safety-3-step-guide-to-a-safer-celebration/. 45. United States Consumer Product Safety Commission. (2017). 2016 fireworks annual report: Fireworks-related deaths and emergency department treated injuries. Retrieved from https://www.cpsc.gov/s3fs-public/Fireworks_Report_ 2016 ?t.YHKjE9bFiabmirA.4NJJST.5SUWIQJ. 46. World Health Organization. (2018). Violence and injury prevention: Drowning. Retrieved from http://www.who.int/ violence_injury_prevention/other_injury/drowning/en/. 47. Centers for Disease Control and Prevention. (2016). Home and recreational safety. Unintentional drowning: Get the Facts. Retrieved from https://www.cdc.gov/homeandrecre- ationalsafety/water-safety/waterinjuries-factsheet.html. 48. Claiborne, R., Francis, E. (Aug 3, 2010). 6 teens drown while wading in Louisiana’s Red River. ABC News. Retrieved from https://abcnews.go.com/WN/teens-drown-wading- louisianas-red-river/story?id=11312631. 49. Committee on Injury, Violence and Poison Prevention, & America Academy of Pediatrics. (2010). Policy statement: Prevention of drowning. Pediatrics, 126. Retrieved from http://pediatrics.aappublications.org/content/early/ 2010/05/24/peds.2010-1264.full +html. doi:10.1542/ peds.2010-1264. 308 U N I T I I n Community Health Across Populations: Public Health Issues 7711_Ch12_283-312 23/08/19 10:39 AM Page 308 50. World Health Organization. (2018). Falls: Key facts. Retrieved from http://www.who.int/en/news-room/ fact-sheets/detail/falls. 51. Centers for Disease Control and Prevention. (2016). Child safety and injury prevention: Fall prevention. Retrieved from https://www.cdc.gov/safechild/falls/index.html. 52. Tuckel, P., Milczarski, W., & Silverman, D.G. (2018). Injuries caused by falls from playground equipment in the United States. Clinical Pediatrics, 57(5), 563-573. doi:10.1177/0009922817732618. 53. Gaw, C.E., Chounthirath, T., & Smith, G.A. (2017). Nursery product-related injuries treated in United States emergency departments. Pediatrics, 139(4), 1-11. doi:10.1542/peds. 2016-2503. 54. Centers for Disease Control and Prevention. (2017). Falls: Children. Retrieved from https://www.cdc.gov/ HomeandRecreationalSafety/Falls/children.html. 55. The U.S. Consumer Product Safety Commission. (2017). Pub- lic playground safety handbook. Washington D.C.: Author. 56. New York City Department of Health and Mental Hygiene. (n.d.). Window guards: Preventing falls. Retrieved from https://www1.nyc.gov/site/doh/health/health-topics/ window-guards-preventing-falls.page. 57. Centers for Disease Control and Prevention. (2015). Home and recreational safety poisoning. Retrieved from https://www. cdc.gov/homeandrecreationalsafety/poisoning/index.html. 58. Centers for Disease Control and Prevention, National Center for Health Statistics. (2017). Accidents and unintentional injuries. Retrieved from https://www.cdc.gov/nchs/fastats/ accidental-injury.htm. 59. Rossen, L.M., Bastian, B., Warner, M., Khan, D., Chong, Y. (2017). Drug poisoning mortality: United States, 1999–2016. National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/data-visualization/drug- poisoning-mortality/. 60. Gummin, D.D., Mowry, J.B., Spyker, D.A., Brook, D.E., Fraser, M.O., & Banner, W. (2017). 2016 annual report of the American Association of Poison Control Centers’ national poison data system (NPDS): 34th annual report. Clinical Toxicology, 55, 1072-1254. doi: 10.1080/ 15563650.2017.1388087. 61. World Health Organization. (2018). Lead poisoning and health. Retrieved from http://www.who.int/en/news- room/fact-sheets/detail/lead-poisoning-and-health. 62. National Capital Poison Center. (2018). Poison statistics: National data 2016. Retrieved from https://www.poison.org/ poison-statistics-national. 63. Safe Kids Worldwide. (2015). Poisoning safety fact sheet. 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Retrieved from https://www.cdc.gov/violenceprevention/suicide/ definitions.html. 70. National Institute of Mental Health. (2018). Suicide. Retrieved from https://www.nimh.nih.gov/health/statistics/ suicide.shtml. 71. Stone, D.M., Simon, T.R., Fowler, K.A., Kegler, S.R., Yuan, K., Holland, K.M., & Crosby, A.E. (2018). Vital signs: Trends in state suicide rates — United States, 1999–2016 and circumstances contributing to suicide — 27 states, 2015. Morbidity and Mortality Weekly Report, 67(22), 617–624. doi:10.15585/mmwr.mm6722a1 72. World Health Organization. (2018). Mental health: Suicide data. Retrieved from http://www.who.int/mental_health/ prevention/suicide/suicideprevent/en/. 73. Dyer, O. (2018, 12 June). U.S. suicide rate is climbing steadily with highest prevalence in sparsely populated western states. British Medical Journal, 361, k2586. doi:10.1136/bmj.k2586. 74. Centers for Disease Control and Prevention. (2017). Suicide: Risk and protective factors. Retrieved from https://www. cdc.gov/violenceprevention/suicide/riskprotectivefactors. html. 75. U.S. Department of Health and Human Services. (2010). To live to see the great day that dawns: Preventing suicide by American Indian and Alaska Native youth and young adults. DHHS Publication SMA (10)-4480, CMHS-NSPL-0196, Printed 2010. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2010. 76. Indian Health Service. (n.d.). Suicide prevention and care program. Retrieved from https://www.ihs.gov/ suicideprevention/. 77. Tsai, J., Trevisan, L., Huang, M., & Pietrzak, R.H. (2018). Addressing veteran homelessness to prevent veteran sui- cides. Psychiatric Service. doi: 10.1176/appi.ps.201700482. [Epub ahead of print]. 78. Montana Department of Health and Human Services: Office of Epidemiology and Scientific Support. (2018). Veteran suicide in Montana, 2013-2016. Retrieved from https://dphhs.mt.gov/Portals/85/publichealth/docu- ments/Epidemiology/VSU/VSU_Veteran_Suicide_ 2013-2016 . 79. U.S. Department of Health and Human Services, Adminis- tration for Children and Families. (n.d.). Keeping Children Safe Act. Retrieved from https://www.childwelfare.gov/ systemwide/laws_policies/federal/index.cfm?event= federalLegislation.viewLegis&id=45. 80. Smith, M. (2018, June 8). 5 takeaways on America’s increas- ing suicide rate. New York Times. Retrieved from https:// www.nytimes.com/2018/06/09/us/suicide-rates-increasing- bourdain.html. 81. Allchin, A., Chaplin, V., Horwitz, J. (2018). Injury Prevention, 0, 1–5. doi:10.1136/injuryprev-2018-042809. C H A P T E R 1 2 n Injury and Violence 309 7711_Ch12_283-312 23/08/19 10:39 AM Page 309 82. Bailey, E., Rice S., Robinson J., Nedeljkovicc, M., & Alvarez- Jimenezab M. (2018). Theoretical and empirical foundations of a novel online social networking intervention for youth suicide prevention: A conceptual review. Journal of Affective Disorders, 238, 499-505. https://doi.org/10.1016/j.jad. 2018.06.028. 83. Brodsky, B.S., Spruch-Feiner, A., & Stanley, B. (2018). The zero suicide model: Applying evidence-based suicide prevention practices to clinical care. Frontiers in Psychiatry, 9, 33. http://doi.org.ezp.welch.jhmi.edu/10.3389/fpsyt. 2018.00033. 84. Stone, D.M., Holland, K.M., Bartholow, B., Crosby, A.E., Davis, S., & Wilkins, N. (2017). Preventing suicide: A techni- cal package of policies, programs, and practices. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. 85. U.S. Health and Human Services: Healthy People 2020. (2017). Topics and objectives: Mental health and mental disorders. Retrieved from https://www.healthypeople.gov/ 2020/topics-objectives/topic/mental-health-and-mental- disorders. 86. U.S. Health and Human Services: Healthy People 2020. (2017). Healthy People 2020 Midcourse Review: Chapter 28, mental health and mental disorders (MHMD). Retrieved from https://www.cdc.gov/nchs/data/hpdata2020/ HP2020MCR-C28-MHMD . 87. Keeping Children and Families Safe Act of 2003. (2003). P.L. 108-36. Retrieved from https://www.acf.hhs.gov/sites/ default/files/cb/capta2003 . 88. World Health Organization. (2018). Violence and injury prevention: Child maltreatment (abuse). Retrieved from http://www.who.int/violence_injury_prevention/violence/ child/en/. 89. World Health Organization. (2017). World health statistics 2017: Monitoring health for the SDGs. Geneva, Switzerland: Author. 90. Centers for Disease Control and Prevention. (2018). Child abuse and neglect prevention. Retrieved from https:// www.cdc.gov/violenceprevention/childabuseandneglect/ index.html. 91. U.S. Department of Health & Human Services, Administra- tion for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2018). Child maltreatment 2016. Available from https://www.acf.hhs. gov/cb/research-data-technology/statistics-research/child- maltreatment. 92. Centers for Disease Control and Prevention. (2018). Child abuse and neglect: Risk and protective factors. Retrieved from https://www.cdc.gov/violenceprevention/ childabuseandneglect/riskprotectivefactors.htmL 93. Dittrich, K., Boedeker, K., Kluczniok, D., Jaite, C., Attar, C.H., Fuehrer, D., ... Bermpohl, F. (2018). Child abuse potential in mothers with early life maltreatment, borderline personality disorder, and depression. The British Journal of Psychiatry, 213,412-418. https://doi-org. ezp.welch.jhmi.edu/10.1192/bjp.2018.74. 94. Ahmadabadi, Z., Najman, J.M., Williams, G.M., Clavarino, A.M., d’Abbs, P., Abajobira, A.A. (2018). Maternal intimate partner violence victimization and child maltreatment. Child Abuse and Neglect, 82(August 2018), 23-33. https:// doi.org/10.1016/j.chiabu.2018.05.017. 95. Centers for Disease Control and Prevention. (2018). Child abuse and neglect: Prevention strategies. Retrieved from https://www.cdc.gov/violenceprevention/ childabuseandneglect/prevention.html. 96. Nurse Family Partnership Program. (2018). About us. Retrieved from https://www.nursefamilypartnership.org/ About/. 97. Triple P Program. (2018). Find out about Triple P. Retrieved from https://www.triplep.net/glo-en/find-out- about-triple-p/. 98. Family Connections. (2018). Home. Retrieved from http://familyconnections.org/. 99. Centers for Disease Control and Prevention. (2018). Intimate partner violence. Retrieved from https://www.cdc.gov/ violenceprevention/intimatepartnerviolence/index.html. 100. World Health Organization. (2018). Violence against women. Retrieved from http://www.who.int/news-room/ fact-sheets/detail/violence-against-women. 101. Breiding, M.J., Basile, K.C., Smith, S.G., Black, M.C., & Mahendra, R.R. (2015). Intimate partner violence surveil- lance: Uniform definitions and recommended data elements, version 2.0 [PDF 283KB]. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. 102. Centers for Disease Control and Prevention. (2018). National intimate partner and sexual violence survey: 2015 data brief. Retrieved from https://www.cdc.gov/ violenceprevention/nisvs/2015NISVSdatabrief.html. 103. Walters, M.L., Chen J., & Breiding, M.J. (2013). The na- tional intimate partner and sexual violence survey (NISVS): 2010 findings on victimization by sexual orientation. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. 104. Centers for Disease Control and Prevention. (2017). Intimate partner violence: Consequences. Retrieved from https://www.cdc.gov/violenceprevention/ intimatepartnerviolence/consequences.html. 105. Hoelle, R.M., Elie, M., Weeks, E., Hardt, N., Wei, H., Hui, Y., & Carden, D. (2015). Evaluation of healthcare use trends of high-risk female intimate partner violence victims. Western Journal Of Emergency Medicine: Integrat- ing Emergency Care With Population Health, 16(1), 107-113. doi:10.5811/westjem.2014.12.22866. 106. World Health Organization. (2012). Femicide. Retrieved from http://apps.who.int/iris/bitstream/handle/10665/ 77421/WHO_RHR_12.38_eng ;sequence=1. 107. World Health Organization. (2009). Changing cultural and social norms supportive of violent behavior. Retrieved from http://www.who.int/violence_injury_prevention/violence/ norms . 108. Wathen, C.N., MacGregor, J.D., & MacQuarrie, B.J. (2018). Relationships among intimate partner violence, work, and health. Journal Of Interpersonal Violence, 33(14), 2268-2290. doi:10.1177/0886260515624236. 109. Yakubovich, A.R., Stöckl, H., Murray, J., Melendez-Torres, G.J., Steinert, J.I., Glavin, C.Y., & Humphreys, D.K. (2018). Risk and protective factors for intimate partner violence against women: Systematic review and meta-analyses of prospective-longitudinal studies. American Journal Of Public Health, 108(7), e1-e11. doi:10.2105/ AJPH.2018.304428. 310 U N I T I I n Community Health Across Populations: Public Health Issues 7711_Ch12_283-312 23/08/19 10:39 AM Page 310 110. Alvarez, C., Fedock, G., Grace, K.T., & Campbell, J. (2017). Provider screening and counseling for intimate partner violence: A systematic review of practices and influencing factors. Trauma, Violence & Abuse, 18(5), 479-495. doi:10.1177/1524838016637080. 111. Campbell, J., Webster, D., Koziol-McLain, J., Block, C., Campbell, D., Curry, M., ... Laughon, K. (2003). Risk factors for femicide in abusive relationships: Results from a multi- site case control study. American Journal of Public Health, 93(7), 1089-1097. doi:10.2105/AJPH.93.7.1089. 112. Niolon, P.H., Kearns, M., Dills, J., Rambo, K., Irving, S., Armstead, T., & Gilbert, L. (2017). Preventing intimate partner violence across the lifespan: A technical package of programs, policies, and practices. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. 113. Ghandour, R.M., Campbell, J.C., & Lloyd, J. (2015). Screening and counseling for intimate partner violence: A vision for the future. Journal of Women’s Health (15409996), 24(1), 57-61. doi:10.1089/jwh.2014.4885. 114. Sharps, P.W., Bullock, L.F., Campbell, J.C., Alhusen, J.L., Ghazarian, S.R., Bhandari, S.S., & Schminkey, D.L. (2016). Domestic violence enhanced perinatal home visits: The DOVE randomized clinical trial. Journal of Women’s Health (15409996), 25(11), 1129-1138. doi:10.1089/ jwh.2015.5547. 115. Agency for Healthcare Research and Quality. (2015). Intimate partner violence screening. Retrieved from http://www.ahrq.gov/professionals/prevention-chronic- care/healthier-pregnancy/preventive/partnerviolence.html. 116. Hamblen, J. & Goguen, C. (2016). U.S. Department of Veterans Affairs: Community violence. Retrieved from https://www.ptsd.va.gov/professional/trauma/other/ community-violence.asp. 117. The National Child Traumatic Stress Network. (n.d.). Community violence. Retrieved from https://www. nctsn.org/what-is-child-trauma/trauma-types/ community-violence. 118. Office of Justice Programs, Bureau of Justice Statistics. (n.d.). Crime in the United States. Retrieved from https://www.bjs.gov/index.cfm?ty=tp&tid=31. 119. Office of Justice Programs, Bureau of Justice Statistics. (2017). Criminal victimization, 2016. Retrieved from https://www.bjs.gov/index.cfm?ty=pbdetail&iid=6166. 120. New York State Office of Mental Health. (n.d.). Violence prevention: Risk factors. Retrieved from https://www. omh.ny.gov/omhweb/sv/risk.htm. 121. Armstead, T.L., Wilkins, N., Doreson, A. (2018). Indicators for evaluating community- and societal-level risk and protective factors for violence prevention: Findings from a review of the literature. Journal of Public Health Management and Practice, 24S, S42- S50. DOI: 10.1097/ PHH.0000000000000681. 122. Centers for Disease Control and Prevention. (2018). Youth violence. Retrieved from https://www.cdc.gov/ violenceprevention/youthviolence/index.html. 123. David-Ferdon, C., Vivolo-Kantor, A.M., Dahlberg, L.L., Marshall, K.J., Rainford, N. & Hall, J.E. (2016). A compre- hensive technical package for the prevention of youth violence and associated risk behaviors. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. 124. Merriam Webster Dictionary. (2018). Definition of war. Retrieved from https://www.merriam-webster.com/ dictionary/war. 125. Levy, B., & Sidel, V. (Eds.). (2007). War and public health (2nd ed.). Oxford, England: Oxford University Press. 126. Leitenberg, M. (2006). Deaths in wars and conflicts in the 20th century. Retrieved from http://www.cissm.umd.edu/ papers/files/deathswarsconflictsjune52006 . 127. Johnson, S.A. (2017, Jan 12). The cost of war on public health: An exploratory method for understanding the impact of conflict on public health in Sri Lanka. PLoS One, 12(1), e0166674. doi: 10.1371/journal.pone.0166674. eCollection. 128. Elsafti, A.M., van Berlaer, G.A., Safadi, M., Debacker, M., Buyl, R., Redwan, A., & Hubloue, I. (2016). Children in the Syrian Civil War: The familial, educational, and public health impact of ongoing violence. Disaster Medicine and Public Health Preparedness, 10(6), 874-882. doi: 10.1017/ dmp.2016. 129. Roser, M. (2018). War and peace. Retrieved from https:// ourworldindata.org/war-and-peace. 130. Hogopian, A. (2017). Why isn’t war properly framed and funded as a public health problem? Medicine Conflict Survival, 33(2), 92-100. doi: 10.1080/13623699.2017. 1347848. Epub 2017 Jul 10. 131. White, S.K. (2017). Public health and prevention of war: The power of transdisciplinary, transnational collaboration. Medicine and Conflict Survival, 33(2), 101-109. doi: 10.1080/13623699.2017.1327155. Epub 2017 May 25. C H A P T E R 1 2 n Injury and Violence 311 7711_Ch12_283-312 23/08/19 10:39 AM Page 311 7711_Ch12_283-312 23/08/19 10:39 AM Page 312 313 Public Health Planning Chapter 13 Health Planning for Local Public Health Departments Susan Bulecza, Laurie Abbott, and Barbara Little LEARNING OUTCOMES After reading the chapter, the student will be able to: KEY TERMS 1. Describe the historical development of public health departments (abbreviated in this chapter as PHDs). 2. Describe the structure and services of PHDs. 3. Describe the interdisciplinary workforce in PHDs. 4. Analyze key roles and responsibilities of public health nurses (PHNs) in PHDs. 5. Discuss current issues related to delivery of essential public health services by PHDs. 6. Investigate the role of PHDs in community assessment and planning for health needs of the community. 7. Identify the most frequent activities and services provided by PHDs. 8. Discuss financial and information technology resources needed to support PHDs. 9. Describe the challenges facing PHDs. 10. Discuss accreditation and evaluation of services provided by PHDs. Behavioral Risk Factor Surveillance System (BRFSS) Categorical funding Centralized system Community health assessment Decentralized system Directly observed therapy Geographic information system (GIS) Federally qualified health centers (FQHCs) Fetal death Healthy Start Medication electronic monitoring system Public health department (PHD) Public health informatics Public health system Public health systems and services research Shared or mixed system Vital statistics Women, Infants, and Children (WIC) n Introduction An official governmental body responsible for assuring the health of citizens residing within a county, municipality, township, or territory is called a public health department (PHD). PHDs are considered trusted conveners that fa- cilitate partnerships and coalitions to assess and address local public health issues. The basic mandate of the PHD is to protect and improve health in partnership with the community (see Chapter 1). Citizens generally think that the PHD is responsible for providing services related to commu- nicable diseases or immunization services. However, they may not be aware of the overarching mission of the PHD to promote and protect the health, defined more broadly than communicable diseases, of all peo- ple in the community. This mission can only be ac- complished through a host of health-care providers and community partners who pool together resources and coordinate services. These partners and their serv- ices make up the public health system.1 Although the PHD is not responsible for providing all health services U N I T III 7711_Ch13_313-342 21/08/19 11:13 AM Page 313 for a population, governmental agencies are responsi- ble for assuring essential community health services.2 The purpose of this chapter is threefold. It is important for all nurses to be aware of the role of local health depart- ments to (1) facilitate linkages between clients and serv- ices, (2) describe the role of the public health nurse in a PHD, and (3) discuss current challenges affecting PHDs. History of Public Health Departments Local official agencies in the United States developed out of local boards of health in the late 18th century.3 The first city to form a board of health was Philadelphia (1794), followed by Baltimore (1797), Boston (1799), Washington, DC (1802), New Orleans (1804), and New York City (1805).4 The concerns at that time were fo- cused on communicable diseases within densely popu- lated cities. In part because of a growing understanding of the connection between proper sanitation and disease, there was an expansion of municipal health departments in the 1880s and early 1900s.5 Another major growth pe- riod occurred with the passage of the Social Security Act in 1935, which provided millions of dollars for maternal and child health services for public health.4 The delivery of public health services in rural commu- nity settings presented unique challenges. Prior to the es- tablishment of formalized governmental units in rural areas, district nurses provided much of the work of public health.5 The progression of time and population growth within rural communities influenced the formation of county health departments, which provided public and en- vironmental health services including sanitation. In 1908, the first PHD to provide public health services was estab- lished in Jefferson County, Kentucky, and in 1911, two oth- ers were formed. Guilford County, North Carolina, expanded school health programs, and Yakima County, Washington, responded to a typhoid epidemic.5 The first exclusively rural county health department was in Robeson County, North Carolina.5 By 1921, the county movement had spread to 186 counties in 23 states, often with the help of private foundations.6,7 The Rockefeller Foundation de- veloped rural programs between 1910 and 1913 to:5 • Educate medical professionals and the public about hookworm disease; • Provide funds to sanitize communities for protection against hookworm and typhoid diseases; • Fund the employment of personnel to continue work in the counties. The financial support from the Rockefeller Founda- tion and other private foundations including the Commonwealth Fund, W.K. Kellogg Foundation, and, eventually, the Public Health Service (PHS) contributed to the rapid increase in county health departments during the early 20th century, from 1 in 1908 to 610 in 1932.5 Mission of Public Health The mission of public health had its beginnings in the mid- 19th century when physicians, housing reformers, advo- cates for the poor, and scientists trained in housing and civil engineering came together to target health problems associated with urbanization, industrialization, and immi- gration.8 The focus was largely on housing conditions and communicable diseases. The work of social reformers at Hull House in Chicago or the Henry Street Settlement with Lillian Wald (Chapter 1) are examples of this work. Beginning in the 1920s, the Committee on Adminis- trative Practice of the American Public Health Associa- tion (APHA) sought to define the mission of public health agencies.3,9 In 1933, the Committee on Administrative Practice of APHA listed two primary goals for local public health agencies:3 • Control of communicable diseases • Promotion of child health These goals reflected the basic public health needs of the time, recognizing that children suffered the most from communicable diseases. By 1940, another APHA statement produced a clearer listing of the six minimum functions of local health departments:10 • Vital statistics • Environmental sanitation • Communicable disease control • Public health laboratories • Maternal and child health • Public health education The mission of public health was revisited with the In- stitute of Medicine (IOM) report in 1988. At that time, public health was redefined (see Chapter 1), and the mis- sion was defined as fulfilling society’s interest in assuring conditions in which people can be healthy.11 The three core functions of assurance, assessment, and policy for- mation evolved from this work. Structure of Public Health Departments As hospitals have different corporate and organizational structures, so does the infrastructure for public health agencies vary on the state and local levels. Thus, the adage, “When you have seen one health department, you have seen one health department,”1 means that no two health departments are alike. Knowing how the PHD is 314 U N I T I I I n Public Health Planning 7711_Ch13_313-342 21/08/19 11:13 AM Page 314 organized is of key importance for nurses to understand how public health services are delivered in their state and community. Generally, PHDs are organized by one of three major delivery modes: • Centralized (state) system: PHDs are operated by a state health agency or board of health, and the PHD functions under the state agency (five states). • Decentralized (local) system: PHDs are operated by local government with or without a board of health (27 states). • Shared or mixed system: PHDs are operated under shared or combined authority of the state health agency, board of health, and local government (16 states).12,13 • Hawaii and Rhode Island have state, not local, PHDs.12 Similar to the size of the hospital (number of beds) and nurse-to-patient ratio, the size of the population the PHD serves is a critical factor in local public health service delivery. Figure 13-1 illustrates the percentage of small, medium, and large PHDs and the percentage of the U.S. population served by these PHDs. It is interest- ing to note that 51% of the population is served by only 6% of large PHDs, whereas 62% of small PHDs cover 10% of the population.12 The type of jurisdiction or territory served by the PHD is another organizational factor. The majority of PHDs C H A P T E R 1 3 n Health Planning for Local Public Health Departments 315 (69%) are county-based with smaller percentages serving a city or town (20%) as well as city/county (3%) areas such as Miami-Dade in Florida12 (Fig. 13-2). Proposed as a method for strengthening public health services in rural areas, multicounty or regional jurisdictions encom- pass 8% of all PHDs.12,13 PHDs located in rural areas are challenged by infra- structural issues related to limited resources and isola- tion.14 And yet, they are often called upon to address widening health disparities and worsening health out- comes than those in urban areas.15 For example, mor- bidity and mortality rates reported for rural areas are often higher, and the environmental health challenges related to agricultural pollution and unsafe mining and logging practices contribute to the problem. People liv- ing in rural areas are typically older, poorer, and more likely to have been diagnosed with chronic diseases.15 In fact, the more remote the rural area is, the lower the life expectancy.15 Public Health Workforce The PHD workforce is interdisciplinary, and the majority of PHDs have fewer than 100 employees. The types of oc- cupations typically found in PHDs include physicians, environmental health specialists, dietitians, social work- ers, pharmacists, epidemiologists, information technol- ogy (IT) specialists, health educators, public information specialists, and nurses. The 2016 National Association of City and County Health Officials (NACCHO) survey re- ported that registered nurses comprised 18% of the pub- lic health workforce composition, a notable decrease from 24% in 2005 (Fig. 13-3).12 Depending on the juris- diction, some PHDs employ mental health service providers (2%), physicians (1%), and licensed practical nurses (2%).12 Staffing patterns vary depending on the size and services provided by the PHD. Historically, the sociodemographic characteristics of the public health workforce have not adequately repre- sented the diversity of the communities served. The re- ported findings of a study by NACCHO were that the local health department workforce is predominately Cau- casian (72.2%).16 The PHD employees belonging to spe- cific racial and ethnic minority groups (overall, 27.8%) were African American (15.8%), American Indian/Alaska Native (0.5%), Asian (3.8%), Native Hawaiian/Other Pacific Islander (1.9%), and Some Other Race/Two or more Races (5.8%).16 Regarding ethnicity, a small per- centage of all PHD employees are Hispanic (10.5%), but most are Not Hispanic or Latino (89.5%).16 The larger the size of the population served, the greater the percentage of diverse workers employed by the PHD.16 Small (<50,000) 62% 33% 6% 51% 10% 39% 0 N = 2,533 10 20 30 40 50 Percent Percent of U.S. Population Served by PHDs 60 70 Medium (50,000–499,999) Large (500,000+) Percent of all PHDs Percent of population served by PHDs Figure 13-1 Percentage of PHDs and percentage of U.S. population served, by size of population served. (© 2017. National Association of County and City Health Officials. The 2016 national profile of local health departments. Retrieved from http://nacchoprofilestudy.org/wp-content/uploads/2017/10/ ProfileReport_Aug2017_final ) 7711_Ch13_313-342 21/08/19 11:13 AM Page 315 Role of Public Health Nurses in Public Health Departments Nurses who work within a PHD are usually considered public health nurses (PHNs). PHNs make up one of the largest professional groups within the health department. Not all PHNs work within an official agency. The relevance of nursing to public health was rec- ognized in the early 1920s when C.E. Winslow’s defi- nition of public health highlighted the role of nursing services:17 Public health is the science and art of preventing disease, prolonging life, and promoting physical and mental health well-being through organized community effort for the san- itation of the environment, the control of communicable infections, the organization of medical and nursing services for the early diagnosis and prevention of disease, the education of the individual in personal health, and the development of social machinery to assure everyone a stan- dard of living adequate for the maintenance or improve- ment of health. In addition, APHA’s 1933 and 1940 statements of the mission of public health emphasized the role of public health nursing in several functions of the health depart- ment, especially communicable disease and maternal- child health.3 Core Functions Today, PHNs who work in PHDs promote and protect the health of the entire population in a community through the three core public health functions:11 • Population assessment • Assurance of a well-coordinated system of health promotion and health-care services • Policy development to support the health of the community 316 U N I T I I I n Public Health Planning City or town County Multi-city Multi-county Geographic Jurisdictions Served by PHDs Figure 13-2 Percentage distribution of PHDs by type of geographical jurisdiction. (© 2017. National Association of County and City Health Officials. The 2016 national profile of local health departments. Retrieved from http://nacchoprofilestudy. org/wp-content/uploads/2017/10/ProfileReport_Aug2017_final ) 7711_Ch13_313-342 21/08/19 11:13 AM Page 316 C H A P T E R 1 3 n Health Planning for Local Public Health Departments 317 Figure 13-3 Percentage distribution of occupations in the PHD workforce. (© 2017. National Association of County and City Health Officials. The 2016 national profile of local health departments. Retrieved from http://nacchoprofilestudy.org/ wp-content/uploads/2017/10/ProfileReport_Aug2017_final ) Agency Leadership (5%) Business Operations Staff (5%) Preparedness Staff (2%) Nutritionists (4%) Health Educators (4%) Community Health Workers (4%)Nursing or Home Health Aide (2%) Oral Health Care (1%) Info Systems (1%) Lab Workers (1%) Animal Control (1%) Physicians (1%) Epi/stats (1%) Office Support Staff (18%) Estimates shown (detail lost due to rounding). Public information professional (0.4%) not shown. n = 1,611–1,828 Registered Nurses (18%) Other Occupations Not in Profile (18%) Licensed Practical or Vocational Nurse (2%) Behavioral Health Staff (2%) Environmental Health Workers (10%) Workforce Composition These functions and their related essential services18 were introduced in Chapter 1 (see Box 1-1), and their rel- evance for guiding local health departments is further explored in this chapter. We can apply the core functions to public health nursing within a PHD setting using immunization as an example of an intervention to promote the health of a population/community. Assessment is illustrated when PHNs working in PHDs gather epidemiological data to determine the rate of children fully immunized against specific communicable diseases (e.g., measles, H1N1 influenza). A high immunization rate (>70%) is

7711_Ch13_313-342 21/08/19 11:13 AM Page 317

and assuring the provision of health care when otherwise
unavailable.18 Continuing with the immunization exam-
ple, PHD PHNs refer college students to their primary
care provider, college health center, or local health de-
partment to obtain needed immunizations.

Public Health Interventions
A useful conceptual framework for understanding how a
health department provides population-based care is the
Intervention Wheel, which was introduced in Chapter 2.21

The Intervention Wheel depicts 17 PHN interventions
provided on the individual, community, or systems level
to affect the health of individuals and families that make
up the community.

PHD PHNs usually provide several types of interven-
tions to address a single issue and these interventions
may be directed at different levels of care. The Interven-
tion Wheel model depicts three levels of care: (1) indi-
vidual, (2) community, and (3) systems.21 For example,
interventions for reducing tobacco use can be provided
for all three levels of care. On the individual level, a PHD
PHN may counsel a pregnant woman about ways to stop
smoking. A community-level intervention may be used
to have an impact on more smokers through group edu-
cation. The PHD PHN may teach tobacco cessation
classes that target teens. Nurses working in PHDs also
direct interventions at the systems level, which affects the
health of the populations and may have the greatest

318 U N I T I I I n Public Health Planning

needed to provide a community level of immunity (herd
immunity) to protect the population (see Chapter 8).19

Another example of the application of core functions
by PHNs in PHDs is their involvement in writing and
implementing policies that require immunizations for
entry into day care, schools, and colleges to help ensure
that herd immunity level is obtained for the protection
of students, staff, and families. If the rate is lower, PHNs
assure immunization services are provided by mobiliz-
ing community partners to target specific groups that
have low immunization rates and by providing easily
accessible immunizations in pediatric clinics and
schools. This example demonstrates the role of PHD
PHNs in assessment, assurance, and policy develop-
ment to decrease the risk of communicable disease
transmission in their community. Underlying these
three functions is the assumption that the PHN work-
ing in the PHD will provide ethical and moral leader-
ship in providing public health services as outlined by
the Public Health Leadership Society20 (Box 13-1).

Essential Services
The core functions of a PHD are further delineated in the
10 essential public health services that illustrate to legis-
lators and the general public what public health does (see
Chapter 1) (Fig. 13-4). For example, the assurance func-
tion is further defined in the essential public health serv-
ice of linking people to needed personal health services

• Public health should principally address the fundamental
causes of disease and requirements for health, aiming to
prevent adverse health outcomes.

• Public health should achieve community health in a way
that respects the rights of individuals in the community.

• Public health policies, programs, and priorities should be
developed and evaluated through processes that ensure
an opportunity for input from community members.

• Public health should advocate and work for the empow-
erment of disenfranchised community members, aiming
to ensure that the basic resources and conditions neces-
sary for health are accessible to all.

• Public health should seek the information needed to
implement effective policies and programs that protect
and promote health.

• Public health institutions should provide communities
with the information they have that is needed for deci-
sions on policies or programs and should obtain the
community’s consent for their implementation.

• Public health institutions should act in a timely manner
on the information they have within the resources and
the mandate given to them by the public.

• Public health programs and policies should incorporate a
variety of approaches that anticipate and respect diverse
values, beliefs, and cultures in the community.

• Public health programs and policies should be imple-
mented in a manner that most enhances the physical
and social environment.

• Public health institutions should protect the confidential-
ity of information that can bring harm to an individual or
community if made public. Exceptions must be justified
on the basis of the high likelihood of significant harm to
the individual or others.

• Public health institutions should ensure the professional
competence of their employees.

• Public health institutions and their employees should
engage in collaborations and affiliations in ways that build
the public’s trust and the institution’s effectiveness.

BOX 13–1 n Principles of the Ethical Practice of Public Health

Source: (18)

7711_Ch13_313-342 21/08/19 11:13 AM Page 318

potential for improving health-care outcomes. For ex-
ample, in considering a population, intervening on the
systems and policy levels to levy tobacco taxes is likely
more effective for tobacco cessation at a community level
than individually counseling people to quit smoking22

(see Chapter 11).
What does intervening at a systems level mean?

For at least 10 years, the Tobacco Control Research
Branch of the National Cancer Institute studied a trans-
disciplinary initiative to explore systems thinking
approaches and methods in tobacco prevention and
control, resulting in a 2007 monograph titled Greater
Than the Sum: Systems Thinking in Tobacco Control.23

The complexity involved in systems thinking was dis-
cussed, for example, by presenting a framework for
investigating the social ecology of tobacco use. The mul-
tiple factors at play included actions of the tobacco in-
dustry, regulatory systems (smoke-free laws, taxation
levels), and the tobacco use control subsystem (quit lines,
social marketing, multilevel networks).24,25 One can
address any of these factors from a systems perspective.

Ideally, PHD PHNs and community partners work to-
gether to implement the core functions, essential services,
and public health nursing interventions to ultimately

meet the Healthy People 2030 (HP 2030)-proposed vision
of a “society in which all people achieve their full potential
for health and well-being across the life span.”26 To help
illustrate how this is done, the next section describes how
a PHD implements core functions, essentials services, and
interventions to address high infant mortality rates in
their community (Fig. 13-5).

C H A P T E R 1 3 n Health Planning for Local Public Health Departments 319

Monitor
Health

ResearchResearchResearch

Diagnose
& Investigate

Inform,
Educate,

Empower

Mobilize
Community
PartnershipsEnforce

Laws
Develop
Policies

Link
to/Provide
Care

Assure
Competent
Workforce

Evaluate

Sy
st

em
Management

A
S

S
U

R
A

N
C

P
O

LICY DEVELOPMENT

ASSESSMENT
Figure 13-4 Essential services and core functions of
public health. (From the Public Health Functions Steering
Committee, 1995. Retrieved from http://www.health.gov/
phfunctions/public.htm)

w SOLVING THE MYSTERY
The Case of the Dying Babies
Public Health Science Topics Covered:
• Assessment
• Epidemiology
• Surveillance
• Rates

Health problems are identified in a variety of ways,
often simultaneously. In hypothetical Beach County, the
death of a 5-month-old infant of a 14-year-old mother
was highly publicized in the local media, and community
members were outraged that this occurred in their
“backyard.” A nurse leader at the PHD was asked to
convene a community work group to assess the issues,
especially because this was not viewed as an isolated
case, and to make recommendations for addressing
infant mortality in her community.

The nurse leader decided to begin by conducting
an assessment on the population level. Community
health assessments (see Chapter 4) are ongoing
activities by PHDs, and formal community health as-
sessments are usually conducted every 3 to 5 years.25

There are several frameworks for conducting a com-
munity health assessment, including the Community
Health Assessment and Group Evaluation tool
(CHANGE) (see Chapters 4 and 5). Beach Health
Department selected the Mobilizing for Action
Through Planning and Partnerships (MAPP) because
of its emphasis on a community-driven process facili-
tated by the PHD.25 This framework, which consists
of four different types of assessments, allows commu-
nities to apply strategic thinking to prioritize public
health issues and identify resources to address them
(see Chapters 4 and 5). In this case, the PHD was
very concerned about the infant mortality issue and
decided to focus its assessment on a specific popula-
tion: mothers and babies. Because a comprehensive
assessment was due in approximately 2 years, this
phase was viewed as a narrower perspective for
identifying the issues surrounding the infant mortality
problem.

7711_Ch13_313-342 21/08/19 11:13 AM Page 319

320 U N I T I I I n Public Health Planning

Local health departments

Partners in the local public
health system:
•Churches
•Civic groups
•Community centers
•Corrections
•Drug treatment
•Economic development
•Elected officials
•Emergency medical
services/Hospitals
•Environmental health
•Employers
•Federally funded
community health centers
•Fire department
•Health care providers
•Home health
•Laboratory facilities
•Mass transit
•Mental health
•Nursing homes
•Schools
•Parks and recreation
•Police
•Tribal health
•And many more!

“A society in which all
people live long, healthy
lives” – Healthy People,
https://www.healthy
people.gov/2020/
About-Healthy-People

Core Functions
• Assessment
• Assurance
• Policy Development
10 Essential services
• Monitor health status
• Diagnose and investigate health problems and health hazards
• Inform, educate & empower people about health issues
• Mobilize community partnerships
• Develop policies & plans
• Enforce laws & regulations
• Link people to needed services & assure provision of services
• Ensure a competent workforce
• Evaluate effectiveness, accessibility & quality of health
services
• Research for new insights and innovative solutions
Public Health Nursing Interventions
• Surveillance
• Disease & Health Event Investigation
• Case Finding
• Outreach
• Screening
• Referral & Follow-up
• Case Management
• Delegated Functions
• Health Teaching
• Counseling
• Consultation
• Collaboration
• Coalition Building
• Community Organizing
• Advocacy
• Social Marketing
• Policy Development & Enforcement

Inputs Strategies

Vision: A healthy and safe community where individuals can thrive and prosper
Mission: Collaborate with community partners to promote and assure high quality,

accessible health and human services for local residents

Outcomes

Figure 13-5 Framework for the delivery of population-focused health services on the local level. (Created by B. Little and
S. Bulecza, 2013.)

There were several steps involved in the assess-
ment, all exhibiting evidence of the essential services.
The nurse leader contacted the state department of
health and arranged for training on MAPP, thus assur-
ing a competent workforce, the eighth essential public
health service. A MAPP committee was formed to
guide the health planning process, with broad repre-
sentation of the community and local public health
system including community members, nurses, and
health-care providers from the local hospital, schools,
and private practices. Elected officials were asked to
join as well as a pregnant woman and teen mothers.

This committee is an example of the fourth essential
public health service: mobilizing community partner-
ships to identify and solve health problems. The
assessment was initiated by the PHD in this case,
bringing not only a public health perspective to the
issue but also a governmental legitimacy and sense of
urgency.

The committee began with a brainstorming activity
to formulate a shared community vision and values
statements to guide the community-driven planning
process. A timeline was established, and a preliminary
plan was written that identified the work to be done.

7711_Ch13_313-342 21/08/19 11:13 AM Page 320

C H A P T E R 1 3 n Health Planning for Local Public Health Departments 321

As explained in Chapter 4, MAPP is divided into four
assessments:25

1. The Community Themes and Strengths As-
sessment provides a deep understanding of the is-
sues that residents feel are important by answering
the open-ended questions about what is important
to the community. In this case, it might involve
some key informant interviews or focus groups as-
sessing the strengths and problems surrounding the
care of mothers in the community.

2. The Local Public Health System Assessment
focuses on the organizations and entities that con-
tribute to the public’s health. In this case, it would
be important to assess the organizations providing
services to mothers and babies.

3. The Community Health Status Assessment
identifies priority community health and quality of
life issues. It includes identifying the indicators fo-
cused on maternal-child health and gathering sec-
ondary and primary data related to these indicators.

4. The Forces of Change Assessment focuses on
identifying forces such as legislation, technology, and
other impending changes that affect the context in
which the community and its public health system
operate. In this case, a key question was focused
on the impending changes regarding funding for
maternal-child services in the county.

The members of the core steering committee di-
vided themselves according to interest or expertise
into one of four groups. The nurse and the PHD epi-
demiologist provided support to each of the subcom-
mittees. This assessment illustrates how the PHD
implements the essential services of monitoring health
status to identify, diagnose, and investigate health prob-
lems and health hazards in the community.

During the next several months, subcommittees met
on a regular basis and periodically reported on progress
and findings to each other. For example, the Forces of
Change subcommittee reported on a newly funded
grant for the development of a federally funded health
center in a neighborhood where there was a high infant
mortality rate. The Community Health Status subcom-
mittee asked the PHD epidemiologist for additional vital
statistics and geographic information systems (GIS) data,
described later in this chapter, and assistance with ana-
lyzing the rate of infant mortality and teen births by ZIP
code, race, and age. The committee also gathered
secondary data from the state and county Behav-
ioral Risk Factor Surveillance System (BRFSS)

survey data about high-risk behaviors as well as county
data about neonatal mortality, infant mortality, per-
centage low birth weight, percentage very low birth
weight, percentage of prenatal care initiated in the first
trimester, percentage of mothers who smoke, and the
prevalence of sudden infant death syndrome (SIDS).
BRFSS is a behavioral and noncommunicable disease
surveillance system sponsored by the Centers for
Disease Control and Prevention (CDC).26 The surveys
are conducted via land line telephones and recently
expanded to include cell phones. The Community
Themes and Strengths Assessment group decided to
focus on a series of listening or focus groups with mi-
nority residents and youth, whereas the Local Public
Health System Assessment group focused on identify-
ing resources within the community addressing health
concerns. They conducted an Inventory of Resources
(see Chapter 4).

After the subcommittees completed their assess-
ments, the nurse leader compiled the results and pre-
pared a presentation and agenda for the next MAPP
committee meeting. The report consisted of county-
specific data, health status compared with state
objectives, trends, disparities, assets, and summary con-
clusions. The results showed that the infant mortality
rate was 9.6 deaths per 1,000 live births compared with
7.1 for the state. There were racial differences, also:
a rate of 12.7 deaths per 1,000 live births for African
Americans and a rate of 6.2 for the white population.
Only 68.4% of the African American population re-
ceived prenatal care in the first trimester compared
with 80% for the total population. Fifteen percent of
pregnant women smoked in Beach County compared
with 12% statewide. The percentage of low birth weight
was much higher for the minority population (12%)
compared with that of the white population (7.8%). Low
birth weight was similar to the state findings. The teen
birth rate was 71 per 1,000 live births compared with
67 per 1,000 live births only 2 years earlier.

The core committee met to review the data. Com-
munity issues were discussed and a list of four issues
were identified and arranged by priority. In Beach
County, some of the issues directly related to infant
mortality were delayed prenatal care, increased low
birth weight, high birth rates among teens, and tobacco
use during pregnancy. Each issue was further re-
searched for best practices, and goals and strategies
were developed. In addition, the committee estab-
lished a community goal for reducing infant mortality
to 6 per 1,000 live births within 3 years.

7711_Ch13_313-342 21/08/19 11:13 AM Page 321

Local Health Department Activities
In 2016, PHDs were surveyed by NACCHO to identify
not only structure but also function and capacity of local
PHDs. The role of PHDs has changed during the past
century and has been shaped by historical events. The
events of September 11, 2001, brought to the forefront
an awareness of the role of PHDs in disasters. The recent
natural disasters in the United States including hurri-
canes, wildfires, and floods as well as manmade tragedies
such as mass shootings have emphasized the necessity of
public health services to an even greater degree.

The following section describes a contemporary view
of the activities of PHDs and recognizes that separating
out activities solely performed by local health departments
is indeed difficult. The 2016 NACCHO survey asked
PHDs to report those activities performed only by the
PHD, those done in concert with the state, and those done
by contracting out to other members of the public health
system. The 10 most frequent activities and services pro-
vided by PHDs directly are found in Table 13-1.12 It is clear
that more than three-fourths of PHDs provide these serv-
ices. Other services are provided through contractual re-
lationships with other organizations such as lab services,
by other governmental agencies (animal control), or
through nongovernmental organizations (NGOs). The
contractual agreements are one way for PHDs to assure
that needed health services are available to its citizens.29

There are five categories used to summarize the major
activities of PHDs:30

1. Environmental health services
2. Data collection and analysis: health and vital

statistics
3. Individual and community health
4. Disease control, epidemiology, and surveillance
5. Regulation, licensing, and inspection

322 U N I T I I I n Public Health Planning

This MAPP example illustrates the PHD role in
conducting community assessments, facilitating health
planning, and collaborating with partners to target high-
priority issues. During the next year, the MAPP com-
mittee entered the action cycle and sought funding
from public and private donors to establish a Nurse-
Family Partnership27,28 community health program with
nurse home visits for low-income, first-time mothers.
Through administration of the home visitation
program, the PHD addressed the essential service of
linking people to needed personal health services and
assuring the provision of health care when otherwise
unavailable.

n EVIDENCE-BASED PRACTICE
The Nurse-Family Partnership Model
for Providing Home-Visiting for
Low-Income, First-Time Mothers
and Their Children

Practice Statement: Nurses provide prenatal
and child health education, care coordination, and
life coaching during home visits that begin during
pregnancy and continue through the child’s second
birthday.
Targeted Outcome: Improved prenatal health,
fewer childhood injuries, fewer subsequent
pregnancies, increased intervals between births,
increased maternal employment, improved school
readiness
Evidence to Support: Randomized controlled
trials and economic analysis suggest improved
long-term outcomes for mothers and children in the
nurse-family partnership home visitation program.
Nurse-family partnership programs are available in
43 states and participate in a web-based data collec-
tion and evaluation system that allows programs to
measure progress toward meeting nurse-family part-
nership benchmarks for maternal and child health
outcomes.
Recommended Approaches: The nurse-family
relationship is the cornerstone of the home-
visiting program that is based on a client-centered,
strengths-based approach to support personal and
family functioning. Nurses are equipped with tools,
education, and resources to improve family out-
comes. The nurse-family partnership agency provides
the infrastructure to ensure high quality implementa-
tion and ongoing program evaluation in local
communities.

Sources:
1. Nurse-Family Partnership.27 (2018a). Overview. Retrieved

from https://www.nursefamilypartnership.org/wp-
content/uploads/2017/07/NFP_Overview

2. Nurse-Family Partnership.28 (2018b). Research trials and
outcomes. Retrieved from https://www.nursefamily
partnership.org/wpcontent/uploads/2017/07/NFP_
Research_Outcomes_2014

3. Nurse-Family Partnership.29 (2018c). Nurses and
mothers. Retrieved from https://www.nursefamily
partnership.org/wpcontent/uploads/2017/07/NFP_
Nurses_Mothers

7711_Ch13_313-342 21/08/19 11:13 AM Page 322

Environmental Health Services
Environmental health services are focused on ensuring
that communities have safe water, safe food, and
sanitary environments. For example, local health de-
partments located near beaches are responsible for
conducting periodic water sampling to ensure that the
water does not contain high levels of contaminants or
bacteria. If bacteria or contaminants are found at levels
out of the normal range that pose a risk to persons
swimming at the beach, then local health departments
have the authority to close the beach until levels return
to an acceptable range.

Environmental services are the backbone of public
health infrastructure in developed countries and have
eliminated such problems as cholera and diarrheal dis-
ease. In fact, in 1940, environmental sanitation was
viewed as a minimum function of local health depart-
ments to address proper public and private water sup-
ply systems and sewage disposal, restaurant inspections,
insect and rodent control, housing inspections, and
environmental complaints.3 The development of solid
waste management is interesting. At the time of the
infectious epidemics in the 1800s, funding was not

available for a regional approach to solid waste man-
agement, which resulted in municipal approaches to
dealing with the problems.30 Today, solid waste man-
agement is largely handled by municipalities and oper-
ated by private companies.

Environmental concerns today are often seen as the
responsibilities of both local and state agencies as well
as other local governmental agencies or NGOs. In the
most recent NACCHO 2016 survey, food safety educa-
tion and vector control activities were most often con-
nected with the PHD as the resource. State health
departments were most often listed as resources for
indoor air quality, groundwater protection, noise pollu-
tion, hazardous waste disposal, air pollution, and radia-
tion control.12 With any of these activities, there is a
great deal of variability, with many agencies often
assuming some level of responsibility. In another study
examining the combined roles of state and local health
departments, the PHD was typically found to oversee
private water supplies and septic systems.31 A list of typ-
ical environmental concerns is found in Box 13-2 (see
also Chapter 6).

C H A P T E R 1 3 n Health Planning for Local Public Health Departments 323

TABLE 13–1 n Percentage of Public Health
Department Jurisdictions With
10 Most Frequent Activities
and Services

Available Through PHDs Directly

Percentage of
Activity or Service Jurisdictions

Adult Immunization Provision

Communicable/Infectious Disease
Surveillance

Child Immunizations Provision

Tuberculosis Screening

Food Service Establishment Inspection

Environmental Health Surveillance

Food Safety Education

Tuberculosis Treatment

Schools/Day Care Center Inspection

Population-Based Primary Prevention:
Nutrition

Source: (12)

90%

93%

88%

84%

79%

85%

77%

79%

74%

• Inspect and investigate food service and outlets, from
wholesale to retail.

• Inspect and investigate wastewater management
systems, either community or individual homes
(septic tanks).

• Inspect and investigate solid and hazardous waste site
investigations.

• Conduct sanitary surveys of potential or existing water
systems and watersheds.

• Conduct investigations of facilities, institutions, and
licensed establishments.

• Inspect swimming pools and recreational facilities.
• Investigate hazardous materials and radiation hazards

or spills.
• Manage occupational health and safety programs.
• Investigate and analyze potential toxic exposures.
• Conduct community education and provide expertise

on environmental conditions.
• Assure animal and vector control including rabies

surveillance.
• Address sanitary nuisances.

BOX 13–2 n Environmental Health Services
Potentially Provided by Public Health
Departments

Source: Centers for Disease Control and Prevention. (2014). Environmental public
health performance standards. Retrieved from http://www.cdc.gov/nceh/ehs/
envphps/Docs/EnvPHPSv2

7711_Ch13_313-342 21/08/19 11:13 AM Page 323

Data Collection and Analysis: Health
and Vital Statistics
Most data collection and analysis activities are state-level
functions, although the process of collecting statistics be-
gins at the local level. Vital statistics are data collected
regarding births, deaths, marriages, and divorces. Data
are forwarded to the state, where they are compiled and
sent to the CDC National Vital Statistics System.32 This
is the oldest process for sharing public health data across
governmental agencies. It requires that these agencies
share standards and procedures so that the National
Center for Health Statistics can monitor, store, and
disseminate the nation’s official vital statistics.

When a baby is born, the hospital completes a birth
form that is submitted to the PHD. The PHD then issues
the official birth certificate to the child’s parents. The
birth record includes data that can be found on the offi-
cial birth certificate such as the birth date, place of birth,
and parents’ names. It also includes a wealth of other in-
formation not listed on the official birth certificate. These
data include neonatal outcomes, risk factors related to
adverse outcomes, and protective factors related to pos-
itive outcomes.33 Information is included on parental de-
mographic and behavioral variables such as age, level of
education, race, and maternal use of alcohol, tobacco,
and other drugs during pregnancy. Information is also
collected related to the pregnancy and delivery, such as
the number of prenatal visits, when the trimester prena-
tal care began, and the type of delivery. Finally, data are
collected on the newborn. In addition to weight, head
circumference, and length, data are collected on infor-
mation related to the neonate’s weeks of gestation and
congenital defects. Data are obtained from the medical
record, the health provider of record, and from family
members. These data provide important information
needed to understand population-level trends related
to birth and facilitates evaluation of how well Healthy
People objectives are being met.

Likewise, PHDs collect mortality data based on the in-
formation obtained from death records. The first part of
the document includes basic demographic information
about the deceased that is completed by the funeral direc-
tor or other person in charge of internment. This same
person is also responsible for filing the certificate with the
registrar in the location where the death occurred. The
medical examiner or coroner certifying the death com-
pletes the second section of the document that specifies
the cause of death. The certificate contains essential de-
mographic data as well as date and time of death, where
the death occurred, and the primary cause of death. Like
the birth record, the death record includes more data than

what is contained in the death certificate. The death
record includes information about the conditions that
contributed to the death, history of tobacco use, race, and
other variables.33 These data are used to evaluate mortality
trends at the population level. If the death was due to an
injury, information related to the injury is also collected.
Data regarding causes of death are compiled from death
certificates and used to determine specific disease, injury,
or mode of death rates within communities and the state.
For example, death data are used to determine the num-
ber of cancer deaths in a community and to help during
community assessments and health system planning. For
infants aged less than 1 year, linked birth and death cer-
tificate files provide information to determine significant
risk factors that influenced fetal mortality.

Another required vital record is fetal death. Fetal
death is a spontaneous intrauterine death of a fetus at
any time during pregnancy. Again, the record includes a
section to complete the basic information related to
parental demographic data, time and date of delivery,
and gender of the fetus. The second section relates to the
cause of death and conditions contributing to the fetal
death. The data not only provide an official record of
the death, the additional information also facilitates
population-level assessments and program planning.
Most states report fetal deaths of at least 20 weeks of ges-
tation and/or birth weight of 350 grams or more.

Although states are responsible for the analysis of
most data, the PHD is typically responsible for the col-
lection and analysis of data regarding the Reportable Dis-
eases category.12 In addition, in some states with local
boards of health, morbidity data are sometimes collected
at the local level.

There are many uses for vital statistics. Birth and death
certificates are used to legally establish citizenship and ob-
tain drivers licenses and Social Security cards, and are
required in the probating of a will. Vital statistics help
genealogists conduct family research and establish ties be-
tween individuals. Most importantly, vital statistics from
a global perspective are vital to understanding the health
of populations, determining life expectancy, and helping
to guide interventions aimed at improving health.

324 U N I T I I I n Public Health Planning

n CULTURAL CONTEXT
The Future of the Public’s Health in the 21st Century35

“A healthy community is a place where people pro-
vide leadership in assessing their own resources and
needs, where public health and social infrastructure and
policies support health, and where essential public

7711_Ch13_313-342 21/08/19 11:13 AM Page 324

Individual and Community Health
The role of some PHDs in assuring the health of popula-
tions sometimes involves providing direct individual care
as well as providing care at the community level. Direct
individual care provided by PHDs can include a variety of
services such as prenatal and well-baby clinics, clinics for
communicable diseases (e.g., tuberculosis [TB], sexually
transmitted infections [STIs]), primary care clinics, school
health services, and vaccination clinics. Comparing PHDs,
there is probably no area within the local public health sys-
tem with as much diversity in programs for the provision
of direct individual care. Some health departments provide
no direct care at all, whereas others provide a wide variety
of care. The City of Cincinnati Health Department, for
example, includes home-care services, pharmacy, school
nursing, and multiple clinics.34 Other PHDs contract out
services or the services are available only through NGOs.

At one time, the provision of primary care services
(see Chapter 15), particularly to underserved and eco-
nomically disadvantaged citizens (and areas), was part of
the mainstream of public health activities. There has been
a national effort to have governmental public health
services return their attention to more population-based
public health services.35 Consequently, a transfer of
services has taken place, and this has been done in many
different formats. PHDs have contracted or networked
with their local hospital system to fund primary care
services as a more cost-effective alternative to emergency
room visits for the same service. In some cases, the most
recent 2016 NACCHO survey found that certain activi-
ties were exclusively provided through contracts:12

• Laboratory services, 14%
• HIV/AIDS treatment, 9%
• HIV/AIDS screening 8%
• STI screening, 8%
• STI treatment 7%
• Population-based tobacco prevention services, 7%
• TB treatment, 7%

• Cancer screening, 6%
• Oral health, 6%

Another process for PHDs to obtain funding for
providing care is through federally qualified health
centers. Federally qualified health centers (FQHC)
are funded through the Health Resources and Service
Administration (HRSA) under section 330 of the Pub-
lic Health Service Act. There are multiple benefits for
having a FQHC, including enhanced reimbursement
from Medicare and Medicaid. FQHC must serve an
underserved area or population, offer a sliding fee
scale, and provide comprehensive services.36 They
must also have an ongoing quality assurance program
with a governing board of directors.

Maternal and Child Health
Maternal-child services have traditionally been a key
component of any PHD (see Chapter 17). This goes back
to the early 20th century as evidenced in the APHA mis-
sion statements.9,10 The overall goal of maternal-child
services has been to improve the health of mothers and
children through the delivery of preventive interven-
tions. Although these efforts have changed over time,
they are still an important aspect of PHD services. PHDs
either provide these services directly or help to link their
constituents with available services. For maternal-child
health services overall, the 2016 NACCHO survey shows
that the current services provided most often in PHDs
are Women, Infants, and Children (WIC) services
(66%), MCH home visits (60%), and family planning
(53%).12 The importance of these programs was under-
scored by HRSA in 2017 when they provided $342 mil-
lion in funding to 55 states, territories, and nonprofit
organizations through the Maternal, Infant, and Child-
hood Home Visiting Program.37 The money is awarded
to provide evidence-based home visiting services to preg-
nant women and families with young children from birth
until entry into kindergarten.37

One example of a comprehensive maternal-child health
program is Healthy Start, which focuses on reducing in-
fant mortality and low birth weight. The Healthy Start ini-
tiative was signed into law in 1991 and is funded through
HRSA.38 In this program, nurses working at PHDs engage
in multiple services from group-level activities, such as
health education for expectant and new mothers to indi-
vidual care in prenatal and well-baby clinics or home vis-
iting. Healthy Start addresses multiple issues such as
providing adequate prenatal care, meeting basic health
needs, reducing barriers to access, and empowering
clients. There is growing evidence that these programs
have been successful in reducing infant mortality rates,

C H A P T E R 1 3 n Health Planning for Local Public Health Departments 325

health services, including quality health care, are avail-
able. In a healthy community, communication and col-
laboration among various sectors of the community
and the contributions of ethnically, socially, and eco-
nomically diverse community members are valued. In
addition, the broad array of determinants of health is
considered and addressed, and individuals make in-
formed, positive choices in the context of health-
protective and supportive environments, policies,
and systems.”

7711_Ch13_313-342 21/08/19 11:13 AM Page 325

increasing access to early prenatal care, and providing
community services to lower preterm delivery and inci-
dence of low birth weight.39

In addition to maternity care programs, PHDs provide
nutritional support for pregnant women and children
through the federally funded WIC programs.12 WIC was
established as a pilot program in 1972, made permanent
in 1974, and is administered at the federal level by the
Food and Nutrition Service of the U.S. Department of
Agriculture. In April 2014, there were 9.3 million women,
infants, and children enrolled in the WIC program, and
almost three-quarters of them (74.2%) were at or below
the poverty line.40 Nurses and dietitians work collabora-
tively to provide nutrition counseling and breastfeeding
support.

Family planning programs are a third example of ma-
ternal-child health care in PHDs. Family planning pro-
grams in the United States were implemented in the
1960s and 1970s in response to the reproductive needs
of populations at some level. Family planning grew out
of federal legislation, originally the Office of Economic
Opportunity in 1965 and then the enactment of Family
Planning Services and Population Research Act of 1970,
or Title X.41 Family planning programs did not share a
universal acceptance upon their inception. These pro-
grams coincided with the approval of oral contraceptives
and were associated with the changing societal attitudes
regarding sexual activity. Many communities initially re-
sisted the provision of these services. Over the years, lev-
els of acceptance of these programs have risen and fallen,
with most of the controversy focusing on whether there
should be public financing of family planning. This
demonstrates the role that public opinion plays in public
health policy. Core family planning services have
centered on individual counseling regarding contracep-
tive method selection, annual physicals, and follow-up
services.

An example of comprehensive family planning serv-
ices can be found at the New York State Department of
Health website: http://www.health.state.ny.us/health_
care/medicaid/program/longterm/familyplanbenprog.
htm. The purpose of the program is to “…increase
access to confidential family planning services and to
enable teens, women, and men of childbearing age to
prevent and/or reduce the incidence of unintentional
pregnancies.”42

School Health
School health is concerned with assuring the health
of the entire school population, students, and staff

(Chapter 18). As the health-care expert in the school
setting, school nurses take a leadership role in devel-
oping policies and providing clinical care activities that
promote health and assure safe health-care practices in
a nonmedical setting. School nursing services include
medication administration, immunizations, and re-
sponse to emergencies during medical crises and dis-
asters. School-based screening programs identify
children with potential health problems associated
with vision, hearing, and obesity that may be barriers
of academic achievement. When underlying medical
conditions are detected, the school nurse will make re-
ferrals to specialists and other health-care providers
and conduct follow-up activities to assure access to
care and adherence to treatment (see Chapter 18).43 By
delivering case management services, school nurses co-
ordinate care and help families locate resources for
medical, social, and mental health services. School-
based wellness programs are designed to address com-
mon childhood issues such as obesity; dental caries;
asthma; and health education needs related to growth
and development, communicable diseases, and sexual-
ity. Funding and staffing patterns for school nurses
employed by PHDs and school districts vary between
states and counties. Not every school has a school
nurse, and for the 5% of children without health insur-
ance, the school nurse may be their only access to
health screening and care.44

Immunization and Health Protection Programs
Providing immunizations to protect a population from
communicable diseases is an essential component of
public health. Vaccinations are mandated by school dis-
tricts and in some cases employers, especially in health-
care settings. If an outbreak of disease occurs, the PHD
is often the entity responsible for mass immunization, as
occurred in the H1N1 influenza outbreak in 2009.

Immunization practices have been in place for cen-
turies. For example, variolation (the exposure of well per-
sons to material from an infected person such as pus or
scabs) was used to prevent smallpox. Although variola-
tion resulted in death for some, the overall death rate re-
lated to smallpox fell. In the late 1700s, Edward Jenner,
a physician, discovered that milkmaids exposed to cow-
pox, a less deadly disease, developed immunity to small-
pox. The term vaccine comes from the word vaca, which
means “cow” in Latin. He exposed a small boy to pus
from a milkmaid with cowpox and then exposed him to
smallpox. The boy did not contract the disease. Although
it took a while for vaccinations to enter into mainstream

326 U N I T I I I n Public Health Planning

7711_Ch13_313-342 21/08/19 11:13 AM Page 326

practice, by 1800, the use of vaccines spread across Eu-
rope and to other parts of the globe.45 Today, through the
successful efforts of a global campaign, smallpox has
been eradicated worldwide.

Immunizations are a major responsibility of PHDs.
PHDs manage the program requirements associated
with administration and utilization of vaccines for pre-
ventable diseases. Immunization administration may
be integrated into the PHD clinical service program.
Immunization program components include ordering
and tracking vaccines, ensuring that individual immu-
nizations are recorded into registries if used in that ju-
risdiction, and coordinating special immunization
clinics. In addition, immunization programs coordinate
the Vaccine for Children program. This program facil-
itates the delivery of adequate supplies of vaccines to
health-care providers who provide services and vac-
cines to children. This ensures that all children, regard-
less of ability to pay, have access to immunizations for
vaccine-preventable diseases.

In addition to childhood vaccination programs,
PHD immunization programs provide services to other
populations at risk. This includes international travel
vaccinations and the rabies postexposure prophylaxis
vaccine. PHDs often work with community partners to
provide clinics where anyone can come for immuniza-
tions for diseases such as influenza. These types of clin-
ics help increase a community’s level of immunity from
these diseases. PHNs often coordinate the planning and
implementation of these open clinics. Schools have
often been a place where immunizations and other
child-focused services are provided. Through these ac-
tivities, not only does the PHD protect individuals who
receive the vaccine, but it also reduces the overall preva-
lence of communicable diseases, thus reducing the op-
portunity for the spread of disease and providing herd
immunity (see Chapter 8).

Role of Nurses in Providing Individual Care
Nurses are often employed by PHDs to provide the direct
individual care at the clinics. The nursing care provided
often includes one-on-one clinical interventions such as
vaccinations, prenatal care, and dispensing of medica-
tions for STIs or TB. In addition, PHNs often provide
home visiting and a focus on high-risk families as part of
these services.46 Establishing working relationships with
these families has been a strength of public health nurs-
ing, and home visitations by registered nurses has
been associated with improved outcomes.47,48 A recent
qualitative study illustrates that PHNs are flexible and

especially adept at recognizing the sociohistorical factors
that influence families while simultaneously focusing on
strengths and chaotic life situations.46

Community Health Primary Prevention Efforts
As described in Chapter 2, primary prevention is a strategy
used to avert occurrences of illness or injury. In addition
to services focused on individuals, PHDs provide a wide
array of primary prevention services aimed at health pro-
motion and protection at the community level. Health
promotion includes activities that focus on improving the
ability of individuals and populations to practice healthy
living. Health protection interventions involve protecting
individuals and populations from disease by improving
the immune system through vaccination for individuals
or providing protective barriers such as the use of personal
protective equipment by health-care providers.

Health promotion efforts at the community level in-
clude educating about healthy lifestyles. Examples of
health education include HIV prevention education for
teens or Back to Sleep campaigns for reducing SIDS. The
Back to Sleep campaigns began in 1994 and focused on
educating parents, caregivers, and health-care providers
about ways to reduce the risk of SIDS. Since the cam-
paign started, there has been a 50% reduction in SIDS
deaths, and the percentage of babies being placed on
their backs to sleep has increased significantly.49 Unfor-
tunately, health promotion interventions and the latest
advances in primary prevention and screening activities
are less likely to be delivered among vulnerable popula-
tions having lower socioeconomic status, racial and eth-
nic minorities, and people living in rural and remote
areas of the United States.50,51 Culturally relevant, evidence-
based health promotion interventions can be especially
useful for improving health and reducing disease risk
among at-risk populations.

Communication is a key component to the provision
of primary prevention programs for PHDs. In today’s
world, there are multiple methods for communicating
important health data and health promotion informa-
tion. For example, during the H1N1 influenza outbreak
in 2009, PHDs used multiple methods to communicate
with communities regarding the locations where im-
munizations were available as well as potential public
health priorities associated with vaccinating certain
groups, such as pregnant women and children, before
the general population. Technological strategies tradi-
tionally used to communicate public health messages in-
clude television, radio, newspapers, and sending printed
information home with school-aged children. During

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this century, PHDs are increasingly using computer-
mediated technologies, including social media such as
YouTube, Twitter, and Facebook, as effective avenues
for providing health information.

A Healthy Community: Sarasota, Florida: An ex-
ample of a community-wide health promotion initiative
is the Community Health Improvement Partnership in
Sarasota, Florida.52 The Sarasota PHD led this partner-
ship and brought together many stakeholders from the
community. Partners included community organiza-
tions, individual citizens, and health-care professionals.
Together, they identified evidence-based strategies and
chose those that had the most applicability to their com-
munity. These strategies were multipronged; that is, they
used different venues and methods to engage the com-
munity in a healthier lifestyle. They developed Healthy
Living kiosks throughout the community. These kiosks
provided information about health insurance options,
health-care resources, and consumer tips. Users were able
to access a county health scorecard that provided data on
health status and linkage to a community pharmacy where
those who were uninsured or underinsured could have
access to needed medications. The development of this
required that PHD nurses understand the basics of public
health science so that they could develop an intervention
based on the community priority health needs and service
gaps within the community. It also required understand-
ing implementation and evaluation strategies to determine
whether the kiosk was an effective intervention. PHDs
provide essential leadership and skills in the promotion of
the health of the community they serve.

Disease Control, Epidemiology,
and Surveillance
Disease Control
Because communicable disease is a primary concern
of PHDs, their ability to provide necessary training
and services surrounding communicable diseases is
important. This will vary depending on the size of the
public health system. Many small health departments
gather private physician case reports and provide the
information to a regional or central office for analysis
and compilation. Larger PHDs may have internal units
devoted to the communicable disease program, includ-
ing core epidemiological services and biostatistical
analysis of the determinants of diseases in animals
and man.

Tuberculosis Management: TB management is one
of public health’s oldest communicable disease programs
for one of the oldest diseases noted in history. With the
advent of effective therapies, elimination of TB was

considered a possibility. However, this remarkable or-
ganism continues to be a major threat to public health
both globally and in the United States. A resurgence of
the disease is sometimes now accompanied by a rise in
multidrug-resistant TB (MDR-TB), which is defined as
TB resistant to the two most effective first-line therapeu-
tic drugs, isoniazid and rifampin. The CDC established
a task force to develop a plan of action to address the
issue of drug-resistant TB.53 TB is a complex interaction
of medical, societal, behavioral, and economic factors.

Because of the communicability of TB, PHDs and
PHNs take a leading role in both the prevention and
treatment of TB. One approach by state and PHDs is to
provide TB clinics that include screening assessment, di-
agnosis, and treatment components. Efforts at the local,
state, and national levels have resulted overall in a re-
duced incidence of TB.54 It is possible that TB could be
eliminated in the United States. It will take continued ef-
forts on the part of PHDs to continue to screen those at
risk, assess persons with positive screens, and treat those
with active disease.

328 U N I T I I I n Public Health Planning

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Tuberculosis
Neighborhood Investigation
Public Health Science Topics Covered:

• Surveillance
• Disease investigation
• Prevention

Sara Johnson, communicable disease nurse at Creek
County Health Department, received a call from the
infection control nurse at Providence Hospital report-
ing a newly diagnosed case of TB in a hospitalized pa-
tient. The patient was a 40-year-old male (Mr. H.) who
worked for the grounds maintenance unit of the local
college. Sara advised the infection control nurse that
she would come to the hospital that day to review the
chart and interview the patient. She remembered that
there had been another university employee from the
same unit diagnosed a year ago and that all of the em-
ployees had received appropriate TB testing. No other
cases had been identified during that case follow-up, so
she was somewhat concerned about the appearance of
this case.

Sara learned the following from her chart review
and patient interview:

• The patient had only been employed with the univer-
sity for 4 months.

7711_Ch13_313-342 21/08/19 11:13 AM Page 328

C H A P T E R 1 3 n Health Planning for Local Public Health Departments 329

• He lived with his girlfriend and her two daughters.
• He presented with classic TB symptoms—night

sweats, weight loss, no appetite, and persistent
cough. His sputum was acid-fact bacillus (AFB) posi-
tive and his chest x-ray was indicative of pulmonary
TB. Pharmacological therapy was consistent with the
CDC’s TB treatment protocols. He would be hospi-
talized in isolation until three consecutive AFB
sputum smears were negative.

• Names of coworkers, family, and friends were
obtained.

• He wasn’t sure whether he had been around
anybody with TB. One of his neighbors had been
sick a few months ago with similar symptoms, but
the patient didn’t know what the neighbor had.

Based on this information, Sara ruled out that he
had been exposed from the previous case and began
to prioritize the contact list for follow-up. What crite-
ria should Sara use to prioritize the contacts? To
answer this question and the rest of the questions
related to this case, see Box 13-3.53–55

Sara contacted the patient’s girlfriend and arranged
for her and her daughters to come to the health de-
partment for evaluation and tuberculin skin testing be-
cause they had closest contact with the patient. Then,
she contacted the patient’s supervisor to advise him of
the situation and the need to interview coworkers. To
minimize disruption to the workers, Sara agreed to
bring a small interview team to the site to conduct
evaluations and provide tuberculin skin testing.
She agreed to go back to the site to read the tests
72 hours later so the workers would not have to
miss work.

After about a week, Sara received notification
from the hospital that the patient was ready for
discharge and he would need to be on directly
observed therapy for several months to ensure
adherence to the medication regimen. It was decided
that Sara would meet the patient at his home the
next day after he was discharged. During this
meeting, Sara reviewed activity restrictions and
the medication plan, explained the process of directly
observed therapy, and told him that she would be
coming to his home each day to watch him take the
medications.

Two key issues in the treatment of TB are the
length of treatment and the emergence of MDR-TB.
For the most part, MDR-TB occurred because of
nonadherence to recommended treatment. That is,
those with an active infection did not complete the

required drug regimen, and the bacterium became
resistant to the drug. Today, the World Health
Organization (WHO) recommends treatment to
continue for 6 months or longer.56 In the United
States, the populations most at risk for active TB
are often those hardest to reach (e.g., foreign-born
persons from countries with a high TB prevalence,
those exposed to persons with active TB, those
who are immune-compromised, persons with
alcohol or substance abuse, and persons with
latent TB infections [they are infected but do
not have active disease]).55 To assist with this,
nurses working in PHDs often function as case

1. How is the infectious period for TB defined?
2. What is the difference between active and latent

TB infection?
3. What factors had an impact on the decision to

initiate a contact investigation? What are the goals
of a contact investigation?

4. What groups are most at risk for TB infection? How
should the nurse prioritize contact for follow-up?

5. What factors would require a contact be placed on
chemoprophylaxis?

6. Directly observed treatment is a resource-intensive
intervention. How should the nurse prioritize contacts
for it?

7. If the neighborhood had been different, what other
interventions could have been used to reach the
neighbors?

8. Discuss challenges with and solutions for providing
directly observed therapy with someone who is
homeless.

9. This investigation may attract the attention of the
media. What strategies should the nurse use for
communicating with the media?

The following are recommended sources for answering
the preceding questions:

Centers for Disease Control and Prevention. (2005).
Guidelines for the investigation of contacts of persons
with infectious tuberculosis. Morbidity and Mortality
Weekly Report, 54(RR15), 1-37. Retrieved from http://
www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a1.
htm
CDC TB Web site: http://www.cdc.gov/tb/

BOX 13–3 n Questions Related to the
Neighborhood Investigation
of Tuberculosis

7711_Ch13_313-342 21/08/19 11:13 AM Page 329

approved, she identified a Saturday for the event,
recruited health department staff to assist, and
solicited other health department programs to
participate or provide information or give-away
items. The event was very successful, with many
of the neighbors receiving testing and information.
Fortunately, no new cases were identified, but
several people with latent TB infection were placed
on prophylaxis therapy.

Sexually Transmitted Infections: Communities also
rely on PHDs to provide surveillance, prevention, and
treatment of STIs. Most STIs are reportable diseases and
the PHD reports each case to the state department of
health, which then reports to the CDC. PHDs also com-
bine clinical care for the diagnosis and treatment of the
disease with a strong field investigative component
needed to identify and notify contacts. Many PHDs
conduct primary prevention programs, especially with
teens, aimed at preventing STIs with outreach to schools,
correctional facilities, bathhouses, and other community
settings.

There is an enormous burden of STIs in the United
States with more than 1.5 million cases of chlamydia in-
fections, 468,514 cases of gonorrhea, 27,814 cases of
syphilis, and 39,782 new cases of HIV infection in
2016.58 With a disease burden of this magnitude in ad-
dition to the costs for society, the investigative role of
PHDs is critical. The investigation of STIs includes
three steps:
1. Screening for possible infection. Persons with sus-

pected STIs are screened using appropriate tests.
Depending on the STI, a positive screen may require
further laboratory confirmation.

2. Treatment.
3. Screening all known sexual contacts of the person

with the confirmed STI and treat if necessary.
PHNs often conduct the follow-up investigations for

persons diagnosed with an STI such as syphilis. The PHN
follows up with the patient to ensure he has adhered to
the prescribed medications and obtain contact informa-
tion for any sexual contacts before he was treated.

In 2012, NACCHO published a policy statement
about the prevention and control of STIs.59 PHDs have
traditionally fulfilled a critical role in this arena but there
is a current threat to this coverage because of dwindling
funds. In 2011, 57% of PHDs had to make cuts in their
core programs, which in some cases resulted in an elim-
ination of programs and services.60

330 U N I T I I I n Public Health Planning

managers to help ensure that patients with TB
follow through with the required treatment.
Nurses apply their holistic approach to care and
are able to appreciate and mitigate factors that
exist in the patient’s life.

A key function of TB case management is ensuring
adherence to the medication regimen. As noted ear-
lier, one of the oldest ways of ensuring adherence
is through the use of directly observed therapy,
in which the patient takes the required daily
medication in the presence of a public health-care
provider, often a nurse. Either the patient goes
directly to the PHD, or the public health-care
provider comes to the patient’s home. As with
other areas of health care, technology has been
developed that enhances the ability to monitor
medication adherence. One example is a medica-
tion electronic monitoring system, which
tracks adherence to a medication regimen through
a chip placed in the medication bottle cap that up-
loads the date and time the cap is opened.57 Other
examples include use of text messaging, phone call
reminders, and e-mail reminders.

With case management under way in the case of
Mr. H., it was critical to continue to investigate for
additional exposures. In trying to determine how he
may have been exposed, Sara began reviewing pre-
vious cases. She found that the case from the prior
year lived on the same street as the patient, and
there had been several contacts who could not be
found. She also determined that there had been
another earlier case on the same street. Based on
this information, should Sara expand the contact
investigation? Sara determined that there needed to
be outreach to all the neighbors to ensure there
were not any additional undiagnosed cases. She
decided to learn more about the neighborhood by
conducting a windshield survey of the street. Her
findings were the following: (1) The street was
isolated and not connected to a larger neighbor-
hood; (2) there were about 15 houses; (3) there
appeared to be children of all ages living on the
street; and (4) there were several open, grassy
areas on the street.

Sara decided that a community information fair
and testing clinic would be the best way to provide
outreach services to the neighbors without com-
promising the patient’s privacy. She developed
the plan and presented it to the health department
administrator for approval. After the plan was

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C H A P T E R 1 3 n Health Planning for Local Public Health Departments 331

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Unintended Death
Public Health Science Topics Covered:

• Surveillance
• Community Organizing
• Advocacy
• Policy Development and Enforcement

Community members seek assistance from PHDs
for a variety of health issues. In hypothetical Beach
County, Mrs. McIntire requested a meeting with the
director of the PHD to discuss her concern about
misuse of prescription drugs by young adults in the
county. She shared that her son accidently died from
an overdose of prescription pain drugs and alcohol. She
explained her concern that this was a growing problem
in the county and that she wasn’t the only person in
the community that lost their son or daughter. The
PHD director listened to her and agreed to take a look
at the data on prescription drug misuse and overdose.

Data analysis by the PHD epidemiologist revealed the
county had the highest rates in the state. The director
called a meeting with Mrs. McIntire and the PHD leader-
ship team to discuss what to do next. They decided to
bring up the issue at the next meeting of the Behavioral
Health Consortium to see if they were aware of this dis-
turbing trend and if this was something that the Consor-
tium could address as a community concern. The
Consortium consisted of a variety of community agen-
cies including social services, law enforcement, health
care, mental health, substance use, as well as advocacy
groups. During the meeting, Mrs. McIntire told the story
of her son’s accidental overdose. PHNs from the
Healthy Start program also shared stories of young fami-
lies with at-risk substance use issues and children who
were orphaned as a result of their parent’s unintentional
deaths. The epidemiologist presented data on mortality
rates related to substance abuse.

The Numbers
Deaths caused by drugs, medications, and biological
substances are categorized as unintentional poisoning.
Mortality data showed the county experienced a 22%
increase in unintentional poisonings, which was twice
that of the state rate. The crude death rate for ages
15-29 due to unintentional poisoning steadily increased
over the previous 4 years from a rate of 7.3 (N=3) to
52.9 (N=24). In comparison to the state rate, the county
rate was statistically higher (52.9 county, 15.7 state). In
addition, there was a 90% increase in patients admitted

to local Addictions Receiving Facilities for prescription
drug misuse over the previous 4 years. The epidemiol-
ogist explained these rates reflect the health and well-
being of this age group as well as the quality of the
health care available, particularly mental health and
substance abuse counseling.

Collaboration
The Consortium members agreed to work together
to address this urgent public health problem by col-
laborating with local governments and organizations
to identify existing services and designate available
resources. The next steps involved making a similar
presentation to local hospital administrators. The
medical examiner in attendance reported that approx-
imately 40% of the deaths were related to the com-
bined use of prescription opioids and alcohol. The
hospital agreed to join in the effort to educate the
public, police, and local governmental officials and to
develop solutions.

Meetings with the Sheriff’s Office revealed that
several new pain management clinics had recently
opened in the county and were thought to be con-
tributing to increased access to prescription pain
medications. The Sheriff reported a pattern of illegal
drug use and distribution associated with clinics that
dispense narcotics on-site and were trafficked by
users from other states. Increased arrests for drug
trafficking near some of these clinics were also re-
ported. Addressing the source of prescription drugs
through regulation of pain management clinics was
proposed as a solution and presented to the Board
of County Commissioners.

Implementation of Strategies
The PHD Consortium and community partners imple-
mented an array of strategies to address the epidemic
including the following.

The PHD and Sheriff’s Office worked with the
county government to develop legislation that regu-
lated pain clinics and placed a moratorium on new oc-
cupational licenses for pain management clinics. The
PHD Community Health Improvement Project (CHIP)
worked with local hospitals and medical providers to
present educational programs for clinicians regarding
the epidemic. This included the need to inform patients
of the risks of opioids and to monitor them closely. A
public awareness campaign was implemented by CHIP
to inform the public of the problem and available com-
munity resources. A local database was established to

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Epidemiology and Surveillance
Emerging or Re-emerging Infections: As we move

ahead into the 21st century, PHDs will face two signif-
icant challenges: increased mobility due to globaliza-
tion and emergence of new human pathogens. Joshua
Lederberg coined the term emerging infections for the
IOM in 2000.61 Morens and Fauci (2013) define emerg-
ing infections as “diseases that are recognized in the
human host for the first time “and re-emerging dis-
eases as “diseases that historically have infected hu-
mans, but continue to appear in new locations or in
drug-resistant forms, or that reappear after apparent
control or elimination (p. 1).”62

Our global society and rapid transit around the globe
can result in the rapid dissemination of pathogens
throughout the world. Examples of emerging infectious
diseases include the 2009 H1N1 pandemic influenza, se-
vere acute respiratory syndrome (SARS), and Middle
East Respiratory Syndrome (MERS). SARS originated in
China and was rapidly spread across the globe as infected
persons traveled by airplane from China to other coun-
tries. As noted in Chapter 8, SARS infected 8,437 people
with a case fatality rate of 9.6% (813 people).63 Other
recent examples of rapid global dissemination of a com-
municable disease are that of H1N1 and H7N9 (see
Chapter 8). For H1N1, the Mexican government dissem-
inated a wide array of pamphlets and posters to alert their
population about mitigating the impact of H1N1 by
slowing the transmission and lowering mortality.64

Besides globalization, there are a number of factors that
influence emergence and re-emergence of disease. These
factors include climate/natural disasters, economic devel-
opment/urbanization, poverty, limited or lack of public
health services, war/social disruption, and famine. Popu-
lation movement has been associated with the re-
emergence of Dengue virus and West Nile virus in the
United States and Caribbean countries. Likewise, the
global emergence of antibiotic resistant organisms is linked
to antibiotic overuse and inadequate antibiotic steward-
ship, medical tourism, and economic globalization. This
has resulted in multidrug-resistant TB and malaria, and
bacterial diseases like vancomycin-resistant enterococci.62

Zoonotic Diseases: Another challenge in the modern
world is the growth of cities and suburbia, which en-
croaches on the natural habitats of wild animals. Across
the United States, deer, fox, and other wild animals are
now living in suburbia and even in urban settings, in-
creasing the likelihood of the transmission of zoonotic
disease. Zoonotic diseases are diseases transmitted from
animals to humans in the community through direct con-
tact, as with rabies, or indirect contact through a vector,

332 U N I T I I I n Public Health Planning

track narcotic prescriptions by patients and providers.
This was later implemented on the state level.

Conclusion
The rates of unintended poisonings declined over the
next few years. This case illustrates the role of the
PHD in:

• Being open to early identification of problems facing
the community

• Using data to validate the depth and breadth of the
problem

• Bringing key community leaders to work together to
create a comprehensive array of solutions

• Utilizing public health practices related to surveil-
lance, community organizing, policy development,
and advocacy (see Box 13-4 for discussion questions)

1. What are the rates for deaths caused by unintentional
poisoning in your community?

2. How is your local and state PHD involved in address-
ing the issue? What other community agencies are
addressing the issue?

3. What types of substance abuse services are provided
in your community? Is there a waiting list for inpatient
services?

4. How is the community informed about the problem
and community resources?

5. What types of prevention programs are offered in the
schools?

6. What are the challenges to addressing substance
abuse in your community?

7. Would the strategies in Beach County work in
your community? Review the literature on best
practices for addressing the opioid crisis. What
additional strategies would you recommend for
your community?

The following are recommended sources:

1. National Institute on Drug Abuse. Opioid crisis.
https://www.drugabuse.gov/drugs-abuse/opioids/
opioid-overdose-crisis

2. National Institute on Drug Abuse. Opioid summaries
by state. https://www.drugabuse.gov/drugs-abuse/
opioids/opioid-summaries-by-state

3. Department of Health & Human Services. National
opioids crisis-help, resources & information. https://
www.hhs.gov/opioids/

BOX 13–4 n Questions Related to The Case
of the Unintended Death

7711_Ch13_313-342 21/08/19 11:13 AM Page 332

such as Lyme disease65 (see Chapter 8). PHDs are called
on to conduct surveillance of zoonotic disease and insti-
tute prevention programs.

Rabies is a preventable viral disease of mammals usu-
ally transmitted through the bite of a rabid animal such
as a dog or a raccoon. Efforts from PHDs, both at the local
and state levels, have reduced the incidence of rabies in
the United States dramatically during the past 100 years.66

Through public health campaigns to vaccinate domestic
animals, 90% of all cases reported to the CDC are now in
bats and wild carnivores. Human deaths due to rabies
rarely occur because of effective and early intervention
with post-bite exposure prophylaxis. The PHD provides
education to health-care providers; tracks and reports all
known cases to the state department of health, both ani-
mal and human; and works in partnership with animal
control programs and veterinarians

Disaster Preparedness: An increasingly prominent
role of PHDs, especially PHNs, is public health prepared-
ness for responding to emergencies and disasters. Prior
to the events of 2001, the preparedness functions were
dictated by the regularity of events that affected the pop-
ulation and the health-care systems. Southeastern coastal
states regularly face hurricanes. Midwestern states con-
tinually experience tornados. West Coast states are con-
stantly threatened by earthquakes and fires. All have
created robust emergency response systems. However,
the realities of the 21st century have placed an additional
responsibility on these systems because of threats caused
by humans. Disaster planning programs evolved into “all
hazards” planning. For example, a biological event,
whether it is an anthrax attack or a widely distributed
Escherichia coli contamination, calls for a concerted re-
sponse action. Preparedness has five major requirements
PHDs need to address (see Chapter 22):

• Preparedness
• Mitigation
• Response
• Recovery
• Evaluation

In 2002, the Bioterrorism and Emergency Readiness
Competencies for All Public Health Workers was devel-
oped and became the standard for ensuring the public
health workforce was prepared and ready to respond to
emergencies and disasters.67 As more experience has
been gained through public health response and more
discipline-specific competencies have been devel-
oped, these initial competencies have evolved into
the Public Health Preparedness & Response Core Compe-
tency Model.67b The Association of Public Health Nurses

integrated this model into its 2013 The Role of Public Health
Nurses in Emergency and Disaster Preparedness, Response,
and Recovery position paper, which provides guidance to
PHNs on how to work in a disaster or emergency.67

Preparedness functions and planning rely heavily on
the use of partners and data sets to achieve success. Each
community is different in the resources it can bring to
bear in dealing with an emergency or disaster. Consis-
tently, the PHD is looked to as the community lead, in
collaboration with local emergency management, for
health and medical response activities in an emergency
or disaster. PHNs have key roles to play in disaster plan-
ning and preparedness efforts. A key preparedness func-
tion uses a basic public health nursing skill, community
assessment. By knowing the aspects of the community,
plans can be written to meet the unique needs of that
community during an emergency or disaster. During the
disaster, the PHN’s role may center on staffing emer-
gency shelters for persons with special health and med-
ical needs or providing tetanus immunizations in the
community for persons engaged in clean-up activities.
During the recovery phase of a disaster, the PHN may be
assigned to go into the community to assess the current
and long-term needs of the area. Identification of these
needs is essential to ensure the delivery of services to the
community so that normal functioning may return.

Regulation, Licensing, and Inspection
Regulatory, licensing, and inspection activities are common
roles for a PHD. The 2016 NACCHO survey of PHDs
revealed that the areas of particular focus in PHD were food
service, schools/daycare centers, swimming pools, septic
systems, and smoke-free ordinances.12 Other areas in-
cluded private drinking water, body art (tattoos/piercings),
camps, campgrounds, and, in some cases, housing.

Public Health Department Challenges
for the Future
Healthy People
As one thinks about the future, the objectives for HP
provide some insight into the issues of importance to
the functioning of local health departments. HP’s goal
is to increase public health infrastructure. It is this in-
frastructure that provides the foundational capacity for
national, state, and local actions to prevent disease and
promote health. An example of an objective is “to in-
crease the proportion of tribal and state public health
agencies that provide or assure comprehensive laboratory
services to support essential public health services.”68

C H A P T E R 1 3 n Health Planning for Local Public Health Departments 333

7711_Ch13_313-342 21/08/19 11:13 AM Page 333

Other objectives relate to assuring the workers’ compe-
tencies, monitoring performance, and assuring practice
is guided by standards. In an effort to highlight the need
to strengthen the public health workforce, increased
workforce diversity and reducing the shortage are
critical and are reflected in the objectives added
to HP 2020 that targeted public health education and
competencies.

Other challenges of PHDs include issues of relevance
to the public health workforce, IT, quality improvement
and PHD accreditation, and PHD financing, especially
as it relates to the economic recession.

Public Health Workforce
Currently, there is a shortage of public health workers,
and this shortage is projected to increase in the coming
years. In 2016, the Association of State and Territorial
Health Officials conducted a survey of state agencies. It

334 U N I T I I I n Public Health Planning

n HEALTHY PEOPLE
Healthy People 2020 Objectives
Relevant to Public Health Department
Infrastructure

Selected Objectives:
PHI-1: Increase the proportion of federal, tribal, state,
and local public health agencies that incorporate core
competencies for public health professionals into job
descriptions and performance evaluations.

PHI-2: Increase the proportion of Tribal, State, and
local public health personnel who receive continuing
education consistent with the Core Competencies for
Public Health Professionals.

PHI-3: Increase the proportion of Council on Educa-
tion for Public Health (CEPH) accredited schools of
public health, CEPH accredited academic programs,
and schools of nursing (with a public health or commu-
nity health component) that integrate Core Competen-
cies for Public Health Professionals into curricula.

PHI-4: Increase the number of public health or re-
lated graduate degrees, post-baccalaureate certificates,
and bachelor’s degrees awarded.

PHI- 5: (Developmental) Increase the proportion of
4-year colleges and universities that offer public health
or related majors and/or minors consistent with the core
competencies of undergraduate public health education.

PHI-6: Increase the proportion of 2-year colleges
that offer public health or related associate degrees
and/or certificate programs.

PHI-11: Increase the proportion of tribal and state
public health agencies that provide or assure compre-
hensive laboratory services to support the essential
public health services.

PHI-12: Increase the proportion of public health
laboratory systems (including state, tribal, and local)

which perform at a high level of quality in support of
the 10 Essential Public Health Services.

PHI-13: Increase the proportion of tribal, state,
and local public health agencies that provide or assure
comprehensive epidemiology services to support
essential public health services.

PHI-14: Increase the proportion of state and local
public health jurisdictions that conduct a public health
system assessment using national performance standards.

PHI-15: Increase the proportion of tribal, state, and
local public health agencies that have developed a
health improvement plan and increase the proportion
of local health jurisdictions that have a health improve-
ment plan linked with their state plan.

PHI-16: Increase the proportion of tribal, state, and
local public health agencies that have implemented an
agency-wide quality improvement process.

PHI-17: Increase the number or proportion of tribal,
state and local public health agencies that are accredited.
Midcourse Review: Of the 61 objectives for this topic,
2 were archived, 6 were developmental, and 53 were
measurable. Of the measurable objectives, 12 met or ex-
ceeded their 2020 targets, 9 improved, 4 demonstrated
little or no change, 7 were getting worse, 17 only had
baseline data, and 4 were informational (Fig. 13-6).68b

32.1%
13.2%

7.5%

22.6%
7.5%

Baseline only
Informational
Target met or
exceeded
Getting worse
Little or no change

Healthy People 2020 Midcourse Review:
Public Health Infrastructure

Figure 13-6 HP 2020 Midcourse Status of the Public
Health Infrastructure Objectives.

7711_Ch13_313-342 21/08/19 11:13 AM Page 334

found an average of 14% of state health agency positions
were vacant, an average of 365 positions per state health
agency. There are a number of factors contributing to this
shortage, including budget reductions and hiring freezes,
a rapidly aging workforce whose average age was 47, and
25% of the workforce eligible to retire by 2020.69 All of
these issues raise concern for PHDs as well.

The U.S. public health workforce has been of suffi-
cient interest to policy makers during the past 4 decades
to lead to regular efforts to enumerate it. In 1980, there
was a ratio of public health workers to the general pop-
ulation of 220/100,000, and in 2000 that had dropped
to 158/100,000.70 Although there is an overall shortage,
the critical shortage of PHNs is a threat to the public’s
health and of great concern because they make up a
large sector of the public health workforce.71,72 Execu-
tive leadership for PHDs is also a major concern, espe-
cially in light of the aging public health workforce and
projected shortages.73

Core competencies for various public health workers
or in specific functions have been developed to enhance
the public health workforce capacity. These include the
Public Health Nursing: Scope and Standards of Practice,74

Public Health Preparedness and Response Core Compe-
tencies,75 Council on Linkages: Core Competencies for
Public Health Professionals,76 and Competencies for Pub-
lic Health Informaticians.77

Because the public health workforce comprises a
broad range of educational backgrounds and training,
these competencies provide a common framework for
measuring and improving public health workforce skills
and abilities (Box 13-5). To further support public
health workforce competency, public health workers

have the ability to become certified in public health
through the National Board of Public Health Examiners.78

Sustainment of the public health workforce is a major
concern and is influenced by several factors. First, many
of the health-care professions have experienced shortages
in available workers, thus many health-care facilities are
competing for the same candidates. Second, many PHD
jurisdictions are located in rural or remote areas, making
recruitment of qualified personnel difficult. Third, limited
financial resources may make it difficult for PHDs to pro-
vide compensation that is competitive with private-sector
entities. Finally, there are faculty shortages within the ac-
ademic setting that limit the ability of colleges and univer-
sities to graduate large numbers of qualified individuals.79

Currently, there are critical PHN nursing faculty shortages
that have significantly limited the exposure to and special-
ization in public health nursing.80

Information Technology
IT is a key infrastructure component within a PHD, from
clinical records management to supporting a PHD Web
site. IT is used in every aspect of operations. All persons
working in a PHD use IT at varying degrees. The level of
use and knowledge required is position-dependent. For
example, an administrative assistant would require just
basic knowledge and skills to use IT for general office
functions, whereas an epidemiologist will need more ad-
vanced knowledge and skills for data collection and
analysis. IT is much more than just using computer
equipment and programs. The field of public health in-
formatics focuses on the use of IT by public health pro-
fessionals. There are several definitions for public health
informatics, all of which essentially define it as public
health information systems and infrastructure that are
population-based and used for surveillance, program
outcome evaluation, quality assurance, systems analysis,
and evidence-based disease management.81

In 2002, the CDC created a work group of subject
matter experts to define overarching public health infor-
matics competencies for all persons working in public
health. These competencies focused on three areas:
(1) information for public health practice, (2) use of IT
by the public health professional to enhance personal
performance, and (3) utilization of IT projects to im-
prove PHD effectiveness.77 These competencies provide
the framework to ensure that PHDs have the capacity to
adequately perform in today’s technologically demand-
ing environment.

Although PHDs use IT to support general business
operations, new regulations and technology create new
demands on PHDs to enhance IT use. Two key examples

C H A P T E R 1 3 n Health Planning for Local Public Health Departments 335

• Core Competencies for Public Health Workers.
http://www.phf.org/resourcestools/Documents/Core_
Competencies_for_Public_Health_Professionals_
2014June

• Public Health Preparedness and Response Core
Competencies
https://www.cdc.gov/phpr/documents/perlcpdfs/
preparednesscompetencymodelworkforce-version1_
0

• PHN Scope and Standards of Practice
http://www.nursesbooks.org/Main-Menu/Standards/
O—Z/Public-Health-Nursing.aspx

• Public Health Informatics Competencies
https://www.cdc.gov/informaticscompetencies/

BOX 13–5 n Public Health Core Competencies

7711_Ch13_313-342 21/08/19 11:13 AM Page 335

of this are geographic information system (GIS) appli-
cation and electronic health records. Both of these activ-
ities have required PHDs to expand staff knowledge and
hardware capacity to effectively integrate these applica-
tions into daily operations.82 The use of GIS has trans-
formed a number of functions within PHDs. It can be
used to visualize data geographically within a designated
area. For example, in a disease outbreak, the case data
can be entered into a GIS program and maps can then
be created to show various characteristics of the cases.
An epidemiology nurse can easily identify where cases
may be clustering geographically or identify density of
cases through a color-coding system. Likewise, the PHN
can use GIS to identify potential exposure risk from en-
vironmental hazards by applying layers of demographic
data to environmental data layers. GIS technology is a
very effective tool for understanding the dynamics be-
tween health status, health system access, and physical
environment.

Regulations and requirements to move health records
from paper-based systems to electronic systems have re-
sulted in a paradigm shift for medical record management.
PHDs have faced unique challenges in implementing these
systems because public health practitioners’ health focus
is much broader than that in clinical care. Public health
electronic systems need to (1) integrate clinical data from
all providers for public health use, such as disease surveil-
lance and investigation, and (2) include expanded capacity
for psychosocial, behavioral, and environmental client
data collected by PHDs. The impact of electronic health
record implementation affects public health systems in
two ways: (1) There is a need to implement an electronic
system for individual patient care, and (2) PHDs need to
maintain the ability to conduct population-based core
functions such as assessment, policy development, and
assurance through interfaced integration of electronic
data from providers. This will require public and private
providers to come together to ensure electronic health
record systems include a public health orientation. By ef-
fectively integrating this focus, reporting duplication can
be reduced and community decision making can be en-
hanced through more comprehensive data availability.83

Quality Improvement and Public Health
Department Accreditation
The emerging areas of PHD accreditation and public
health systems and services research expand our
knowledge about the relationship between characteris-
tics of PHDs, local public health system performance,
and public health outcomes. Continuous quality im-
provement initiatives are led by multidisciplinary teams

to systematically apply evidence-based practice, im-
prove service delivery, and achieve the best outcomes.
In the NACCHO 2016 survey of PHDs, 89% of PHDs
reported conducting some type of quality improvement
activities.12 The Public Health Accreditation Board has
developed a national voluntary accreditation program
for state and PHDs to formalize and advance quality
and performance of PHDs and improve population
health outcomes. In early 2018, more than 200 state and
local PHDs had received national accreditation.84 Ac-
credited PHDs have reported many benefits from the
accreditation process. These benefits include increased
transparency, stronger management processes, and in-
creased ability to identify organizational weaknesses.
However, the most significant benefit identified was the
increased use of quality improvement information in
decision making and a more robust quality improve-
ment culture.85,85b

Studies show that the strongest predictor of PHD per-
formance is the size of the jurisdiction population.73,85 In
general, PHDs serving larger populations with greater
numbers of staff and higher funding per capita perform
better than PHDs serving populations of less than 50,000.2
PHD leadership structure also influences the staffing
model and service focus. Bekemeier and Jones86 found
there were distinct differences between programmatic
service delivery and the core functions of assessment and
planning in PHDs led by nurse executives and non-nurse
executives. PHDs under nurse executive leadership had
stronger prevention programs to address unintended
pregnancy, obesity, injury prevention, immunization, and
maternal-child health than non-nurse-led PHDs. How-
ever, assessment and planning functions were performed
less by nurse executives than by medical or nonclinical
senior executives, indicating the need for additional train-
ing in these areas.86

Public Health Department Financing
Public health systems have historically been designed as
a function of local (county or city) government opera-
tions. The structure of PHDs previously described has an
impact on PHD financing. The vast majority of states
have county-operated systems, usually governed by local
boards of health, but large metropolitan areas, such as
Los Angeles or New York City, may have city structures
as well. Some states (e.g., Florida) have a state-centered
program with contractual agreements with counties for
provision of public health services. The financing of PHD
operations can become very complex, related to dispar-
ities in county size, needs, and local community capabil-
ities to provide services. There is an inverse relationship

336 U N I T I I I n Public Health Planning

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between per person expenditures and revenues and size
of population served. Small PHDs have higher per per-
son expenditures ($49) and revenues ($51) compared to
large PHDs ($31 expenditures and $33 revenues). Due
to decreasing funding, PHD per person expenditures
have declined from an average of $63 in 2008 to $48 in
2016. This translates into fewer services available to pop-
ulations the PHD serves.12 However, the 2016 NACCHO
survey noted that more PHDs reported higher budget
amounts than in any previous survey. Hopefully, this
increasing revenue trend will continue.

The three primary funding streams for PHDs are fed-
eral (24%), state (21%), and local (55%)12. There is not
an overriding formula for any of these financing layers.
However, there are guidelines developed to assure that
allocations are used appropriately and may be designated
for specific programs or services. These funds, often
called categorical funds, are usually federal funds either
directly disbursed to PHDs from the federal government
through grants or received by the states and reallocated
to the PHDs. Either way, budgets must show the expen-
ditures by category (personnel, expenses, fixed capital)
and require annual reporting back to the federal govern-
ment.87 An example of this might be a PHN position that
performs family planning, STI, and school-based health
services. The PHN will then need to record her time
spent in each service area to ensure her time is allocated
to the appropriate funding source. This is a common oc-
currence in PHDs; therefore, tracking systems and re-
porting procedures have been developed to manage the
funding reporting requirements.

A significant part of PHDs clinical service funding
is through insurance billing such as Medicaid or
Medicare. The amounts generated through billing will
vary greatly among PHDs depending on the types of
services provided and the robustness of their billing
process to fully leverage the revenue return. For exam-
ple, Alabama PHDs have been able to generate 29.5%
of their total revenue through Medicare and Medicaid
billing. Whereas, Georgia only generated 1.3% of rev-
enue from Medicaid or Medicare billing.91 Maximizing
billing opportunities allows PHDs to utilize other pub-
lic funds to provide more clinical services to uninsured
or underinsured populations.

The 2016 NACCHO survey of PHDs found a loss of
43,000 employees since 2008. The economic recession had
a significant impact on jobs, budgets, and programs. Many
of the PHDs reported that the cuts are most often in local
and state funding, and that the dramatic cuts threaten the
general use funds that enable PHDs to respond to urgent
community needs not covered by specific disease grants.10

One way the PHDs have survived these changes has
been through one-time funding for diseases, such as the
H1N1 influenza outbreak and Ebola virus prepared-
ness. What is needed, however, is stable, long-term
funding. The key to funding the PHD in the future will
be the ability to clearly articulate its mission. Policy
makers will need to support PHDs by ensuring an ade-
quate investment in public health by assuring that pre-
vention dollars do go to PHDs to help build their
capacities. This is critical, considering the important
role that PHDs play in keeping communities safe.
“[PHDs] have been described as the country’s ‘best kept
secret.’ As one PHD official states, ‘Unless there is an
outbreak, no one even knows that we exist. We operate
diligently and quietly in the background, keeping our
community healthy and safe.’”88

Additional Challenges
Keeping the community healthy and safe is key. Although
there is a growing emphasis on emerging or re-emerging
communicable diseases or on disaster preparedness, a
major threat to the health of populations is noncommu-
nicable disease. PHDs often lack structure as well as
money to address noncommunicable disease and con-
tributing factors like obesity. This challenge raises issues
of what strategies to use in addressing multiple health is-
sues as well as how to finance new initiatives. Some health
departments provide an exemplar of what can be done.
In a local collaboration between the PHD, the school
board, and city of Anchorage, a multiyear project was ini-
tiated to reduce childhood obesity using a broad set of
policies. These policies included increased weekly physical
education in public schools and day care centers, no sodas
sold during school hours, healthier school lunches, and
increased healthier food options in campus vending
machines as well as a public awareness campaign on the
consequences of childhood obesity. Because of these
efforts, elementary and middle school obesity rates de-
clined by 2.2%.89

In an effort to engage communities more effectively
within a limited funding environment, 12 Utah PHDs
collaborated to initiate a month long social media cam-
paign to promote healthy family meals and family dinner
together. They used a variety of social media platforms
with videos, competitions, and a designated interactive
Web site. Some of the results were an average of 121 in-
dividuals visited the Web site daily, Facebook likes had
reached 1,454, and Twitter followers were 255 by the
month’s end. The authors estimate between 10% and
12% of the target population was reached. Additionally,
the campaign was cost effective at an overall cost of

C H A P T E R 1 3 n Health Planning for Local Public Health Departments 337

7711_Ch13_313-342 21/08/19 11:13 AM Page 337

the services being provided and the level of expert-
ise needed.

• Challenges for PHDs include the shortage of public
health workers, using IT to enhance care, quality
improvement, and financing efforts in the future.

• PHD accreditation is a voluntary program to
advance quality and performance of PHDs.

• The mission of public health is to assure conditions
in which people can be healthy. Although there are
emerging and re-emerging infections from a global
concern that affects population health, noncom-
municable diseases, which are additional challenge
for PHDs, are the major threats to the health of
populations.

27 cents per engagement.90 The PHDs built their capacity
by relying on categorical funding supplemented by flex-
ible funding and sometimes the use of state revenue as
well as creative community collaborations.

n Summary Points
• The basic mandate of the PHD is to protect and im-

prove health in partnership with the community.
• PHDs are organized by three major delivery modes:

centralized system, decentralized system, and shared
or mixed system.

• The PHD workforce is interdisciplinary, with nurses
making up 17% of it.

• The 10 most frequent activities and services available
through the direct services of the PHD are: adult
immunization provision, communicable disease
surveillance, child immunization provision,
TB screening, food service establishment inspection,
environmental surveillance, food safety education,
TB treatment, schools/day-care center inspections,
and population-based nutrition services.

• PHDs also work in collaboration with the state
or contract with other partners to fulfill the core
functions of public health.

• The major responsibilities of PHDs lie with environ-
mental health services, data collection and analysis
(which includes the collection of vital statistics),
assurance of individual and community health,
communicable diseases, epidemiology and surveil-
lance, and licensing.

• Nurses’ roles within health departments include
providing primary prevention efforts, making
health policy, designing health programs, and pro-
viding care at the individual and community levels.
The role of the nurse in a PHD varies depending on

338 U N I T I I I n Public Health Planning

n CELLULAR TO GLOBAL
Multidimensional interventions, such as those previ-
ously discussed, are frequently implemented by PHDs
in communities across this country. However, middle-
to low-income countries are challenged to implement
even the most basic interventions, such as directly
observed therapy for TB control or bed net distribu-
tion for malaria prevention, due to the lack of re-
sources and public health infrastructure. Lack of a
robust public health workforce with high quality train-
ing and strong leadership at local and national levels
significantly affects a nation’s ability to provide basic
services or response to expanding disease threats.92

t CASE STUDY
Collaborating with Community
Partners

Learning Outcomes
At the end of this case study, the student will be able to:

• Investigate the role of PHDs in community
assessment and planning for health needs of
the community.

• Describe the structure and services of your PHD.
• Identify the major partners involved in community

health planning.

You have been asked by your hospital to be the rep-
resentative on a community needs assessment. This
will involve measuring and evaluating health status and
developing collaborative programs that will address the
health needs of your community. You realize that you
need to learn more about your local health department
and the population that it serves. Research your local
health department and answer the following questions:

1. What type of public health system is used in your
state (centralized, decentralized, mixed, shared)?

2. What type of jurisdiction does your PHD serve
(city, town, county, multiple county, district,
region)?

3. Is there a local board of health and, if so, what is its
role and function?

4. What types of assessment and planning are under
way? Who are the main community partners?

5. Where is the PHD located? Are there branch
offices?

6. What types of services are provided? What services
exist that (a) ensure a safe environment; (b) provide

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1744-8603-8-11.

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343

Chapter 14

Health Planning for Acute Care Settings
Kathleen Ballman, Christine Savage, and Mary Nicholson

LEARNING OUTCOMES

After reading the chapter, the student will be able to:

KEY TERMS

1. Describe the relationship between acute care and
population health.

2. Identify the role of population-level data in the
development of the discipline of critical care.

3. Discuss the relevance of cohort studies to the delivery
of tertiary care.

4. Explain the application of health planning in an acute
care setting.

5. Recognize the basic steps in the quality improvement
process.

6. Identify key infection control issues related to the acute
care setting.

Acute care
Acute coronary syndrome

(ACS)
Acute myocardial ischemia
Cardiopulmonary

resuscitation (CPR)
Critical care nursing
Critically ill/injured patients
Door-to-balloon time
Electronic medical record

(EMR)

Epidemiology
Health care-associated

infections (HAIs)
Hospital-associated

pneumonia (HAP)
Hospital discharge rate
Hospital recidivism
Institutional review board
International Classification

of Diseases, 9th Revision
(ICD9)

International Classification
of Diseases, 10th
Revision (ICD10)

Major diagnostic category
(MDC)

Multiple drug-resistant
organisms

Plan-Do-Study-Act
(PDSA) cycle

Patient populations
Polio

Performance
improvement

Quality improvement
Sepsis
ST-elevation myocardial

infarction (STEMI)
Surgical site infection (SSI)
Survival rate
Ventilator-associated

pneumonia (VAP)

n Introduction
Sixty-one percent of the nursing workforce works in an
acute care setting.1 Acute care is care provided during a
severe episode of illness, following surgery, or following
a traumatic injury. Acute care usually occurs in a hospital
setting and requires skilled care provided by health-care
providers. Acute care is provided for a short time during
the severe episode and may be followed by chronic care
in the home or a long-term care facility.2

Acute care occurs mostly at the tertiary prevention
level (see Chapter 2), and the focus of the care is to pre-
vent further morbidity and reduce disability related to
the disease or injury. The majority of the care is clinical
rather than environmental or even behavioral. Although
an effort is made during the hospital stay to provide ed-
ucation on behavioral changes that will increase the
chances of return to a healthier state and reduce the

chances of death or disability, the primary focus of the
hospital stay is direct clinical interventions.

Hospitals provide care to persons who are acutely ill,
many of them critically ill. Adults who seek care in a hos-
pital setting require highly skilled nurses competent to
provide care to the individual addressing the acute episode
of illness or aftermath of an injury. It would seem at first
glance that the public health sciences have little to con-
tribute to the acute care setting. However, the high level
of care now available to patients experiencing an acute
episode of illness or injury is based on a clear understand-
ing of the natural history of disease that evolved out of
cohort and case control studies (see Chapter 3). Our
knowledge of the effectiveness of interventions is based on
the findings from rigorous clinical trials (see Chapter 3).
These research designs have their basis in epidemiology.

Nurses have a long history of applying population-
level research and an understanding of determinants of

7711_Ch14_343-371 22/08/19 11:36 AM Page 343

health to their delivery of care at both the macro (popu-
lation) level and the micro (individual) level. As hospitals
strive to meet criteria for accreditation and recognition
of excellence, the role of the staff nurse in improving pa-
tient outcomes includes actively applying public health
science to the evaluation and improvement of the care
they provide.

The Acute Care Setting and Population
Health
Often, the distinction between the community/public
health nurse (PHN) and the nurse working in a hospital
is based on the concept of direct and indirect care as pre-
sented in the Essentials of Doctoral Education for Ad-
vanced Nursing Practice.3 However, that distinction
becomes blurred because many nurses who define them-
selves as PHNs provide direct care to individuals, for ex-
ample, administering flu vaccines, whereas hospital-based
nurses frequently tackle problems from a public health
perspective, for example, reducing the rate of health care-
associated infections (HAIs) (see following section on
HAIs) or improving targeted patient outcomes for a par-
ticular population.

If, instead of a dichotomous concept of direct and in-
direct care, nursing practice is viewed across the contin-
uum of care from micro/individual health to macro/
population health, it is easier to demonstrate the applica-
tion of public health science to nursing practice in acute
care settings. Nurses in acute care settings are continu-
ously involved in efforts to improve care for the popula-
tions they serve, not just for each individual. If nurses on
a unit are working on a performance improvement proj-
ect, they have moved along the continuum to look at an
issue at the group level, the group they serve. Development
of an understanding of the patient data they collect for the
project requires the application of epidemiology such as
computing discharge rates, establishing odds ratios (see
Chapter 3), or looking at HAI rates. In most hospitals, the
performance improvement committee provides frequent
updates on care issues within the hospital and evidence to
demonstrate whether efforts to address specific problems
have resulted in improved patient outcomes.

The challenge is differentiating the term population
used in public health and the term population used in a
hospital setting. In Chapter 1, the term was defined as a
mass of people that make up a definable unit to which
measurements pertain. Chapter 1 explains that population
health occurs within the context of the social, economic,
cultural, and environmental influences on populations

and, thus, on individuals. This implies that, from a public
health perspective, population includes persons who share
a similar social setting, culture, and/or geographical com-
munity over a period of time. In a hospital setting, popu-
lations are instead grouped based on a particular health
issue or a hospital unit with individuals rapidly entering
and exiting the population. For example, within the hos-
pital the concern may be the diabetic population being
treated at the hospital, or it may be the patient population
on a specific unit. Thus, the term population within a hos-
pital context does not usually refer to a group of persons
who share other attributes other than being admitted
to the hospital on a certain unit and/or having a specific
diagnosis.

344 U N I T I I I n Public Health Planning

w SOLVING THE MYSTERY
The Case of the Nurse Who Wanted
to Know “Who, Why, What, Where,
and When?”
Public Health Science Topics Covered:
• Assessment
• Epidemiology

• Computing rates
• Comparing rates with national rates

• Health planning
• Conducting a setting-specific assessment
• Population-level conclusions: Identifying priorities

A large midwestern teaching hospital contracted
with a college of nursing to have a faculty member
with research experience provide mentorship to the
staff engaged in nursing practice research. A nurse
researcher who was also a PHN, Cheryl, was assigned
to the project. She found that the hospital had a history
of nurses on the units initiating small nursing-practice
studies; they also reviewed the literature to examine the
evidence related to a particular nursing intervention.
These projects were conducted by individual nurses
and typically culminated in a brief report on their
findings from the literature. The projects did not nec-
essarily result in a change in practice. There was no in-
formation on the effect any of these activities had on
patient outcomes. The newly appointed chief nursing
officer (CNO), Janet, stated that she wanted to change
the process to seek evidence that demonstrated
whether these studies or projects resulted in a change
in how nursing care was delivered and if there was a
positive impact on patient outcomes. Janet asked
Cheryl how to change the process so it was clear what

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C H A P T E R 1 4 n Health Planning for Acute Care Settings 345

patient outcomes should be targeted, how to plan
change, and how to evaluate the impact of the change.

Cheryl explained to Janet that a good starting point
was to take a public health perspective. When Janet
asked her to explain, Cheryl replied that a health-
planning model that included an assessment phase
and health program phase was the best approach
(Chapters 4 and 5). Cheryl said the best place to begin
was to answer the questions related to who, why,
what, where, and when; that is, to find out who was
being admitted to their hospital, why were they being
admitted (diagnosis), what were their outcomes, where
were they coming from, and whether there was a vari-
ation in these variables over the months and years.

As explained in Chapter 4, there are different types
of community/population assessments. Cheryl pro-
posed to Janet that the nursing department conduct a
setting-focused assessment. In addition, Cheryl
explained that this assessment would be conducted
using an epidemiological model; that is, the assessment
would focus on quantifying hospital-based data using
existing data sources and would then compare these
data with national data such as that available from the
Healthcare Cost and Utilization Project (HCUP).4 The
purpose of the assessment would be to determine
what patient issues were priorities for nursing practice
research in the hospital. The choice of priorities would
be based on the discharge diagnostic category with the
highest volume, longest mean length of stay, and high-
est mean charges as well as trends over time.

The CNO liked this approach and, together with
Cheryl, assembled a small team of graduate student
nurses and nurses familiar with the nursing units. They
were able to use a de-identified database (no patient
names or other means of identification) that included
all hospital discharges during a 5-year period. For each
discharge, they had information on gender, diagnoses
(including primary diagnosis and all other diagnoses
applied during the hospital stay), procedures, length
of stay, hospital charges, ZIP code, and payer source.
They used the HCUP Web site4 to access national-
level data to compare these parameters with national
statistics.

The team first calculated hospital discharge rates for
each diagnostic category. A hospital discharge rate
is the rate of a particular discharge diagnosis divided by
the total number of discharges times a constant, and is
computed in the same way other rates are computed
(see Chapter 3). Thus, a hospital discharge rate repre-
sents the number of discharges for that diagnosis in

comparison with all other discharges for that time pe-
riod. It is calculated using the number of discharges for
the diagnostic category or group divided by all dis-
charges times a constant, usually per 100 discharges
(Box 14-1).

While doing the assessment, one of the students
asked Cheryl to explain the difference between
International Classification of Diseases, 10th Re-
vision (ICD-10) codes and the Major Diagnostic Cat-
egories (MDC) used by HCUP. Cheryl explained that
the major diagnostic category (MDC) is a taxon-
omy that groups the principal diagnosis of patients
into similar diagnosis-related groups. There are
25 categories based on systems designed to be
mutually exclusive.4 Conversely, although ICD-10 is
also a taxonomy, it was developed to code very spe-
cific diagnoses related to the discharge rather than
categories of diagnoses, although the codes can be
collapsed into broader categories based on systems
such the circulatory system or disease group such as
neoplasms. A person with diabetes who has heart
failure (HF) may be admitted primarily to treat an
acute episode of HF. Therefore, the primary diagno-
sis coded using an ICD-10 code would be specific to
HF. They may have subsequent secondary and terti-
ary ICD-10 codes entered related to the circulatory
system and would have an ICD-10 code for diabetes
listed as the fourth or fifth diagnosis. ICD-10 allows
the hospital to code for billing a very specific diagno-
sis under the broader ICD-10 category that indicates
exactly what particular diagnoses were related to this
admission. To help illustrate this for the student,
Cheryl took the data for one admission from the data-
base and demonstrated what ICD-10 categories were
entered for that patient including the primary diag-
nosis and all other diagnoses related to the admission

The total number of discharges assigned to the MDC
Cardiovascular System was 4,179, and the total number
of discharges was 29,585.

The discharge rate per 100 discharges is as follows:

4,179/25,585 × 100

and is read as

14.1 per 100 discharges in 2009

Note: This reflects discharges, not patients.

BOX 14–1 n Calculating a Discharge Rate

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346 U N I T I I I n Public Health Planning

TABLE 14–1 n Comparison of Major Diagnostic Category Listing and ICD10 Codes for a Discharge

MDC

Discharge

Diagnoses

Major Diagnostic
Category

Diseases of the
digestive system

ICD10 Primary Diagnostic
Category

D21.4

Neoplasm of the abdomen

ICD10 Tertiary
Diagnostic Code

I11.2

Hypertensive
disease

ICD10 Secondary
Diagnostic Category

172

Diseases of arteries,
arterioles, and capillaries

TABLE 14–2 n Top 10 Major Diagnostic Categories for Nonmaternal Nonneonatal Hospitalizations

Rank Rank All Rank All Rank All
Rank Males Females Genders Genders Genders

Major Diagnostic Category Aged 0–85+ Aged 0–85+ Aged 18–44 Aged 45–64 Aged 65+

Diseases of the circulatory system

Diseases of the respiratory system

Diseases of the digestive system

Diseases of the musculoskeletal
system and connective tissue

Diseases of the nervous system

Diseases of the kidney and urinary
tract

Mental disorders

Infectious and parasitic diseases

Diseases of the hepatobiliary system

Endocrine, nutritional, and metabolic
systems

Diseases of the female reproductive
system

(Table 14-1). She then pointed out that only one
MDC category was applied to that specific admission.
In this case, the MDC was used to identify the princi-
pal diagnosis for admission and was a broader cate-
gory, whereas the ICD-10 code identified for what
specific diseases the patient was being treated during
the admission (Table 14-1).

The team ran frequencies on the discharge data to
determine the top five MDCs, which MDC had the
highest mean length of stay, and which had the highest
mean charges. They also calculated hospital discharge
rates for each MDC. The MDC with the highest dis-
charge rate was the circulatory system. They con-
structed a table that displayed the top 10 MDC
discharge rate bases on gender and age (Table 14-2).

They then compared these data with the available na-
tional data related to hospital discharges. They found
that although their discharge rate was higher, when
compared with the national data, the hospital had a
lower mean length of stay and mean charges for that
MDC. Despite the evidence that they were better than
the national norms on these two indicators, they con-
cluded that, because of the high discharge rate, the pa-
tients admitted with an MDC related to the circulatory
system would be a focus area for development of
health programs aimed at improving outcomes.

The team had now answered the “why” question.
They went on to answer the rest of the questions.
They used gender, payer source, and place of residence
to answer the “who” and “where” questions. They

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C H A P T E R 1 4 n Health Planning for Acute Care Settings 347

completed the analysis for each of the 5 years of data
and trending discharge rates during the 5 years and by
month. They then used the discharge status variable to
examine outcomes. This was an extensive project, but
it provided answers to their questions and, most im-
portantly, provided a clear picture of the patients they
served and the subpopulations most at risk for poorer
outcomes. They also identified other information that
they wished to add to the assessment such as hospital
recidivism, that is, readmission to the hospital within
30 days of discharge.

The assessment project not only helped the nursing
department establish these priorities, but also provided
baseline data from the past 5 years. In this way, the
nursing department could track discharge rates and
other quality indicators such as length of stay and
charges over the next 5 years to help determine
whether institution or revision of nursing interventions
resulted in any changes in patient outcomes. At this
hospital, the nursing department moved from focusing
on the evaluation of effectiveness of nursing interven-
tions on individual patient outcomes to an inclusion of
the population-level perspective and the evaluation of
the outcomes for both levels.

n CULTURAL CONTEXT
AND ACUTE CARE SETTINGS

Culture is an important aspect of nursing care within
an acute care setting. Nurses understand the need for
culturally relevant care for individuals and families, but
it also helps if nurses working in an acute care setting
are aware of the different cultures represented in their
community. An excellent hypothetical example based
on an actual story is the issue of the Burundian
refugees who settled in a midwestern city. In this ex-
ample, a total of 106 Burundian refugees came to the
city with support from the Catholic Archdiocese of the
city. They were able to find housing in one of the
poorer sections of the city and faced multiple chal-
lenges, including obtaining health care. They had lived
in refugee camps since the 1970s and were unable to
speak English, with low literacy in their own language.

To address the challenges faced by these refugees,
the parish nurse employed by a large urban hospital as
part of their community outreach project began to
work with the Burundians to help establish a means for
them to access care and communicate with health-care
providers. This required that she learn their culture
and normative health-care practices. The parish nurse

located an interpreter and began meeting with the
women in the community on a regular basis. Together
they learned from one another: The Burundians
learned the culture of their new country, and the
parish nurse learned the culture of the Burundians. She
was able to use this cultural knowledge to provide the
hospital with key cultural insights into Burundian cul-
ture, especially in relation to health beliefs, so that the
physicians and nurses providing care would understand
health from a Burundian perspective. Without the
work of the parish nurse, the hospital would have had
difficulty not only in understanding the Burundians
when they came for care but also in understanding
their cultural perspective on the care received.

The Epidemiology of Populations Treated
in Acute Care Settings in the United States
As defined in Chapter 3, epidemiology is the study and
quantification of illness and disease within human and
animal populations. From an acute care perspective,
epidemiology provides the framework for the study of
the frequency, distribution, cause, and control of dis-
eases or injury in persons who receive care in an acute
care setting. Thus, epidemiology revolves around sev-
eral factors, including patients with noncommunicable
diseases, communicable diseases, violence, abuse, and
injury. Its purpose is to assist public health officials as
well as the registered nurse (RN) to understand the
causes of disease, the distribution and impact of disease,
and the groups at risk so that prevention efforts along
the continuum from primary to tertiary levels can be
developed. Hospital morbidity and mortality rates are
published each year by the Centers for Disease Control
and Prevention (CDC) and the Agency for Healthcare
Research and Quality (AHRQ). PHNs as well as nurses
working in the acute care setting may access any of
these databases to determine specific health risk factors
based on age group, gender, and residence. This infor-
mation may then be used to target interventions to im-
prove the health of those they care for in acute care
settings.

According to the CDC, in 2016 the top two leading
causes of death in the United States were heart disease
and cancer for both males and females. There were differ-
ences between genders; the third leading cause of death
for males was unintentional injuries, and for females, it
was chronic lower respiratory diseases (Table 14-3). Fol-
lowing cancer and chronic respiratory diseases were
stroke, Alzheimer’s disease, unintentional injury, diabetes,

7711_Ch14_343-371 22/08/19 11:36 AM Page 347

influenza and pneumonia, kidney disease, and sepsis.5 In
2016, 6.4% of the U.S. population aged 1 and older had
at least one hospital stay, down from 7.8% in 1997. When
broken down by age, 15.2% of those over the age of 64
had at least one hospital stay and for those over the age
of 84, almost a quarter (22.5%) had at least one hospital
stay.6 The average length of stay was 6.1 days.7 In 2015,
The most common diagnosis for inpatient stays after live
birth was septicemia (Table 14-4).8

Discharge Status of Hospitalized Patients
The goal on discharge is to return the patient to his op-
timal state of health and, if possible, to independent liv-
ing. Return to independent living is attainable for the
majority of all hospitalized adults in the U.S. Others are
able to return to their home environment with home
health-care services or are transferred to an extended
care facility for both short-term and long-term stays. Fi-
nally, patients may have been discharged to another hos-
pital, died, or left against medical advice.8 Assessing
patients at the time of admission and developing indi-
vidual discharge plans will make the postdischarge tran-
sition easier for all of those involved. Tracking discharge
status is another indicator of patient outcomes and
could easily be added to an ongoing hospital population
assessment such as the one conducted by Janet and
Cheryl.

Inpatient Populations
Understanding public health science and its daily role
in the hospital setting is an essential competency for all
nurses working across various units including critical
care, emergency departments (EDs), and medical-
surgical units. They participate through their daily ac-
tivities in the improvement of health for the patients for
whom they care, the patients’ families, and the commu-
nities to which those patients return. Understanding the
patients they care for within the broader context of the
community served by the hospital can be a challenge. As
the nation takes its slow march toward health promo-
tion and disease prevention, as evidenced in the Afford-
able Care Act of 2010,9 the need for more health-care
activities on the population end of the continuum con-
tinues to increase. Nurses working in acute care settings
have an important role to play.

348 U N I T I I I n Public Health Planning

TABLE 14–3 n 2015 Differences in Top 10 Leading Causes of Death by Gender

Leading Causes of Death Males Percentage Leading Causes of Death Females Percentage

1. Heart disease
2. Cancer
3. Unintentional injuries
4. Chronic lower respiratory diseases
5. Stroke
6. Diabetes
7. Suicide
8. Alzheimer’s disease
9. Influenza and pneumonia

10. Chronic liver disease

22.3
21.2
6.2
6.1
5.7
4.0
2.7
2.3
1.8
1.6

1. Heart disease
2. Cancer
3. Chronic lower respiratory diseases
4. Stroke
5. Alzheimer’s disease
6. Unintentional injuries
7. Diabetes
8. Influenza and pneumonia
9. Kidney disease

10. Septicemia

24.4
22.8
6.8
5.3
4.2
3.1
2.5
2.0
2.0
1.9

TABLE 14–4 n 2015* U.S. National Inpatient Stays

Rate of Stays
Principal Diagnosis per 100,000

Liveborn

Septicemia (except in labor)

Osteoarthritis

Congestive heart failure;
nonhypertensive

Pneumonia (except that
caused by tuberculosis or
sexually transmitted disease)

Mood disorders

Cardiac dysrhythmias

Complication of device;
implant or graft

Acute myocardial infarction

Other complications of birth;
puerperium affecting
management of mother

*Maternal/Neonatal Stays Included
Source: (8)

1,195

552

339

297

276

267

212

203

196

195

7711_Ch14_343-371 22/08/19 11:36 AM Page 348

Within hospitals, there are numerous settings that are
usually referred to as units. These units vary based on the
type of services required (e.g., surgery, medical, emer-
gency care) and the severity of the patients’ condition
(e.g., intensive care, trauma, step-down units). Hospitals
also vary in relation to the level of care they provide, the
communities they serve, and whether or not they are
teaching hospitals. Some services, such as infection con-
trol, are provided across all units of the hospital. Com-
munity hospitals located in suburban or rural areas are
less apt to provide care to high-level-of-acuity patients
such as those requiring complex surgical procedures or
trauma level-one care. By contrast, a large urban medical
center, especially one affiliated with a large university,
has a wide array of units, many of which provide com-
plex or specialized services.

Critical Care
An excellent example of the relationship between public
health science and acute care settings is the role that
public health science has played in the development of
critical care as a specialty in the acute care setting. Crit-
ical care nursing requires specialized skills related to
human responses to life-threatening health problems,9
and is usually provided within an area in the hospital
designed to provide care to the most critically ill or in-
jured patients. Critically ill or injured patients are
patients who are at high risk for actual or potential
life-threatening health-care problems.10 Critical illness
can result from a progressive disease such as chronic
obstructive pulmonary disease or may occur in an acute
situation such as myocardial infarction (MI). Acute
illness can involve a rapid change in condition for the
worse or a condition that arises quickly, such as an
exacerbation of fluid overload in the patient with HF.
Patients in the critical care arena have varied disease eti-
ologies, background demographics, socioeconomic sta-
tus, and complexities. Also, a patient may be in critical
condition from blood loss due to an acute injury sus-
tained in motor vehicle crash. The more critically ill the
patient is, the more vulnerable they are for instability
and threat to life, requiring intense and highly skilled
nursing care.

The care of the critically ill patient takes place in sev-
eral different arenas within the hospital setting. This pa-
tient population can be found in the intensive care units
(ICUs), step-down or transitional care units, EDs,
postanesthesia care units (PACU), cardiac catheter lab-
oratories (cardiac cath lab), and cardiac care units. The
focus of the critical care nurse is not only on the patient’s
responses to illness and optimal care but also on the

family’s response. Almost two-thirds of all working RNs
work in the hospital setting (61%). Of those, more than
a third work in the critical care area.1,10,11 Critical care
nurses rely on a vast body of knowledge, skill, and expe-
rience so that they can provide care to the patient and
the patient’s family while performing as a patient advo-
cate and liaison. Included in the body of knowledge is
public health science.

Although nurses working in critical care settings
spend the majority of their time providing individual
care to patients and families, hospital-based, population-
level data are needed to evaluate the effectiveness of
that care. Nurses use well-established epidemiological
models to guide their health prevention activities,
mostly at the tertiary prevention level. These activities
include health education and careful discharge plan-
ning to promote recovery and reduce the risk of disabil-
ity and mortality. In addition, over time critical care
nurses actively engage in population-level care through
performance improvement activities and participation
in research studies aimed at gathering evidence to
demonstrate the effectiveness of interventions for
improving the outcomes of the patient populations
they serve.

Evolution of Critical Care: Population Driven
Over the past few decades, critical care nursing has been
recognized as a distinct and essential specialty, providing
care to those who are the most severely ill or injured.10 The
origin and development of the critical care field occurred
in response to several different factors, each of which was
population driven. The initiating factors first occurred in
response to wartime injury. The progression of critical
care can be attributed to the advancement in technology
and the utilization of an improvement process shaped by
evidence-based practice (EBP).

War: Critical care, in part, was developed using knowl-
edge and skill obtained during wartime efforts. The true
origin has been difficult to establish, but Florence
Nightingale12 is considered to be the first to have used an
ICU approach to help focus care on those who were in
the need of the highest level of nursing care. She served
with the British during the Crimean War from 1854 to
1856. In her book Notes on Hospitals, she wrote about
the advantages of establishing a separate area of the hos-
pital for the sickest or most severely injured soldiers. She
maintained this area close to her nursing station where
she could keep a close watch on their condition and pro-
vide quick help when needed. The next report of a similar
effort was in 1929, when Dr. Walter Dandy of Johns
Hopkins Hospital in Baltimore developed a specialized

C H A P T E R 1 4 n Health Planning for Acute Care Settings 349

7711_Ch14_343-371 22/08/19 11:36 AM Page 349

postoperative unit containing three beds for neurosurgi-
cal patients.13

Advancements in care for the critically ill also oc-
curred as a consequence of wartime injuries. During
World War I, the importance of recognizing shock and
treating it with the intravascular volume replacement
using saline and colloid solutions was demonstrated.
Early in World War I, before the United States entered
into the war, Bruce Robertson first introduced blood
transfusion. He was a Canadian physician who, while
training in the U.S., became convinced that whole blood
was superior to saline infusions. The blood was collected
from soldiers on the battlefield who were willing and
ready to donate. It was not until World War II that the
technique of blood transfusion was widely used. This war
provided the stimulus for organized blood collection; as
the war progressed, a national blood program was estab-
lished, which provided massive quantities of blood for
overseas use.14

Also, during World War II, advances in surgical tech-
niques led to survival after injuries that were previously
considered lethal. These injured soldiers subsequently
needed prolonged supportive care for recovery. Shock
wards were developed to resuscitate and care for soldiers
injured in battle or undergoing surgery, and postopera-
tive patients were admitted to recovery rooms to facilitate
nursing care.15

With each subsequent war, advances have been made
in the care of the critically ill and injured. In the Iraq and
Afghanistan wars, significant advances were made in the
treatment of traumatic brain injuries that resulted from
roadside bomb explosions. These have translated into ad-
vances in caring for civilian injuries both unintentional,
such as motor vehicle crashes (MVCs) and football in-
juries, and intentional, such as the mass shooting event
that occurred at a high school in Parkland, Florida. These
advances occurred because of the focus on the care of a
population, in this case soldiers, and the particular type of
injuries they were experiencing. This has resulted in a
steady improvement in the mortality rate of soldiers in
U.S. conflicts.16,17 During the American Civil War, the
chance of dying was about one in four (250 per 1,000).
Only a fraction actually died during battle because much
of the deaths were attributable to disease and infections of
wounds sustained during battle.17 By the time of the war
in Vietnam, the death rate dropped to 21.8 per 1,000,
which was five times higher than the death rate during the
war in Iraq as measured between the beginning of the war
under George Bush in 2003 and the functioning of the new
Iraq government in 2006.19 Some of these advancements
were a result of innovations not that dissimilar to what

Florence Nightingale did in the Crimean War. For exam-
ple, in Iraq, medical teams were deployed closer to combat
areas, and evacuation times were greatly improved.19

All of these innovations in care were driven by
population-level data. In particular, these changes were
made to improve the health outcomes of soldiers who
had sustained life-threatening injuries or contracted dis-
eases on the battlefield. The practices continued to be re-
fined and used because population-level data demonstrated
that survival rates improved. Survival rate is defined as
the number of persons who survive an event divided by
the total number of persons who experience an event.
Thus, these innovative clinicians, including Florence
Nightingale (see Chapter 1), effectively used public
health science to improve the health of the critically ill.

Polio and Intensive Care: Critical care has evolved
not only through the care of those injured during war
but also through advances related to communicable dis-
eases (see Chapter 8) and noncommunicable chronic dis-
eases (see Chapter 9). Innovations in the delivery of care
to those who are critically ill have developed in response
to communicable disease outbreaks. In other cases, pub-
lic health science findings have resulted in changes in
how we care for chronic diseases.

A good example of how a communicable disease out-
break changed practices in critical care is the po-
liomyelitis (polio) epidemic that started in the late 1940s.
Polio, one of the most dreaded diseases of childhood
during the 20th century, is caused by the poliovirus, a
human enterovirus member of the family Picornaviridae.
It is transmitted from person to person via the fecal-oral
route. Until the 20th century, the virus was readily trans-
mitted via water, and most exposures to the virus oc-
curred during infancy. At this young age, when most
have at least partial protection via maternal antibodies,
the resulting infection was subclinical. This asympto-
matic infection in turn gave lifelong immunity. Only a
few suffered from paralysis, which was labeled infantile
paralysis. As advancements in water treatment took
place, the early childhood exposure to the poliovirus de-
creased. As a consequence of better hygiene, the first ex-
posure to the virus was more apt to occur during late
childhood or young adulthood. In this older age group,
the infection caused more severe sequelae: a paralysis
syndrome. At the peak of the epidemic in 1952, there
were more than 21,000 cases. With the introduction of
the Salk vaccine, the incidence rapidly decreased. By
1965, there were only 61 cases, and the last known case
caused by wild poliovirus was in 1993.20

Prior to the introduction of the vaccine, the epidemic
in the late 1940s and early 1950s resulted in an increased

350 U N I T I I I n Public Health Planning

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demand on the health-care system. More than 90% of
poliovirus infections are asymptomatic, however, in
cases that do show symptoms, the most severe potential
effect of the virus is paralysis. The paralytic syndromes
range from paralysis of one or more limbs to respiratory
muscle paralysis. The mortality rate from respiratory
polio was greater than 90%. Boston Children’s Hospital
was the first to use a mechanical respiratory machine
called the iron lung to prevent likely death (Fig. 14-1).
Use of this respiratory therapy resulted in a significant
reduction of mortality but was found to be cumbersome
and expensive, which made it difficult to provide nursing
care. As years passed, improvements were made to this
mechanical respiratory unit, and it was broadly used
throughout North America and Europe during severe
polio outbreaks.

In 1952, during a large polio outbreak in Denmark,
Bjorn Ibsen, an anesthesiologist in Blegdam Hospital,
used the positive pressure ventilation concept used in the
operating room for the respiratory support for the polio
victims. Dr. Ibsen had his medical students hand-ventilate
dozens of patients through tracheostomy tubes until the
worst of the paralytic phase had passed. For efficiency and
convenience, the patients who needed the respiratory
support were placed in a single location within the hos-
pital. This is often cited as the world’s first ICU, “a ward
where physicians and nurses observe and treat ‘desper-
ately ill’ patients 24 hours a day.”13,21 It is considered the

origin of today’s ICU. Again, improved outcomes and de-
creased mortality for this particular hospital-based pop-
ulation drove the development of these interventions.

Despite the innovative use of an iron lung and an ICU
concept, the polio pandemic spurred public health re-
search aimed at primary prevention. Based on the epi-
demiological triangle reviewed in Chapters 3 and 8,
clinicians had the choice to eradicate the virus, change the
environment, or protect the host (humans). There was a
major public health program using public service an-
nouncements that warned parents about the risk of polio
with a focus on public swimming areas. Polio outbreaks
often occurred during the summer months as a result of
children swimming in contaminated water. Thus, initial
efforts were to alter the chance of exposure. However,
public health research concentrated on protecting the
host through the development of a vaccine that would
boost human resistance to the virus. It was the introduc-
tion of the Salk vaccine in 1952 and the Sabin vaccine in
1962 that dramatically reduced the incidence of polio to
less than one per 100,000 persons annually in the early
1960s. Thus, public health science can often help bring
solutions to health issues which result in the need for crit-
ical care. Since the initiation of the ICU concept during
the polio pandemic, ICUs have come to provide care for
many different kinds of patients, from the neonate to
adults with specific intensive care needs (Box 14-2).

C H A P T E R 1 4 n Health Planning for Acute Care Settings 351

• Neonatal intensive care unit (NICU)
• Special care nursery (SCN)
• Pediatric intensive care unit (PICU)
• Psychiatric intensive care unit (PICU)
• Coronary care unit (CCU)
• Cardiac surgery intensive care unit (CSICU)
• Cardiovascular intensive care unit (CVICU)
• Medical intensive care unit (MICU)
• Medical surgical intensive care unit (MSICU)
• Surgical intensive care unit (SICU)
• Overnight intensive recovery (OIR)
• Neurotrauma intensive care unit (NICU)
• Neurointensive care unit (NICU)
• Burn wound intensive care unit (BWICU)
• Trauma intensive care unit (TICU)
• Surgical trauma intensive care unit (STICU)
• Trauma-neuro critical care (TNCC)
• Respiratory intensive care unit (RICU)
• Geriatric intensive care unit (GICU)
• Mobile intensive care unit (MICU)

BOX 14–2 n Specialized Types of Intensive
Care Units

Figure 14-1 A 1960 historical photograph of a nurse
caring for a victim of a Rhode Island polio epidemic, who
is inside an Emerson respirator, also sometimes referred
to as an “iron lung” machine. (From Centers for Disease
Control and Prevention, Public Health Image Library, No. 12009.
Retrieved from http://phil.cdc.gov/phil/details.asp)

7711_Ch14_343-371 22/08/19 11:36 AM Page 351

Technology and Acute Care: Cardiopulmonary
Resuscitation: Advances in technology have also re-
sulted in changes in the delivery of critical care. The use
of these technologies demonstrates a combination of
population data, advances in the understanding of
human physiology, and technological advances. As in the
field of pharmacy, the randomized clinical trial (Chapter 3)
is the gold standard for determining the effectiveness and
efficacy of technological interventions in critical care.
These advances often began with bench science; in the
end, however, they translate into how care is provided
because of positive changes in the outcomes of the
patient populations involved. One of the most dramatic
examples is the whole issue of cardiopulmonary resus-
citation (CPR), an emergency procedure that includes
the use of external cardiac massage and artificial respira-
tion for persons who experience sudden cardiac arrest.
The technique was developed within the acute care set-
ting and adopted for use by the general public. Overall,
CPR has dramatically reduced mortality attributed to a
variety of events that result in cessation of breathing,
heartbeat, or both.

Peter J. Safar, the “father” of CPR, converted the method
of CPR used in the hospital for use by the general public.
He promoted the development of life-supporting first
aid, which is known as basic life support. In 1957, he pub-
licized the “A” (airway), “B” (breathing), and “C” (circula-
tion system). Safar was a public health advocate who gave
the first step to the general public to aid others in an emer-
gency. He worked hard to popularize the procedure around
the world and collaborated with a Norwegian company to
create “Resusci Anne,” the first CPR training mannequin.
His contribution to life-saving medical technique has
earned him a reputation as one of the pioneers of critical
care medicine and has saved countless lives.22

In 1960, the American Heart Association (AHA)
started a program to acquaint physicians with closed-
chest cardiac resuscitation, and it became the forerunner
of CPR training for the general public. Although only 40
communities in the United States regularly measure and
report survival rates, these population-level data have
proved invaluable in the evaluation of the success of CPR
and the development of changes aimed at improvement
of survival rates. Initially, it was recommended that
laypersons administering CPR first clear the airway
(A), then administer breaths (B), and then initiate chest
compressions (C). In 2010, dramatic revisions were
made to the CPR guidelines. The recommendations were
for the three steps of CPR to be rearranged: the new
first step is now chest compressions instead of first es-
tablishing the airway, and then administering breaths.

Newborns are an exception to the change. Thus, for the
single rescuer, A-B-C has become C-A-B for compres-
sions, airway, and breathing (Fig. 14-2). For laypersons,
the AHA states that the most effective approach is to im-
mediately deliver chest compressions at a rate of greater
than 100 compressions per minute “the same rhythm as
the beat of the Bee Gees’ song, ‘Stayin’ Alive.’”24 Although
it is difficult to determine the exact outcomes associated
with long-term survival, according to 2014 data, nearly
45% of out-of-hospital cardiac arrest victims survived
when bystander CPR was started.23 Using the AHA in-
formation to guide the administration of CPR, supportive
programs such as public access defibrillation programs
were implemented aimed at improving survival rates.24,25

Role of Cohort Studies in the Delivery
of Acute Care
Population data have not only been gathered from within
the hospital to help improve patient outcomes but have
also been gathered from general populations. A longitu-
dinal cohort study (see Chapter 3) provides valuable ev-
idence on who will potentially develop disease based on
different risk factors. At baseline, information is collected
about the health of the individuals in the cohort and then
these individuals are tracked over time to determine who
develops disease and who does not. A cohort study can
be focused on a particular disease, for example, the Fram-
ingham Health Study (FHS),26 or a particular population,
such as the Nurses’ Health Study.27

The Framingham Heart Study
and Cardiovascular Disease
As reported in Chapter 9, the leading cause of death in
the United States is cardiovascular disease (CVD). Nearly
2,300 Americans die of CVD each day, an average of one
death every 38 seconds. CVD claims more lives each year
than all forms of cancer and chronic lower respiratory
diseases combined. There are an estimated 92,100,000
American adults (more than one in three) with CVD.28

The FHS is directly responsible for the remarkable ad-
vances made in the prevention of heart disease in the
United States and throughout the world.

In 1948, the town of Framingham, Massachusetts, was
selected as the study site by the U.S. Public Health Serv-
ice, and 5,209 healthy residents between 30 and 60 years
of age, both men and women, were enrolled as the first
cohort of participants. It was the first major cardiovas-
cular study to recruit women participants. At the time,
little was known about the general causes of heart disease

352 U N I T I I I n Public Health Planning

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C H A P T E R 1 4 n Health Planning for Acute Care Settings 353

Figure 14-2 C-A-B for cardiopulmonary resuscitation. (See [24]. Used with permission.)

7711_Ch14_343-371 22/08/19 11:36 AM Page 353

and stroke, but the death rates for CVD had been in-
creasing steadily since the beginning of the 20th century
and had become an American epidemic. The FHS be-
came a joint project of the National Heart, Lung, and
Blood Institute (NHLBI) and Boston University.27

The objective of the FHS was to identify the common
risk factors that contribute to CVD by following its de-
velopment over a long period of time in a large group of
participants who had not yet developed overt symptoms
of CVD or suffered a heart attack or stroke. Since 1948,
the subjects have continued to return to the study every
2 years for a detailed medical history, physical examina-
tion, and laboratory tests. In 1971, the study enrolled a
second generation, 5,124 of the original participants’
adult children and their spouses, to participate in similar
examinations. In 1994, the need to establish a new study
including a more diverse community of Framingham
was recognized, and the first Omni cohort (OMNI1) of
the FHS was enrolled. Due to the predominantly white
population in the first cohorts, the OMNI cohorts were
enrolled as a way of representing the growing diversity
of Framingham from a racial and ethnic perspective. In

April 2002, the study entered a new phase, the enroll-
ment of a third generation of participants, who were the
grandchildren of the original cohort. In 2003, a second
group of Omni participants was enrolled.26

The FHS continues to make important scientific con-
tributions by enhancing its research capabilities and cap-
italizing on its inherent resources. Some of the more
recent data from the FHS, from the original and offspring
cohorts (1980–2003), show that the average annual rate
of first major cardiovascular events is on the rise. Events
have gone from 3 per 1,000 in men at ages 35 to 44, to 74
per 1,000 at ages 85 to 94. For women, comparable rates
occur 10 years later in life, and the gap narrows with ad-
vancing age. Before age 75, men suffer a higher propor-
tion of CVD events due to coronary heart disease (CHD)
than do women, and a higher proportion of events due
to stroke occur in women. From 1996 to 2006, death
rates from CVD declined 29.2%. Data from the FHS in-
dicate that the lifetime risk for CVD is two in three for
men and more than one in two for women at age 40.26

Over time, the impact of the study on heart health is
substantial (Box 14-3).28,29

354 U N I T I I I n Public Health Planning

1960
1961
1967
1970
1976
1978
1988
1994
1996
1998

1999
2001

2002
2002
2004
2005
2006

2007

2008

Cigarette smoking found to increase the risk of heart disease.
Cholesterol level, blood pressure, and electrocardiogram abnormalities found to increase the risk of heart disease.
Physical activity found to reduce the risk of heart disease, and obesity found to increase the risk of heart disease.
High blood pressure found to increase the risk of stroke.
Menopause found to increase the risk of heart disease.
Psychosocial factors found to affect heart disease.
High levels of high-density lipoprotein cholesterol found to reduce risk of death.
Enlarged left ventricle (one of two lower chambers of the heart) shown to increase the risk of stroke.
Progression from hypertension to heart failure described.
Development of simple coronary disease prediction algorithm involving risk factor categories to allow physicians
to predict multivariate CHD risk in patients without overt CHD.
Lifetime risk at age 40 years of developing CHD is one in two for men and one in three for women.
High-normal blood pressure is associated with an increased risk of CVD, emphasizing the need to determine
whether lowering high-normal blood pressure can reduce the risk.
Lifetime risk of developing high blood pressure in middle-aged adults is 9 in 10.
Obesity is a risk factor for heart failure.
Serum aldosterone levels predict future risk of hypertension in non-hypertensive individuals.
Lifetime risk of becoming overweight exceeds 70%; risk for obesity approximates one in two.
The NHLBI of the National Institutes of Health announced a new genome-wide association study at the FHS in
collaboration with Boston University School of Medicine to be known as the SHARe project (SNP Health Associ-
ation Resource).
Based on evaluation of a densely interconnected social network of 12,067 people assessed as part of the FHS,
network phenomena appear to be relevant to the biological and behavioral trait of obesity, and obesity appears
to spread through social ties.
Based on analysis of a social network of 12,067 people participating in the FHS, researchers discover that social
networks exert key influences on decision to quit smoking.

BOX 14–3 n Framingham Heart Study Milestones

7711_Ch14_343-371 22/08/19 11:36 AM Page 354

Women and Cardiovascular Disease
CVD is the leading cause of death in women.30 Initially
CVD was perceived by many health-care providers as a
predominately male disease linked to stress and lifestyle. It
was thought that women had a low risk for developing CVD
and were protected by female sex hormones. Since the
1990s, there has been an effort to increase the amount of
research done to help understand heart disease in women.
This research is leading to a better understanding of risk
factors, early signs and symptoms, and treatment.31,32

As mentioned earlier, the FHS is one of the few long-
term prospective studies of CVD that has included both
men and women. Women participated from the very be-
ginning, and investigators recognized that CVD occurs
later in life and with lower frequency in females. With
follow-up of 5,209 original study participants (2,873
women and 2,336 men), researchers have documented
information about the incidence of CVD in the FHS
women and risk factors unique to women.29

There are specific physiological, pathophysiological,
clinical, and socioeconomic issues that differentiate
women and men with CVD. Because of these differences,
symptoms of an acute myocardial infarction (AMI) are
different between genders. Women are more likely to ex-
perience atypical chest pain, abdominal pain, dyspnea,
nausea, and fatigue during a cardiovascular event. Be-
cause these symptoms are different from the “elephant
sitting on the chest” type of pain that males often expe-
rience, the atypical presentation may be missed or be at-
tributed to another etiology. If the suspicion of CVD has
not been raised by symptoms, underinvestigation and
undertreatment may occur. Women typically wait longer
to seek medical assistance; this may be due to the atypical
presentation of symptoms.32,33 Delay of treatment has a
devastating effect on the outcome of a cardiovascular
event, which certainly may be seen in the mortality rate
for a woman following an AMI (Box 14-4). The risk of

CVD increases with age, and as the baby boomers age,
the morbidity and mortality rate related to CVD in
women will grow. Because of this increasing number, it
is important to raise awareness of this major public
health issue for older women.

C H A P T E R 1 4 n Health Planning for Acute Care Settings 355

Source: (29)

2008

2009

2009
2010s

Discovery by FHS and publication of four risk factors that raise probability of developing precursor of heart failure;
new 30-year risk estimates developed for serious cardiac events.
FHS cited by the AHA as being among the top 10 cardiovascular research achievements of 2009, “Genome-wide
Association Study of Blood Pressure and Hypertension: Genome-wide Association Study Identifies Eight Loci
Associated With Blood Pressure.”
A new genetic variant associated with increased susceptibility for atrial fibrillation, a prominent risk factor for
stroke and heart failure, is reported in two studies based on data from the FHS.
FHS researchers find parental dementia may lead to poor memory in middle-aged adults.
Sleep apnea is tied to increased risk of stroke; Additional genes identified that may play a role in Alzheimer’s
disease; and hundreds of genes were discovered that are underlying major heart disease risk factors.

BOX 14–3 n Framingham Heart Study Milestones—cont’d

• CVD, particularly coronary heart disease (CHD) and
stroke, remain the leading causes of death of women
in America and most developed countries, with nearly
37% of all female deaths in the United States occurring
from CVD.

• CVD is a particularly important problem among
minority women. The death rate due to CVD is
higher in black women than in white women.

• One in 2.7 females who die, die of heart disease,
stroke, and other CVD compared with one in 30 who
die of breast cancer.

• At age 40 and older, 23% of women compared with
18% of men will die within 1 year after a heart attack.

BOX 14–4 n Facts About Women and
Cardiovascular Disease

Source: (30)

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Waiting Women
Public Health Science Topics Covered:

• Health planning
• Conducting a setting-specific assessment
• Population-level conclusions: Identifying priorities

Two nurses, Susan and Maria, work together in a
cardiac catheterization laboratory (cath lab) in a large
urban tertiary center. The cath lab is a very busy area
within this medical center. This specialized area holds

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356 U N I T I I I n Public Health Planning

diagnostic imaging equipment used to support diagnos-
tic and interventional procedures. The cath lab is
staffed by a multidisciplinary team including physicians
(interventional cardiologists, vascular surgeons, or radi-
ologists), nurses, and radiology technicians.

A diagnostic procedure called a cardiac catheteriza-
tion is performed in the cath lab to determine the ex-
tent of disease present in the vascular system. Left
heart catheterization (arterial) is performed to deter-
mine blockages in the coronary vascular system. Right
heart catheterization (venous) is performed to deter-
mine how well the heart valves are functioning and
how effectively the heart is pumping blood to the lungs.
The method involves threading a catheter through a
femoral artery or vein or the radial artery and then
threading it into the heart. During cardiac cath, a radio-
opaque dye is injected through the catheter to highlight
the coronary arteries. This test is called a coronary
angiogram or coronary arteriogram.

Depending on what is found during the coronary an-
giogram, different interventions may be necessary dur-
ing the cardiac cath. For example, an angioplasty that
uses a balloon on the end of the catheter is able to
open narrowed coronary arteries. Stents, which are
small, mesh-like devices that act as supports, or scaf-
folds, inside of a vessel, may be placed at the time of
angioplasty.

During one particularly busy shift in the cath lab,
Susan relieved Maria for lunch and received a report
on a patient who was coming from the ED with a diag-
nosis of a suspected AMI. The patient was a 60-year-
old woman with no known history of CVD who
arrived in the ED about an hour before with vague
complaints of fatigue, shortness of breath, and chest
pressure. After a detailed history and physical, this pa-
tient was found to have an ST-elevation myocardial
infarction (STEMI), a heart attack caused by a pro-
longed period of blocked blood supply.33 While Susan
was with this patient in the cath lab, the coronary an-
giogram showed a severely occluded left main coronary
artery, a surprising discovery given her atypical com-
plaints. Knowing that this type of obstructive disease
holds an increased mortality risk, Susan wanted to
know why this patient was in the ED for such a long
time before the diagnosis was made. She was also con-
cerned because the door-to-balloon time was just at
the 90-minute mark.

Door-to-balloon time is defined as the amount
of time between a patient’s arrival at the hospital
and the time he/she receives percutaneous coronary

intervention, such as angioplasty.33 Because “time is
muscle,” meaning that delays in treating an AMI in-
creases the likelihood and amount of myocardial
damage resulting from localized hypoxia, the Ameri-
can College of Cardiologists and the AHA guidelines
recommend a door-to-balloon time of no more than
90 minutes. A national Door-to-Balloon Initiative was
launched in November 2006 and has become a core
quality measure for The Joint Commission.

When Maria returned from her lunch break, she and
Susan discussed the circumstances of the patient with
the STEMI. Susan voiced her concerns about the sever-
ity of the CVD in the presence of atypical complaints
and the length of door-to-balloon time despite the suc-
cess of the intervention. Maria was equally concerned
in light of the fact that she had just cared for a post-
menopausal patient with a STEMI who also presented
with vague complaints earlier in the day that had gone
beyond the 90-minute door-to-balloon time. After
much discussion and a review of the recorded door-
to-balloon times during the past several months, which
showed other cases of women with prolonged times,
both nurses felt strongly that they needed to take ac-
tion so that they could make a difference in the care
of women with CVD.

Unsure of what to do next, Susan and Maria decided
to consult Karen, the director of nursing research at
the hospital. They knew that their short-term goal
was to discover the red flags that could be used to
alert the ED personnel to the possibility of CVD in
postmenopausal woman with atypical symptoms. After
educating the ED staff, Susan and Maria then wanted to
use this information to educate women at risk.

Karen encouraged the two nurses to learn more
about the population at risk. Was the event that Susan
witnessed unusual or more the norm in the ED? What
was the evidence to support the door-to-balloon time
frame? Were women at greater risk than men? Susan
and Maria had hunches but no real data on the issue.
Karen suggested that they conduct a retrospective
chart review to answer these questions. She reminded
them that they would have to follow the hospital poli-
cies related to chart reviews. The two nurses, with
Karen’s help, wrote up a proposal for doing the review.

Focused Assessment

The purpose of their review was not only to determine
the length of time between arrival in the ED and treat-
ment but also to determine the length of time between
the point at which the women first had symptoms and

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C H A P T E R 1 4 n Health Planning for Acute Care Settings 357

their arrival at the ED. Thus, the team embarked on a
focused assessment (Chapter 4) that allowed them to
examine the population of women who arrived in the
ED over a specified period of time. They collected data
on all adult women who arrived with a non-trauma
event and then compared the presenting symptoms for
those who actually had STEMI with those who did not.
They collected information on time from first symp-
toms to arrival at the ED and what those first symp-
toms were. All of these assessment data were needed
not only to determine whether indeed the door-to-
balloon time standard was or was not being met, but
also to more accurately describe the presenting symp-
toms of the women with a STEMI compared with those
without a STEMI. This vital information helped in the
development of an intervention for health-care
providers and for the educational program the nurses
wanted to develop for women at risk for a STEMI.
Both centered on how to recognize a possible STEMI,
and both interventions used a population approach.

Ethics in an Acute Care Setting

One issue Susan and Maria faced was how to address
the privacy of the patient information they obtained
during their chart review. Karen showed them how to
write a proposal, which they would then send to the
institutional review board for approval. Karen ex-
plained to them that they could not access patient data
without going through this process. In that way, they
would design the review so that they would ensure the
privacy of the patients and also allow them to dissemi-
nate their findings at an aggregate level with no per-
sonal identifiers.

Nurses interested in using population-level data to
improve patient outcomes must be fully aware of the
ethics of utilizing individual patient-level data for pur-
poses other than what they were intended. There are
two legal areas that nurses must remember at all
times when conducting assessments or doing health
program evaluations using patient data. The Health
Insurance Portability and Accountability Act (HIPAA)
of 1996 was designed to protect the use of electronic
patient data. It set national standards for the security
of electronic protected health information such as
the electronic medical record. An EMR is a digital
version of the patient chart that has replaced paper
charts in most acute care settings. HIPAA also in-
cludes rules on the use of identifiable confidential pa-
tient information to analyze patient safety events and
improve patient safety.34

Although patient information obtained during a hos-
pital stay is protected under HIPAA, there are times
when the information can be or must be shared. This
represents the conflict between the individual’s right
to privacy and the public health perspective of pro-
tecting the health of the whole. The law includes
regulations that recognize the need for public health
authorities, and others mandated to protect the public
safety, to have access to patient data. Thus, a physician
may report information on dog bites or gunshot
wounds to those with authority without violating
HIPAA. Agencies with such authority include state and
local health departments, the Food and Drug Adminis-
tration (FDA), the CDC, and the Occupational Safety
and Health Administration (OSHA). Situations in
which individual information may be shared to help
protect the public include child abuse or neglect, ad-
verse events associated with an FDA-approved activity
or product, and reportable communicable diseases. It
is important to note that the information may only
be released to agencies with recognized authority as
stipulated in the law.34

HIPAA is an important factor for nurses who plan
to collect patient data to conduct a study related to
their care. For example, in some cases, nurses make
changes to practice based on existing evidence and do
this within the scope of their practice. They do not
report the assessment data or the success of their
program outside of their hospital because it is not a
research study. Susan and Maria remembered cover-
ing human subjects’ research in their research class
but were not sure how to proceed. Their hospital had
a policy that all projects that involved obtaining data
from patient records and/or collecting patient data
from patients must be reviewed by the institutional
review board (IRB) prior to collecting any data. An
institutional review board is a committee formally
charged with reviewing biomedical and behavioral re-
search conducted with human subjects to ensure the
protection of research participants. These commit-
tees must comply with federal regulations related to
conducting research with human subjects. The two
nurses worked with the hospital nurse researcher to
delineate exactly what their process was and then
provided the information as required to their institu-
tion’s IRB. They clarified that, when collecting the
data from the medical records, they would include
information on the residence of the patient and that
they would need to link medical records from the
two different areas. Although they were planning to

7711_Ch14_343-371 22/08/19 11:36 AM Page 357

Thus, nurses working in acute care settings are faced
with multiple ethical issues. From a public health per-
spective, the nurse must be aware of the need to protect
the health of the public while protecting the right to in-
dividual privacy. In addition, as more hospitals encour-
age nurses working in acute care settings to engage in
research, they must become aware of the ethical dilem-
mas posed in the collection of patient data. Improving
patient outcomes requires a constant review of the evi-
dence and health planning to improve practice. During
this process, human subjects must always be protected
from unnecessary risk.

The Nurses’ Health Study
The Nurses’ Health Study is similar to the FHS but fo-
cuses on the health of women rather than on incidence
of a particular disease. It started in 1976 and has ex-
panded to include two more cohorts, one in 1989 and
one in 2008. Initially, the primary objective was to study
the long-term consequences related to the use of oral
contraceptives. However, the findings from the studies
are providing insights into a broad array of health issues
including breast cancer, diabetes, and CVD in women.
Based on the results of the studies, researchers have con-
cluded that diet, physical activity, and other lifestyle fac-
tors promote better health and reduce risk for disease to
a significant degree.35

Health Planning and Acute Care
The first case study in this chapter, Solving the Mystery,
is an example of a health planning approach to the de-
livery of nursing care in a hospital setting. The team com-
pleted the first step in heath planning, the assessment
(see Chapter 4). The data from that step helped to iden-
tify populations at risk for poorer outcomes. Armed with

these data, the nursing department could now move to
the next steps, the development, implementation, and
evaluation of a health program aimed at improving pa-
tient outcomes (see Chapter 5). For Cheryl, who wanted
to know the who, what, why, when, and where, the final
results of the assessment identified the areas in need of
nursing activities related to searching for the evidence to
support practice, as well as conducting research studies
aimed at improving outcomes. For the CNO, the assess-
ment provided her with the outcomes-focused approach
and the baseline data she needed to evaluate change over
time from an organizational perspective. The results were
distributed to the nursing staff as a whole, and nursing
units were encouraged to explore opportunities to de-
velop population-level interventions that would improve
outcomes for patients admitted with a diagnosis that
matched those included in Table 15-2.

Noncommunicable Diseases and Acute
Care Settings
Chapter 9 provided an overview of noncommunicable dis-
eases and their contribution to the overall burden of dis-
ease. Acute care settings provide care to persons with
noncommunicable diseases when they are experiencing
an acute stage of the disease. They may come to the hos-
pital when they have first been diagnosed, or the admis-
sion may be one of many related to the noncommunicable
disease. Providing acute care for a disease process that will
not result in a cure leaves the care provider focused on de-
creasing disease-related morbidity and disability, and re-
ducing the risk of premature death. Thus, the nurse in the
acute care setting who is caring for a person with a non-
communicable disease is providing tertiary prevention
(see Chapter 2). This can be challenging for the nurse be-
cause of short hospital stays. The nurse must adapt the
plan of care to fit the individual’s needs. However, devel-
opment of a program that addresses population-level
barriers to care and improves the ability of patients to
self-manage their disease upon discharge can make a big
difference. This again requires using a population approach
and often requires the identification of subpopulations
within the patient population who may be experiencing
significant barriers to self-management of their diseases.

The first step for the nurse working on a hospital unit
who wishes to develop an intervention program is to
identify the level of prevention involved in the interven-
tion. For example, if a nurse wanted to develop a pro-
gram focused on acute coronary syndrome (ACS), she
would have to begin with an understanding of the dis-
ease. ACS is defined by the AHA as any set of clinical
symptoms associated with acute myocardial ischemia.

358 U N I T I I I n Public Health Planning

use the information for an internal change in practice,
they wished to also examine whether there was a dif-
ference between those patients who actually had a
STEMI and those who did not, and then report those
findings in a journal article or at a conference. Thus,
they wished to generalize the findings of their assess-
ment. They submitted their proposal with specific in-
formation on how they would protect the privacy of
the patient’s medical record. The IRB determined that
it did constitute human subjects’ research but met the
requirements for an expedited review because it in-
volved a review of medical records only, with minimal
risk to the patients.

7711_Ch14_343-371 22/08/19 11:36 AM Page 358

Acute myocardial ischemia presents as chest pain due
to an insufficient blood supply to the heart muscle. The
underlying cause is CAD. The majority of known risk
factors for CAD are modifiable by specific preventive
measures. Primary prevention focuses on prevention
of disease in those who do not have the disease (see
Chapter 2). The AHA goal for primary prevention is to
educate all adults about the levels and significance of risk
factors related to CAD. The AHA guide to primary pre-
vention of CAD has a risk reduction focus. The major
risk factors targeted include smoking, blood pressure
control, dietary intake, blood lipid management, physical
activity, and weight management. Comprehensive risk
factor interventions can prevent disease from occurring.
In addition, secondary prevention, early identification of
those with subclinical disease, can extend overall sur-
vival, improve health-related quality of life, and decrease
the need for interventional procedures, such as angio-
plasty and bypass grafting. Ultimately, the goal is to
reduce the incidence of subsequent heart attack (MI). Ex-
amples of secondary prevention include identifying and
treating people with established disease and those at very
high risk of developing CAD. Examples of tertiary pre-
vention include treating and rehabilitating patients who
have had a heart attack or to prevent another cardiovas-
cular event. Healthy People (HP) includes heart disease
and stroke as one of its topics, and one objective is to re-
duce hospitalizations.35 Meeting these objectives requires
interventions across the prevention continuum and a
population health perspective.

Performance Improvement and Acute
Care Settings
One of the most important aspects in the progression of
hospital-based health care has been the change in em-
phasis from the hospital as a location or a place that holds
acutely ill patients to a focus on the provision of evi-
dence-based care with documented improved patient
outcomes. To achieve this goal, acute care settings use a
specific process called quality improvement (QI) and/or
performance improvement (PI) that works to provide
safe and consistent care to the acutely ill and injured. This
process is population-based and provides the appropriate
framework for conducting studies that evaluate the effec-
tiveness of actions taken. The type of studies conducted

C H A P T E R 1 4 n Health Planning for Acute Care Settings 359

n HEALTHY PEOPLE
HEART DISEASE AND STROKE

Goal: Improve cardiovascular health and quality of life
through prevention, detection, and treatment of risk
factors for heart attack and stroke; early identification
and treatment of heart attacks and strokes; prevention
of repeat cardiovascular events; and reduction in
deaths from CVD.
Overview: Heart disease is the leading cause of death
in the United States. Stroke is the fifth leading cause of
death in the United States. Together, heart disease and
stroke, along with other CVDs, are among the most
widespread and costly health problems facing the na-
tion today, accounting for approximately $320 billion in
health care expenditures and related expenses annually.
Fortunately, heart disease and stroke are also among
the most preventable.36.

HP 2020 Midcourse Review: Of the 36 measurable
objectives, 15 objectives had met or exceeded their

2020 targets, 8 objectives were improving, 7 objectives
demonstrated little or no detectable change, and 2 ob-
jectives were getting worse. Three objectives had base-
line data only, and 1 objective was informational
(Fig. 14-3).37 An example of an objective that exceeded
its target was the age-adjusted rate of coronary heart
disease deaths (HDS-2). By 2013, it had declined from
129.2 per 100,000 population in 2007 to 102.6 exceed-
ing the 2020 target. Another example is that between
2009 and 2014, the percentage of heart attack patients
receiving percutaneous intervention within 90 minutes of
hospital arrival (HDS-19.2) increased from 90.4% to
95.9%. Despite moving toward the 2020 target, there is
still a statistically significant difference based on gender,
with women less likely to meet the 90-minute threshold.37

44%

23%

21%

9%
3%

Baseline only
Informational
Little or no change
Improving
Target met or
exceeded

Healthy People 2020 Midcourse Review:
Heart Disease and Stroke

Figure 14-3 Midcourse Review Heart Disease and
Stroke.

7711_Ch14_343-371 22/08/19 11:36 AM Page 359

may involve the calculation of rates of infections, deter-
mining the impact of risks such as diabetes on MI, and
developing interventions like a walking program to
decrease risks of osteoporosis.

According to the Health Resources and Services
Administration, quality improvement in health care
“…consists of systematic and continuous actions that
lead to measurable improvement in health care services
and the health status of targeted patient groups..”38 From
a public health nursing perspective, performance im-
provement is a “process that considers the organiza-
tional context, describes desired performance, identifies
gaps between desired and actual performance, identifies
root causes, selects interventions to close the gaps, and
measures changes in performances with the goal of
achieving desired results or outcomes.”39

The terms quality improvement and performance
improvement are often used interchangeably; the dif-
ference is, PI takes a more bottom-up approach and
acknowledges that improvement is an ongoing, rather
than a static, process. For the purposes of this chapter,
the term PI is used because it matches the term used
in Public Health Nursing: Scope and Standards of Prac-
tice. Basically, the goal is to improve the care of hos-
pitalized patients through the implementation of EBPs
or system changes. No project is too small if it im-
proves patient outcomes. For the majority of direct
patient care staff, questioning a specific practice by
asking, “Why do we do this task this way?” may initi-
ate a PI project.

For programs to be successful, data collection must
occur within the context of a continuous improvement
strategy so that the caregivers in the acute care setting
can implement changes that improve the quality of
health care. Two examples of PI projects are (1) compar-
ison of hospital antibiotic timing rates among patients
who receive required preoperative antibiotics before the
start of the operative procedure with data from the Cen-
ters for Medicare and Medicaid Services and (2) compar-
ing the rates of postoperative infections against the
national rates reported by the CDC.

Why Do We Need PI in Acute Care Settings?
A groundbreaking report published by the Institute of
Medicine (IOM), now known as the Health and Medi-
cine Division of the National Academies of Sciences, En-
gineering and Medicine (HMD), at the start of the 21st
century entitled To Err Is Human: Building a Safer
Health Care System created a stir in the health-care in-
dustry.40 The findings from this report brought the lack
of consistent quality programs in hospitals in the United

States to the forefront. The report identified the follow-
ing deficiencies:

• In 1997, there were more than 33.6 million admis-
sions to U.S. hospitals.

• Approximately 44,000 Americans die each year as a
result of medical errors and other data suggest that
the number may be as high as 98,000.

• More people die due to medical errors than MVAs,
breast cancer, and AIDS each year.

• Total national costs (including loss of income, dis-
ability, and health-care costs) were estimated to be
between $37 and $50 billion for all adverse events,
and for preventable adverse events between $17 and
$29 billion.

• In terms of lost lives, patient safety is as important as
worker safety. More than 6,000 American workers
die each year of workplace injuries as compared
with the 7,000 lives lost to medication error deaths
as reported in 1993.40

As a result of these findings, the group recom-
mended a fundamental redesign of the entire health-
care system. It recommended the following six aims for
improving the system around the following core needs
of health care:

1. Safe—Avoid injuries to patients.
2. Effective—Care should be evidence and scientifically

based.
3. Patient centered—Care should be built upon patient

preferences, needs, and values.
4. Timely—Reduce waits and delays.
5. Efficient—Avoid waste.
6. Equitable—Care should be equal to all persons

regardless of age, gender, ethnicity, location, and
socioeconomic status.40

Based on the IOM report and recommendations, the
Institute for Healthcare Improvement (IHI) developed a
patient safety initiative because it believes that patients de-
serve safe and effective health care. The IHI exists to close
the gap between the health care we have and the health
care we should have.41 Thus, the IHI launched its 100,000
Lives Campaign and then its 5 Million Lives Campaign
with positive results. According to IHI, the campaign re-
sulted in “Hospitals … demonstrating impressive results.
At its formal close in December 2008, the Campaign cel-
ebrated the enrollment of 4,050 hospitals, with more than
2,000 facilities pursuing each of the Campaign’s 12 inter-
ventions to reduce infection, surgical complication, med-
ication errors, and other forms of unreliable care in
facilities.”42 To assist hospitals in implementing these PI

360 U N I T I I I n Public Health Planning

7711_Ch14_343-371 22/08/19 11:36 AM Page 360

projects, the IHI supplies template tools to implement
as well as tracks progress in achieving these goals. The
IHI created steps for incorporating these QI initiatives
(Box 14-5).

C H A P T E R 1 4 n Health Planning for Acute Care Settings 361

• Set AIM—Defining the specific population to be
studied and what the group wishes to accomplish.

• MEASURE results—Specific rate or number as a
benchmark for comparison to determine whether
the changes being made lead to improvement (e.g.,
reduction in bloodstream infections, or reduction in
the wait time from ED visit to hospital room).

• TEST changes—This may be accomplished through
the Plan (P) Do (D) Study (S) Act (A) cycle (PDSA)
(Fig.14-4).

• Plan = Plan the change
• Determine the key personnel
• Where/when it will take place
• How it will be tested
• What data need to be collected
• Who will collect the data and record the results

• Do = Test the change/intervention.
• Study = Determine the results—did it work?
• Act = Was the intervention/change successful?

• If yes, can it be expanded to more patients?
• If yes, then implement another PDSA cycle.

• If the intervention/change did not work:
• Determine why it failed.
• Reassess and develop a new plan and test it again.

• IMPLEMENT changes—Move the program on a
broader scale. This may include other shifts on the
nursing unit, similar nursing units, or hospital-wide.

BOX 14–5 n Institute for Healthcare Improvement
Steps for Incorporating Quality
Improvement Initiatives

Source: (41)

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Hospital Partners
Public Health Science Topics Covered:

• Epidemiology and biostatistics
• Determining rates
• Assessment

A group of 10 Cincinnati area hospitals collabo-
rated to reduce HAIs as part of a patient safety
initiative. One goal of the project was to reduce
catheter-related bloodstream infections (CR-BSI)
through the implementation of EBP. The hospitals

met monthly to discuss their progress and share in-
formation about their progress toward meeting their
specific goal. A team was formed in Hospital A to
work on their institutional-level efforts to meet the
regional goals. The group not only used the IHI
model described earlier but also applied the four-
step Plan-Do-Study-Act (PDSA) cycle to their PI
project. The PDSA cycle is an interactive process
adopted from business, also known as the Deming
Wheel, and has been around since the 1920s
(Fig. 14-4). This cycle is based on action-oriented
learning, provides shorthand for testing a change,
and is accomplished through a cycle of planning the
change, trying it, observing the results, and then
acting on what is learned.44

The first step in the IHI process is to set an aim. For
Hospital A, they decided their aim would be to reduce
CR-BSIs. The second step is the measurement state-
ment, in this case, a reduction in CR-BSI by 50% over
the next 12 months. This was chosen based on the evi-
dence that more than 200,000 CR-BSIs occur each year
in the United States, with an associated mortality of 4%
to 35%.43 Hospital A determined that, to reduce the
rates of CR-BSIs, they would first have to develop a
tool to measure adherence to treatment with best
practices outlined by the CDC (Box 14-6).44 These
best practices included performing hand hygiene before
insertion of catheters, applying maximum sterile barri-
ers (gowns, masks, head cover, and sterile gloves) prior
to the insertion of central line catheters, covering the

Plan

Continuous
Performance
Improvement

Study

DoAct

Figure 14-4 Plan (P) Do (D) Study (S) Act (A) cycle.

7711_Ch14_343-371 22/08/19 11:36 AM Page 361

362 U N I T I I I n Public Health Planning

With each central line insertion, the nursing staff collected
data on each of the best practices and reported adher-
ence back to all end-users on the following:

• Percentage adherence to hand hygiene
• Percentage adherence to maximum barriers (mask,

head cover, surgeon gown, and sterile gloves)
• Percentage adherence to full body drapes
• Percentage adherence to chlorhexidine antiseptic for

each central line insertion

BOX 14–6 n Central Line Insertion Guidelines

Source: (84)

patient with a full body drape, and prepping the inser-
tion site with a chlorhexidine-based product.

Once the nursing staff determined what they
wanted to measure, they initiated the PDSA cycle (see
Fig. 14-4). The PLAN identified the key personnel to
be included in the central line insertion—the chief
medical resident and patient’s RN. The line insertion
would take place in a patient’s room on day shift in the
medical intensive care unit (MICU). The data to be col-
lected were outlined on a central line check sheet de-
veloped by Hospital A, and the person collecting the
information would be the charge RN.

The next step is DO. Once it was determined there
was a patient who needed a central line, the charge
nurse gathered all the supplies including a central line
insertion tray, surgical attire from the operating room,
a large surgical thyroid drape with an opening (fenes-
tration) near the top of the drape, and the chlorhexi-
dine antiseptic swabs. The MICU RN and the chief
resident donned the sterile garb. The MICU charge RN
applied a mask and remained at the bedside to act as a
circulating nurse to record the events and to complete
the checklist. The medical resident and the MICU RN
applied the drape and prepped the patient’s insertion
site with chlorhexidine. The resident inserted the cen-
tral line per hospital protocol.

The next step is STUDY. During the covering with
the sterile drape, several problems were encountered.
First, neither the chief medical resident nor the MICU
RN had much experience with applying a large surgical
drape and had difficulty maintaining sterility. Thus, they
went through several drapes during the application
process. Using several drapes decreased the volume in
the operating room. This resulted in placing an urgent
order to the manufacturer. This had an impact on the
cost of the procedure. Also, the current central line kit

was found to be missing some of the supplies needed
to meet the CDC recommendations,45 so the MICU
charge RN had to leave the room several times to find
the supplies not included in the current central line
trays.

The final step is ACT. The group concluded that
this first test was not successful, and they regrouped.
They determined there were a number of processes
that needed to be corrected before they proceeded
with the next line insertion: requesting the OR staff
provide the MICU nurses/residents with in-service
teaching on the proper application of a full body drape,
working with the purchasing department to have more
drapes stocked in the MICU and the operating room,
and reviewing the contents of the current central line
kits to determine what supplies would be needed to
meet the intent of the CDC recommendations to de-
crease the number of interruptions during the insertion
process. The group asked the purchasing department
to schedule meetings with the central line tray manu-
facturers to revise the trays to include the supplies
needed.

The group concluded that employing the PDSA
cycle allowed them to test the new protocols before
instituting it in all the other ICUs and the hospital.
This was a new approach, replacing the usual practice
in which a policy was developed, and the users were
then required to determine how they would adhere to
it. They were able to determine what worked on a
small scale and what needed to be corrected to pro-
vide their patients with the best care they deserved.
Eventually, the group was able to work with the manu-
facturers of surgical drapes and central line insertion
trays to develop efficient and EBP central line trays
and surgical packs.

They collected data by using the check sheets, re-
ported adherence to the best practices back to the
end users, and published the rates in their respective
units for staff, physicians, and families to review. The
nurses were empowered to stop any procedure
wherein any of the components on the checklist were
not followed. Eventually, through repeated PDSA cy-
cles, the MICU unit reduced their CR-BSI rates by
more than 50%, and the process was instituted in
the rest of the hospital. The checklist was followed
throughout Hospital A for all central line insertions.
Adherence rates continued to be reported to all
users, and committees and infection rates were then
posted in all ICUs, allowing for immediate action and
the continuous use of the PDSA cycle.

7711_Ch14_343-371 22/08/19 11:36 AM Page 362

Infection Control and Acute Care Settings
Health care-associated infections are infections caused
by pathogens acquired as a consequence of a health-care
intervention.46 Prevention of HAIs requires an upstream
population health approach.2 HAIs may be localized or
systemic responses to the presence of an infectious
agent(s) or its toxin(s) that (1) occurs in a patient in a
health-care setting (e.g., a hospital or outpatient clinic);
(2) was not found to be present or incubating at the time
of admission, unless the infection was related to a previ-
ous admission to the same setting; and (3) if the setting
is a hospital, meets the criteria for a specific infection site
as defined by the CDC.46-48 The major issues include sep-
sis/bacteremias, pneumonia, and urinary tract infections
(UTIs). Based on data collected by the CDC, it is esti-
mated that approximately one in 25 U.S. patients con-
tracts at least one infection in association with his or her
hospital care.49

Sepsis
Globally, there are an estimated 30 million cases of sepsis
annually with 6 million deaths.52 In the U.S. at least
1.7 million people develop sepsis every year and 270,000
die. In addition, one in three patients who die in U.S.
hospitals die of sepsis.52 Infants, children, older adults,
and pregnant and postpartum women are at higher risk
for hospital-associated sepsis (HAS).10 Sepsis is “…life-
threatening organ dysfunction caused by a dysregulated
host response to infection.”53,54 It is the body’s response
to the invasion of pathogenic microorganisms in which

severe sepsis and septic shock are the end results of the
interaction between infecting organisms and the body’s
host responses. These responses cause inflammation, im-
munosuppression, abnormal coagulation, and blood
flow and circulatory dysfunction, which lead to organ in-
jury and cell death.52,55

When sepsis causes dysfunction in one organ, it is
diagnosed as severe sepsis. Signs and symptoms of sep-
sis include (1) fever; (2) chills; (3) inflammatory re-
sponses such as increased WBC and increased serum
concentrations of C-reactive protein; (4) hemodynamic
symptoms of increased heart rate, increased cardiac
output, low oxygen saturation rate; (5) metabolic re-
sponses such as increased insulin requirements; (6) tis-
sue perfusion changes such as altered skin perfusion
and decreases in urinary output; and, (7) organ dys-
function such as increases in urea and creatinine levels,
decreases in platelets, and coagulation abnormalities.55

If sepsis results in induced hypotension that does not
respond to increased fluid challenges, then the diagno-
sis of septic shock is made.53 There is a wide variety in
patient presentation thus there is no “one-size-fits-all”
approach to care of the patient with severe sepsis.54

Initial antibiotic therapies are based on the likely
source of the infection and the most common pathogens.
For instance, urosepsis treatment is based on the most
likely source of UTIs such as Escherichia coli and ente-
rococcal species. Antibiotic therapies should begin as
soon as possible and always within the first hours of rec-
ognized sepsis and septic shock.54,55 Blood, urine, and
sputum cultures should be sent to the laboratory before
antibiotics are given for proper identification of the in-
criminating organism. Once the organism is identified,
antibiotic treatments should be reassessed to decrease the
risk of antibiotic resistance.54,59

Ventilatory and volume support are also crucial for
patient survival to combat hypotension and respiratory
insufficiency. Hemodynamic support includes fluid re-
placement, crystalloids, or colloids. Vasopressor support
includes dopamine and norepinephrine; inotropic ther-
apy may include dobutamine. Steroids may be used
when hypotension responds poorly to fluids and vaso-
pressors. Other supportive measures may include blood
products, glucose control, and renal replacement ther-
apy (e.g., dialysis and continuous renal replacement
therapy, deep venous thrombosis prophylaxis, and stress
ulcer prophylaxis).56-60

Because of their increased age and variance of present-
ing symptoms, older adults frequently do not develop
fever. Thus, initial treatment is geared toward antibiotic
therapy, after urine, sputum, blood, or wound cultures

C H A P T E R 1 4 n Health Planning for Acute Care Settings 363

n HEALTHY PEOPLE
Health Care-Associated Infections

Targeted Topic: Health care-Associated Infections
Goal: Prevent, reduce, and ultimately eliminate HAIs.
Overview: HAIs are infections that patients get while
receiving treatment for medical or surgical conditions.
They are among the leading causes of preventable
deaths in the United States and are associated with a
substantial increase in health-care costs each year.50

HP 2020 Midcourse Review: Both objectives for
HAI in HP 2020 showed improvement. For central
line infections, the rate fell from 1.0 standardized
infection rate in 2006-2008 to 0.54 in 2013. Invasive
health care-associated methicillin-resistant staphylo-
coccus aureus (MRSA) infections dropped from 27.08
infections per 100,000 persons in 2007–08 to 18.23
infections per 100,000 persons in 2013.51

7711_Ch14_343-371 22/08/19 11:36 AM Page 363

have been analyzed. The initial antibiotics are geared to-
ward a broader spectrum of suspected pathogens such as
E. coli and MRSA. In addition to antibiotic therapy, fluid
resuscitation as well as invasive monitoring for blood
pressure, urinary catheters for renal output, and oxygen
therapy must be considered and used as needed. Older
adult patients do respond well to treatment protocols,
but health-care providers need to have a high level of sus-
picion for sepsis in older adults so that treatment may
begin in a timely manner.56,60

Cerebrospinal and Postoperative Central
Nervous System Infections
Hospital-associated central nervous system (CNS) in-
fections include meningitis, encephalitis, and in-
tracranial abscesses. Meningitis is an inflammation of
the meninges, the membrane that covers the brain
and spinal cord.61 There are four types of meningitis
categorized based on the causative agent: bacterial,
parasitic, fungal, and amoebic. Sometimes there are
noninfectious causes of meningitis including cancer,
lupus, and brain injury.61 Globally, the World Health
Organization (WHO) warned of a possible meningitis
epidemic that could expand beyond sub-Saharan
Africa to neighboring countries, with the main concern
being the low stockpile of vaccines.62,63 Universal vac-
cinations can help boost herd immunity and reduce the
incidence of disease. In the U.S., the recommendation
is to vaccinate all children aged 11 to 12 years old with
a booster at age 16. In sub-Saharan Africa, national
preventive campaigns were conducted.64 Following
the campaigns, routine vaccinations were recom-
mended for children under the age of 1.16 This illus-
trates the importance of understanding the incidence
of community-acquired infections when examining the
possibility of hospital-associated infections. In geo-
graphic areas with a high incidence of a communicable
disease, the risk of a hospital-associated case of the dis-
ease increases.

High morbidity and mortality highlight the impor-
tance of preventing health care-associated meningitis and
other CNS infections in the acute care setting.65 Patients
at greater risk are those who have had neurosurgery, those
over the age of 65, children, and those who have a shunt,
lumbar drain, or other foreign material placed in their
CNS.65 Steps can be taken from an institutional and pop-
ulation perspective using the CDC guidelines21 to prevent
hospital-acquired CNS infections.65

Early identification and treatment of a hospital-
associated CNS infection is essential to prevent spread
of the infection and reduce mortality.66 If the infection

is not diagnosed early and antibiotics are not initiated
promptly, patients may develop sepsis (meningococ-
cemia), which results in hypotension and bilateral
adrenal hemorrhage. Thus, intravenous (IV) antibiotics
must be initiated promptly.67 With the rise in incidence
of viral meningitis, there is an increasing need for fur-
ther research on treatment.68

Surgical Site Infections
A surgical site infection (SSI) occurs after surgery or
other invasive procedure in the area of the body where
the surgery or procedure took place.69,70 Up to one-fifth
of all HAIs are SSIs; 5% of patients who had a surgical
procedure later develop an SSI.69 As many as 300,000
SSIs occur each year in the U.S. Most (55%) SSIs are pre-
ventable.71,72 An SSI not only reduces the quality of life
for patients but also increases the risk of morbidity and
mortality as well as the cost of care.70 Prevention includes
actions taken preoperatively, intraoperatively and post-
operatively.70,72 Types of SSIs are separated into three
categories: superficial incisional, deep incisional, and
organ/space.71

Strategies to prevent SSIs begin with having a surveil-
lance system within the acute care organization. Because
the length of stay following a surgical procedure is short,
it is important to incorporate a method for conducting
surveillance post-discharge.70 In the U.S., the CDC pub-
lishes guidelines on SSI prevention that provide the pre-
ventionists in the hospital, such as the infection control
nurse, with an up-to-date evaluation of the evidence as
to what works and what does not work over all three
phases of prevention. For example, in 2017, the guide-
lines supported the administration of the appropriate an-
timicrobial agent prior to skin incision (versus at cord
clamping) for patients having a caesarean section. The
guidelines also included a list of strategies determined
to be unnecessary to prevent an SSI such as antimicro-
bial prophylaxis after surgical closure (clean and clean-
contaminated procedures).72

Based on programs in different states, taking a
population-level approach to prevent SSIs has resulted
in reduced rate of SSIs. For example, Georgia addressed
the overuse of antibiotics by developing an Antibiotic
Stewardship Committee of key stakeholders. These stake-
holders established a strategic framework for statewide
activities along with support for implementation. Some
of their initiatives included implementing a method for
determining baseline hospital prescribing practices and
for tracking practices over time, and they instituted train-
ing programs for pharmacists and physicians on antibi-
otic use.73

364 U N I T I I I n Public Health Planning

7711_Ch14_343-371 22/08/19 11:36 AM Page 364

Hospital-Associated Pneumonia and
Ventilator-Associated Pneumonia
Pneumonia is the leading cause of HAI with an estimated
rate of mortality associated with hospital-associated pneu-
monia (HAP) from 33% to 50%.74 The majority of HAP
infections are linked to gram-negative bacteria, whereas
20% to 30% of cases involve gram-positive cocci.29 The mor-
tality rate is high and is the leading cause of HAI deaths.74

The two main risk factors are intubation and mechanical
ventilation. To help track these risk factors, experts have
differentiated between cases of HAP, an episode of pneu-
monia that occurs after admission to the hospital that is not
associated with mechanical ventilation, and ventilator-
associated pneumonia (VAP), pneumonia that presents
more than 48 hours after endotracheal intubation.75-77

Risk factors for developing HAP/VAP also differ based
on geography, specific characteristics of the health care set-
ting, length of stay before onset of the disease, and risk
factors for multiple drug-resistant (MDR) pathogens (see
Chapter 8).76 Estimating the incidence of VAP is done
by calculating the number of episodes per ventilator days
within the health care setting. In the U.S., VAP incidence
ranges from 2 to 16 episodes for 1,000 ventilator-days, with
an attributable mortality of 3% to 17%.75

Prevention of HAP/VAP requires a systems-based pop-
ulation approach. The 2016 guidelines provide detailed in-
formation on steps to take both from a systems approach,
to prevent HAP/VAP from occurring, as well as appropri-
ate treatment to improve outcomes for those diagnosed
with HAP/VAP. The main focus has been prevention of
VAP with recommended bundling of treatments.74 In ad-
dition, the 2016 guidelines provide guidance to hospitals
on generating antibiograms aimed at reducing MDR
organisms (MDROs).75

Catheter-Associated Urinary Tract Infections
Among UTIs acquired during a hospital stay, approxi-
mately 75% are associated with a urinary catheter. Be-
cause up to 25% of hospitalized patients receive urinary
catheters while in the hospital, the risk for a catheter-
associated urinary tract infection (CAUTI) is high. The
main risk factor for a CAUTI is prolonged use of the uri-
nary catheter. Thus, the main prevention step is to remove
the urinary catheter as soon as possible.79 Other risk fac-
tors include colonization of the drainage bag, diarrhea,
diabetes, female gender, renal insufficiency, errors in
catheter care, catheterization late in the hospital course,
and immunocompromised or debilitated states.80

CAUTIs occur because the urethral catheter can actu-
ally inoculate pathogens into the bladder. They also help
in the colonization of pathogens by providing a surface for

bacterial adhesion and by causing mucosal irritation.80

The CDC has set criteria for what qualifies as a CAUTI
(Box 14-7).81 Complications of an indwelling Foley
catheter include: prostatitis, epididymitis, and orchitis
in males; and cystitis, pyelonephritis, gram-negative
bacteremia, endocarditis, vertebral osteomyelitis, septic
arthritis, endophthalmitis, and meningitis in all patients.81

Adverse consequences include: discomfort to the patient,
prolonged hospital stay, and increased cost and mortality;
an estimated 13,000 deaths annually are associated with
UTIs.82 Organisms most frequently associated with
CAUTIs generally originate in the gastrointestinal tract
such as enterococci (Fig.14-5).

Preventing CAUTIs includes the following key
components:

• Practice hand hygiene before and after catheter
insertion and when manipulating the catheter site
or device.

C H A P T E R 1 4 n Health Planning for Acute Care Settings 365

• A UTI where an indwelling urinary catheter (IUC) was
in place for >2 calendar days on the date of event,
with day of device placement being Day 1,

• AND an indwelling urinary catheter was in place on
the date of event or the day before.
• If an indwelling urinary catheter was in place for >2

calendar days and then removed, the date of event
for the UTI must be the day of discontinuation or
the next day for the UTI to be catheter-associated.

BOX 14–7 n Catheter-Associated UTI (CAUTI)

Source: (81)

Figure 14-5 Enterococci, leading causes of nosocomial
bacteremia, surgical wound infection, and urinary tract
infection. (From Centers for Disease Control and Prevention
Public Health Image Library. Photograph by Pete Wardell.)

7711_Ch14_343-371 22/08/19 11:36 AM Page 365

• Use aseptic technique when inserting the catheter
and obtaining urine samples, and always use sterile
equipment.

• Properly secure the catheter to prevent movement
and urethral traction.

• Consider using portable ultrasound devices to assess
the volume of urine in the bladder and to reduce un-
necessary catheterization.

• Maintain a closed drainage system and unobstructed
flow of urine.82

QI programs have been implemented to promote
proper usage of urinary catheters and to reduce the risk
of CAUTIs. Key initiatives include appropriate use of
catheters, removing catheters when no longer needed,
monitoring adherence to hand hygiene practices and
proper care of catheters, developing alert systems or re-
minders among patients with catheters for early removal,
and developing protocols for placement of catheters, the
use of ultrasound devices, and assessing the need for
catheters.82

Central Line-Associated Bloodstream
Infections
A central line-associated bloodstream infection (CLABSI)
is defined by the CDC as an infection that occurs when
pathogens enter the bloodstream through the central line.83

The most common source of a health care-associated
bloodstream infection is a central line. The estimated health
care cost per case of a bloodstream infection is $25,000.84

After the CDC instituted guidelines to prevent CLABSIs in
2009, incidence dropped, yet it is estimated that more than
30,000 health care-associated CLABSIs still occur.84 Treat-
ment of a CLABSI generally depends on the severity of the
patient’s clinical disease, risk factors for the infection, and
the bacteria associated with the infection.84,85 Complica-
tions may include septic thrombosis and infective endo-
carditis, which require long-term antibiotic treatment. A
number of actions can be taken to prevent CLABSI. For ex-
ample, in one study the use of antimicrobial-impregnated
(AIP) peripherally inserted central catheters (PICCs) versus
nonantimicrobial-impregnated (NAIP) catheters lowered
the risk of CLABSIs.86

366 U N I T I I I n Public Health Planning

n EVIDENCE-BASED PRACTICE
Prevention of CLABSI

Practice Statement: Patients in acute care settings
are at risk of developing CLABSIs because of the need
for invasive monitoring in critical care medicine. A
patient safety goal for ICU patients is to reduce the
risks of CLABSI through the adoption of best practices

including: hand hygiene, maximal sterile barriers, full
body drapes, and chlorhexidine-based products for
insertion site antisepsis.

Targeted Outcome: Reduction in CLABSI
Evidence to Support: The CDC has always sup-
ported the use of maximum sterile barriers and cover-
ing the patient with a full sheet during insertion of
central lines as a means to reduce CLABSIs.1 One
hospital instituted a Comprehensive Unit-Based Safety
Program (CUSP) that resulted in a reduction in CLABSIs
from 1.95 to 1.04 per 1,000 central line days.2 Another
PI project in a Maryland hospital included interventions
at the organizational and the unit level to reduce
CLABSIs in a burn unit. Interventions included a
“…development of new blood culture procurement
criteria, implementation of chlorhexidine bathing and
chlorhexidine dressings, use of alcohol-impregnated
caps, routine performance of root-cause analysis with
executive engagement, and routine central venous
catheter changes”. These interventions resulted in the
reduction of CLABSI rates from 15.5 per 1,000 central-
line days to zero with a sustained rate of zero CLABSIs
over 3 years.3

Recommended Approaches and Resources:
• Insert central line catheters into the subclavian site

when possible. Femoral sites have been associated
with higher rates of infection.

• Perform hand hygiene before insertion of catheters
as well as when manipulating or accessing central line
catheters.

• Apply maximum sterile barriers (gowns, masks, head
cover, and sterile gloves) prior to the insertion of
central line catheters.

• Cover the patient with a full body drape.
• Prepare the insertion site using chlorhexidine-based

products.
• Cover the insertion site with a sterile occlusive

dressing.
• Use aseptic technique when accessing or changing

central line dressing.
• Remove catheters when no longer needed.

Sources:
1. Marschall, J., Mermel, L., Fakih, M., Hadaway, L., Kallen, A.,

O’Grady, N., … Yokoe, D. (2014). Strategies to prevent
central line–associated bloodstream infections in acute
care hospitals: 2014 update. Infection Control and
Hospital Epidemiology, 35(7), 753-771. doi:10.1086/
676533.

7711_Ch14_343-371 22/08/19 11:36 AM Page 366

Health Care-Associated Infections and
Multiple Drug-Resistant Organisms
Multiple drug-resistant organisms pose a public health
issue for hospitals. According to the CDC “…antibiotic
resistance happens when germs like bacteria and fungi
develop the ability to defeat the drugs designed to kill
them.”87 According to the CDC, annually in the U.S., ap-
proximately 2 million people are infected with antibiotic-
resistant bacteria; 23,000 deaths are associated with
antibiotic-resistant bacteria.87 According to the WHO,
antibiotic resistance is increasing related to the treatment
of malaria and HIV-related infections. In addition, 490
000 people developed multidrug-resistant TB globally.88

Persons with resistant infections require more care
resulting in increased cost.88

One example of an MDRO is the carbapenem-
resistant enterobacteriaceae family of infectious agents.
This family of pathogens presents a challenge to health-
care workers in acute care settings because these infec-
tions are resistant to most front-line antibiotics. Some
enterobacteriaceae are normally present in the human
gut and can become carbapenem-resistant through
enzymes that break down these antibiotics so that
they are no longer effective.89 Other MDROs include
MRSA, Clostridium difficile, and vancomycin-resistant
enterococci.

The most common mechanism for acquiring a MDRO
in a hospital is patient-to-patient via the hands of a
health-care worker. Prevention efforts include a wide
range of interventions conducted at the organizational
and individual levels. They require the application of
public health principles and an understanding of how
communicable diseases are transmitted. The CDC lists
the following as components of an MDRO prevention

program: education, judicious use of antimicrobials,
MDRO surveillance, infection control precautions, and
environmental controls aimed at reducing transmission.90

n Summary Points
• A public health perspective applies to the acute care

setting.
• Focused assessments related to acute care population–

level data provide the necessary information for set-
ting priorities.

• The improvement of health-care delivery and patient
outcomes in an acute care setting has occurred because
of population-level interventions.

• Differences exist between males and females in rela-
tion to health care received in the acute care setting.

• The evolution of critical care has occurred at the
population level.

• Health planning occurs in acute care settings using
the same process used in community settings.

• PI within an acute care setting uses public health
science and health planning principles throughout
the process.

• The prevention of HAIs is a major public health issue
and the responsibility of every nurse.

C H A P T E R 1 4 n Health Planning for Acute Care Settings 367

2. Richter, J.P., & McAlearney, A. (2018). Targeted
implementation of the Comprehensive Unit-Based
Safety Program through an assessment of safety culture
to minimize central line-associated bloodstream infec-
tions. Health Care Management Review, 43(1), 42–49.
https://doi-org.ezp.welch.jhmi.edu/10.1097/HMR.
0000000000000119

3. Sood, G., Caffrey, J., Krout, K., Khouri-Stevens, Z.,
Gerold, K., Riedel, S., … Pronovost, P. (2017).
Use of implementation science for a sustained
reduction of central-line–associated bloodstream
infections in a high-volume, regional burn unit.
Infection Control & Hospital Epidemiology, 38(11),
1306–1311. https://doi-org.ezp.welch.jhmi.edu/
10.1017/ice.2017.191

t CASE STUDY
Health Planning to Prevent Falls

Learning Outcomes
At the end of this case study, the student will be
able to:

• Apply the techniques for a focused assessment.
• Identify risk factors associated with an identified

patient safety issue.
• Apply program planning to the development, imple-

mentation, and evaluation of a hospital fall prevention
program.

The recent safety reports for the medical units in a
hospital caught the attention of the nursing department
because there had been an increase in falls. The CNO
asked the nurse managers of the medical units to de-
termine what was behind the increased fall incidence
rate. After examining the hospital incident report data,
they found that three medical units had an increased
fall rate and two did not. The nurse managers formed a
committee of nurses across the five units to examine
the issues related to falls and develop a fall prevention
program.

7711_Ch14_343-371 22/08/19 11:36 AM Page 367

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59. López-Mestanza, C., Andaluz-Ojeda, D., Gómez-López, J.R.,
& Bermejo-Martín, J.F. (2018). Clinical factors influencing
mortality risk in hospital-acquired sepsis. Journal of
Hospital Infection, 98(2), 194–201. https://doi-org.ezp.welch.
jhmi.edu/10.1016/j.jhin.2017.08.022.

60. Ward, C. (2018). Overview of the incidence, early identifica-
tion and management of sepsis. Nursing Standard, 32(25),
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128026946&site=ehost-live&scope=site.

61. Centers for Disease Control and Prevention. (2017).
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62. World Health Organization. (2018). Risk of meningitis epi-
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meningitis-2018-2019 ?ua=1.

63. World Health Organization. (2018, April 6). Epidemic
meningitis control in countries of the African meningitis
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64. Centers for Disease Control and Prevention. (2018). Vaccines
and preventable diseases: Meningococcal vaccine. Retrieved
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65. Lee, J.J., Lien, C.Y., Huang, C.R., Tsai, N.W., Chang, C.C.,
Lu, C.H., & Chang, W.N. (2017, Dec 15). Clinical character-
istics and therapeutic outcomes of post neurological bacterial
meningitis in elderly patients over 65: A hospital-based
study. Acta Neurol Taiwan, 26(4), 144-153.

66. Anderson, D.J., Podgorny, K., Berríos-Torres, S.I., Bratzler,
D.W., Dellinger, E.P., Greene, L., … Kaye, K.S. (2014). Strate-
gies to prevent surgical site infections in acute care hospitals:
2014 update. Infection Control & Hospital Epidemiology,
35(Suppl 2), S66–S88.

67. Mount, H.R., & Boyle, S.D. (2017). Aseptic and bacterial
meningitis: Evaluation, treatment, and prevention. American
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direct=true&db=rzh&AN=124575352&site=ehost-live&
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68. McGill, F., Griffiths, M.J., & Solomon, T. (2017). Viral
meningitis: Current issues in diagnosis and treatment.
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69. Centers for Disease Control and Prevention. (2012). Surgical
site infection (SSI). Retrieved from https://www.cdc.gov/
hai/ssi/ssi.html.

70. National Institute for Health and Care Excellence. (2017).
Surgical site infections: Prevention and treatment. Clinical
guideline [CG74]. Retrieved from https://www.nice.
org.uk/guidance/cg74/chapter/Introduction.

71. Anderson, D.J., Podgorny, K., Berríos-Torres, S.I., Bratzler,
D.W., Dellinger, E.P., Greene, L., … Kaye, K.S., et al. (2014).
Strategies to prevent surgical site infections in acute care

hospitals: 2014 update. Infection Control and Hospital
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72. Preas, M.A., O’Hara, L., & Thom, K. (2017). 2017 HICPAC-
CDC guideline for prevention of surgical site infection:
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guidelines_final .

73. Centers for Disease Control and Prevention. (n.d.). HAI
prevention stories from the states: Georgia. Retrieved from
https://www.cdc.gov/hai/state-based/pdfs/success_story-
Georgia_stewardship .

74. Rodriguez, T. (2017). Challenges in managing hospital-
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managing-hospital-acquired-pneumonia/article/681011/.

75. Kalil, A.C., Metersk, M.L., Klompas, M., Musceder, J.,
Sweeney, D.A., Palmer, L.B., … Brozek, J.L. (2016).
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76. Luyt, C.-E., Hékimian, G., Koulenti, D., & Chastre, J. (2018).
Microbial cause of ICU-acquired pneumonia: Hospital-
acquired pneumonia versus ventilator-associated pneumonia.
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org.ezp.welch.jhmi.edu/10.1097/MCC.0000000000000526.

77. Barbier, F., Andremont, A., Wolff, M., & Bouadma, L.
(2013). Hospital-acquired pneumonia and ventilator-
associated pneumonia: recent advances in epidemiology
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MCP.0b013e32835f27be.

78. Cunha, B.C., & Brusch, J.L. (2018). Hospital-acquired pneu-
monia (Nosocomial Pneumonia) and ventilator-associated
pneumonia. Medscape. Retrieved from https://emedicine.
medscape.com/article/234753-overview.

79. Centers for Disease Control and Prevention. (2017). Catheter-
associated urinary tract infections (CAUTI). Retrieved from
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80. Brusch, J.L. (2017). Catheter-related urinary tract infection
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medscape.com/article/2040035-overview.

81. Centers for Disease Control and Prevention. (2018). Urinary
tract infection (catheter-associated urinary tract infection
[CAUTI] and non-catheter-associated urinary tract infection
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82. Gould, C.V., Umscheid, C.A., Agarwal, R.K., Kuntz, G., &
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83. Centers for Disease Control and Prevention. (2011). Central
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84. Pathak, R., Gangina, S., Jairam, F., & Hinton, K. (2018). A
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cost to a community-based hospital. Therapeutics & Clinical
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85. Kagan, E., Salgado, C.D., Banks, A.L., Marculescu, C.E., &
Cantey, J.R. (2018). Peripherally inserted central catheter-
associated bloodstream infection: Risk factors and the role
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86. Tobar, S., Olmsted, R., & Kast, R. (2018). Intersection
between sepsis not present on admission and central
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88. World Health Organization. (2018). Antimicrobial resistance.
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89. Centers for Disease Control and Prevention. (2018).
Carbapenem-resistant Enterobacteriaceae in healthcare
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90. Centers for Disease Control and Prevention. (2018).
Antibiotic/antimicrobial resistance: Protecting patients
and stopping outbreaks. Retrieved from https://www.cdc.
gov/drugresistance/protecting_patients.html.

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Chapter 15

Health Planning for Primary Care Settings
Christine Colella

LEARNING OUTCOMES

After reading the chapter, the student will be able to:

KEY TERMS

1. Describe the evolution of primary care at the national
and global levels.

2. Apply the principles of epidemiology to the primary care
setting.

3. Discuss the integration of primary, secondary, and
tertiary care interventions in the primary care setting.

4. Describe chronic disease management and case
management.

5. Discuss current policy issues related to the delivery of
primary care.

6. Describe the patient-centered medical home (PCMH)
component of the Affordable Care Act.

Case management
Food desert
Health promotion

Health protection/risk
reduction

Patient-centered medical
home (PCMH)

Primary care

Primary health care
Vaccine

n Introduction
“Primary health care now more than ever” was declared
by the World Health Organization (WHO) in 2008.1
More than a decade later, barriers remain from local ob-
stacles to global challenges. Noncommunicable diseases
(NCDs) such as cardiovascular disease, respiratory
disease, diabetes, and cancer are the leading causes of
death and disability across the world. Despite decades of
research by Starfield and others, that demonstrated a
positive association between access to primary care and
better health outcomes, the supply of general primary care
practitioners continues to be low.2 The question then
arises: “If the importance of primary care is known, why
is it not realized?” The issue at the forefront in the United
States, and the world, is that the demand for primary care
providers continues to exceed the supply. Due to this
trend, there is a projected shortfall of the primary care
workforce by 2030.3

In response to the looming shortage, more states
have sought to expand the role of advanced practice
registered nurses (APRN). The APRN as nurse practi-
tioner (NP) has increased access to primary care
where it is needed. A report by the University of
Michigan (2018)4 demonstrated that more NPs worked

in low-income areas. This effort has placed nursing in
the center of the struggle to address the increasing de-
mand for primary care services in the United States.
What is behind the focus on primary care, and what
does primary care have to do with public health?
According to the WHO, the answer is found in the
theme used for the 2018 World Health Day: “Universal
Health coverage: Everyone, everywhere under the
slogan: Health for All.”5

Populations that have access to health care, especially
preventive care on a primary and secondary level, are
healthier.1 Primary health care includes preventive care
such as vaccines and immunizations, health education,
health promotion, and monitoring of health status.
Primary care provides individuals and families with vital
secondary prevention such as screening and early treat-
ment. These efforts can decrease the overall burden of
disease experienced by a population through the preven-
tion of disease and reduction of mortality and morbidity.
Primary care is central to the health of the public, and
primary health-care providers who apply public health
science to their practice become active participants in
the promotion of health in the populations they serve.
Primary care is delivered across a continuum from the
individual to the community (Fig. 15-1).

372

7711_Ch15_372-397 21/08/19 11:12 AM Page 372

Evolution of Primary Care
According to the WHO, globalization is putting the so-
cial cohesion of countries under stress, and health-care
systems are not performing at the level needed to ade-
quately address the health-care needs of their citizens.
The WHO reported that, in 2018, almost 100 million
people were being pushed into extreme poverty by hav-
ing to pay for health-care services out of their own
pocket.5 In their 2008 plea for increasing primary care,
the WHO argued that primary health care would make
a difference in the capability of health-care systems to re-
spond better and faster to the need for services.1 Despite
overall improvement worldwide in health and life ex-
pectancy, the WHO explained that these improvements
are not consistent across countries or populations. In ad-
dition, trends in the delivery of health-care services are
problematic, especially the following:

• The focus by health-care systems is on curative care.
• The approach to disease control is short term and

fragments service delivery.
• A laissez-fare approach to health systems has allowed

unregulated commercialization of health care.1

United States
Primary care, as we think of it today in the United States,
has evolved out of population demand and political
changes. The definition of primary care is dependent on
the services provided to the patient and the provider of
that service, and for the most part focuses on the method
for delivery of primary health-care services to individuals
and families. In the past, the local general practitioner
cared for a patient from birth to death. After World
War II, that method of care delivery dwindled, and spe-
cialty care grew. Because of population demand, it was not
until the late 1960s and early 1970s that family practice be-
came a new specialty with the launch of family practice
medical education programs in 1969.6 According to the
American Academy of Family Physicians (AAFP), to de-
fine primary care one must describe the nature of the serv-
ices provided and identify the provider of these services.6

The patient is the core of primary care; patients must
be partners in their care for it to be effective. Primary care
is often referred to as the gatekeeper or control center for

access to care. It is the entryway to the maze known as
the health-care system. Although this is true, we should
also see the opportunity that primary care brings to fully
meet the needs of the patient. The services delivered en-
compass health promotion, disease prevention, health
maintenance, counseling, patient education, diagnosis,
and treatment of acute and chronic illness.5 In addition
to providing health care to patients, the primary care
provider also acts as a patient advocate. The primary care
environment promotes patient-centered care that is cost
effective and focused on both accomplishing the goals of
individual patients, and reducing morbidity and mortal-
ity in the population served through prevention, early
detection of disease, and engagement in treatment. The
importance of increasing access to care is part of the
Healthy People (HP) objectives.7

Global
In 1978, the International Conference on Primary Health
Care in Alma-Ata, USSR, resulted in a declaration that
urged action from all governments, health-care workers,
and the global community to protect and promote the
health of all peoples. The declaration defined primary
health care as:

Primary health care is essential health care based on practi-
cal, scientifically sound, and socially acceptable methods and

C H A P T E R 1 5 n Health Planning for Primary Care Settings 373

Figure 15-1 The continuum of primary care.

The
Individual

Families
and Groups

The
Community

n HEALTHY PEOPLE
Topic: Access to Health-Care Services
Goal: Increase access to comprehensive quality
health-care services
Overview: Access to comprehensive, quality health-
care services, including oral care and prescription
drugs, is important for promoting and maintaining
health, preventing and managing disease, reducing un-
necessary disability and premature death, and achieving
health equity for all Americans.

There are three components of access to care:

• insurance coverage
• health services
• timeliness of care

Midcourse Review: Of the HP 2020 26 objectives,
6 were archived, 10 were developmental, and 10 were
measurable. Of those that were measurable, 4 showed
improvement, 5 showed little or no improvement, and
1 worsened (Fig. 15-2).8

Sources: (7, 8).

7711_Ch15_372-397 21/08/19 11:12 AM Page 373

technology made universally accessible to individuals and
families in the community through their full participation
and at a cost that the community and country can afford to
maintain at every stage of their development in the spirit of
self-reliance and self-determination. It forms an integral part
both of the country’s health system, of which it is the central
function and focus, and of the overall social and economic
development of the community. It is the first level of contact
of individuals, the family and community with the national
health system, bringing health care as close as possible to
where people live and work, and constitutes the first element
of a continuing health-care process.1

The goal set at the end of the conference was to
achieve an acceptable level of health care for all people
of the world by 2000. Although this has not been
achieved, a 2008 report by the WHO showed some
progress in the building of primary health-care infra-
structure. The report, however, also pointed to the exis-
tence of barriers. The WHO makes the argument that the
core values of primary health care are equity, solidarity,
and the active participation of people in the decisions
that affect their health. These values then drive reforms
that reflect concrete expectations of citizens within de-
veloping and developed societies (Fig. 15-3).1

374 U N I T I I I n Public Health Planning

Figure 15-2 Healthy People 2020 midcourse review:
Access to health services.

Getting worse
Little or no change
Improving

Healthy People 2020 Midcourse Review:
Access to Health Care Services

72%

14% 14%

• Health Equality
• Solidarity
• Social Inclusion

• People Centered
Care

• Health promotion
and protection in
communities

• Reliability of
health authorities

Public
Policy

Reforms

Leadership
Reforms

Patient
Centered

Care

Universal
Coverage

Figure 15-3 Social values that drive primary health care
and the corresponding set of reforms. (Adapted from the
World Health Organization.)

n CELLULAR TO GLOBAL
From a global perspective, the term primary health
care has a broader meaning than it does in the
United States. In the United States, the term primary
health care is used to describe the level of delivery
of care to individuals and families rather than to

populations. However, at the International Conference
on Primary Health Care in Alma-Ata, USSR, in 1978,
primary health care takes a broader approach that
includes all aspects related to health, including access
to health services, environment, and lifestyle. The
difference in the definition of primary care from the
global perspective is evident in the central values of the
Alma-Ata Declaration related to the achievement of
health for all. The declaration began a movement that
tackled political, social, and economic inequalities in
health care. The agenda for the 2008 WHO report was
to renew the effort to reform health-care systems
across the globe to achieve that equality.1

More than 10 years have passed since the 2008
agenda was set, yet equality is still not in place. The
WHO 2018 Global Conference on Primary Care was
focused on the goal of achieving universal health cover-
age (UHC) and meeting sustainable developmental
goals (SDG).9 On World Health Day, the WHO stated
that, “we need to get 1 billion more people to benefit
from universal health care by 2023 if we are to meet
sustainable development goals by 2030”.5 Looking at
the issue from a global perspective, 90% of a person’s
health needs in a lifetime can be covered by primary
care.9 The two perspectives of primary care come to-
gether in their central commitment to people-centered
health care built on the development of a personal re-
lationship between health-care providers and seekers
of care. Both function under the belief that people are
partners in the management of their health. Primary
health care, as defined by the WHO, takes it one step

7711_Ch15_372-397 21/08/19 11:12 AM Page 374

UNICEF is another organization that looks at the
health and well-being of children and their access to care
and needs. Their Strategy for Health 2016-203010 speaks
to some successes of countries improving health-care
outcomes, but the need for continued achievement is
paramount. For example, it discusses the tremendous
achievement in improving the under-5 mortality rate as
well as the maternal mortality rate, but is quick to note
that, despite these achievements, unacceptable inequities
remain within and among countries. UNICEF has also
launched a global strategy for women’s, children’s, and
adolescents’ Health 2016-2030: Survive, Thrive, Trans-
form initiative (Box 15-1).11 The vision as presented by
Ban Ki-moon, the UN Secretary-General, is explained as:

The three overarching objectives of the updated Global
Strategy are Survive, Thrive, and Transform. With its full

implementation—supporting country priorities and plans,
and building the momentum of Every Woman and Every
Child—no woman, child, or adolescent should face a greater
risk of preventable death because of where they live or who
they are. But ending preventable death is just the beginning.
By helping to create an enabling environment for health,
the Global Strategy aims to transform societies so that

C H A P T E R 1 5 n Health Planning for Primary Care Settings 375

further with the idea that primary care is responsible
for the health of the community across the life span,
and that primary care must tackle the determinants of
ill health.1

This approach has brought criticisms. Some thought
the Alma-Ata Declaration primarily supported the cre-
ation of one health-care delivery system with a narrow
goal of providing adequate health care to the poor.1 In
reality, the declaration addressed much larger issues
than just providing care to one group. Since 1978, large
gaps have been exposed in the ability of current health
systems to address the changing health needs of popu-
lations. Many systems are facing increased demands and
changing expectations of what the health-care system
should deliver. In addition, the issues raised by emerg-
ing chronic and communicable diseases are bringing to
the forefront evidence that primary health care not
only meets the needs of individuals, but also can im-
prove the health of entire communities. The WHO
General Director stated “Health is a human right. No
one should get sick and die just because they are poor
or because they cannot access the services they
need.”9 This is very powerful language that speaks to
the need and importance of primary care access for all.
Primary care as defined in the Alma-Ata Declaration
provides an overall model for the delivery of health
care across the globe. Under this model, primary care
should provide access to care from individuals to com-
munities and address key health issues related to both
communicable and noncommunicable disease, mental
health, substance use, and injury from the cellular to
global level.

SURVIVE: End preventable deaths

• Reduce global maternal mortality to less than
70 per 100,000 live births

• Reduce newborn mortality to at least as low as
12 per 1,000 live births in every country

• Reduce under-5 mortality to at least as low as
25 per 1,000 live births in every country

• End epidemics of HIV, tuberculosis, malaria, neglected
tropical diseases, and other communicable diseases

• Reduce by one-third premature mortality from non-
communicable diseases and promote mental health
and well-being

THRIVE: Ensure health and well-being

• End all forms of malnutrition and address the
nutritional needs of children, adolescent girls, and
pregnant and lactating women

• Ensure universal access to sexual and reproductive
health-care services (including for family planning)
and rights

• Ensure that all girls and boys have access to good-
quality early childhood development

• Substantially reduce pollution-related deaths and
illnesses

• Achieve universal health coverage, including financial
risk protection and access to quality essential services,
medicines, and vaccines

TRANSFORM: Expand enabling environments

• Eradicate extreme poverty
• Ensure that all girls and boys complete free, equitable,

and good-quality primary and secondary education
• Eliminate all harmful practices and all discrimination and

violence against women and girls
• Achieve universal and equitable access to safe and

affordable drinking water and to adequate and equi-
table sanitation and hygiene

• Enhance scientific research, upgrade technological
capabilities, and encourage innovation

• Provide legal identity for all, including birth registration
• Enhance the global partnership for sustainable

development

BOX 15–1 n UNICEF Objectives and Targets

7711_Ch15_372-397 21/08/19 11:12 AM Page 375

women, children, and adolescents everywhere can realize
their rights to the highest attainable standards of health and
well-being. This, in turn, will deliver enormous social, de-
mographic, and economic benefit.11

According to the UNICEF State of the World’s Chil-
dren 2017 report,12 changes have occurred, but there is
significant room for improvement. Pneumonia and diar-
rhea, both treatable and preventable diseases, still claim
1.4 million young children every year. They report that
one in four deaths among children under 5 is caused by
either pneumonia or diarrhea. Low and lower middle-
income countries are home to 62% of the world’s under-5
population but account for 90% of global pneumonia and
diarrhea deaths.12 There has been a decline in the deaths
however, because of the work being done. Between 2000
and 2015 the death rate fell from 2.9 million to the current
1.4 million. This is a significant decline, but as their pub-
lications state, even one death is too many.

The focus going forward is to continue to implement
the interventions that have been successful. That includes
a threefold strategy of protection, prevention, and treat-
ment. Protection means that to decrease the number of
deaths you must have healthier infants. The strategy is to
encourage breastfeeding exclusively for the first 6
months with adequate complimentary feeding and vita-
min A supplementation. Prevention places an emphasis
on hand washing with soap, safe drinking water and san-
itation, and vaccines for pertussis, measles, hepatitis B,
PCV, and rotavirus. It also requires reducing household
pollution and spread of HIV; approximately half of the
deaths from pneumonia are associated with air pollution
and HIV. Treatment means access to health care, which
requires improved care seeking, case management, and
availability of supplies such antibiotics.

What do these changes in the overall health of the
population have to do with primary health care? The
basic need is to have a health-care system that provides
resources that can effect change. This requires a con-
certed effort of a government to put in place agencies and
people dedicated to the health of their nation. To be suc-
cessful at the population level, a primary health-care sys-
tem must consider the social, economic, and political
context in which it functions.

Epidemiology and Targeted Prevention
Levels in Primary Care
Primary care encompasses all levels of prevention: pri-
mary, secondary, and tertiary. Interventions vary based
on the level of prevention, gender, and age. Helping our

country achieve optimal health requires a comprehensive
understanding of the community. Health promotion and
protection should be provided to all members of the
community despite their disease status. Primary care
nurses who apply public health science, including assess-
ment and health-planning skills, will not only have a bet-
ter chance of providing optimal care to individuals and
families, but also are more apt to contribute to the build-
ing of a healthier community. Public health nurses
(PHNs) who work in primary care settings develop
health programs that help prevent disease and manage
NCD. Examples of the programs implemented for pop-
ulations include case management, health education pro-
grams, and community outreach.

A major challenge in the United States and globally is
ensuring access to primary care services. The Patient Pro-
tection and Affordable Care Act (ACA) of 2010 (see
Chapters 1 and 21) was built on the assumption that in-
creasing access to care will improve the health of the U.S.
population. Among other things, this legislation made
funds available to create and support nurse-managed
clinics that would focus on promoting and maintaining
optimal health. Changes to the ACA later eroded away
some of this support, but the primary care setting re-
mains central to the reform bill. The interventions pro-
vided by nurses working in primary care are built on the
application of public health science. This requires that
nurses working in primary care settings have knowledge
not only of the health of individuals seeking care but also
an understanding of the context in which they live. Thus,
nurses working in a primary care setting who are car-
ing for individuals, families, and/or communities and
populations must have current information on the
prevalence of diseases within the community they serve,
information on the current recommendations for primary
and secondary prevention relevant to their community,
and the ability to engage community partners in develop-
ment of sustainable and effective interventions.

376 U N I T I I I n Public Health Planning

w SOLVING THE MYSTERY
The Case of the Sleeping Mom
Public Health Science Topics Covered:
• Assessment
• Advocacy

Nurses who know the community their clients live
and work in have a great advantage in primary care.
Sometimes they can intervene at a level that goes be-
yond assessment, diagnosis, and treatment. Consider
Terry, a nurse working at a primary care clinic located

7711_Ch15_372-397 21/08/19 11:12 AM Page 376

An important component to all levels of prevention
is education of patients about what they can do to mini-
mize their own risk factors for disease (see Chapter 2).
Understanding the relationship of diet, exercise, and
maintaining a healthy weight can be key to disease pre-
vention or minimizing complications of disease. The
diabetic who controls his blood sugar will minimize
micro- and macrovascular complications. The smoker
who enters a smoking cessation program will reduce her
risk of cardiovascular disease and chronic obstructive
pulmonary disease. Other important items a nurse can
address with a patient during a primary care visit include
use of sunscreen, dental hygiene, and alcohol intake.
When these risks occur across a group of patients, the
nurse can develop population-level interventions such as
education packets or working with the health depart-
ment to implement the use of public safety announce-
ments specific to their community.

Primary Prevention Within the Primary Care
Setting
The first and desired level of intervention is primary pre-
vention to keep a person free of disease (see Chapter 2).
For individuals who are free of disease and seek primary
care, the major focus for the nurse is to conduct a routine
checkup, provide health education (see Chapter 2), sup-
port positive health practices, and provide information
and support related to changing unhealthy behaviors. The
challenge for the nurse working in a primary care setting
is how to engage in primary prevention at the aggregate

C H A P T E R 1 5 n Health Planning for Primary Care Settings 377

in one of the poorer neighborhoods in New York City.
Brenda, a single African American mother, came in
with her 4-month-old baby for a routine well-baby
checkup. The mother was seen initially by the primary
care physician working in the clinic. He came out of the
examining room and asked Terry to put together a so-
cial services referral. The physician told Terry, “This
mother has real problems. When I was examining the
baby, the mother fell asleep in the chair and I had to
keep waking her up to answer questions. She obviously
is not capable of caring for this child if she can’t stay
awake in the middle of the day!” Terry told the physi-
cian that she would go in and talk with the mother.

When Terry went into the room, she found the
baby safely nestled in the car seat and Brenda asleep in
the chair. Terry gently woke up Brenda up and identi-
fied herself. She asked Brenda to tell her about her
baby. Brenda glowed and said that the baby was won-
derful. Terry then told her that she noticed Brenda was
asleep when she came in. Was there a reason for this?
Brenda hesitated and said that it was nothing. Terry
gently probed further, and Brenda explained that she
has been staying up at night because the apartment in
which she is living is infested with rats. If she doesn’t
stay awake, the rats will get into the baby’s crib and
hurt him. She was pleased that she has been able to
keep her baby safe but worried that she was so tired
that she may fall asleep during the night.

Terry asked her whether she had issued a com-
plaint. Brenda said she had complained to the landlord,
but nothing had happened. Terry assured her that
there are steps that can be taken to address the issue
and then began the process, not for a social service
visit, but to work with the public health department
and the housing authority to implement the process
for getting the rodents eliminated from the building. In
addition, Terry looked through the charts to find
other families attending the clinic who lived in the
same building and called each one to determine
whether the rat problem was being experienced
throughout the building. Many of the clients com-
plained of a similar problem, and Terry helped the ten-
ants begin to work together to address the issue as
well. Within a short period of time, an effective pro-
gram was put in place that included action from the
public health department, the housing authority, and
the newly formed tenants group. The result was land-
lord compliance with rodent eradication and elimina-
tion of rats from the building. Brenda was at last able
to sleep at night.

Terry built on the knowledge she had obtained in
her community health course. When she accepted the
job, she took the time to learn about the community
where the clinic was located, including identifying key
contacts in the public health department. This knowl-
edge had helped her in the past to address problems
with immunization of children, distribution of flu
vaccines, and now a problem with rodent infestation.
Over time, she not only knew the patients who came
to the clinic but also had a growing understanding of
the environment in which they lived. This knowledge
meant that she immediately understood the possibility
that there was an alternative explanation for the sleep-
ing mom. Her knowledge of key stakeholders helped
her determine who had the power to act and effect
change. In addition, her understanding of how a com-
munity works helped her to include the residents of
the building in the problem-solving process.

7711_Ch15_372-397 21/08/19 11:12 AM Page 377

level as well as at the individual and family levels. This
requires knowledge of the community, the resources
available, leaders within the community, and the other
stakeholders in the community who can support efforts
to promote and protect the health of the community.
Thus, it is important to know how to conduct a commu-
nity assessment and make a plan (see Chapters 4 and 5).

Let’s consider the example of the nurses working in
a primary care setting in the Midwest, where a key be-
havioral issue that affects overall health is the high rate
of tobacco use. According to the Centers for Disease
Control and Prevention (CDC),13 the Midwest has the
highest regional prevalence of smoking; 19 out of every
100 adults smoke.13 Furthermore, nearly 18 out of every
100 adult men and 14 out of every adult female smoke.
A comprehensive smoking cessation program at a clinic
in the Midwest should include not only efforts to help
individuals quit, but also primary prevention programs
at the community level. If nurses seek further informa-
tion at the community level, they will identify the re-
sources available to the community. They will also be
able to identify cultural issues related to tobacco use that
may influence the success of a smoking prevention cam-
paign. Knowledge of the community will also help them
engage other potential partners in the community in
doing an anti-smoking campaign among the youth of
the community.

Primary prevention is the first step in reducing the
number of adults who smoke over the next decade. In
the example of tobacco use in a Midwest community,
the primary care nurse could collaborate with the school
system to develop a culturally grounded anti-smoking
campaign in the hope that, over time, they would see
fewer patients in their clinic suffering from smoking-
related adverse health consequences. Such a campaign

could encompass the development of policies that not
only reduce youth access to tobacco products but also
reduce exposure to secondary smoke. Information
would also be shared about vaping and electronic ciga-
rettes as this activity is being seen in both adults and
adolescents. As per the CDC,14 electronic cigarettes are
not safe for youth, young adults, pregnant women, nor
adults who don’t smoke. Vaping is also targeted by ad-
vertisers to young children and adults, and poses a threat
to the smoking prevention process.

To be effective, primary prevention in a primary care
setting requires both individual- and community-level
interventions. It includes both health promotion and
health protection activities. As defined in Chapter 2,
health promotion at the individual and family levels
helps people change their lifestyle to achieve optimal
health.15 Health promotion as defined by the WHO is
“the process of enabling people to increase control over
and to improve their health. It moves beyond a focus on
individual behaviors toward a wide range of social and
environmental interventions”.15 As stated in Chapter 2,
health protection/risk reduction includes primary pre-
vention interventions that protect the individual from
disease by reducing risk and usually focuses on behav-
ioral change with health education a main tool, whereas
health protection involves a clinical intervention such as
immunization (Table 15-1).

Health Promotion
Most health promotion in primary health-care settings is
delivered at the individual and family levels. However, to
be effective, these interventions should be developed, im-
plemented, and evaluated from a population level (see
Chapter 5). This requires an understanding of the com-
munity, including cultural, environmental, socioeconomic

378 U N I T I I I n Public Health Planning

TABLE 15–1 n Levels of Prevention in Primary Care and Recommended Interventions

Primary Prevention—Adult (to prevent illness from occurring)

Primary Prevention Focus

Health protection: Immunizations

Health promotion: Education

Examples

• Flu shot
• Pneumococcal vaccination
• Tetanus booster (every 10 years)
• Human papillomavirus (females aged 9–26)
• Chicken pox (VZV) for those born after 1980

• Healthy diet
• Exercise
• Weight loss
• Smoking cessation
• Low-risk alcohol use

7711_Ch15_372-397 21/08/19 11:12 AM Page 378

C H A P T E R 1 5 n Health Planning for Primary Care Settings 379

TABLE 15–1 n Levels of Prevention in Primary Care and Recommended Interventions—cont’d

Secondary Prevention—Adult (to identify disease in a patient with asymptomatic illness)

Men

Women

Testing

• Blood pressure (BP), body mass index (BMI), health risks
• HIV discussion
• Depression screening
• Diabetes screening
• Lipids for men at age 35

• BP, BMI, health risks
• HIV discussion
• Depression screening
• Diabetes screening
• Lipids every 5 years

• BP, BMI, health risks
• HIV discussion
• Depression screening
• Diabetes screening
• Colorectal screening (at age 50)

• BP, BMI, health risks
• Depression screening
• Diabetes screening
• Colorectal screening until 75

Testing

• BP, BMI, health risks
• HIV discussion
• Depression screening
• Diabetes screening
• Chlamydia/gonorrhea (sexually active women through age 24

and then as needed)
• Cervical cancer (first should be done at age 21 or 3 years after

first sexual contact, then every 3 years)

• BP, BMI, health risks
• HIV discussion
• Depression screening
• Diabetes screening
• Cervical cancer (every 3 years)
• Mammography (optional as a baseline every 2 years)

• BP, BMI, health risks
• Depression screening
• Diabetes screening
• Cervical cancer screening up to age 65
• Colorectal screening (at age 50)
• Mammography (every 2 years)
• Bone density (age 65 or women at a high risk for fractures per

risk factors)
• Lipids optional every 5 years until 70 as per risk factors

Age Range

19–39

40–49

50–70

70 and older

Age Range

19–39

40–49

50–70

Continued

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380 U N I T I I I n Public Health Planning

TABLE 15–1 n Levels of Prevention in Primary Care and Recommended Interventions—cont’d

Secondary Prevention—Adult (to identify disease in a patient with asymptomatic illness)

Tertiary Prevention—Adult (identifies the disease state the patient may have to minimize complications)

Diabetes

Cardiovascular

• BP, BMI, health risks
• Depression screening
• Diabetes screening
• Colorectal screening
• Mammography every 1 to 2 years until 74, then optional

• Tight glycemic control
• Lipid management
• BP control
• Healthy weight
• Exercise
• Foot care

• Lipid management
• BP control
• Healthy weight
• Exercise

71 and over

For further information on interventions in primary care refer to:
1. Agency for Healthcare Research and Quality (2014). Guide to Clinical Preventive Services, 2014. Rockville, MD, Author. Retrieved

from http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/index.html
2. U.S. Preventative Services Task Force. (2018). Retrieved from http://www.uspreventiveservicesraskforce.org/BrowseRec/Index/

browse-recommendations

aspects of the community, and the resources available in
the community.

For example, if you worked in a primary care setting
in Arizona with a high percentage of American Indians
as clients, it would be important to know what diseases
this population is most at risk for. Based on data from
the CDC, a major concern would be prevention of type
2 diabetes in American Indian youth (Table 15-2).16,17

This requires a review of population-level information
related to risk factors. In the case of the American Indi-
ans, the risk factors include genetic predisposition and a
shift in diet from traditional foods they grew themselves
to processed foods.14,15 Less than 100 years ago, diabetes
was unknown in the American Indian population but

started be reported after World War II.18 The Pima In-
dians of Arizona have the highest rates of diabetes in the
world;17 they have a higher incidence of long-term com-
plications from diabetes, and their problems develop ear-
lier in life. Based on these facts, primary prevention
strategies would require buy-in from the community and
need to begin as early as possible, even during the pre-
natal period instead of waiting until a problem develops.
Partnering with the community would be a key first step
prior to initiating evidence-based prevention strategies
that have been used in other parts of the country. The
Pima Indians have their own unique culture as well as a
genetic predisposition that requires modification of any
other programs to match the specific needs of the com-
munity. Fortunately, much work has been done in part-
nership with Pima Indians to understand how to
improve their health.18 Again, primary care requires a
population perspective not only as the starting point but
also for ongoing evaluation of the effectiveness of inter-
ventions delivered across the continuum in primary care
(see Fig. 15-1).

Immunization and Health Protection
Immunization through the administration of a vaccine is
one of the most frequently used health protection efforts
conducted in primary care. As explained in Chapter 8, a

TABLE 15–2 n Prevalence of Type 2 Diabetes
>18 yrs in the United States

Ethnic Group Prevalence

American Indians

Asian, non-Hispanic

Black, non-Hispanic

White, non-Hispanic

Source: (16)

15.1%

8.0%

12.7%

7.4%

7711_Ch15_372-397 21/08/19 11:12 AM Page 380

vaccine refers to the immunizing agent that is used to in-
crease the host’s resistance to viral, rickettsial, and bacte-
rial diseases. They can be killed, modified, or become a
variant form of the agent. In the United States, the CDC
provides detailed guidance to the health-care provider re-
lated to the recommended vaccination schedule for all age
groups. An example is the recommended adult immu-
nization schedule compiled for the health-care provider
(see https://www.cdc.gov/vaccines/schedules/hcp/imz/
adult.html). The schedule includes immunizations rec-
ommended for all adults based on age group, including:

• Tetanus
• Human papillomavirus
• Varicella
• Measles, mumps, and rubella
• Influenza

Other vaccines are recommended if some risk factor
is present, such as the occupational risk of exposure to
hepatitis A and B for health-care providers.19 The pri-
mary care nurse often administers the vaccine. Nurses
providing the vaccines use population-level data related
to risk, helping them identify persons who would most
benefit from the vaccine. Recommendations for vaccina-
tion from the CDC are based on age, risk factors, and
medical conditions.20

Immunizations are central to the patient’s risk reduc-
tion and health promotion. Every interaction with the
health-care team is an opportunity to assist the patient in
making choices that will enhance his/her health. Patient
education regarding how immunizations can affect health
is often the role of the primary care nurse. With every in-
teraction with each patient, the nurse has the opportunity
to make the information relatable to that patient and his
concerns or needs. The young mother who cannot miss
work for illness needs to understand that getting the flu
vaccine could decrease her risk for illness this year. The
farmer working in the soil needs to understand how im-
portant his tetanus booster is to keep him working with-
out a problem. The student starting a career in health care
needs to see the relationship between getting his/her hep-
atitis B series and his/her new role. One of many things
the primary care nurse does is show patients the relation-
ship between their own needs and how preventive health
care can help them meet those needs. The understanding
and availability of immunizations such as the flu vaccine
helps the patient adhere to this mandate. Thus, the pri-
mary care nurse actively participates in the achievement
of the HP goal related to immunization.

The HP 2020 goals for immunization and communi-
cable diseases were rooted in evidence-based clinical and

community activities and services for the prevention and
treatment of infectious diseases. Objectives new to HP
2020 focused on technological advancements ensuring
that states, local public health departments, and non-
governmental organizations are strong partners in the
federal attempt to control the spread of communicable
diseases. Objectives for 2020 reflected a more mobile so-
ciety and the fact that diseases do not stop at geopolitical
borders.7 Awareness of disease and completing preven-
tion and treatment courses remain essential components
for reducing transmission of communicable disease and
meeting the proposed visions and mission of Healthy
People 2030 (see Chapter 1).

Secondary Prevention Within the Primary
Care Setting
Secondary prevention is a major activity in primary care.
Secondary prevention focuses on identifying individuals
with subclinical disease and initiating early treatment.
The activity usually associated with secondary prevention
is screening. Most primary care settings follow the cur-
rent recommendations for screening. Screening in pri-
mary care includes a wide range of tests, from taking
weight and height done in the office to colonoscopies
that require aesthesia. (For more detail on screening, see
Chapter 2.) Primary care settings are where most screen-
ing occurs; thus, primary care providers are essential to
the process of early detection and treatment. However,
note again that aggregate-level approaches are also vital
to the success of screening. Some screening procedures
such as colonoscopy can be expensive and require access
to health-care facilities that provide the service. Patients

C H A P T E R 1 5 n Health Planning for Primary Care Settings 381

n HEALTHY PEOPLE
Immunization and Infectious Disease

Goal: Increase immunization rates and reduce
preventable infectious diseases.
Targeted Topic: Immunizations and infectious
diseases
Overview: The increase in life expectancy during the
20th century is largely due to improvements in child
survival; this increase is associated with reductions in
infectious disease mortality, due largely to immuniza-
tion. However, infectious diseases remain a major
cause of illness, disability, and death. Immunization
recommendations in the United States currently target
17 vaccine-preventable diseases across the life span.
HP 2020 Midcourse Review: (See Chapter 8.)

Source: (7)

7711_Ch15_372-397 21/08/19 11:12 AM Page 381

who are less likely to have a colonoscopy covered by their
insurance, if they have insurance, can be offered a fecal
for occult blood, which is less costly and a valid pretest
for colon cancer. Knowledge about the community and
the population served can help improve access to screen-
ing services, thus improving the health of the population
served.

Screening
Here is an example of how nurses take an active role in
screening and health promotion. Access to mammogra-
phy screening in the rural communities of southeastern
Indiana was limited. In response, nurses developed a
screening program that has resulted in a regional drive to
bring screening to the women living in these communi-
ties. This program, funded by the Susan G. Komen Foun-
dation and others, uses the mammography van from a
local hospital to go to the women who need the service.
With advanced advertisement, women are registered for
a screening, clinical breast exam, and education.

This example of a grassroots approach to breast cancer
screening has been successful. Many women have
been reached, screened, and referred for follow-up care.
A parallel opportunity that came out of this project in
southern Indiana was the development of a nurse-run
clinic for the uninsured. This free clinic opens twice a
month, staffed by nurses, a pharmacist, and an NP who
offer education, episodic intervention, and referral to pri-
mary care providers in the community who will care for
patients using an economic sliding scale. These interven-
tions were implemented by nurses living in the area who
identified a need and responded to it from a primary care
perspective. Nurses in the community applied their un-
derstanding of the community to find a way to respond
to that need. This included knowledge of the community
demographics, the regional and ethnic cultural practices,
and community resources such as treatment facilities
available for those who screened positive for breast can-
cer. The focus was secondary prevention with the long-
term goal of reducing morbidity and mortality in a
population of women at risk.21

The CDC is an excellent source for recommendations
related to screening in primary care settings. For exam-
ple, it has a Web page dedicated to HIV screening in pri-
mary care with a recommendation that all patients aged
13 to 64 be screened.22 The CDC also has recommenda-
tions on screening for cancer, including breast and col-
orectal cancers.23

Screening is basic to care because health-care providers
are looking for illness that is asymptomatic. In the primary
care population, we screen routinely for elevated blood

pressure, cholesterol, and hyperglycemia. We screen for
these because we know through evidence-based practice
that people who have these underlying issues are at greatest
risk for disease. Hypertension, hyperlipidemia, and diabetes
are the root causes for diseases that have the highest
incidence of mortality and morbidity. Taking a blood pres-
sure is noninvasive and simple to do, uses minimal equip-
ment, and can identify the patient who is at risk for coronary
artery disease. To identify this patient and then offer the
education and opportunities to improve their health is
foundational to primary care. Screening must be followed
up with education that includes information on lifestyle
changes such as diet, exercise, weight loss, and medications.
Screening without follow-up leaves the patient without the
direction or knowledge to take charge of his health.

Ethics of Screening in Primary Care
Chapter 2 addressed the ethical issues related to screen-
ing in detail, but the importance of ethics in screening
bears repeating here. A major issue in primary care is
conducting screening when treatment is not available.
Prior to screening, the primary care nurse must first
know what to do if the patient screens positive. Is this
something the patient wants to know? Does the family
want to know? For example, you may have a woman with
two sisters who wants to know whether she carries the
gene for breast cancer, but the other sisters do not want
to know. This can become an ethical issue for the family.
Think about the family in which a member may have a
disease for which there is no known cure, such as amy-
otrophic lateral sclerosis, also known as Lou Gehrig’s dis-
ease. Do the children want to know whether they are
carriers and how does this affect their lives going for-
ward? Does the nurse know what facilities are available
to the client to take the next steps—assessment, diagno-
sis, and treatment? Availability includes geographical
availability, the patient’s access to transportation to get
the facility, and whether the patient can pay for the treat-
ment. For example, if a surgical intervention is required
and the patient is uninsured and has no savings, the only
option may be Medicaid. The state Medicaid program
may require that the patient sell any assets, such as a
home, prior to qualifying for Medicaid. These ethical is-
sues related to screening should be considered prior to
conducting routine screening.

Tertiary Prevention Within the Primary
Care Setting
Despite our best efforts with primary prevention, some
people will become ill with either a communicable dis-
ease (Chapter 8) or an NCD (Chapter 9). Certainly,

382 U N I T I I I n Public Health Planning

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primary care plays a key role during the acute phase of
the illness, but it also is crucial to successful tertiary
care. The goal of tertiary prevention is to minimize the
complications or sequelae to NCDs. All NCDs carry
a risk of lifelong complications.

Nurses are familiar with the macro- and microvas-
cular changes that occur if diabetes is not well con-
trolled. A cerebral vascular accident or myocardial
infarction can occur in the patient with uncontrolled
hypertension or hyperlipidemia. It is the follow-up,
management, and education of the patient with an
NCD in primary care that reduce this risk. Reduction
of risk of possible complications occurs through the
careful evaluation of the patient done on a set schedule
of appointments. However, care recommendations
made to a patient are based not only on patient-specific
data but also on population-level data. For example, the
recommendations that the diabetic patient on insulin
should be seen every 3 months and the diabetic patient
on oral agents should be seen every 4 to 6 months are
based on the epidemiological evidence that these time
frames provide adequate coverage for the average pa-
tient. However, specific patients may need to be seen
more often based on the management of their disease.
This schedule of care minimizes complication by a care-
ful evaluation on the success of the current plan of care
or the opportunity to adjust the interventions.

Management of Noncommunicable Diseases
As reviewed in Chapter 9, management of NCDs is an
essential component of care aimed at reducing the asso-
ciated morbidity and premature death. For example,
patients with diabetes require long-term management
related to regulation of blood sugar, medications, foot
care, diet, and exercise. Although management of dia-
betes is most frequently delivered to the individual, a
population approach is also required. Primary care
nurses rely on already developed health education ma-
terials to help teach their patients how to self-manage
their disease. However, not all materials work across
populations because of a lack of cultural relevance or
health literacy levels (see Chapter 2). Based on one lit-
erature review, development of self-management inter-
ventions in populations with low income or low health
literacy need careful review. Those that were most effec-
tive included three to four self-management skills espe-
cially when teaching patients to learn problem-solving
skills.24 The application of public health science in a pri-
mary care setting does not always require time-consuming,
sophisticated studies. It can often be accomplished using
simple assessment tools.

Case Management
Visits to primary care allow health-care workers to rein-
force health education and answer questions. It is this
follow-up that establishes the trust and provides the basis
for outcomes that will improve the patient’s overall
health and well-being. To help guide this effort, nurses
in primary care often use a case management approach.
According to the Case Management Society of America,
case management is “a collaborative process of assess-
ment, planning, facilitation, and advocacy for options
and services to meet an individual’s health needs through
communication and available resources to promote
quality cost-effective outcomes.”25 Case management in-
volves the monitoring and managing of a patient’s health
needs. The role can be designated in different ways. A
case manager can be diagnosis-focused (diabetes, heart
failure, multiple sclerosis), patient type-focused (home-
less, older adult, obese, pediatric), or site-focused (hos-
pital, clinic, shelter).

Nurse case managers actively participate with their
clients to identify and facilitate options and services for
meeting individuals’ health needs to reduce fragmen-
tation and duplication of care.26 Contemporary case
management began in the 1970s to assure both quality
outcomes and cost containment.27 The essence of case
management is the incorporation of the client, the
family, and the community in meeting the needs of the
patient. Case management has a positive impact on
cost containment and improves patient outcomes.25-27

This focus on patient outcomes improves the quality
of patient care and, therefore, the overall health of the
community.

Public Primary Care
Primary care occurs in public settings such as health
clinics run by public health departments, federally
qualified health centers, and free clinics. Not all public
health departments have primary care clinics, and
most are located in urban areas. Federally qualified
health centers provide health care to underserved pop-
ulations on a sliding scale and have received grants
under section 330 of the Public Health Service Act.
These clinics qualify for enhanced reimbursement
from Medicare and Medicaid. They must also provide
comprehensive services.28 These primary care settings
are funded at the federal, state, or local level and aim
to improve access to primary care for populations who
have limited resources.

Another source of primary care for the underserved
population is a free health clinic. The National Association

C H A P T E R 1 5 n Health Planning for Primary Care Settings 383

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of Free Health Clinics says the following about free health
clinics:

Free clinics are volunteer-based, safety-net health-care or-
ganizations that provide a range of medical, dental, phar-
macy, and/or behavioral health services to economically
disadvantaged individuals who are predominately unin-
sured. Free clinics are 501(c)(3) tax-exempt organizations or
operate as a program component or affiliate of a 501(c)(3)
organization. Entities that otherwise meet the previous defi-
nition, but charge a nominal fee to patients, may still be con-
sidered free clinics provided essential services are delivered
regardless of the patient’s ability to pay.29

These organizations are not directly supported by pub-
lic funds and depend heavily on a volunteer workforce.

The ACA, enacted in 2010, brought an increased focus
on primary care and the need to build the workforce. In
2010, the Department of Health and Human Services an-
nounced the availability of $250 million aimed at increas-
ing the number of health-care providers working in
primary care, especially in clinics that provide care to un-
derserved populations. Congress has reduced this fund-
ing through changes to the ACA. One of the major aims
of the ACA was to increase access to primary care with
the goal of reducing the morbidity and mortality related
to untreated disease and lack of preventive care.

Increasing the capacity of public primary care through
public health clinics helps to provide care to those with
limited access. One of the challenges for these clinics is
matching care to the resources available to promote and
protect health. Once again, nurses who restrict them-
selves to the individual level of care miss opportunities
to maximize the ability of a community to support
healthy living. In the case of one primary care nurse, the
identification of the lack of nutritional resources led to a
communitywide effort that far exceeded her initial one-
on-one health education with her patients.

384 U N I T I I I n Public Health Planning

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Nurse Who Thought
She Lived in the City—Not the Desert
Public Health Science Topics Covered:

• Assessment
• Collaboration
• Health planning

Katherine, a nurse, lived and worked in the inner
city for many years. “I’m a city girl,” she would often
say, explaining that she could get whatever she needed

in the city. However, she heard that there was a prob-
lem with hunger in the city. She noticed an article that
discussed inner-city nutrition and the article used the
term food desert. From a public health perspective, a
food desert is a large, often isolated, geographical
area where there is little or no access to the food
needed to maintain an affordable and healthy diet.30 In
many major cities, large grocery stores are closing their
doors in inner-city neighborhoods, especially poor
neighborhoods, thus limiting access to fresh produce,
food varieties, and nutritional choices. In the United
States, food deserts tend to be in urban and rural low-
income neighborhoods, where residents are less likely
to have access to supermarkets or grocery stores that
provide healthy food choices.

Through her review of the literature on food
deserts, Katherine discovered that an increasing num-
ber of communities had few food retailers or super-
markets that regularly stocked fresh produce, low-fat
dairy, whole grains, and other healthy foods.31,32 This
phenomenon has been slowly occurring over time with
the movement of people out of the city, the economic
downswing, and the loss of jobs. The 2008 Farm Bill di-
rected the U.S. Department of Agriculture (USDA) to
study food deserts in the United States, assess their
incidence and prevalence, identify characteristics and
factors causing and influencing food deserts, and deter-
mine the overall effect of food deserts on local popula-
tions.33 Based on this, the USDA was asked to provide
recommendations for addressing the causes and ef-
fects. There has been little improvement in accessibility
to food, which results in poor nutrition that in turn
affects the overall health of the individual. Seventy-five
retailers opened 10,000 new locations between 2011
and 2015, and only 250 of those were in the country’s
food deserts.30 A USDA report found that not only do
low-income people have less access to healthy food, it
costs more if they do have access. Nearly 10% of the
U.S. population is low income and lives more than a
mile from a grocery store with healthy options. There
are some “convenient” markets in these locations, but
they do not have fresh fruits and produce. Coupled
with either the lack of transportation or the cost of
transportation, you truly can be stranded on a desert
island in the middle of the city when it comes to food.

Katherine realized that a major supermarket had left
the community in which her clinic is located, and she
wondered about the impact. With this on her mind,
she began to ask the patients in the primary care clinic
where she worked a simple question: “Where do you

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C H A P T E R 1 5 n Health Planning for Primary Care Settings 385

shop for food?” The responses of the patients began to
identify this as a real concern. The convenience store
or fast-food restaurants were the most common an-
swers. The patients explained lack of transportation as
the main reason for shopping at the convenience store
even though the prices were higher. Ms. Reid, an older
adult patient, related how hard it was for her to get on
the bus and carry groceries home. James told Kather-
ine that the convenience store was close by but so
expensive that he could not purchase much food. The
most disturbing comment came from Mary, the mother
of four children, who said, “I know my children need
fresh fruits and vegetables, but I cannot get that around
here.” All the patients, in one way or another, felt the
impact of living in a “desert.” Katherine did further
reading and found that the economic and nutritional
sequelae to this loss of access to supermarkets were
far reaching. It is well documented that dietary choice
may reverse or lessen the disease burden of many
NCDs as well as prevent communicable diseases.30-33

When the choice is limited to red meats, fatty
foods, added fats, desserts, and sweets, there is a
substantially increased risk for obesity, type 2 dia-
betes, and heart disease.34 The effect goes across
the life span, affecting adults, older adults, and the
younger population. The growth and development of
the child and adolescent are compromised by the
unavailability of quality foods. The long-term effect
for the younger population is twofold; it affects their
health, certainly, but it also provides a pattern of eat-
ing that will be detrimental for the rest of their lives.
The goal of adequate nutrition in childhood is to pre-
vent nutritional disorders such as malnutrition and
obesity, as well as the increased morbidity and
mortality that accompany them.35 Nearly one in
three children are overweight or obese, which puts
them at risk for chronic long-term conditions that
will negatively affect their health through their life
span. Snack, convenience, and fast foods as well as
sweets continue to dominate food advertisements
viewed by children. The marketing of these items
contributes to the fast-food consumption of U.S. chil-
dren.35,36 Children spend more time, an average of
44.5 hours per week, in front of a television, com-
puter, and/or game screen; that’s more than any
other activity except sleeping.36,37 They are repeat-
edly exposed to advertisements and often cannot dis-
tinguish between an advertisement and programming.37

The other issue is the use of restaurants as opposed
to cooking healthy food in the home. According to

the National Restaurant Association, in 2017,38 48% of
the food dollar was spent in a restaurant with a total
intake of $799 billion dollars spent at a restaurant.

Katherine and the other nurses at her clinic re-
viewed HP objectives related to nutrition and weight
status and found a new objective. The goal was listed as
“promote health and reduce chronic disease risk
through the consumption of healthful diets, and
achievement and maintenance of healthy body
weights”. To achieve this goal of a healthful diet and
healthy weight, HP 2020 stated that it must encompass
increasing household food security and eliminating
hunger.39

Based on this, the nurses decided to attack this
problem on two fronts. They realized that education
must take place to inform and advise the patients on
the importance of good nutrition. In addition, because
the lack of availability of the food was a serious bar-
rier to healthy eating, the food desert in their com-
munity needed to change first. Katherine decided to
investigate ways to get a neighborhood farmer’s mar-
ket into the city. She learned that this concept helps
bring fresh produce, eggs, and meats to the city as
well as helps the small farm owner.40 It can also be a
method to develop local gardens, new business, em-
ployment, and camaraderie in a neighborhood. In a
project in Florida, a town with issues such as elderly,
no transportation, multiple chronic conditions, and no
local store suffered from a severe food desert. They
decided to make a change and developed a commu-
nity garden. The results showed a true effect on the
social determinates of health: increased access to
fresh foods, increased physical activity, creation of so-
cial ties, and a greater feeling of community.41 She re-
alized that this was something doable and contacted a
group in New York City, Greenmarket, to find out
where to start. Greenmarket began in 1976 with
12 farmers and one farmers’ market located in Man-
hattan. It grew to 54 markets and 230 family farms and
fishermen.42 The registered nurse group that Kather-
ine worked with on this project used what they
learned in their undergraduate public health nursing
courses to tackle the problem. They knew they had
to begin with an assessment but had little time in their
busy clinic schedules to do this. One of the more re-
cent graduates of a local school of nursing suggested
that they enlist the help of the students and the
nearby school of nursing. They added a member of
the nursing faculty from the school to their planning
group. The faculty member agreed to have students

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Private Primary Care
Primary care is also provided through private practices.
Providers include physicians, NPs, nurses, and other
health-care providers. Private practices do not receive di-
rect federal support, but most accept payment through
federal programs such as Medicaid and Medicare. The
financial structure is based on a fee-for-service model.
However, the delivery of care is the same. Again, the
nurse must be attuned to the larger context of the com-
munity in which the patients of the clinic live. This un-
derstanding helps the nurse identify issues that require
intervention at the community level.

386 U N I T I I I n Public Health Planning

who were taking their public health nursing practicum
help conduct the assessment and contribute to the
planning and evaluation stages of the project. The
nurses now had a team.

The team began with a geographical assessment of
their community and the surrounding area, plotting the
location of fast-food restaurants, convenience stores,
and the closest supermarkets (see Chapter 4). They
then plotted the public transportation routes. To help
with the assessment, they asked members of the com-
munity to join their team. The community members
described the realities of trying to shop for food. With
the help of the community members, they conducted a
more formal survey of the patients coming to their
clinics, asking about their nutritional intake and for in-
formation on where they purchased their food. This
provided them with baseline data.

Using the data from their community-specific assess-
ment, the team constructed a viable plan to bring
farmers’ markets into the community, which included
measurable objectives, impact, and outcomes (see
Chapter 5). The plan included organizing local food
cooperatives and farmers’ markets to set up sites in
the neighborhoods. Once availability of the food was in
place, the group of nurses supplemented their nutri-
tional education for patients with added knowledge of
what was available in the community. They provided
their patients with pamphlets and information about
the new offerings. They put up posters in their office.
After 6 months, they reissued their survey and found
that the nutritional intake had improved, and patients
reported easier access to healthy foods through the
farmers’ markets. Thus, Katherine’s concern as well as
application of basic public health assessments and pro-
gram planning resulted in a change of the health of an
entire neighborhood.

w SOLVING THE MYSTERY
The Case of the Wobbly Men
Public Health Science Topics Covered:
• Surveillance and case finding
• Epidemiology
• Communication

Madelyn, a nurse who works as the intake nurse at
the primary care office in Rivertown, Ohio, began her
busy day reviewing the schedule. She noticed that
James T., a 45-year-old male, was on the schedule again
for a chief complaint of “feeling weak, a wobbly gait,
and his wife says he is irritable.” Madelyn recalled that
James was at the clinic last month with a similar com-
plaint, and he was not the only one. She wondered why
the local men had been visiting the office so often re-
cently. Usually, it is very difficult to get this age bracket
of men into the office for risk prevention and routine
checks. James was the fifth man this week with a similar
complaint.

As she did the initial intake of James T’s history, she
noticed a listing of symptoms that she had heard re-
cently from the other five middle-aged male patients.
The complaints of weakness, unsteady gait, and feeling
depressed and irritable were new for these patients.
She decided to explore this change in the usual patient
population. She realized that these symptoms can be
attributed to many different diagnoses, but it was the
similarity of the symptoms in a specific group of male
patients in the same age group that got her attention.

Madelyn pulled the charts of all five of the men with
similar chief complaints and started on a basic public
health mission, looking for anything that might link these
five men. They did not live on the same street, and they
worked at different jobs. She then called each of the men
and asked them other questions to try and find a link be-
tween them. She found one very quickly when she asked
whether they knew each other. They reported that they
had formed an informal fishing group and fished regularly
for relaxation. Because most of their wives did not like to
clean the fish or cook it, they ate most of the catch the
same day on the boat. The rest they cleaned themselves
and froze for eating during the week. They regularly
caught Rock Bass, Smallmouth Bass, and Yellow Bullhead.
They also threw back the smaller fish, even those that
met regulations, and sought the bigger fish. When asked
how many times a week they ate fish that they had
caught, they replied that they ate between three and four
meals per week. For Madelyn, the common denominator
across this patient population was the ingestion of large

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C H A P T E R 1 5 n Health Planning for Primary Care Settings 387

quantities of river fish over the past few years. She found
no other common denominator. She remembered hear-
ing something about freshwater fish being contaminated
with chemicals. She reviewed the men’s symptoms again
and noticed that the symptoms pointed to mercury poi-
soning. Madelyn’s attention to detail and her understand-
ing of basic epidemiology led her to a possible solution to
the puzzle of the wobbly men. She explained her conclu-
sions to the physician and the two NPs who worked in
the clinic with her. She shared her information with the
providers in the office, who then followed up on her rec-
ommendation to test the men for mercury poisoning.
When the levels came back elevated in excess of 20
mcg/L (normal value is less than 5 mcg/L), the providers
were able to initiate appropriate treatment. Madelyn also
made a call to the county public health department to
alert them to the cluster of cases.

Mercury poisoning has been around for centuries
and noted as early as 1500 BC in Egyptian tombs. In the
manufacture and processing of felt hats in the 18th and
19th centuries, chronic exposure of workers to the
mercury used to process the felt led to the term “mad
as a hatter.” Mercury in any form is toxic. Exposure can
be via ingestion, vapor inhalation, injection, and absorp-
tion through the skin.43,44 The presentation of symptoms
relates to the most commonly affected systems, which

are the neurological, gastrointestinal, and renal systems.
The concentration of mercury is very low in most food-
stuffs (below 0.02 mg Hg/kg). However, certain types of
marine fish (such as shark, swordfish, and tuna) and cer-
tain fish taken from polluted freshwaters (such as pike,
walleye, and bass) may contain high concentrations of
mercury (Fig. 15-4).44 In this setting, mercury is almost
completely in the form of methylmercury. It is not un-
common that concentrations of methylmercury in these
fish are 1 mg/kg or even higher.44 Organic mercury can
be found in three forms—aryl, short-chain, and long-
chain alkyl compounds. Once absorbed, the aryl and
long-chain alkyl compounds convert to their inorganic
forms and possess similar toxic properties to inorganic
mercury. The short-chain alkyl mercurials are readily
absorbed in the gastrointestinal tract (90%–95%) and
remain stable in their initial forms. Alkyl organic mercury
has high lipid solubility and distributes uniformly
throughout the body, accumulating in the brain, kidney,
liver, hair, and skin. Organic mercurials also cross the
blood-brain barrier and placenta and penetrate erythro-
cytes, attributing to neurological symptoms, teratogenic
effects, and high blood to plasma ratio, respectively.44

The presentation of acute mercury poisoning includes
burning of the throat, edema of oral mucous mem-
branes, abdominal pain, vomiting, bloody diarrhea, and

Figure 15-4 How mercury enters the environment. (From U.S. Environmental Protection Agency [2012]. Mercury
in your environment.)

Emissions
and

Speciation

Atmospheric
Transport and

Deposition

Ecosystem Transport,
Methylation, and
Bioaccumulation

Consumption
Patterns

Dose
Response

Emissions
From Power

Plants and Other
Sources

Wet and Dry
Deposition

Mercury transforms into methylmercury
in soils and water, then can

bioaccumulate in fish

Atmospheric
Deposition

Lake Ocean

Fishing
• Commercial
• Recreational
• Subsistence
Humans and
wildlife affected
primarily by eating
fish containing
mercury

Impacts
• Best documented
impacts on the
developing fetus:
impaired motor and
cognitive skills
• Possibly other impacts

7711_Ch15_372-397 21/08/19 11:12 AM Page 387

388 U N I T I I I n Public Health Planning

TABLE 15–3 n EPA Advisory Table: Small selection of Bodies of Water in Ohio

One Meal
Body of per Month or
Water Area Under Advisory Species Two Months Contaminant

Dicks
Creek

Great
Miami
River

Little
Scioto
River

Lake
Erie

Mercury,
Polychlorinated
biphenyls (PCBs)

Mercury, PCBs

PCBs and PAHs

PCBs

Mercury

All species

All Suckers

All species: Common Carp, Black
Crappie, White Sucker 16”
and over

Channel Catfish, Common
Carp 27” and over, Lake Trout

Chinook Salmon 19” and over,
Coho Salmon, Common Carp
under 27”, Freshwater Drum,
Smallmouth Bass, Steelhead
Trout, White Bass, Whitefish,
White Perch

Brown Bullhead, Largemouth Bass

Month

2 Months

Month

Cincinnati – Dayton Road,
Middletown to the Great
Miami River (Butler County)

Lowhead Dam at Monument
Avenue (Dayton) to mouth
(Ohio River) (Butler,
Hamilton, Montgomery,
Warren Counties)

State Route 739, near Marion
to Holland Road, near
Marion (Marion County)

All Waters (Ashtabula,
Cuyahoga, Erie, Lake,
Lorain, Lucas, Ottawa,
Sandusky Counties)

Source: (46)

shock.43 Chronic mercury poisoning, which these men
were experiencing, causes weakness, ataxia, intentional
tremors, irritability, and depression. Exposure to alkyl
(organic) mercury derivatives from contaminated fish or
fungicides used on seeds has caused ataxia, convulsions,
and catastrophic birth defects.43 Without a complete
history, mercury toxicity, especially in older adults, can
be misdiagnosed as Parkinson’s disease, senile dementia,
metabolic encephalopathy, depression, or Alzheimer’s
disease.45 It is imperative to do a thorough history that
includes occupation, hobbies, and level of seafood intake
if clinical suspicion includes mercury exposure.

Based on her own research and her discussion with
the public health department, Madelyn found that the
Environmental Protection Agency (EPA) (see Chapter 6)
released regular reports on the safety of freshwater fish
with recommended levels of consumption (Table 15-3).46

For the river flowing through Rivertown, the recommen-
dation for consumption of Rock Bass, Smallmouth Bass,
and Yellow Bullhead was one meal per month. These
men were consuming 12 to 16 times more than the

recommended amounts. Madelyn was concerned that,
although this information was available on the Web site,
the information was not getting out to the community.

Madelyn decided to contact the other two primary
care groups in Rivertown and ask them whether they
have seen anyone with similar complaints. The two
other offices reported that they had, for a total of eight
more patients, all male and all between aged 35 to 60.
She joined forces with the nurses in these two clinics
and proposed to the health department that a public
campaign be launched to alert fishermen to the potential
danger of eating a large quantity of fish caught in the
local river. One of the men being treated told Madelyn
that he belonged to a local fish and game club that had
recently organized in the community. The nurses asked
this club to help spread the word, thus reducing the risk
of mercury poisoning in their community. Madelyn pro-
vided a valuable service to her community, not only be-
cause she solved the problem of the wobbly men, but
also because she took it to the next step and worked at
preventing more cases.

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C H A P T E R 1 5 n Health Planning for Primary Care Settings 389

Emerging Primary Care Public Health
Issues
Public health issues that challenge primacy care continue
to emerge. For example, issues with insufficient supply
of flu vaccine or it not being affective against the flu are
problematic. In a time when we want all people to be im-
munized, it shakes the faith of people in the effectiveness
and can undermine usage of the flu vaccine. Widespread
administration of the flu vaccine promotes herd immu-
nity. Herd immunity means if a significant proportion of
a population are vaccinated (the herd) it provides a
measure of protection for individuals who are not able
to receive the vaccine.47 For example, if a person under-
going chemotherapy for cancer has a low white count
and a compromised immune system, she is susceptible
to the flu but not able to take the flu shot. If she is sur-
rounded by people who are protected, she too will be
protected because she has less of a chance being exposed
to it. This requires that primary care nurses remain on
top of the public health information.

Some public health issues reflect the emergence of
health problem that can have a devastating effect on the
community. A current problem is the opioid epidemic
(see Chapter 11). This is an especially difficult problem
for providers and health-care workers in primary care.
Opioid comes from48 the word opium, and these drugs
were developed to replicate opium’s pain-reducing prop-
erties. There are legal painkillers like morphine, oxy-
codone, or hydrocodone and illegal drugs like heroin
or illicitly made fentanyl and carfentanil. Fentanyl is
100 times more powerful than morphine, and carfentanil
is 10,000 times more potent than morphine; when these
are added to heroin, the loss of life increases. How did
this all start and why do people continue to use when
they almost die from it? These are important questions
that need to be understood so you can help your patient
and their families try and understand.

Hydrocodone and oxycodone are semisynthetic
opioids manufactured in labs with natural and syn-
thetic ingredients. Between 2006 and 2014, the most
widely prescribed opioid was hydrocodone (Vicodin).
In 2014, 7.8 billion hydrocodone pills were distributed
nationwide, and the second most prevalent opioid was
oxycodone (Percocet). In 2014, 4.9 billion oxycodone
tablets were distributed in the United States. The Inter-
national Narcotics Control Board reported that, in 2015,
Americans represented about 99.7% of the world’s hy-
drocodone consumption.49

Those are staggering numbers, and they are where
the problems begin. Looking at the management of pain

historically gives us some insight. This is not the first opioid
epidemic that has occurred with increased use; records
show epidemics occurring as early as 1840.50 The national
supply of opium and morphine soared by 538% before the
end of the 19th century, and those using were a diverse pop-
ulation. It included soldiers, persons with an alcohol use
disorder, mothers and children, and Chinese immigrants.
The model individual with an opioid use disorder was a
native-born white woman with a chronic painful disorder;
most were exposed to opium with child birth. In an inter-
esting twist of history, heroin was first produced in 1898 by
Bayer and was thought to be less addictive than morphine
so it was used for people addicted to morphine. One reason
that this first epidemic occurred was because cures for
painful diseases were scarce. With the invention of the mor-
phine injectable, it was easier to use and more effective.
However, the institution of public health cleaned up some
of the squalor that had caused the diarrhea and other dis-
eases treated with opium; this helped to get the epidemic
under control. In 1924, the Anti-Heroin Act banned the
production and sale of heroin in the United States, and the
prescribers of that time were educated against the practice.
Later in the 20th century, transient nonmedical heroin use
in urban areas affected disproportionately inner-city
minority populations. In 1970, the Controlled Substance
Act became law which created groupings (schedules) of
drugs based on the potential for abuse.50

Heroin is a schedule 1 drug whereas morphine, fen-
tanyl, oxycodone (Percocet, OxyContin), and methadone
are schedule II. So how are we in the state today of such
staggering loss of life related to opioid abuse? It starts with
a drug company that did a small study in 1986. The study
was of 38 patients with chronic pain who were treated
with opioid pain relievers (OPR), and it was concluded
that these were safe for long-term use. In 1995, this study
was used as the advertising campaign to introduce the
medication OxyContin, an extended release formulation
of oxycodone. By 1996, the rate of opioid use was accel-
erating rapidly. Between 1996 and 2002, the manufacturer
funded more than 20,000 pain-related educational pro-
grams through direct sponsorship or financial grants to
encourage OPR use for non-cancer patients. This com-
pany provided financial support to the American Pain So-
ciety, American Academy of Pain Medicine, Federation
of State Medical Boards, Joint Commission, and patient
groups who then all advocated for more aggressive iden-
tification of and treatment of pain with OPRs.

In 1995, the American Pain Society introduced the
campaign of “pain is the 5th Vital Sign” embraced by
Veterans’ Affairs health system and Joint Commission
to increase identification and treatment with OPRs.

7711_Ch15_372-397 21/08/19 11:12 AM Page 389

There was caution about imprudent prescribing, but it
was overshadowed by assertions that the risk of toler-
ance and addiction were low, and abuse should not con-
strain prescribing.50 Exaggerated benefits of long-term
use of OPR was put forth without any high-quality long-
tern clinical trials being conducted. Customer satisfac-
tion was a Joint Commission survey criterion, and
it may have influenced a study showing that physicians
prescribed high-dose opioids in more than 50% of
1.14 million nonsurgical hospital admissions from
2009-2010. On May 10, 2007, the federal government
brought criminal charges against the pharmaceutical
company for misleadingly advertising OxyContin as
safer and less addictive than other opioids.50

How does opioid misuse constitute a public health
crisis? The National Institute on Drug Abuse estimates:50

• Half of all young people who inject heroin turned to
it after abusing painkillers

• Three in four new heroin users start out using
prescription drugs

• Overdose deaths related to heroin increased 533%
between 2002 and 2016 from an estimated 2,089
in 2002 to 33,219 in 2016

• Every day, more than 90 Americans die after
overdosing on opioids

The CDC estimates that the total “economic burden”
of prescription opioid misuse alone in the United States
is $78.5 billion a year, including the costs of health care,
lost productivity, addiction treatment, and criminal jus-
tice involvement. Roughly 21% to 29% of patients pre-
scribed opioids for chronic pain misuse them, and
between 8% and 12% develop an opioid use disorder. It
is crucial for primary care nurses and PHNs to under-
stand the effect of this crisis. We need to think about
who is at risk. It can be anyone: teens, college students,
middle-aged adults, elderly adults, medical users of
OPRs, or nonmedical users of OPRs.

We understand the physiology of pain, but what hap-
pens to cause addiction? The use of OPRs affects the re-
ward circuit of the brain. The drug floods the brain with
dopamine causing the person to feel pleasure, which is
motivation to repeat the behaviors. Unfortunately, over
time the brain adjusts to the excess dopamine resulting
in tolerance, and the patient needs more and more to
reach the desired high. This circuit is permanently
changed, and other functions such as learning, judg-
ment, decision making, stress, memory, and behaviors
are affected.51

This change in circuity leads to addiction, and over-
coming that addiction is difficult for many. There is no

one factor that means someone will develop an opioid
use disorder; it is a combination of genetics, environ-
ment, and when they start. The issue is now what can be
done. As with the first epidemic, we need to educate pre-
scribers and the public. In primary care, it is imperative
to screen appropriately, prescribe appropriately, and help
patients recognize potential problems. Also, it is neces-
sary to note any increases in “need or request” for more
medications or unscheduled refills.52 It is important for
offices to use a state-wide automated reporting system,
if available, to cut down on multiple medications and
inappropriate refills. Having a contract with patients
regarding opioid use is imperative as well as urine drug
screens. Another important component is the overall re-
duction of the use of nonmedical OPR use and the issue
of diversion concerns, that is, when persons who have
been legally prescribed OPRs transfer this controlled
substance to another person for illegal use.52

Many people think that they should never have pain
and that there is a “pill” for everything; we need to edu-
cate our patients regarding appropriate use. The key rec-
ommendations for practice in primary care include:

• Identify cause of pain: History, assessment, testing,
diagnosis

• Assess risk factors for medication use
• Appropriate for level of pain, physiologic risk to

kidneys, liver, GI, history of abuse
• Use nonopioid analgesics when possible
• Scheduled as opposed to prn better control pain
• Use of adjunctives
• Avoid the use of extended release OPRs
• Limit supply to 3-5 days (some states have specified

time)
• Reduce patient exposure and reduce the supply of

OPRs in the home

Pain management guidelines, 53-57 patient education,58

patient follow-up, and thoughtful care of the patient’s
needs are all factors that can help to manage the current
crisis.

Ongoing Use of Public Health Science
in the Primary Care Setting
Nurses working in primary care consistently apply public
health science to their practice. This includes trending
disease and risk factors in the community they serve.
They do not have to collect the data themselves. They can
use local, state, and national public health surveillance
data to help identify significant trends in the population

390 U N I T I I I n Public Health Planning

7711_Ch15_372-397 21/08/19 11:12 AM Page 390

they serve. In addition, primary care nurses who actively
employ public health communication skills will build a
partnership with the community and key stakeholders.

Tracking Health Trends in the Community
Served
Many issues, such as the opioid crisis, require a popula-
tion perspective to effectively treat the individual. For
example, recent trends might show a rise in emergency
department admissions for exacerbations of asthma.
Members of the community, such as parents, school
teachers, or PHNs, raise the question—Why is there an
increase? Upon investigation by these members of the
community, it is discovered that a new factory has
opened that manufactures aromatics released into the air.
There is a direct correlation between this change in the
environment and the rise in asthma exacerbations. A
community seems to have a higher incidence of a certain
cancer than another, and the cause must be addressed.

A rise in the population complaining of back and foot
pain because they started a new job at a warehouse is
evidence that education on proper body mechanics is
needed. The community-focused approach to problems
has patient/public education at its heart, and nurses as
educators are foundational to the success of these pro-
grams. Knowing the community means understanding
their needs, values, education level, and what is impor-
tant to them. When this part of the community can be
identified, the best approach can be developed, and suc-
cess will occur. To develop a plan without the input and
buy-in from a community will cause a weak foundation
and result in failure.

Health-Care Policy and Primary Care
Due to funding available through the ACA, there has
been an increased focus on the use of community health
centers (CHCs). The ACA provided funding for existing
and new CHCs and enabled them to serve an estimated
28 million new patients by 2018.59 The CHCs were
launched in 1965 by the Office of Economic Opportunity
as part of Lyndon Johnson’s War on Poverty. They were
designed to reduce or remove the health-care disparities
among the poor, racial and ethnic minorities, and the
uninsured. The plan was that the governance of these fa-
cilities be centered in the host community. There are
more than 8,000 urban and rural sites in every state and
territory. They are federally funded but must meet budget
requirements and offer services according to an eco-
nomic sliding scale. CHCs are dedicated to the delivery
of primary medical, dental, behavioral, and social serv-
ices to the underserved populations, and they have

demonstrated their ability to provide care in a compre-
hensive fashion.60 This may explain the influx of patients.
The CHC core values coincide with the patient-centered
medical home (PCMH) concept. The PCMH is built
on the premise of a holistic approach that encompasses
accessible, coordinated, and team-driven delivery of
primary care that relies on outcome measurement and
evidence-based practice.

Another issue is the inclusion of the medical home in the
ACA. The PCMH is a model or philosophy of primary care
that drives primary care excellence. The features of a Med-
ical Home include: (1) patient-centered, (2) comprehen-
sive, (3) coordinated, (4) accessible, and (5) committed to
quality and safety. These five functions of a medical home
are listed in more detail in Box 15-2.61 The ACA includes
the medical home as one of the required quality measures.
Individuals with an NCD covered under Medicaid may
choose a PCMH, which can be an individual provider
(such as a CHC or comprehensive primary care clinic) or
a health team. This PCMH would provide the care needed

C H A P T E R 1 5 n Health Planning for Primary Care Settings 391

The five functions and attributes of the medical home
are as follows:

1. Patient-centered: A partnership among practitioners,
patients, and their families that ensures decisions re-
spect patients’ wants, needs, and preferences, and that
patients have the education and support they need to
make decisions and participate in their own care.

2. Comprehensive care: Team of care providers is
wholly accountable for a patient’s physical and mental
health-care needs, including prevention and wellness,
acute care, and chronic care.

3. Coordinated care: Care is organized across all ele-
ments of the broader health-care system, including
specialty care, hospitals, home health care, community
services and supports.

4. Accessible: Patients are able to access services with
shorter waiting times, “after hours” care, 24/7 elec-
tronic or telephone access, and strong communication
through health IT innovations.

5. Committed to quality and safety: Clinicians and staff
enhance quality improvement to ensure that patients
and families make informed decisions about their
health.

BOX 15–2 n Association for Health Care Research
and Quality: The Medical Home
Encompasses Five Functions and
Attributes

Source: Patient-Centered Primary Care Collaborative. (2018). Defining the medical
home. Retrieved from https://www.pcpcc.org/about/medical-home

7711_Ch15_372-397 21/08/19 11:12 AM Page 391

to manage the NCD and could include care management,
care coordination, health promotion, transitional care,
family support, and referral to community and social sup-
port services when needed. The medical home should also
use health information technology to link services.62

Communication and Collaboration
One of the standards in public health nursing is collabo-
ration. One of the characteristics of collaboration is that
the nurse partners with key individuals, group, coalition,
and organizations to effect change in public health poli-
cies, programs, and services to generate positive out-
comes.63 This standard holds true for the primary care
nurse. Nurses working in primary care settings enhance
their practice when they build collaborative relationships
with these entities. In each of the case studies presented
in this chapter, primary care nurses needed to commu-
nicate and collaborate with individual members of the
community, with organizations, and with other stake-
holders. The building of these relationships takes time
and requires a conscious effort to do so that goes beyond
creating a list of referrals for patients. It means building
strong partnerships and requires specific skills. Although
this is not unique to primary care nurses, there are part-
nerships that should be a part of every primary care
nurse’s practice.

Community Organizations
A good starting point is the local public health department
(see Chapter 13). Primary care health providers are re-
quired to report certain diseases to the public health de-
partment (Table 15-4). This system is a good starting point
and can be a two-way street. For example, some commu-
nicable diseases are rare enough that they may be missed
during the first assessment, but if the primary care nurse
knows that there has been an increase in a particular dis-
ease, the level of suspicion increases. Then, if a patient
comes into the primary care clinic, the nurse is more apt
to be on the alert for symptoms that match that disease.

Many initiatives begin with the local public health de-
partment and require buy-in by primary care providers.

392 U N I T I I I n Public Health Planning

n EVIDENCE-BASED PRACTICE
Patient-Centered Medical Home

Practice Statement: A PCMH is based on the inte-
gration of patients as active participants in their own
health and well-being.
Targeted Outcome: Improved health outcomes, in-
creased ability to self-manage NCDs, prevention of
both NCDs and communicable diseases, improved
quality of health care, and decreased health-care costs.
Evidence to Support: The move to a PCMH is a core
concept in the ACA. Crabtree and colleagues1 pointed
out that, based on their own 15-year program of re-
search, successful transformation of primary care set-
tings to a PCMH model is unlikely to be successful
unless a stronger theoretical foundation is established.1
The evidence to support PCMH is growing.2,3 Key as-
pects of PCMH included organizational access and in-
creased knowledge as well as the interpersonal skills of
the provider.4,5 However, findings related to the effec-
tiveness of PCMHs remains mixed.6,7

Sources
1. Crabtree, B.F., Nutting, P.A., Miller, W.L., McDaniel, R.R.,

Stange, K. C., Jaen, C.R., & Stewart, E. (2011). Primary
care practice transformation is hard work: Insights from a
15-year developmental program of research. Medical Care,
49, S28-S35. doi:10.1097/MLR.obo13e318cad65c

2. Meo, N., Wong, E., Sun, H., Curtis, I., Batten, A., Fihn,
S.D., & Nelson, K. (2018). Elements of the Veterans
Health Administration patient-centered medical home are
associated with greater adherence to oral hypoglycemic
agents in patients with diabetes. Population Health Manage-
ment, 21(2), 116-122. doi:10.1089/pop.2017.0039

3. Shippee, N.D., Finch, M., & Wholey, D. (2018). Using
statewide data on health care quality to assess the effect
of a patient-centered medical home initiative on quality
of care. Population Health Management, 21(2), 148-154.
doi:10.1089/pop.2017.0017

4. Bilello, L.A., Hall, A., Harman, J., Scuderi, C., Shah, N.,
Mills, J.C., & Samuels, S. (2018). Key attributes of
patient-centered medical homes associated with patient
activation of diabetes patients. BMC Family Practice, 191-8.
doi:10.1186/s12875-017-0704-3

5. Platonova, E.R., Warren-Findlow, J., Saunders, W.,
Hutchison, J., & Coffman, M. (2016). Hispanics’ satisfaction

with free clinic providers: An analysis of patient-centered
medical home characteristics. Journal Of Community Health,
41(6), 1290-1297. doi:10.1007/s10900-016-0218-2

6. Chou, S., Rothenberg, C., Agnoli, A., Wiechers, I., Lott, J.,
Voorhees, J., … Venkatesh, A.K. (2018). Patient-centered
medical homes did not improve access to timely follow-up
after ED visit. American Journal of Emergency Medicine,
36(5), 854-858. doi:10.1016/j.ajem.2018.01.070

7. Marsteller, J.A., Hsu, Y.J., Gill, C., Kiptanui, Z., Fakeye,
O.A., Engineer, L.D., … Harris, I. (2018). Maryland multi-
payor patient-centered medical home program: A 4-year
quasiexperimental evaluation of quality, utilization, patient
satisfaction, and provider perceptions. Medical Care, 56(4),
308-320. doi:10.1097/MLR.0000000000000881

7711_Ch15_372-397 21/08/19 11:12 AM Page 392

Developing a relationship with the public health depart-
ment brings a primary care clinic into the public health
arena and increases the likelihood that the clinic’s patients
will benefit from these initiatives. Primary care nurses are
in the “trenches” and often have a good grasp of the health
issues faced by their patients. Collaborating with the
public health department can result in the building of
population-level initiatives that build on the experiences
of the primary care nurses. This two-way communication
can have a powerful effect on community-level public
health that will work in the field.

There are a multitude of organizations with which pri-
mary care nurses can build a relationship to help better
serve their patients. These include but are not limited to
governmental organizations, other health-care providers,
churches, community groups, and other primary care
providers. Most student nurses learn how to conduct a
community assessment (see Chapter 4), but once the
course is completed, they fail to apply it when they move
out into the real world of nursing care. In primary care, the
community assessment component is essential. Consider
the cases presented in this chapter. The nurses in these cases
tapped into the resources available from various organiza-
tions such as the housing authority and the EPA.

Often, the collaboration can result in the building of
coalitions. The role a primary care clinic can play in these
coalitions is substantial. If a community wishes to ad-
dress a specific health issue such as lead poisoning or sec-
ondary smoke exposure, the primary care setting is ideal
for screening, distribution of health education materials,
and other health protection and promotion activities.

Community Members
The primary care setting is not an island but exists
within a community. Again, the lessons learned related
to community assessment are essential to the primary

care setting. The success of a primary care clinic depends
on the trust built between the clinic and the population
it serves. This requires reaching out to the community,
not just persons in leadership positions such as a mayor
or a school superintendent, but residents of the commu-
nity. What is the nature of the community? Is it rich,
poor, urban, suburban, or rural? How many people live
in the community served by the clinic and what propor-
tion uses the clinic? What are the age groups? What is
the ethnic background of the community? These ques-
tions and more help to build a picture of the community
and help primary care nurses tailor the services provided
to the patients being served.

A case in point is a public primary care clinic located
in a community of subsidized housing. This clinic oper-
ates on a first-come, first-served basis, using a sliding
scale fee. The community is on the city bus line but is on
the outskirts of the city and built next to the city landfill.
It is also located close to a major interstate. The popula-
tion is made up primarily of younger families, and there
are no major grocery stores within walking distance. The
nearest grocery store requires a transfer from one bus to
another. The clinic is the only one in the community, and
other clinics require at least one bus transfer to get to,
but many residents opt to go to other clinics rather than
to the clinic in their neighborhood.

The nurses working in the clinic struggle with a full
waiting room, crying children, and clients who complain
about the long waits. What can the nurses do? Where
should they start? Contacting a few members in the com-
munity is a good place to start. This is the first step to
looking outside the clinic, finding out what the residents
think about the clinic, and beginning to work on ways to
solve the problems. In this example, potential issues
could include the long waiting times for mothers who do
not have access to day care and must bring their children

C H A P T E R 1 5 n Health Planning for Primary Care Settings 393

TABLE 15–4 n Classification of Common Class A Notifiable Diseases Into Disease Type

Bloodborne
(Excludes Vaccine Sexually
HIV/AIDS) Enteric/Food-Borne Preventable Transmitted Other

Hepatitis B
Hepatitis C

Aseptic meningitis
Meningococcal disease
Haemophilus influenzae
Tuberculosis
Legionellosis
Streptococcal group A,

invasive

Hepatitis A
Measles
Mumps
Pertussis

AIDS
Chlamydia
Gonorrhea
Syphilis (primary,

secondary, latent,
congenital)

Campylobacteriosis
Cryptosporidiosis
Giardiasis
Escherichia coli 0157:H7
Listeriosis
Salmonellosis
Shigellosis
Yersiniosis

7711_Ch15_372-397 21/08/19 11:12 AM Page 393

with them. The nurses providing the care might not fully
understand the culture within the community. Another
possibility is the perception of public assistance. If the
nurses at the clinic begin to build a relationship with the
community, they will include the community in solving
these issues and truly form a partnership. These partner-
ships can result in multiple interventions that improve
the health of all, not just those who come in for care on
a given day. Without these partnerships, the primary care
nurses may continue to create barriers to care without
realizing it.

Public health science makes a strong contribution to
the effectiveness of primary care nursing. It provides pri-
mary care nurses with the skills needed to be full mem-
bers of the public health team, even if their focus is care
of the individual and the family. Through active partici-
pation in disease surveillance and the building of part-
nerships with other organizations and the community
itself, primary care nurses contribute to the health of the
community in powerful ways.

Culture and Primary Care
As in any setting where nursing care is provided, culture
is an important aspect of the provision of primary care.
Cultural issues not only play a part in the assessment and
development of a plan of care but also affect the availabil-
ity of resources for the family and the community. Be-
cause primary care clinics are located in a community, it
is important for the primary care providers to learn about
the culture of their community. Patients seek health care
within the context of their own culture, and that culture
affects how they perceive illness, birth, and death. Learn-
ing about the culture of a community can be challenging,
especially if the community is made up of culturally di-
verse populations. However, this process is essential to
meet cultural competence requirements.

The patient does not need to be from another country
to be from another culture. Often people in our own
communities feel marginalized due to race, poverty, or
other differences. Understanding the sensitive issues of
the lesbian, gay, bisexual, and transgender populations
(see Chapter 7), and providing opportunities for patients
to provide information within a safe environment, is im-
perative to gaining trust. The trust needed to truly “hear”
what the patient is saying begins at the first moment
of the patient visit. Asking questions that are gender-
neutral and done without judgment will allow the patient
to completely have their needs met. If a patient feels that
their health-care giver is judgmental, trust will not be
formed. It is imperative to treat all with the respect and
dignity that each human deserves. When we do that, we
will be able to learn about all peoples and construct a safe
environment.

Application of the community assessment approach
described in Chapter 4 is essential if primary care–level
interventions are going to be effective. The primary care
provider, located in the community, is in an excellent
position to gather this information and gain partners in
developing culturally relevant interventions. Each day
coming to work, the provider can observe the community
by performing a brief windshield survey (see Chapter 4).
Individuals and families can develop trusting relationships
with the nurses who work in primary care settings, because
this is often their only interaction with the health-care sys-
tem. This is where they come for their physical checkups,
where they bring their children for care, and where they
go first when they do not feel well. An understanding of
the cultural context of the persons seeking primary care
enhances a nurse’s ability not only to provide care to in-
dividuals and families but also to develop programs such

394 U N I T I I I n Public Health Planning

n CULTURAL CONTEXT
Providing care to immigrant populations illustrates the
complexity of integrating culture into the primary care
setting. In Cincinnati, Ohio, a group of refugees from
the small country of Burundi settled in a poor, largely
African American community within the city. These
refugees came from a different climate and did not
share in the culture of the predominant group in the
community. They experienced acculturation issues as
they tried to fit in their new country. For the most
part, they were young families and needed primary care
services. However, they did not speak English and had

low literacy in their own language. The primary care-
givers located in the community had to not only locate
an interpreter but also become knowledgeable about
the health practices and beliefs of the Burundians. As-
pects of the Burundian culture important to the deliv-
ery of care included understanding gender roles with
women responsible for child care and housekeeping yet
highly respected for their life-giving role. Kinship con-
stitutes the core of Burundi social units with women
becoming assimilated by their husband’s family. Chil-
dren are highly valued. Incorporating these cultural
components into the care of Burundians seeking
treatment, such as building on close kinship ties, will
improve the success of interventions offered by
primary care providers.

7711_Ch15_372-397 21/08/19 11:12 AM Page 394

as an immunization program. Failure to consider the cul-
ture of the persons served can result in poor follow-up
care, miscommunication, and failure to build that essential
trusting relationship.

n Summary Points
• Primary care in the United States is a delivery sys-

tem, and primary health care from the WHO per-
spective is a movement to bring about health-care
reform that will result in achieving equitable health
care for all.

• Primary care encompasses all levels of prevention:
primary, secondary, and tertiary.

• In the United States, primary care occurs in public
settings such as health clinics run by public health
departments as well as in private settings such as
private practices and hospital-run clinics.

• Primary care is often the first line of action for
emerging health issues such as the opioid epidemic.

• Primary care involves policy, advocacy, and collabo-
ration in an effort to address public health issues and
enhance the health of populations.

• The importance of primary care is growing along
with the introduction of the PCMH.

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t CASE STUDY
Measles Vaccination Program
for Parents

Learning Outcomes
At the end of this case study, the student will be
able to:

• Apply principles of descriptive epidemiology to trend
a disease over time.

• Describe the steps taken to develop an intervention.
• Discuss national current recommendations for

vaccination.

In 2018-2019, there was an increase in measles cases
across the United States, particularly in New York City,
with predictions that the incidence rate would be the
highest it had been in that state for 50 years. Across
the United States, efforts were made not just to im-
munize children but also to immunize adults. You have
been assigned the task of developing a vaccination pro-
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public health well-baby clinic. Begin with the current
incidence rates in the city or county nearest to you for
measles in both children and adults. Then determine

the recommendations for immunizations on the CDC
Web site located at https://www.cdc.gov/measles/
vaccination.html

Based on your findings and building on what you
learned about health assessment and planning in
Chapters 4 and 5, develop a vaccination program for
the clinic. Be sure you include the following:

• A summary of the incidence rates for your city or
county compared with those for the state and
the nation

• Have the incidence rates increased or declined in
the past 5 years?

• Which population is at greatest risk?
• Current immunization recommendations from

the CDC
• A plan to inform clinic patients and their families

about vaccination that includes:
• Communication methods (e.g., TV, flyers, school

newsletters)
• Cultural considerations
• Other communication strategies

• A mechanism for handling potential increase in
demand

• A plan to deal with a possible outbreak

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41. Diaz de Villegas, C. & Rodriguez, K. (2015). Medley food
desert project. Retrieved from https://www.epa.gov/sites/
production/files/2016-05/documents/floridainternational
universitymedleyfooddesertproject .

42. Greenmarket. (n.d.). Greenmarket farmers. Retrieved from
http://www.grownyc.org/greenmarket.

43. Olsan, D.A. (2017). Mercury toxicity. Retrieved from http://
emedicine.medscape.com/article/819872-overview.

44. U.S. Environmental Protection Agency. (2018). Mercury in
your environment. Retrieved from http://www.epa.gov/hg/
exposure.htm.

45. McPhee, S., & Papadakis, M. (2018). Current medical diagno-
sis & treatment (ed 57, pp 1611-1612). New York, NY:
McGraw-Hill.

46. Ohio Environmental Protection Agency. (2018). 2018 Ohio
sport fish health and consumption advisory. Retrieved from
http://www.epa.ohio.gov/dsw/fishadvisory/index.aspx.

47. Vaccines Today. (2018). What is herd immunity? Retrieved
from https://www.vaccinestoday.eu/stories/what-is-herd-
immunity/.

48. National Institute on Drug Abuse. (2016). Understanding
drug use and addiction. Retrieved from https://www.
drugabuse.gov/publications/drugfacts/understanding-
drug-use-addiction.

49. Kolodny, A., Courtwright, D., Hwang, C., Kreiner, P.,
Eadie, J., Clark, T., & Alexander, G. (2015). The prescrip-
tion opioid and heroin crisis: A public health approach to
an epidemic of addiction. Annual Review of Public Health,
36, 559-74.

50. Mihm, S. (2017, July 17). This isn’t the first opiate addiction
crisis. Bloomberg. Retrieved from https://www.bloomberg.
com/view/articles/2017-07-17/this-isn-t-the-first-u-s-opiate-
addiction-crisis.

51. National Institute on Drug Abuse. (2018). Drugs, brains, and
behavior: The science of addiction. Retrieved from https://
www.drugabuse.gov/publications/drugs-brains-behavior-
science-addiction/drugs-brain.

52. Politico Staff. (2016). The opioid crisis: Changing the culture
of prescribing. Retrieved from https://www.politico.com/
story/2016/03/opioid-crisis-prescriptions-working-group-
221350.

53. American Academy of Family Physicians. (2013). Acute pain
guidelines. Retrieved from http://www.aafp.org/afp/2013/
0601/p766.html.

54. Centers for Disease Control and Prevention. (2016). Chronic
pain management. Retrieved from https://www.cdc.gov/
mmwr/volumes/65/rr/rr6501e1.htm

55. Chou, R., Gordon, D.B., de Leon-Casaola, O.A., Rosenberg,
J.M., Bicker, S., Brennan, T., … Wu, C.L. (2016). Manage-
ment of postoperative pain: A clinical practice guideline
from the American Pain Society, the American Society of
Regional Anesthesia and Pain Medicine, and the American
Society of Anesthesiologists’ Committee on Regional
Anesthesia, Executive Committee, and Administrative
Council. The Journal of Pain, 17(2), 131–157. doi:
10.1016/j.jpain.2015.12.008

56. American Association of Colleges of Nursing. (2016).
Understanding the opioid epidemic: The Academic Nursing
Perspective. Retrieved from http://www.aacnnursing.org/
Portals/42/Policy/Newsletters/Inside%20Academic%20
Nursing/June-2016 .

57. American Academy of Nurse Practitioners. (2018). Education
tools: Opioids. Retrieved from https://www.aanp.org/education/
education-toolkits/opioids-and-other-controlled-substances.

58. Junquist, C., Vallerand, A., Sicoutris, C., Kwon, K., & Polomano, R.
(2017). Assessing and managing acute pain: A call to action.
American Journal of Nursing, 117(3), Supplement 1-4.

59. National Association of Community Health Centers. (2018,
August 12). Community Health Centers August 2018.
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2018/08/AmericasHealthCenters_FINAL .

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Community health centers in the Dakotas, 2018. South
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61. Patient-Centered Primary Care Collaborative. (2018).
Defining the medical home. Retrieved from https://www.
pcpcc.org/about/medical-home.

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pcmh-success.

63. American Nurses Association. (2013). Public health nursing:
Scope and standards of practice. Silver Springs, MD: Author.

C H A P T E R 1 5 n Health Planning for Primary Care Settings 397

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Chapter 16

Health Planning with Rural and Urban Communities
Paula V. Nersesian and Christine Savage

LEARNING OUTCOMES

After reading the chapter, the student will be able to:

KEY TERMS

1. Describe the unique characteristics of rural and urban
environments.

2. Identify specific health needs of rural communities and
of urban communities.

3. Discuss potential solutions to decrease disparities in
rural areas.

4. Define and implement the concepts of community
partnership, community linkage, and community
collaboration.

5. Describe the steps in community organizing and coalition
building; identify how these activities can be a tool for
positive community change.

6. Discuss the potential role of the nurse and the impact on
the health-care system in community-based participatory
research, parish nursing, healthy communities/healthy
cities, nurse-managed clinics, and community academic
partnerships.

Community empowerment
Community organizing
Community partnerships
Coalition building
Collaboration

Community-based
participatory research
(CBPR)

Federally qualified health
centers (FQHC)

Metropolitan statistical
area (MSA)

Patient-centered medical
homes

Rural

Telehealth
Urban
Urban agglomeration

Nursing In Partnership
with Communities
Community members and leaders want to create a
healthy and welcoming environment for their residents.
To accomplish this, they form partnerships with collab-
orators and stakeholders. Consider the example of
Chicago’s Walking School Bus Program.1 Through a
partnership among community members, the school sys-
tem, the City of Chicago, and the police department’s
Chicago Alternative Policing Strategy (CAPS), a strategy
was developed to protect children from drugs, guns,
strangers, and traffic on their way to and from school.
Children need a safe, secure environment at school and
in their community. Partnerships with key stakeholders
can make this happen. The walking school bus program
provides adult supervision for children as they walk to
and from school. Parents rotate the responsibility of
walking children to and from school through a carefully
managed volunteer system. By walking the same route

each day, parent volunteers pick up children at specified
locations, like school bus stops. By reducing the number
of children being dropped-off at school in a private ve-
hicle, traffic congestion around schools and the increased
risks that come with it, are reduced. Other positive out-
comes include physically active and healthier children
and adults, reduced noise and air pollution, increased
interaction among community members, more “eyes
on the street,” exposure to positive adult role models,
healthier relationships between adults and children, and
decreased incidence of bullying.2 The benefits of part-
nerships are greater than what an individual can create
alone.

Definition of Partnership
Community partnerships are collaborative working
relationships between local organizations, government
entities, and sometimes private companies to achieve
common goals. The groups may have a long-lasting rela-
tionship and guide their efforts with a formal agreement.

398

7711_Ch16_398-419 21/08/19 11:12 AM Page 398

Or they may be in a temporary alliance to achieve a time-
limited objective. A search of the term “community part-
nerships” reveals a large number of groups that seek
to attain objectives through partnerships. They may be
focused on a subpopulation, such as children with dis-
abilities, improvements in a school setting, or elimination
of a communicable disease. Community partnerships
are often needed for health-promoting community serv-
ices as those efforts are often fragmented. Communica-
tion among health services, the education system, job
placement services, and affordable housing organizations
can be challenging. This calls for effective collaboration
among these entities, so that they can work together and
reach outcomes that they cannot reach alone.

Collaboration is an essential component of successful
nursing interventions. Collaboration, as defined in The
Intervention Wheel from the Minnesota Department of
Health (Minnesota Wheel)3 (Chapter 2), is an activity that
“commits two or more persons or organizations to achieve
a common goal through enhancing the capacity of one or
more of the members to promote and protect health.”4

From a family perspective, a collaborative relationship
exists when clients and nurses view each other as partners,
with both providing expertise and knowledge that will
help the family reach its goals. Interpersonal and commu-
nication skills are essential for successful collaboration.
Partnerships are based on respect and equity, whether the
partnership is between a nurse and a family or among
multiple organizations. A successful partnership has syn-
ergy; it is larger than the sum of its parts. The participating
agencies and their clients realize benefits that could not be
achieved by a single organization. Successful partnerships
are built on clear roles and responsibilities, a shared vision
of desired outcomes, processes that are transparent, fre-
quent open communication among members, and strate-
gic use of resources.

The Center on Education and Training for Employ-
ment at The Ohio State University created a six-step
guide that facilitates development of community collab-
oration by creating linkages among agencies.5 By linking
them together, client needs are served better because the
emphasis is on community needs, not the needs of the
individual agency.

Step 1: Assess the need to work in partnership with
other agencies. The first step involves assessing
whether an interagency partnership is needed and
whether the local climate favors a partnership.
Sometimes it’s best to have a single agency solve
local problems. Sometimes problems are best
addressed or needs are best filled by the involvement
of multiple agencies. Questions to help identify

whether a partnership makes sense include: How
might relationships with other agencies improve
client outcomes? What challenges could be
addressed more effectively through interagency
linkages?

Step 2: State the key challenges; articulate why they
are better addressed by multiple agencies; and name
potential key players. Also, during this step, existing
linkages are identified.

Step 3: Identify the key players. Narrow the potential
key player agencies down to a priority list and name
the people who will represent each agency. Agency
representatives should either be decision makers or
have access to their agency’s decision makers to
maximize efficiency and effectiveness of the group.

Step 4: Establish effective collaboration among the
agencies. Cooperation is important, but not suffi-
cient. Funders want to see evidence of collaborative
efforts among the agencies. Coalitions that collabo-
rate have a better chance of using resources effec-
tively and producing better results.

Step 5: Create a harmonious planning environment
among agencies and then establish mutual goals,
objectives, and a plan that includes administrative
support from all the partners.

Step 6: Implement the plan.5

Importance of Partnerships
Partnerships among collaborative agencies can improve
client access to programs, referrals between agencies, co-
ordination of limited resources, working relationships,
and an understanding of the aims of each partner agency
and how to work together.5 Linkages between local health
departments and community members often focus on
a specific purpose or subpopulation. A collaboration be-
tween local health departments and communities can
range from low levels of collaboration to high levels. To
improve health-care coordination and utilization of re-
sources, partnerships between health department officials
and community leaders should be promoted so that com-
munity health priorities, objectives, and strategies can be
set jointly.6

Formulating joint priorities, objectives, and strate-
gies requires a robust partnership among the organi-
zations. To build strategic partnerships, a range of
skills is required. First, the lead organization must have
a keen understanding of the type of partnership they
desire. Then, they need to identify possible partners,
develop a relationship, and negotiate the partnership.
Finally, the partnership must be maintained in such a
way that all parties enjoy benefits.7

C H A P T E R 1 6 ■ Health Planning with Rural and Urban Communities 399

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400 U N I T I I I ■ Public Health Planning

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Polluting Incinerator
Public Health Science Topics Covered:

• Organized community effort
• Environmental science
• Public Health Nursing Skills
• Assessment
• Program planning
• Intervention: Advocacy

Federally qualified health centers (FQHC)
are a critical component of the health-care safety
net, and health centers that receive this designation
receive funding support under Section 330 of the
Public Health Service Act. There are more than
1,400 FQHC in the United States serving more than
26 million clients. The clinics are community-based
and provide comprehensive primary care and behav-
ioral and mental health services to patients regardless
of their ability to pay.8

A public health nurse (PHN) who worked at an
urban FQHC wanted to obtain additional resources
to augment the services provided to the lower-
income community members who attended the
clinic. The PHN discussed her ideas with the profes-
sional staff at the clinic—primarily family nurse practi-
tioners (FNPs) and primary care physicians. They
were very supportive, discussed potential challenges,
and encouraged the PHN to identify potential linkages
with other agencies. They identified multiple agencies
serving the community including a Head Start pro-
gram, social service agencies, schools, and local com-
munity organizers. The PHN explored opportunities
to link the efforts of the FQHC with these agencies
to provide more comprehensive services to the
clients at the FQHC.

The agencies all agreed that building a partnership
with the FQHC would be advantageous, and several
mentioned a newly formed group that included the
identified agencies, community representatives, busi-
ness owners, and religious leaders. The agency repre-
sentatives said the group was quite diverse and that
new members were welcome if they agreed to attend
the meetings and make a commitment to the process.
The PHN met with the social worker who started the
group, and thereafter the PHN began participating.

The PHN was involved with the group for more
than 4 years and learned a great deal about linkages
and partnerships. When all the participants were
sitting around a table, communication was clearer, and

decisions were made. It became abundantly clear that
forming partnerships took considerable time, trust had
to be earned, and larger organizations had less flexibil-
ity. Making the process work was time-consuming
and frequently frustrating, thus it required significant
commitment.

Soon after the PHN joined the group, a community
organizer and members of a small neighborhood in the
larger community discussed their concerns about a
municipal incinerator that deposited pollutants in their
neighborhood. The participants representing the neigh-
borhood affected by the incinerator expressed concern
that representatives of the larger community had not
challenged the placement of the incinerator. They felt
that they were not invited to participate because the
residents of their neighborhood were poor, had low
education levels, and had no influence on city officials.
The residents of the neighborhood said they tried to
discuss the dangers associated with the incinerator
with city representatives, but they felt ignored. Like-
wise, health department staff did not respond when in-
formation was presented to them. Everyone around
the larger community table agreed that the incinerator
was a public health menace. They also agreed that as a
group they might be able to have an impact. The diver-
sity of the partnership resulted in a wide range of ac-
tions. The community organizers considered how
public demonstrations could show the city leadership
how they felt. Other group members contacted faculty
at the local university to request assistance in measur-
ing air quality and identifying other health risks stem-
ming from the incinerator. Other members of the
group developed a social media campaign and explored
other communication channels to get their message
out. They were successful in accumulating many follow-
ers on social media, getting coverage in print newspa-
pers, radio interviews, and television coverage. An
issue that had been hidden was now quite public, and
city officials ultimately shut down the incinerator. The
outcome wasn’t achieved quickly, but it was achieved,
and the group was energized. They took on a specific
issue and made a difference in their community.

Some members of the group who thought the effort
was a waste of time recommitted to it after seeing that
linking agencies and communities can result in meaning-
ful change. By working together on a community issue,
people got to know each other, developed trust, and
communicated. Now they could see the possibility
of organizing around other issues. While the PHN
worked with the group, they convinced the police

7711_Ch16_398-419 21/08/19 11:12 AM Page 400

Rural Communities
People living in rural communities have strengths and
needs that differ from people living in an urban environ-
ment. Statistical data show increased health disparities
among residents of rural communities. These disparities
reflect the economic opportunities, educational systems,
social and cultural factors, and geographic isolation in

rural areas. Demographic differences between rural and
urban Americans are complex. For example, children liv-
ing in rural areas have lower rates of poverty than their
urban counterparts. However, more children are unin-
sured in rural areas compared to urban areas. Rural
Americans are older and less likely to have a bachelor’s
degree.9 The Health Resources and Services Administra-
tion (2018) Federal Office of Rural Health Policy points
to several striking observations about the health of people
who live in rural areas:

• About one-third of rural dwellers lose all of their
teeth by age 65 for lack of dental services and
fluoridation.

• Some 2,000 rural communities have only one
pharmacist, who often is the only local health-care
provider.

• Rural residents experience greater rates of chronic dis-
ease than any other segment of the U.S. population.

• Racial and ethnic minorities comprise 15% of the
total rural population and 30% of the rural poor
population.10

The National Rural Health Association represents
more than 21,000 individual and organizational mem-
bers in providing leadership on rural health issues. They
track statistics and trends about the health of people liv-
ing in rural areas to fulfill their mission of advocacy,
communication, education, and research about rural
health. The Association cites that, for individuals who
live in rural areas of the United States:

• The patient-to-primary care physician ratio in rural
areas is only 39.8 physicians per 100,000 people,
compared to 53.3 physicians per 100,000 in urban
areas.

• There are 22 generalist dentists per 100,000
residents in rural areas versus 30 per 100,000 in
rural areas.

• On average, per capita income in rural areas is $9,242
lower than the average per capita income in the
United States, and rural Americans are more likely
to live below the poverty level than Americans in
general.

• People who live in rural America rely more heavily
on the Supplemental Nutrition Assistance Program
(SNAP) …as 14.6% of rural households receive
SNAP benefits, while 10.9% of metropolitan house-
holds receive assistance.

• Rural youths over the age of 12 are more likely to
smoke cigarettes (26.6% versus 19% in large metro
areas). They are also far more likely to use smokeless

C H A P T E R 1 6 ■ Health Planning with Rural and Urban Communities 401

department to resume foot patrols in designated high-
crime areas that had large numbers of robberies, aggra-
vated assaults, and homicides. The police patrolled in
pairs starting at 10 a.m. and stopping at 2 a.m. They
engaged community members while on patrol and
stopped suspicious cars and individuals. After initiation
of the foot patrols, the crime rate dropped by 24% in
the patrolled area, and there was little displacement of
crime to nearby areas. All of the partners declared the
foot patrol initiative a success.

The partnership set up other linkages, such as one
with the high schools in their catchment area with the
goal to decrease violence. After the first meeting, they
determined that students needed tutoring. The group
mobilized volunteers to support an after-school tutor-
ing program at the school. It was clear that community
concerns about student performance needed to be met
before the school-based violence prevention program
could be implemented.

This community group, flush with agency linkages, is
intact and active. It became a respected model in the
community and is enmeshed in working toward a
healthier community that includes all the immediate
and distal causes of poor health. No one agency could
achieve this alone; it took partnerships, linkages, dedi-
cated work, and authentic community participation.

This case demonstrates that the process of building
a collaborative partnership is multidimensional and
requires a long-term vision for change. Trust among
collaborators is fostered over time. The appropriate
group structure is not always immediately apparent;
time and experience working together helps to clarify
participant roles and ways to organize the group.
Recognizing and mobilizing people to create change
requires commitment over time and a focus on out-
comes. Ensuring diversity by including people from a
wide variety of backgrounds will help the group form a
complete view of the community strengths and needs.
It is essential to have participants invested in the goals
and activities of the partnership.7

7711_Ch16_398-419 21/08/19 11:12 AM Page 401

tobacco, with usage rates of 6.7% in rural areas and
2.1% in metropolitan areas.

• Fifty-three percent of rural Americans lack access to
25 Mbps/3 Mbps of bandwidth, the benchmark for
Internet speed according to the Federal Communica-
tions Commission.

• In rural areas, there is an additional 22% risk of
injury-related death.

• Rural youth are twice as likely to commit suicide.11

Since 2004, stakeholders in rural areas have been in-
forming priorities through the Rural Healthy People ini-
tiative. Rural Healthy People 2010 (RHP 2010) was a
companion document to Healthy People 2010 (HP 2010)
that identified unique needs of the rural population in the
United States. The top concerns selected by respondents
in the first round of RHP 2010 was access to quality health
care.12 The document proved to be a valuable resource for
policy makers, rural health providers, and rural commu-
nities for planning and policy making, so new survey data
were collected between 2010 and 2012 following the re-
lease of Healthy People 2020. The rural health priorities
for the RHP 2020 changed from the earlier survey. The
top five concerns, with access to quality health care still
the number one priority, are shown in Table 16-1.13,14

Health-care providers have additional challenges
working in rural communities given their small num-
bers in relation to number of people served. In the
United States, as in most countries, there is unequal dis-
tribution of health-care providers. Most often health-
care providers stay in the metropolitan areas after they
complete their education or purposefully select to settle
in urban areas, attracted by well-resourced health-care
centers, cultural and recreational opportunities, better
housing, better work options for their family members,
and a perceived higher quality of life for the family. In

402 U N I T I I I ■ Public Health Planning

TABLE 16–1 ■ Top 10 Priorities from Rural Healthy
People 2020 National Survey by rank

Rank Priority

Source: (13) and (14)
Bolin, J.N., Bellamy, G.R., Ferdinand, A.O., Vuong, A.M., Kash, B.A., Schulze, A.,

& Helduser, J.W. (2015). Rural Healthy People 2020: New decade, same
challenges. Journal of Rural Health, 31(3), 326–333. https://doi.org/10.1111/
jrh.12116.

Bolin, J.N., Bellamy, G., Ferdinand, A.O., Kash, B.A., Helduser, J.W. (Eds.). (2015).
Rural Healthy People 2020. Vol. 1. College Station, Texas: Texas A&M Health
Science Center School of Public Health, Southwest Rural Health Research
Center.

Access to quality health services

Nutrition and weight status

Diabetes

Mental health and mental disorders

Substance abuse

Heart disease and stroke

Physical activity and health

Older adults

Maternal, infant, and child health

Tobacco use

■ RURAL HEALTHY PEOPLE
(RHP)
The Promotion of the Health of
Americans Living in Rural
Communities

Goal: To identify rural health priorities and strategies
Overview: The purpose of Rural Healthy People 2020
(RHP 2020) is to advance the promotion of the health
of Americans living in rural communities by identifying
rural health priorities, supporting rural health leaders
and researchers, and promoting effective rural health
programs. Through the coordinated RHP 2020
initiative, rural communities will benefit by increased
ability to identify and implement right-sized, effective
health programs for rural residents. Like RHP 2010 a
decade ago, RHP 2020 provides policy makers, rural
providers, and rural communities with a valuable
resource to inform planning while also documenting
successes and challenges. Specifically, RHP 2020
identifies and promotes rural-specific health priorities;
documents what is known about health in rural areas;
identifies rural evidence-based best practice programs,
community practices, and interventions; and promotes
rural healthy communities.13

Midcourse Review of Healthy People 2020: Health
disparities persist between urban and rural areas. The
Midcourse Review of Healthy People 2020 analyzed
data according to whether people lived in metropolitan
areas (i.e., urban areas) or nonmetropolitan areas (i.e.,
rural areas). Disparities by geographic location were
found for 339 of the 625 population-based trackable
objectives. Populations in urban areas had more
favorable rates than populations in rural areas for
65.8% of the 339 objectives that showed disparities.15

This demonstrates the need for public health nurses to
be vigilant in addressing the health needs of rural
populations.

7711_Ch16_398-419 21/08/19 11:12 AM Page 402

2014, the Health Resource and Service Administration
reported that there was a higher proportion of health
providers living in rural areas that were from occupa-
tions requiring less education and training (e.g., emer-
gency medical technicians) than those in occupations
requiring more education (e.g., physicians). For exam-
ple, in rural areas, there are 13.1 physicians per 10,000
population compared to 31.2 per 10,000 population in
urban areas.16

Definition of Rural
Rural is defined based on population size, population den-
sity, or by proximity to larger metropolitan areas. Federal
agencies, in defining a rural community, frequently first
define an urban area and then, by exclusion, the remaining

area is considered rural. The most commonly used defini-
tions of rural come from the U.S. Census Bureau and the
U.S. Department of Agriculture (USDA).

An urbanized area (UA) has a central city or core and
a surrounding area that contains at least 50,000 people.
According to the U.S. Census Bureau, areas that are not
urban are considered rural. They can be in areas desig-
nated as metropolitan or nonmetropolitan. The term
metropolitan is commonly used and is defined as an area
and the population in a metropolitan statistical area
(MSA). An MSA comprises an area that includes one or
more counties with an urbanized core of at least 50,000
(Fig. 16-1).17 People living in adjacent counties con-
nected to the urban area as commuters are included in
the MSA.18

C H A P T E R 1 6 ■ Health Planning with Rural and Urban Communities 403

Source: U.S. Census Bureau, 2010 Census Redistricting Data Summary File
For more information visit www.census.gov.

500 mi0

People per
Square Mile

Overall density 88.4

500.0 to 1,999.9
88.4 to 499.9

1.0 to 19.9
0.0 to 0.9

20.0 to 88.3

2,000.0 to 69,468.4

100 mi0

200 mi0

50 mi0

2010 Census Results – United States and Puerto Rico
Population Density by County or County Equivalent

NV
UT

IN
OH

MS
AL

WV
VA

MD DE

CT
RI

VT
NH

Figure 16-1 2010 Population Density by County or County Equivalent—United States and Puerto Rico. (Retrieved from
https://www2.census.gov/geo/maps/dc10_thematic/2010_Profile/2010_Profile_Map_United_States .)

7711_Ch16_398-419 21/08/19 11:12 AM Page 403

The USDA uses a code of 0 to 9 to differentiate urban
and rural. Metropolitan counties are distinguished by
size with a ranking of 0 to 3 and nonmetropolitan coun-
ties with 4 to 9. A code of 9 is equal to completely rural,
or a population of fewer than 2,500 and not adjacent to
a metropolitan area. In 2011, only 16% of the population
was considered rural (51 million living in rural areas and
258 million in urban areas), the lowest ever; in 2000, 20%
was rural, compared with 72% back in 1910.19,20 Rural
areas include open spaces and longer distances between
neighbors (Fig. 16-2).

Specific Health Needs of Rural Communities
A major barrier to obtaining health care in rural set-
tings is access. Residents of rural communities com-
monly travel long distances to access care, and tertiary
care facilities are often even farther away. It is not un-
common for rural health facilities to have funding
shortfalls and staffing challenges.21 Local governments
in rural areas often lack the resources and capability to
establish safety net programs. Primary prevention re-
sources such as gyms and hiker/biker trails are not
commonly available, or they are located an inconve-
niently long distance away.

Potential Solutions to Decrease Health
Disparities in Rural Areas
Addressing scope-of-practice barriers may increase the
number of nurse practitioners in the rural areas and par-
tially address the disparities faced by people living in
rural areas. A recent study found that states with full
scope-of-practice regulations had a higher supply of nurse

practitioners in rural areas than states with more restric-
tive scope-of-practice.22 The Affordable Care Act (ACA)
(2010) provides incentives for educating and training
health-care providers, including nurses and primary care
nurse practitioners, to work in rural areas.23 However, a
survey of rural health clinics 4 years after passage of the
ACA demonstrated challenges recruiting physicians,
physician assistants, and nurse practitioners. The respon-
dents anticipated an increase in their patient population
accompanied by a feeling of being ill-prepared to work
in an environment of value-based care.24 This suggests
that, despite the original intentions of the ACA, attempts
to increase the number of health-care providers in rural
areas may not have been successful.

Another strategy employed to meet the challenge of
providing care in rural areas, especially for people with
chronic illness, is the use of the patient-centered med-
ical home (PCMH) model. The PCMH is an approach
to primary care that aims to make care accessible, con-
tinuous, coordinated, family-centered, comprehensive,
compassionate, and culturally competent. The main
components of the model, as defined in the Bolin article,25

include:

• Patient- and family-centered full scope of care
• Access in time and location
• Coordinated, team-based (integrated) care
• Medication coordination and management
• Community linkages with transition
• Electronic records and other information systems

support

Bolin and colleagues suggest that using this model in
rural communities would help address issues such as
access, efficiency, quality, and sustainability. At the same
time, it would increase linkages, improve integration
of services, and achieve interdisciplinary practice. The
ACA of 2010 was designed to contribute resources to
facilitating the PCMH model in rural settings.23,25 This is
an innovative example of partnerships and linkages that
can decrease rural health disparities. There is emerging
evidence that it is successful in rural settings. In one
rural Mississippi example, researchers found patients
with chronic illness enrolled in a PCMH attend follow-
up appointments more consistently than patients not
enrolled in a PCMH. 26 PCMHs in rural areas face bar-
riers to implementation linked to administration of
electronic medical records and reimbursement, for ex-
ample. Centralized health care systems, such as the Vet-
erans Health Administration, do not face these obstacles
and have a greater PCMH implementation in rural than
urban areas.27

404 U N I T I I I ■ Public Health Planning

Figure 16-2 Rural landscape: Maine, U.S. (Photo by Paula
V. Nersesian, 2018.)

7711_Ch16_398-419 21/08/19 11:12 AM Page 404

Telehealth, first developed in the 1970s, has also been
shown to be useful in increasing access to health services,
decreasing some of the costs of health care, and increas-
ing the efficiency of providing the care. Telehealth is a
broad term that includes using a telecommunication de-
vice to transfer information that enables a health-care
professional to provide health-related services when
there is a distance between client and health-care provider.
Telehealth has been shown to decrease frequency of hos-
pital visits and emergency department-initiated hospital
admissions and to improve management of chronic ill-
nesses. Nurses use telehealth services while providing
home care, conducting health clinics, and delivering care
in schools and prisons. Telehealth can also be used in
hospitals to augment existing clinical services by obtain-
ing expert opinion, for example.

Telehealth nursing is defined and explained in a fact
sheet created by the members of the Telehealth Nursing
Special Interest Group of the American Telemedicine
Association.28 The association describes how nurses use
telehealth technology in a variety of practice settings. For
example, nurses working in rural areas can tele-present a
patient to a health-care provider at a higher-level facility
when further assessment or treatment is needed. This can
be done for conditions that are nonemergent and emer-
gent. Home health nurses use monitoring systems that
transmit physiological data (e.g., blood pressure, pulse,
respiratory peak flow) and images through telephone
lines or the Internet. Telehealth also includes routine
communications such as when patients call their nurse
to review how to give insulin or change a dressing.
Nurses also play key roles in conceptualizing, designing,
developing, and implementing telehealth innovations
that benefit communities and their members. Nurse sci-
entists are exploring communication technologies and
their influence on health care and quality.

Urban Communities
Migration of people from rural to urban areas occurs
worldwide. Sub-Saharan Africa and Asia have the highest
rates of urbanization, which is the proportion of a na-
tional population living in urban areas, and urban popu-
lation growth rates, which are the number of people living
in urban areas. Rural-to-urban migration contributes to
urbanization, but it has a limited contribution to urban
growth, which is primarily attributable to natural popu-
lation growth.29 In 2014, the United Nations Department
of Economic and Social Affairs estimated urbanization at
54% worldwide.30 Migration occurs between countries,
especially regionally, and within countries, sometimes to

an extreme extent, such as in China where hundreds of
millions of people living in rural areas have moved to
urban areas for more favorable work opportunities. Peo-
ple also move to seek security and asylum, and others
move to seek a better life for themselves and their families.
A better life does not always result for people who end up
living in urban areas, particularly those who reside in
slums.31

C H A P T E R 1 6 ■ Health Planning with Rural and Urban Communities 405

■ CELLULAR TO GLOBAL
Much of who we are is embedded in our DNA, but our
families, social settings, and physical environment also
influence us. When faced with difficult experiences,
changes can occur in our epigenome through epigenetic
modification32, our physiology, our relationships, and our
communities. Difficult experiences, such as food scarcity,
neglect, and war can have lasting effects on a person’s
epigenome and their community. Here, we examine the
civil war in Syria, which began in 2011, and how it has af-
fected communities. We do not know if the people who
have been forced to move have epigenetic modifications,
but their experience of community has most certainly
changed. Millions of Syrians have been affected by the
war. The United Nations estimates that at least 400,000
Syrians have died as a result of the war, and the number
is likely much higher.33 Six million people have been inter-
nally displaced, five million people have fled to neighbor-
ing countries in the Middle East and North Africa, about
one million people are in Europe as refugees or asylees,
and about 100,000 have sought refuge in North
America.34 Syria has a complex ancient and modern his-
tory, periodic droughts, limited arable land, and high pop-
ulation density. Their economic growth was around 2%,
and income was about U.S. $5,000 gross domestic prod-
uct per capita just before the war. This allowed Syrian
families to enjoy relatively comfortable middle-class lives
in urban and rural areas. They are well-educated and en-
joyed high literacy levels.35 The war changed all that for
the millions of families that were forced to move. Now,
Syrians are seeking to find safety, stability, and a means of
survival. The extreme experiences faced by millions of
Syrians will have lasting repercussions for individuals, fam-
ilies, and communities. Changes at the community level
will be felt in the places that they left and the places
where they ultimately reside. The biological aftermath of
this tragedy may persist for a lifetime and possibly
through generations via epigenetic modification.36 For
those who move to countries with cultures very different
from their own, the impact on their lives will be pervasive.
They will have to acculturate, build new social supports,

7711_Ch16_398-419 21/08/19 11:12 AM Page 405

The largest metropolitan areas are called urban ag-
glomerations. They form when cities integrate. These
urban clusters, which include all the built continuous
UA within a specified location, may include several mu-
nicipalities. This poses a challenge to elected officials
and administrators tasked with addressing needs across
jurisdictions, such as transportation. As agglomerations
expand, they can cross international borders 37 such as

the San Diego–Tijuana agglomeration spanning the
United States and Mexico, and the one in Lille–Kortrijk
spanning France and Belgium. Table 16-2 lists the 10
largest agglomerations in 1975 and 2000, and projecting
to 2035. It is interesting to note the changes in location
of the largest agglomerations and the significant increase
in population for each of them.38

Definition of Urban
The U.S. Census Bureau defines urban according to the
density of a population (Box 16-1).39 A metropolitan sta-
tistical area, colloquially called a metro area, is a term
used by the U.S. Office of Management and Budget to de-
scribe an UA and adjacent counties or county equivalents
that link the population to the urbanized core through
commuting ties. MSAs or metro areas have at least one
urban core area of at least 50,000 residents. A central UA

406 U N I T I I I ■ Public Health Planning

integrate into schools, find new places of worship, learn
new skills, obtain employment, and mourn great loss.
And the existing members of their new communities—in
rural and urban settings within the Middle East, Europe,
and North America —will also face challenges as they
welcome their new community members and seek to
find a way for everyone to live in harmony.

TABLE 16–2 ■ Top 10 Largest Urban Agglomerations 1975, 2000, and Projected for 2035

Projected
Millions of Millions of Millions of

Cities 1975 Inhabitants Cities 2000 Inhabitants Cities 2035 Inhabitants

1. Tokyo, Japan

2. Kinki M.M.A.
(Osaka), Japan

3. Ciudad de México
(Mexico City),
Mexico

4. New York-Newark,
USA

5. São Paulo, Brazil

6. Mumbai (Bombay),
India

7. Delhi, India

8. Kolkata (Calcutta),
India

9. Al-Qahirah (Cairo),
Egypt

10. Buenos Aires,
Argentina

1. Tokyo, Japan

2. Delhi, India

3. Shanghai, China

4. Ciudad de
México (Mexico
City), Mexico

5. São Paulo, Brazil

6. Mumbai
(Bombay), India

7. Kinki M.M.A.
(Osaka), Japan

8. Al-Qahirah
(Cairo), Egypt

9. New York-
Newark, USA

10. Beijing, China

1. Delhi, India

2. Tokyo, Japan

3. Shanghai, China

4. Dhaka, Bangladesh

5. Al-Qahirah (Cairo),
Egypt

6. Mumbai (Bombay),
India

7. Kinshasa, Democratic
Republic of the
Congo

8. Ciudad de México
(Mexico City),
Mexico

9. Beijing, China

10. São Paulo, Brazil

Source: (38)
United Nations Population Division Department of Economic and Social Affairs. (2018). World urbanization prospects. Retrieved from

https://esa.un.org/unpd/wup/

7711_Ch16_398-419 21/08/19 11:12 AM Page 406

C H A P T E R 1 6 ■ Health Planning with Rural and Urban Communities 407

is a contiguous area of relatively high population density.
The counties containing the urbanized core are called
central counties of the MSA. When the surrounding
counties, called outlying counties, are strongly connected
socially and economically to the central counties, they are
included in the MSA.40 Some outlying counties are actu-
ally rural in nature and are often called bedroom commu-
nities because people live in those areas and commute to
the urban area. According to the 2010 Census, 84% of the
U.S. population lived in metro areas. The five most pop-
ulous metro areas were New York, Los Angeles, Chicago,
Dallas-Fort Worth, and Philadelphia. The three least pop-
ulous metro areas were all located in the Mountain Divi-
sion of the U.S.: Carson City, NV; Lewiston, ID-WA; and
Casper, WY.41 And within metro areas, most people re-
side in cities—also called incorporated places.40

Health problems are present in both rural and urban
areas. Although there are more documented health issues
with higher morbidity and mortality in rural areas of the
United States, the specific health problems of city-dwellers
reflect the conditions of our cities. Medical historian David
Rosner wrote, “One lesson from history is that we create
our own environment and hence we create the conditions
within which we live and die.”42 Health problems can arise
and perpetuate from migration, crowded living conditions,
poverty, homelessness, racism, and other social determi-
nants of health. Creating a healthful environment can im-
prove people’s health in both rural and urban settings.

U.S. Census Bureau Definitions
Urban: Areas of densely developed territory,
specifically all territory, population, and housing
units in urbanized areas and urban clusters. “Urban”
classification cuts across other hierarchies except
for census block and can be in metropolitan or
non-metropolitan areas.
Urban area (UA): Collective term referring to urbanized
areas and urban clusters.
Urban Cluster (UC): A densely developed territory that
contains a minimum residential population 2,500 people
but fewer than 50,000.
Urban Growth Area: Legally defined entity defined
around incorporated places and used to regulate
urban growth. They are delineated cooperatively by
state and local officials and then confirmed by state
law. UGAs are a pilot project, first defined for Census
2000 in Oregon, and added in Washington for the
2010 Census.

Urbanizacion: An area, sector, or residential development,
such as a neighborhood, within a geographic area in
Puerto Rico.
Urbanized Area: An area consisting of a densely devel-
oped territory that contains a minimum residential popula-
tion of at least 50,000 people.
Rural: Territory, population, and housing units not classified
as urban. “Rural” classification cuts across other hierarchies
and can be in metropolitan or non-metropolitan areas.
Metropolitan: Refers to the area and population located in
metropolitan statistical areas.
Metropolitan statistical area (MSA): A geographic entity
delineated by the Office of Management and Budget for
use by federal statistical agencies. Metropolitan statistical
areas consist of the county or counties (or equivalent enti-
ties) associated with at least one urbanized area of at least
50,000 population, plus adjacent counties having a high de-
gree of social and economic integration with the core as
measured through commuting ties.

BOX 16–1 ■ Definitions of Urban and Rural

Source: (39)
U.S. Department of Commerce. (2018). Glossary: United States Census Bureau. Retrieved June 8, 2018, from https://www.census.gov/glossary/

■ CULTURAL CONTEXT
UNESCO Global Report on Culture for Sustainable Urban
Development 43

The United Nations Educational, Scientific, and
Cultural Organization (UNESCO) draws on the 2030
Agenda for Sustainable Development and its associ-
ated goals—the Sustainable Development Goals or
SDGs—to identify entry points to address culture.
They include SDG 2 (Zero Hunger), SDG 3 (Good
Health and Well-being), SDG 4 (Gender Equality),
and many others. Three policy areas categorize ap-
proaches to addressing culture in urban areas: peo-
ple, environment, and policies. These drive the
specific recommendation described in the Global Re-
port. Health and well-being are subsumed in most if
not all the recommendations, and standouts include
enhancing the livability of cites, ensuring social inclu-
sion, promoting a livable built and natural environ-
ment, improving resilience, regenerating linkages
with rural areas, and promotion of a participatory
process. These recommendations directly and indi-
rectly affect health by improving access to green
space for physical activity, to clean water, and to
health services. They also foster opportunities for
employment and social connections by promoting
local culture and integrating people from diverse
cultures.

7711_Ch16_398-419 21/08/19 11:12 AM Page 407

Characteristics of the Urban Population
With our concern about how the public’s health is related
to urbanization, it is important to consider not only the
number of people in an urban environment, but also the
size, density, and economic status of the cities in which
individuals live (Fig. 16-3). From a public health perspec-
tive, we look at the influence of upstream and down-
stream factors on urban living conditions and health
disparities that result from environmental exposures. Too
often, the interactions between culture, social factors, and
the physical environment are not examined together to
deconstruct the health disparities in urban settings.44

Urban environments also have marked disparities in so-
cioeconomic status (see Chapter 7), crime rates, violence
(see Chapter 12), and psychosocial distress.45 Mental health
stressors and exposure to violence and trauma can cause
or exacerbate mental health disorders (see Chapter 10). In
densely populated areas, exercise resources may be lim-
ited, and air quality may be poor, which puts people with
chronic respiratory disease at risk (Chapter 6). The
American Lung Association’s State of the Air 2018 re-
ports that 133.9 million people in the U.S. are exposed to
unhealthy levels of ozone and particulate pollution,
which increase the risk of lung cancer and decrease the
life span.46 A key feature of the ACA was to improve
health insurance coverage for Americans, and it has
largely achieved that outcome.47 One study found that
previously uninsured low-income adults who were eligi-
ble for subsidies under the ACA health insurance mar-
ketplaces had a significant decline in insurance rates.48

Medicaid expansion also played a key role in increasing
coverage. In states where Medicaid was expanded, the

uninsured rate declined 56.7% between 2013 and 2017;
in states where Medicaid expansion was not adopted, the
uninsured rate dropped 25% in the same period.47 In ad-
dition, the 2018 dissolution of the individual health in-
surance mandate may result in some self-employed
people and families with low income dropping their cov-
erage or switching to catastrophic plans that don’t in-
clude the preventive services outlined in the ACA.
Undocumented immigrants remain a hard-to-insure
group because they are not included in any of the safety
net programs and therefore they must either pay directly
for services or obtain individual health insurance cov-
erage, and both tend to be expensive.

Despite the barriers to insurance coverage, people liv-
ing in urban areas have access to emergency department
services, whether they are insured or not, given the sub-
stantial number of hospitals located in cities and their
mandate to not turn people away. Urban areas also have
more safety net services. These include FQHCs, health de-
partment clinics, community health centers, and specialty
clinics. Living in cities also offers opportunities for social
well-being and improved health of its residents. Urban
areas also usually include more economic and educational
options, access to diverse social networks, and more and
better-quality health and social resources closer to the
population. To reach diverse populations, decision mak-
ers and community partnerships should consider the cul-
tures, values, and languages represented by members of
the community. Listening to and understanding the needs
of diverse populations in urban areas may improve efforts
to provide critical resources because communities are in-
fluenced by the cultures they represent and the history of
the residents.

Role of the Public Health Nurse
Community assessment, diagnosis, program planning,
interventions, and evaluation are essential public health
nursing skills for both rural and urban environments (see
Chapters 4 and 5). The PHN either in an urban or in a
rural setting seeks to build collective efficacy among com-
munity members. A community with strong neighbor-
hood cohesion usually has residents willing to contribute
to the common good, which can promote health. A co-
hesive group can access resources not available to indi-
viduals and can respond to threats from inside and
outside the community. The community can form part-
nerships and linkages with local government, organiza-
tions, and other communities, increasing the possibility
for positive change. This exemplifies social capital of a so-
cial group, which might be people in a workplace, within
a voluntary organization, or in a residential community.

408 U N I T I I I ■ Public Health Planning

Figure 16-3 Urban cityscape: Tokyo, Japan. (Photo by
Paula V. Nersesian, 2012.)

7711_Ch16_398-419 21/08/19 11:12 AM Page 408

Within the social group, resources might include an ability
to exchange favors, maintain group norms, and trust among
members. These are attributes that can be enjoyed by
individual group members or by the entire group. Research
on social capital has demonstrated improved health out-
comes in communities with higher levels of social capital.49

Community upheaval can occur in poor urban areas
where the perception is that injustices have run unchecked
or an injustice has occurred. An example of this upheaval
is the riots in Baltimore following the death of Freddie
Grey. This is an example of community violence (see
Chapter 12). As is the case with community violence, busi-
nesses are often affected, disrupting the microeconomy,
and buildings are often damaged beyond repair, requiring
demolition. In some settings, communities remain dam-
aged for decades before urban renewal occurs.

Sometimes gentrification occurs in these distressed
neighborhoods often displacing residents with few re-
sources to relocate. If not conducted in partnership with
the local community, gentrification can force residents
out of their lifelong neighborhoods as taxes rise with in-
creasing property values. When people lose their homes
and social network, they can experience significant stress
and grief. Demolition of buildings can also expose com-
munity members to environmental threats such as lead,
asbestos, and airborne particulates. Abandoned buildings
that remain standing foster proliferation of rodents.
When communities are disorganized, environmental
and social problems flourish. The social milieu changes
and resources become more difficult to obtain, which
creates challenges in the conduct of daily life. Informal
ties within a community are important to its functioning.

These factors are important to consider given the health
inequities linked to whether you reside in a distressed or
prosperous community. Several online interfaces allow ex-
ploration of these factors. The County Health Rankings
and Roadmaps derives from a well-established framework
developed by the University of Wisconsin Population
Health Institute; it links physical environment, social and
economic factors, clinical care, and health behaviors to
health outcomes. The County Health Rankings and
Roadmaps online interface contains comprehensive sta-
tistics for each county in the U.S.50 Information about
policies and programs, and the level of evidence to support
them is also included.51 The City Health Dashboard fo-
cuses exclusively on cities and includes 36 measures of so-
cial and economic factors, physical environment, health
behavior, health outcomes, and clinical care. The project
team has data for the 500 largest cities in the United States,
which is designed for policy makers and community lead-
ers.52 The Distressed Communities Index measures seven

metrics to describe communities in relation to education,
income, employment, housing, and businesses. According
to these metrics, in 2016 the number of Americans
living in prosperous zip codes rose from 10.2 million in
2007 to 86.5 million. During that same time period
the number of Americans living in distressed zip codes
decreased by 3.4 million to a total of 50 million.53

Community Organizing and Public
Health Nursing
Effective partnerships and community linkages may be
the difference between sustained success in addressing
public health needs—whether in urban or rural settings—
and brief programs that fail to produce long-lasting
favorable outcomes.

Community Organizing
Community organizing is a public health nursing activity
in both rural and urban communities. It is a useful tool for
creating positive change domestically and internationally.

Definition of Community Organizing
Using the knowledge and the definition of community
organizing by experts in the field, the Minnesota Wheel3
(Chapter 2) defines this activity as helping “community
groups to identify common problems or goals, mobilize
resources, and develop and implement strategies for
reaching the goals they collectively have set.”3

Minkler and colleagues pointed out the importance of
including the concept of community empowerment as a
logical component of community organizing. Without
empowering the community, the organizing has not
been successful.54 The World Bank defines empower-
ment of communities as the social action “process of in-
creasing the capacity of individuals or groups to make
choices and to transform those choices into desired ac-
tions and outcomes.”55 A focus area of the World Bank’s
social development efforts is community-driven devel-
opment (CDD). Essential elements of CDD include
transparency, participation, local empowerment, demand-
responsiveness, greater downward accountability, and
enhanced local capacity.56 It expands the concept of com-
munity empowerment and its elements of access to infor-
mation by the community, inclusion and participation of
community members in decision-making forums, power
to hold the decision makers accountable, having the ca-
pacity and resources to organize, take on roles as partners
with government and private agencies, and make deci-
sions about things that affect their interests.56

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Nurses and health-care providers utilize empower-
ment and community-driven development to help im-
prove the health of communities. The actions taken
include partnering with local groups such as religious
congregations, local community centers, neighborhood
associations, educational institutions, and civil rights and
social justice organizations to help improve the health of
communities. Amendola’s (2011)57 metasynthesis of em-
powerment of Hispanic and Latinx populations revealed
that shared power with health providers and agencies
and a sense of empowerment was possible to attain. At-
taining these results required health-care professionals
to incorporate strategies for empowerment into their
practice. Davis’ (2016)58 work with people experiencing
homelessness who have diabetes found that people who
served as a peer educator for 4 weeks were empowered,
and people who participated in the education sessions
were found to be more knowledgeable about diabetes
and how to manage it. Importantly, the sense of empow-
erment felt by peer educators decreased over time, albeit
not significantly. Benoit’s (2017)59 work in Canada with
sex workers had similar findings where empowerment
and knowledge gains were reported after serving as a
peer educator.

Usefulness as a Tool for Change
Community organizing is an important facet of public
health nursing. When providing health education or in-
troducing a new program or intervention, addressing
community priorities and addressing their perceived
needs is respectful and has a higher likelihood of success.
In fact, the process of organizing a community and so-
liciting participation of community members in social
action can contribute to improved health outcomes.60

Successful examples of community organizing go
back to the 1900s in the U.S. when women successfully
organized and obtained the right to vote, and when
labor organizers established a 40-hour workweek.
More recently, in the 1960s and 1970s, organizing took
on the fight for civil rights and protested against the
war in Vietnam. Current organizing campaigns have
focused on LGBTQ+ rights, protection of natural re-
sources, abortion rights, and efforts targeting racial
discrimination such as the Black Lives Matter move-
ment. Social media has transformed modern commu-
nity organizing.

An inspiring example of community organization driv-
ing change occurred in Kwara State, Nigeria, where the
local Community Social Development Agency advocated
for and succeeded in bringing electricity to this rural
area. Now, the residents can not only charge their phones

easily, but they can also store food safely and study after
the sun sets.61 In the U.S., a community group in Maine
uses resources from a tool box called Resources for
Organizing and Social Change. The resources adhere
to seven principles for creating social change through
community organizing:

1. Use nonviolence in creating change.
2. Identify the root causes of the problems, look

upstream, and create solutions that will improve
the situation for everyone.

3. Provide communities an opportunity to work with
each other and the support they need to solve their
problems.

4. Address equity and basic needs of community
members.

5. Facilitate the ability of people to gain power
over their lives and the access they need to be
involved in the decision-making processes that
affect them.

6. Promote social equality by enabling participation
and leadership roles for those who experience
discrimination.

7. Build momentum in the movement for social
change.62

Other suggestions on how to organize a community
include doing something interesting or unique to attract
the attention of community members so they engage in
the process. Be sure your colleagues understand the is-
sues and can communicate them to community mem-
bers, so they can effectively engage them. Recruit people
face-to-face, follow-up, and encourage diverse leader-
ship. Identify existing assets and make fundraising a reg-
ular part of the program. Involve as many people in the
group as possible, seek multiple assets and sources of in-
come, and keep good records.7 With the necessary re-
sources, communities have the capability to make their
own decisions. The people who assist, organize, and pro-
vide resources should not lead the organization and dic-
tate policy decisions and action. Rather, they should
amplify the voices of the community members.

Although community organizing is often a tool for
change regarding a contentious topic, such as the removal
of an incinerator or the use of a street patrol to decrease
crime, it can also be used to mobilize the community to
initiate public health programs, such as adolescent preg-
nancy prevention and reducing smoking.7,63 In a college
town, community organizing was used to form coalitions
between the university and the surrounding community
with the goal of decreasing high-risk drinking behavior
by college students. Equity in the partnership was given

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special attention because universities typically appear to
be more powerful than the communities in which they
exist; they tend to drive partnerships. Because of this, a
study was conducted that examined community organ-
izing and the interventions. Schools that used commu-
nity organizing were compared with control schools that
did not. At the end of 3 years, in the schools that used
community organizing, there was a decrease in severe
consequences resulting from student drinking and alco-
hol-related injuries experienced by others. The commu-
nity organizing approach resulted in new programs,
changed institutional policies, and increased law enforce-
ment efforts to prevent underage drinking on campus
and in the community.64

Process of Community Organizing
There are several steps in the process of community or-
ganizing. PHNs can immerse themselves in the commu-
nity, participate in activities, talk with residents, make
home visits, and meet with formal and informal leaders.
Development of mutual respect, trust, and familiarity
takes time. Through community assessment, the nurse
will develop an understanding of the structure of the
community, issues of concern, and strengths. But it is
more than community assessment because the nurse is
seeking to assimilate into the community. It is only after
doing so that the nurse can start to understand the
strengths and problems the community has identified
and begin to understand what role they might play in
helping the community to organize, become empowered,
and create social change.

Once an understanding begins to develop, the nurse
must integrate local leaders into a core group that can
identify and organize the community around public
health needs. Then, the group can motivate others to re-
spond to the same issues, encouraging collective action.
After the problems have been identified and an interested
group with essential leadership skills forms, the group is
ready to act and mobilize the community. Clear goals
must be formed before mobilization. They must also
know what resources are available and identify who will
hinder and who will support the action. Group reflection
after action is taken will help the group evaluate out-
comes and determine next steps. A more permanent or-
ganization may be formed with shared leadership under
a simple structure. Then, the PHN can step back and let
the community own the organization independently.3

Coalition Building
Coalition building is another tool that PHNs can use to
enhance community capacity.

Definition of Coalition Building
According to the Minnesota Wheel (Chapter 2), coali-
tion building “promotes and develops alliances among
organizations or constituencies for a common purpose.
It builds linkages, solves problems, and/or enhances local
leadership to address health concerns.”3 Since 1991, The
Prevention Institute’s eight-step guide to developing
effective coalitions has been a key resource on the topic.
The groups that form a coalition must be clear about
their objectives and the coalition’s needs. The right peo-
ple must be recruited. Objectives and activities must be
detailed and address diversity among the membership.
The coalition must be convened after careful preparation
that includes drafting a mission statement and structure,
which will be finalized at a later date. Assets must be
mapped, and a budget developed. And the vitality of the
coalition must be maintained and evaluated.65

C H A P T E R 1 6 ■ Health Planning with Rural and Urban Communities 411

w SOLVING THE MYSTERY
The Case of the Mysterious Rise
in Sexually Transmitted Infections
Public Health Science Topics Covered
• Epidemiology

• Surveillance
• Comparison of rates

• Health planning
• Community organizing
• coalition building

• PHN Skills
• Assessment
• Health planning
• Community diagnosis
• Organization and management
• Community partnerships

Health-care providers from two FQHCs, three
private clinics, and one university-sponsored clinic in
an underserved urban community formed a partnership
with the goal to better serve the community’s health
needs. They met monthly to discuss innovative strate-
gies and share information about innovative programs,
especially in the area of primary prevention. The
agenda for the current meeting was how to best serve
the clients who fall through the cracks of the ACA and
are left without health insurance coverage. Each clinic
was approaching the problem from a different perspec-
tive and all parties agreed that a unified plan made
more sense. While discussing options, a nurse from
the university clinic mentioned the marked increase in

7711_Ch16_398-419 21/08/19 11:12 AM Page 411

Community-Based Participatory Research
Community-based participatory research (CBPR) in-
volves community members in research projects that in-
clude and affect them. Partnerships and coalition building
are tools employed in CBPR. These tools enable shared
power, respect, and equity between the researchers and
the community. Public health nurses that are already ac-
tive in communities serve as excellent resources for
CBPR. They can introduce community members to re-
searchers, participate in developing research protocols,
and help interpret the collected data. Actively engaging
the community equitably in all aspects of the research
process, ideally starting with a topic of importance to the
community, promotes shared knowledge, expertise, and
responsibility. Active engagement improves the validity
of research outcomes and facilitates translation of the

412 U N I T I I I ■ Public Health Planning

clients without health insurance who tested positive for
at least one sexually transmitted infection (STI). An
FNP from the FQHC said she was also seeing more
STIs in the family planning clinic. By the end of the
meeting, the group had devised a plan to better serve
the uninsured and establish STI surveillance for each
clinic. The surveillance data would allow them to
gather data on current levels of STIs and compare it
with STI rates from 1 year ago.

At the next meeting, representatives of all six clinics
reported a 6%-15% increase in STIs, especially gonor-
rhea and chlamydia. The increase was almost exclu-
sively among young adults ages 18-28 years. The PHN
at the clinic suggested that they contact other agencies
in the community to see whether they would be inter-
ested in forming a linkage to help address the problem.
Health-care providers from other agencies agreed. All
of the providers agreed that they would begin asking
their patients what they thought contributed to the in-
crease in STIs. One of the members of the partnership
suggested they involve the health department and
other official agencies.

The following week, while speaking with a local po-
lice officer, the PHN was told that there had been a
raid on a gambling operation in the community, and
several residents had been arrested. As part of the ar-
rest processing, the young men received several health
screenings. The police officer told the PHN that they
were shocked at the number who tested positive for
STIs as they had never seen such numbers.

The PHN worked with a group of community or-
ganizers who were helping empower the community to
achieve better health outcomes. When she met with
them later in the week, she mentioned the increase in
the number of young men and women with STIs in the
community. They said they would put this on the
agenda for their next meeting. This group had been
meeting over the past 2 years, had developed a shared
vision and mission, and had achieved a number of suc-
cesses. The PHN, providers from the university clinic, and
representatives of two of the FQHCs attended the
next community meeting. The problem of the increased
STIs was presented. The health-care providers reported
that their patients were surprised that there was an in-
crease in numbers but said they were glad that they
could be seen without insurance because the free health
department STI clinic closed 9 months ago. Some com-
munity leaders said the health department downsized
and closed the clinic even though community members
had wanted it to remain open. They stated that the

closest free STI clinic was now more than 10 miles
away in a different ethnic and racial community, and
required two bus transfers to reach it. The group
decided to focus on solving this problem.

Using their organizational linkages and collaborative
relationships, the community members collected and
analyzed the STI data, figured out the cost-benefit of
reopening the health department clinic, and talked to
key informants in the community including people who
previously used the clinic. The informants said it had
been a well-attended walk-in clinic. Prior users of the
clinic said it was difficult to pay for treatment now
because they wanted to avoid going to the other com-
munity for care. And because the alternatives for care
required an appointment, they no longer had the
convenience of being able to walk in when they sensed
symptoms. Without involvement of the local health
department clinic, there was no active case-finding of
sexual contacts, and the patients found to have an
STI were reluctant to notify their sexual contacts.
Without reopening the health department walk-in
clinic, it looked like the surge in STIs had no end
in sight. Two community residents were chosen to
represent the community at the next health department
meeting. The health department officials listened
respectfully to the community presentation and were
both receptive and surprised by all the information
the group had collected. Within 8 weeks, the health
department formally agreed that it was appropriate to
reopen the clinic and concurred that a member of the
community organization could be on the board of direc-
tors of the new STI clinic to enhance communication,
service, and evaluation.

7711_Ch16_398-419 21/08/19 11:12 AM Page 412

findings into practice.66 Effectively engaging the commu-
nity can also promote community development and ad-
dress health disparities as was demonstrated in studies
that decreased environmental hazards through policy-
making initiatives.67

The Secretary’s Advisory Committee on National
Health Promotion and Disease Prevention provides rec-
ommendations to the Secretary of Health and Human
Services about Healthy People 2030 (HP2030). The Com-
mittee considered community capacity and other issues,
such as behavior and health outcomes, interventions, and
socioenvironmental conditions as they developed the list
of objectives for HP2030. Community capacity is a com-
munity’s ability to plan, implement, and evaluate health
strategies.68 Because communities are in the best position
to identify their needs and create change to address public
health problems using their collective knowledge, skills,
and resources, community capacity is inherent in CBPR.
In one study, collaboration between members of a low-
income community and researchers on the presence of
chemicals that trigger asthma in their community in-
creased community members’ understanding and facili-
tated action among the community to improve health.69

Public health nurses practicing in the community can
introduce researchers to the community. A challenge fac-
ing nurses who engage in CBPR is addressing ethical is-
sues that arise. Typically, ethical considerations in the
conduct of human-subject research focus on protecting
the individual, but also CBPR requires addressing ethical
issues related to protecting the community.69 These
issues include ensuring that the community will ben-

efit from the research, sharing leadership roles, and es-
tablishing protocols for data-sharing. Bastida, Tseng,
Mckeever, and Jack (2010) provide six principles that ad-
dress these ethical issues and can help guide the nurse
participating in this type of research (Box 16-2).70

Population Nursing Roles in the
Community
In public health nursing, there are many types of employ-
ment where the community is the primary client. Exam-
ples of specific areas where PHNs provide care within the
community include parish nursing and nurse-managed
health centers (NMHCs) that occur in urban and rural
environments.

Parish Nursing/Faith Community Nursing
Faith community nursing is a specialty practice with its
own scope and standards. Although parish nursing began
in Christian congregations, it has grown to encompass an
inclusive approach to nursing within the context of a spir-
itual community and is practiced around the world. It is
defined as follows:

Faith community nurses are licensed, registered nurses who
practice holistic health for self, individuals, and the com-
munity using nursing knowledge combined with spiritual
care. They function in paid and unpaid positions as mem-
bers of the pastoral team in a variety of religious faiths, cul-
tures, and countries. The focus of their work is on the
intentional care of the spirit, assisting the members of the
faith community to maintain and/or regain wholeness in
body, mind, and spirit.71

Parish nursing was first envisioned by Reverend Dr.
Granger Westburg and first practiced in 1985 as a pilot
project in Park Ridge, Illinois, a suburb of Chicago. The
specialty has grown rapidly, and networks of faith com-
munity nursing exist in 30 countries.71 The activities of
parish nurses include:

• Health promotion, health education, and personal
health counseling for the congregation

• Monitoring and screening for health problems
• Advocacy for individuals and groups
• Collaboration within the church and with

organizations outside the church. Frequently,
it involves establishing linkages with government
and health-care agencies and local nongovernmen-
tal organizations to establish services for the
congregation.

• Congregational health assessment of the faith
community followed by analysis and program
implementation

• Spiritual care through shared faith beliefs individu-
ally and in groups, such as grief counseling, and
at-risk substance use.72

C H A P T E R 1 6 ■ Health Planning with Rural and Urban Communities 413

Principle 1. Respect
Principle 2. Fiduciary transparency
Principle 3. Fairness
Principle 4. Informed consent: Always voluntary
Principle 5. Reciprocity
Principle 6. Equal voice and disclosure

BOX 16–2 ■ Six Principles for the Ethical Conduct
of Community-Based Participatory
Research

Source: (70)
Bastida, E., Tseng, T., McKeever, C., & Jack, L., Jr. (2010). Ethics and community-

based participatory research: Perspective from the field. Health Promotion
Practice, 11(1), 16-20. doi:10.1177/1524839909352841

7711_Ch16_398-419 21/08/19 11:12 AM Page 413

Nurse-Managed Health Centers
NMHCs are increasingly important and common in the
U.S. They are staffed and often owned by advanced prac-
tice nurses and provide primary care for U.S. residents.73

Currently, NMHCs serve as a significant safety net for
the medically underserved. Given the preventive care
services included in the ACA, there is an increase need
for primary care providers to deliver those preventive
care services. The National Nursing Centers Consortium
currently includes more than 200 NMHCs and serves
2.5 million patients in urban and rural setting across the
U.S.74 NMHCs provide high-quality, affordable care and
serve as training sites for future advance practice nurses.

Healthy Communities
In recent decades, there has been a groundswell of inter-
est in healthy communities. In 1986, the World Health
Organization (WHO) launched The Healthy Cities
movement in several industrialized countries and then
expanded it to developing countries in 1994. Currently,
more than 1,000 cities around the world are part of the
Health Cities Network.75 The approach emphasizes col-
laboration between government health authorities, such
as ministries or departments of health, and local organ-
izations to address priority health issues in a climate of
social justice and equity.76 For example, in Europe, where
at least 90 cities have participated, the goal has been to
emphasize equity and health in all government sectors,
especially at the local level, using community participa-
tory governance and emphasis on the determinants of
health.75 This local involvement can promote public
health leadership and create environments that allow
for healthier living. There is an authentic opportunity for
PHNs working with communities that are ready to
embrace the healthy cities and communities’ initiatives.
These strategies offer the chance to decrease disparities,
especially health disparities.

414 U N I T I I I ■ Public Health Planning

l APPLYING PUBLIC HEALTH SCIENCE
The Case of a Family Struggling to Find
Health Care
Public Health Science Topics Covered:

• Health service systems
• Intervention: advocacy

Mary and James Wilson and their two young children
lived in a small rural community and had received pri-
mary care from a health maintenance organization
(HMO) through James’s health insurance plan at work.

The family lost their health insurance when James lost
his job. The manufacturing company closed after moving
its operations overseas. Mary and James eventually found
part-time work, but neither received benefits. They met
most of their expenses with very careful financial man-
agement. They checked the health insurance rates on
their state exchange, but even the bronze plan seemed
out of their reach. Because the ACA no longer required
them to carry health insurance, they decided to go with-
out coverage. But without health insurance, they had to
pay for all their health-care costs. The closest clinic was
20 miles from their home. It was a private facility and,
without any health insurance coverage, the fees were
very expensive. On top of the cost of the care, a visit to
the health-care facility would mean they would have to
miss a day of work. Mary was able to take the children
to the local health department for one well-child visit
and to obtain their immunizations. But the health de-
partment was in the process of closing the clinic as the
state finally opted for Medicaid Expansion. Mary and
James perceived themselves as young and healthy, so
they thought they could get by without medical care.

Things were fine for about 9 months, but then one
of the children got sick and then the other became
ill too. The private clinic was too expensive, and the
children did not improve with over-the-counter med-
ications. Mary turned to the PHN at the health depart-
ment and was told that a rural nurse-managed primary
care clinic had just opened in a nearby town. They saw
uninsured patients and used a sliding scale based on
actual income to determine the fees.

They were able to get an appointment right away
and were relieved that the cost would be manageable.
Mary was pleased with the pediatric nurse practitioner
(PNP) who appeared competent in their examination
and treatment, was friendly, and talked directly with
the children, which put them at ease. The PNP spoke
with Mary about what she could do to help manage the
children’s illness and prevent it. Mary felt the PNP au-
thentically listened to the issues and family concerns
and understood their economic challenges. The nurse
practitioner suggested they apply for the State Chil-
dren’s Health Insurance Program, often called CHIP,
because it was likely that they qualified, and the plan
would cover the medical care cost for the children (see
Chapter 18). Mary was reassured and made an appoint-
ment for herself to receive preventive exams for cervi-
cal and breast cancer. That night, she told her spouse
that she felt that they once again had a medical home
and a practitioner upon whom they could rely.

7711_Ch16_398-419 21/08/19 11:12 AM Page 414

Community-Academic Partnerships
Universities and community organizations often form
partnerships to enable service learning. As students work
with agency staff, they learn about the challenges faced by
community members and the resources to address them.
Learning in the community about community outreach
and community health enables the development of skills
in program planning, implementation, and evaluation.77

Sometimes community groups or employers form a
partnership with a university on a focused topic, such as
raising awareness of the complexity and pervasiveness of
chronic illness and seeking how to address or prevent
them.78 A focused topic unites the partners to work
together for change. Multiple entity partnerships are
strengthened when organizations with different foci are
included, such as those focusing on health, social serv-
ices, business development, and various religions. Inclu-
siveness emphasizes community engagement in social
action and positive change.

C H A P T E R 1 6 ■ Health Planning with Rural and Urban Communities 415

■ EVIDENCE-BASED PRACTICE
Multipronged Home-Based Care
Intervention Promotes Aging in
Place for Older Adult

As the proportion of older adults in rural and urban
areas increases, there is increased attention on how to
enable older adults to safely reside in their homes. For
some, this is an economic necessity. For others, it is a
preference.
Practice Statement: The Community Aging in Place,
Advancing Better Living for Elders (CAPABLE) Program
is an interprofessional approach that aims to enable
older adults to remain in their homes as they age while
enjoying a reduction in the impact of their disabilities.
Targeted Outcomes: The targeted outcomes include:
(1) reduced difficulty with activities of daily living
(ADL), (2) improvement in ability to perform instru-
mental activities of daily living (IADL), (3) improvement
in symptoms of depression, and (4) reduced costs.
Supporting Evidence: Many older adults experience
pain, depression, and functional limitations. This
impacts well-being and the ability to live safely and
comfortably at home. The CAPABLE program was a
randomized controlled trial funded by the Center for
Medicare and Medicaid Innovation.1 It was first piloted
in 2009, and the evidence supporting this intervention
has grown in subsequent applications. CAPABLE
demonstrated a 75% reduction in difficulty performing

ADLs, a 65% decrease in difficulty performing IADLs,
and a 53% improvement in symptoms of depression.2,3

A substantial cost-saving was found for CAPABLE par-
ticipants who were dually eligible for Medicare and
Medicaid; over an average of 17 months, Medicaid
spending on CAPABLE participants was $867 less per
month than matched comparisons who did not partici-
pate in CAPABLE. 4
Recommended Approaches: An interprofessional
team includes a public health nurse, occupational thera-
pist, and handyman. Over a 5-month period, the nurse
made four home visits to the participant, the occupa-
tional therapist visited six times, and the handyman
provided up to one full day’s work. The structured
program includes application of a semistructured inter-
view and goal-setting by the participant on three priori-
ties under each discipline (nursing and occupational
therapy). A home improvement workplan is developed
jointly by the therapist and the participant, and a work
order is developed for the handyman.

References
1. Johns Hopkins Medicine. (2018). CAPABLE: Aging in place.

Retrieved from https://www.johnshopkinssolutions.com/
solution/capable/

2. Smith, P.D., Becker, K., Roberts, L., Walker, J., & Szanton,
S.L. (2016). Associations among pain, depression, and
functional limitation in low-income, home-dwelling
older adults: An analysis of baseline data from CAPABLE.
Geriatric Nursing, 37(5), 348–352. https://doi.org/10.1016/
j.gerinurse.2016.04.016

3. Szanton, S.L., Leff, B., Wolff, J.L., Roberts, L., & Gitlin, L.N.
(2016). Home-based care program reduces disability and
promotes aging in place. Health Affairs, 35(9), 1558–1563.
https://doi.org/10.1377/hlthaff.2016.0140

4. Szanton, S.L., Alfonso, Y.N., Leff, B., Guralnik, J., Wolff, J.L.,
Stockwell, I., … Bishai, D. (2018). Medicaid cost savings of
a preventive home visit program for disabled older adults.
Journal of the American Geriatrics Society, 66(3), 614–620.
https://doi.org/10.1111/jgs.15143

■ Summary Points
• Partnerships among community agencies, health-

care providers, and community residents create
mutual benefits that are greater than an individual
agency or a group of community residents can
accomplish alone.

• Rural and urban dwellers experience health disparities.
• Rural Americans (nearly 20% of the U.S. population),

compared to Americans in urban areas, have more
problems accessing health and dental care, paying for

7711_Ch16_398-419 21/08/19 11:12 AM Page 415

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416 U N I T I I I ■ Public Health Planning

t CASE STUDY
Forming a Partnership to Improve
Access to Primary Care a Rural
Community

In a small town in rural Colorado, there was no primary
health-care provider or facility. The closest provider
was 35 miles away, and the nearest hospital was
45 miles away. The health department provided immu-
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library. All other health department services were pro-
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1. Explore health care issues encountered in rural areas.
https://www.ruralhealthinfo.org/ and https://www.

ruralhealthinfo.org/topics

2. Describe approaches used by rural communities and
their partners to solve this problem.
Community-driven solutions to improve health:
https://www.rwjf.org/en/blog/2017/11/rural-america-

healthier-with-community-driven-solutions.html
A solution that includes service-learning in another

industrialized country:
http://www.health.gov.au/internet/budget/publishing.

nsf/Content/budget2018-factsheet21.htm
A solution in a middle-income country that incorpo-

rates telehealth:
https://www.huffingtonpost.com/entry/

improving-rural-healthcare-in-india_us_
5928a67fe4b08861ed0cc96f

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05/nurse-practitioners-boost-presence-by-43-
in-rural-america/#5452017a648b

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62. Marysdaughter, K., & Dansinger, L. (2000). Community orga-
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66. Center for Community Health and Development. (2018).
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Chapter 17

Health Planning for Maternal-Infant
and Child Health Settings
Erin M. Wright, Phyllis Sharps, Joanne Flagg, and Deborah Busch

LEARNING OUTCOMES

After reading the chapter, the student will be able to:

KEY TERMS

1. Describe maternal, infant, and child health from a global
and national perspective.

2. Identify key concerns for public health planning for
maternal, infant, and child health.

3. Apply health promotion planning to maternal, infant, and
child health.

4. Integrate cultural perspectives into planning for maternal,
infant, and child health interventions.

5. Discuss strategies for community engagement and
consensus building for maternal, infant, and child health
planning.

Fishboning
Infant mortality rateLow

birth weight
Mainstream smoke
Maternal health
Maternal mortality

Maternal mortality rate
Maternal mortality ratio
Preterm birth
Preterm labor
Secondhand smoke
Side stream smoke

Sudden infant death
syndrome (SIDS)

Sudden unexplained infant
death

Teen pregnancy
Teen pregnancy birth rate

Under-5 mortality rate
Upstream approach
Very low birth weight

n Introduction
Maternal, infant, and child health is a global health pri-
ority. According to the World Health Organization
(WHO), the number of children under the age of 5 who
die each year is 5.6 million, or approximately 625 per
hour.1 More than 46% of these deaths occur in the first
28 days of life.1 The top five leading causes of death are
preterm birth complications, pneumonia, birth asphyxia,
diarrhea, and malaria.1 Most deaths of children under 5
are related to malnutrition and are preventable simply
by providing affordable interventions.1 Nurses working
in settings that provide care to mothers and their chil-
dren play a key role in the interventions aimed at im-
proving the health of mothers and their children.

Maternal Mortality
Maternal mortality is defined as the death of a woman
while pregnant or within 42 days of the end of a preg-
nancy.2 Approximately 850 pregnant women and women

giving birth die of preventable causes per day.2 Most com-
mon causes are bleeding, pregnancy-related hypertension
(pre-eclampsia and eclampsia), infections and sepsis, com-
plications from delivery, and unsafe abortion.2 Nearly
all these deaths are preventable. Although almost 99% of
maternal mortality takes place in developing countries,
more resource advantaged counties are not immune.2
Since 1987, rates of maternal mortality in the United States
have skyrocketed from 7.2 to a high of 17.8 maternal
deaths per 100,000 births in 2016.3 Causes of pregnancy
related deaths in the U.S. differ slightly from global
sources. These include cardiovascular disease, cardiomy-
opathy, noncardiovascular disease, hemorrhage, pul-
monary embolism, cerebrovascular accidents, hypertensive
disorders, and infection.3 There are considerable racial dis-
parities in the U.S. concerning the maternal mortality
rate (MMR), which represents the number of pregnancy-
associated deaths per 100,000 births.3 White women
experience the lowest rates at 12.7 deaths per 100,000 live
births, whereas black women have 3 to 4 times that rate
at 43.5 deaths per 100,000 live births.3 The inequities in

420

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outcomes exist in part due to inequities in social determi-
nants of health.4 These include pregnancy intention, access
to an obstetric care provider, level of education among
household members, employment and economic oppor-
tunities, social support, and health insurance coverage.4

Maternal health specifically refers to the woman’s
health during pregnancy, childbirth, and the postpartum
period. Infant health includes the health of newborns, that
is, infants up to 28 days of age, and children younger than
1 year. In this chapter, child health focuses on the health
of children under the age of 5. This age group is the recip-
ient of much of the focus on child health because of the
high risk of morbidity and mortality during this age span.1
The issue of maternal, infant, and child health spans the
globe, with major public health initiatives aimed at im-
proving the health of this vulnerable population.

Historical Perspectives
Lillian Wald was one of the earliest pioneers in population
approaches to health and is considered the founder of
public health nursing (see Chapter 1).5 Her work at the
Henry Street Settlement addressed health disparities
among expectant mothers and children. The interventions
she planned and implemented focused on the health pri-
orities of the population living in the Lower East Side of
New York City during the last decades of the 19th century
and the first decades of the 20th century. Through this
work, she developed maternity services at Henry Street,
including health classes for mothers and home visits for
maternal-infant health assessment and teaching. She
addressed health reform for sanitation and public health,
and developed prevention programs for mothers, infants,
and children. Considered the founder of school health
services and visiting nursing, she also developed what
became known as the Children’s Bureau.5

Unfortunately, more than a century later, health dispar-
ities and high rates of morbidity and mortality persist
for pregnant women and their infants worldwide. Al-
though the leading causes of mortality and morbidity have
changed somewhat during the past 100 years, there is a
continued need for nurses to use public health science to
address maternal-child health issues. Nurses use the science
of epidemiology to examine morbidity and mortality data
and identify priorities for maternal and infant health.

Cultural Contexts for Pregnancy
and Childbirth in the United States
Family and children are highly valued in U.S. culture
with specific practices in place at birth and during
the postpartum period. However, due to advances in

obstetric and neonatal care, pregnancy, birth, and early
childhood are, for the most part, safe for families and
children. In the United States, 99% of births take place
in hospitals rather than in the home. Additionally, safe
and available contraceptive methods and choices are
available to most women, resulting in improved family
planning. This in turn has increased opportunities for
women related to education, employment, and build-
ing a career. These have long-term effects on popula-
tion growth with a predicted decrease in U.S. birth
rates through 2060.6 The majority of the population
growth is increasingly associated with people immi-
grating to the U.S., leading to increasing diversity in
the population.6

With this diversity comes a broad range of cultural
practices surrounding birth. Culture shapes expectations
at birth. Expectations include personal control during the
birthing process, support from the partner, and health of
the baby and pain management during childbirth pro-
vided by health-care providers.7,8 These expectations vary
across cultures.7 From a nursing perspective, under-
standing a mother’s expectations of the birthing process
based on her cultural background during the birthing
process is an important component of the nursing care
provided.

Although major shifts occur in birth rates and how
the U.S. population grows, healthy pregnancy, child-
birth, and parenting requires an emphasis on family-
centered care. This includes access to medical care
from preconception through the prenatal and postpar-
tum period. In addition to medical care providing
parents with paid time off from work to allow for
attachment and bonding and to initiate breastfeeding
further promotes health and wellbeing for both the
mother and the newborn. Finally, based on the increas-
ing diversity in the U.S. population efforts to promote
healthy mothers and babies requires the incorporation
of evidence-based practices that integrate diverse cul-
tural norms and reflect the diversity of the maternal
population served.

C H A P T E R 1 7 n Health Planning for Maternal-Infant and Child Health Settings 421

n CULTURAL CONTEXT FOR
PREGNANCY AND CHILD-
BIRTH IN THE 21ST CENTURY
IN THE UNITED STATES

The biological process of childbirth has not changed
over time. Advances in care over the past century,
however, have greatly reduced infant and maternal

7711_Ch17_420-446 28/08/19 9:16 AM Page 421

Trends in Maternal, Infant, and Child
Health
In the United States, maternal, infant, and child health
remains central to the improvement of the health of the
country’s population. It was a key topic area in Healthy

People 2020 (HP 2020) with 33 main topics and a total of
73 objectives.

422 U N I T I I I n Public Health Planning

mortality. In addition to these medical advances,
cultural perceptions of childbirth have changed includ-
ing women’s expectations of childbirth, methods of
pain management, the economics of childbirth, health-
care systems, and delivery options. Other advances
include being able to plan pregnancies and increased
ability to care for newborns. Cultural norms surround-
ing these changes are still in flux with polarizing
political views of planning pregnancies and abortion.

In the U.S., the delivery of care during labor and
childbirth has changed with the rate of cesarean
sections approaching 30% of all deliveries in the
United States. In addition, the development of the
vacuum extractor has decreased the use of forceps,
although both are still used frequently. Inductions of
labor are becoming increasingly more common; cur-
rently, an estimated 40% of all women are induced,
despite estimates that only 10% of women need to
be induced for a medical reason.8 These changes reflect
a cultural shift in the U.S. that has occurred over the
last 100 years, from most births occurring in the home
to most deliveries occurring in the hospital. In the
latter half of the last century birthing centers began
to incorporate the family setting back into births by
including family members and utilizing birthing rooms
that reflected a setting closer to the home versus a
hospital operating room.

Despite these changes in the U.S., cultural practices
in other countries that put both the mother and the
newborn at risk continue. For example, in Ethiopia,
food taboos can result in poor maternal nutrition.9
When providing care to pregnant women from cul-
tures different from their own, midwives and nurses
encounter complex factors that influence the health
care expectations of pregnant women. These cultural
differences include family relationships, religion,
authoritative knowledge, and how information is
communicated.10 Thus, it is essential to assess
cultural preferences and practices of women during
the pregnancy and incorporate that into the plan of
care throughout the pregnancy, labor and delivery,
and the postpartum period.

n HEALTHY PEOPLE
Targeted Topic: Maternal, infant, and child health
Goal: Improve the health and well-being of women,
infants, children, and families.
Overview: Improving the well-being of mothers,
infants, and children is an important public health
goal for the United States. Their well-being deter-
mines the health of the next generation and can
help predict future public health challenges for fami-
lies, communities, and the health-care system. The
objectives of the Maternal, Infant, and Child Health
topic area address a wide range of conditions, health
behaviors, and health system indicators that affect
the health, wellness, and quality of life of women,
children, and families.11

HP 2020 Midcourse Review: Maternal, Infant, and
Child Health Objectives: Of the 73 HP 2020 objectives
related to maternal, infant, and child health (MCH),
64 objectives were measurable with 26.6% of objec-
tives (n=17) having met or exceeded their 2020
targets; another 26.6% of the objectives (n=17) are
improving; 18.8% of the objectives (n=5) have shown
little or no detectable change, and 7.8% of the objec-
tives (n=5) are getting worse (see Fig. 17-1). Twelve
objectives were baseline only, and one objective was
informational. Among the leading MCH indicators
that have exceeded the 2020 targets are: infant deaths
under 1 year, preterm births less than 37 weeks,
adolescents using illicit drugs, adolescent cigarette
smoking, and children exposed to secondhand smoke.
Important MCH indicators that are improving are chil-
dren receiving recommended vaccinations by ages 19-35
months. Little or detectable change was noted among
these MCH indicators: family planning services among
sexually active women ages 15-44 years, obesity
among adults 20+ years, and obesity among children and
adolescents 2-19 years. MCH objectives getting worse
were oral health/annual dental visits among children,
adolescents, and adults aged 2+ years.12

To understand trends in maternal, infant, and child
health, it helps to begin with three indicators often used
to evaluate this population: infant mortality rate (IMR),
MMR, and under-5 mortality rate. Infant mortality is the
death of a child before his or her first birthday. Infant
mortality rate is the number of infant deaths for every
1,000 live births.13 It does not include fetal demise or

7711_Ch17_420-446 28/08/19 9:16 AM Page 422

miscarriage. The MMR is the number of maternal deaths
per 100,000 births. To be classified as a maternal death,
the woman must be pregnant or within 42 days of the
termination of a pregnancy, and the death must be
directly related to pregnancy, not including accidental or
incidental causes.2 The under-5 mortality rate of chil-
dren is technically not an actual rate but rather represents
the probability of a child born in a specific year dying
before the age of 5. It is calculated per 1,000 births.14

Infant Mortality Rate
Across the world, IMR is used as an indicator of pop-
ulation health. It reflects the quality of pre- and post-
natal care in that population and is an indicator of
access to medical care, socioeconomic conditions, and
public health practices.1 Although some have chal-
lenged the legitimacy of IMR as an indicator of the
health of an entire population, it has withstood the test
of time. In addition, in countries with few resources
to monitor other health indictors, IMR is an easily
calculated indicator.13 As of 2017, and based on esti-
mated infant mortality data, the United States ranked
53rd worldwide for infant mortality with a rate of
5.8 per 1,000 live births.15

Vulnerable Populations and IMR in the U.S.
Within the United States, there are differences among
ethnic/racial groups concerning IMR. For example,
in 2016 the IMR for babies whose mothers were non-
Hispanic black women was double the IMR for babies
whose mothers were white non-Hispanic women
(11.4 per 1,000 live births vs. 4.9 per 1,000 live births)
(see Fig. 17-2).13 The top five leading causes of infant

death in the United States in 2016 were birth defects,
preterm birth and low birth weight (LBW), sudden
infant death syndrome (SIDS), maternal pregnancy
complications, and injuries.13

Preterm Birth
Globally, two of the top leading causes of all childhood
deaths under the age of 5 nearly are preterm birth and
birth asphyxia, with almost 50% of deaths in this age
group occurring in infants.12 Preterm birth is defined
as a birth occurring less than 37 weeks of gestation.
Low birth weight is defined as a birth weight less than
2,500 grams (5 lbs. 8 oz.). The number of preterm babies
born annually worldwide is 15 million, with 1 million
infants dying annually because of preterm births.14,16

Countries in Asia and Africa are most significantly
affected, with almost 60% of all preterm births occurring
in those areas.15

Maternal Mortality Rate
Globally, the MMR is on the decline and has shown
a 37% reduction since 2000.17 Despite this success, the
maternal mortality ratio, defined as the proportion
of mothers who do not survive childbirth compared to
those who do survive, is still 14 times higher than in
developing regions compared to developed regions.17 The
United States is the only industrialized nation to show
an increase in the rates of maternal mortality (Fig. 17-3).
Between 1987 and 2014, the U.S. MMR rose from 7.8 per
100,000 live births to 18 per 100,000 live births.18

Globally, under Sustainable Development Goal number 3
(SDG 3) the objective is to reduce the global rates of
maternal mortality to less than 70 per 100,000 live births
by 2030.17 Promising progress has been made at meeting
the SDG 3 objectives related to maternal health with an

C H A P T E R 1 7 n Health Planning for Maternal-Infant and Child Health Settings 423

Healthy People 2020 Midcourse Review:
Maternal Child Health

Base line
Informational
Getting worse
Little or no change
Improving
Met or exceeded

19%

19%26%

27%

Figure 17-1 Healthy People 2020 Midcourse Review
Maternal Child Health.

Figure 17-2 Infant mortality rate by race and ethnicity,
2016. Rate per 1,000 live births.

U.S. Infant Mortality Rate 2016 by Race

Non-Hispanic
Black

American
Indian/
Alaskan
native

Native
Hawaiian/

Pacific
Islander

Hispanic Non-Hispanic
White

Asian

11.4

9.4

7.4

5 4.9
3.6

7711_Ch17_420-446 28/08/19 9:16 AM Page 423

increase in prenatal care, a decrease in the number of
teens giving birth, and an increase in meeting family
planning needs.17

Vulnerable Populations and MMR in the U.S.
There are racial disparities in the U.S. with regard to the
MMR.3 During 2011-2014, the maternal mortality ratios
were 12.4 for white women, 40.0 or African American
women, and 17.8 for other racial/ethnic groups.3 The
inequities in outcomes exist in part due to inequities in
social determinants of health.4 These include pregnancy
intention, access to obstetric care providers, level of
education among household members, employment
and economic opportunities, social support, and health
insurance coverage.4 However the higher rates that
African American women experience goes beyond social
determinants of health and includes systemic racism that
can occur in health care. An example is the case of new

424 U N I T I I I n Public Health Planning

19
89

19
90

19
91

19
92

19
93

19
94

19
95

19
96

19
97

19
98

19
99

20
00

20
01

20
02

20
03

20
04

20
05

20
06

20
07

20
08

20
09

20
10

20
11

20
12

20
14

20
13

19
88

19
87

7.2

9.4
9.8

10
10.3

10.8

11.1

12.9

11.3

11.3
12.9

12
13.2

14.5

14.7

14.1

16.8

15.2

15.4

15.7
14.5

15.5

17.8
16.7

17.8

15.9
17.3 18

Trends in Pregnancy-related Mortality in the United States: 1987–2014

Figure 17-3 Trends in pregnancy-related mortality in the United States: 1987-2014. (Note: This represents the
pregnancy-related mortality ratio.)

n EVIDENCE-BASED PRACTICE
Practice Statement: Prevent postpartum hemorrhage
Targeted Outcome: Reduce the incidence of post-
partum hemorrhage, a leading risk factor for maternal
mortality.
Supporting Evidence: Based on a promising new
study from the WHO, a new drug used to reduce
maternal hemorrhaging following delivery may help
reduce the MMR. In June of 2018, the WHO stated in
a press release:

Currently, WHO recommends oxytocin as the first-choice
drug for preventing excessive bleeding after childbirth.
Oxytocin, however, must be stored and transported at
2–8 degrees Celsius, which is hard to do, in many countries,
depriving many women of access to this life-saving drug. When
they can obtain it, the drug may be less effective because of
heat exposure.

The study, published today in the New England Journal
of Medicine, has shown an alternative drug – heat-stable
carbetocin – to be as safe and effective as oxytocin in prevent-
ing postpartum hemorrhage. This new formulation of carbe-
tocin does not require refrigeration and retains its efficacy for
at least 3 years stored at 30 degrees Celsius and 75% relative
humidity.

Recommended Approaches: Based on these findings,
the WHO stated that the next step was to submit
the findings for regulatory review and approval by

countries. The WHO Guideline Development Group
will then “… consider whether heat-stable carbetocin
should be a recommended drug for the prevention of
postpartum hemorrhage.”

References:
1. World Health Organization. (2018, June 27). WHO

study shows drug could save thousands of women’s
lives. WHO News Release, Geneva. Retrieved from
http://www.who.int/news-room/detail/27-06-2018-
who-study-shows-drug-could-save-thousands-of-
women’s-lives

2. Widmer, M., Piaggio, G., Nguyen, T.M.H., Osoti, A.,
Mistra, S., … WHO Champion Trial Group. (2018).
Heat-stable carbetocin versus oxytocin to prevent
hemorrhage after vaginal birth. New England Journal of
Medicine, 379(8), 743-752. doi: 10.1056/NEJMoa1805489

7711_Ch17_420-446 28/08/19 9:16 AM Page 424

mother and tennis phenomenon Serena Williams.
Although she does not experience poverty or lack of
access to care, she had a life-threatening complication
after childbirth. Despite her known history of a clotting
disorder and previous pulmonary embolisms, she was
told that she was just having pain from her delivery and
was initially offered a test that would not properly diag-
nose her condition. She had to forcefully advocate for
the appropriate testing and treatment to diagnose the
pulmonary embolism she knew she was experiencing
after childbirth.

Geographic differences also exist in relation to the
U.S. MMR rates. Rural and more impoverished counties
in the United States lack appropriate obstetric care re-
sources, especially in the Southeastern region of the coun-
try.19,20 Vulnerable populations such as the homeless,
those who are incarcerated, and the LGBTQ+ community
experience greater disparities in access to health care.20

Although the rate of maternal mortality among the
LGBTQ+ community has not yet been examined in a
systematic fashion, there appear to be greater disparities
in this population related to health care access.21 There
are also differences in relation to sources of social
support within and outside of the LGBTQ+ commu-
nity.22 In 2012, The American College of Obstetricians
and Gynecologists (ACOG) released a white paper ad-
vocating for equitable care for LGBTQ+ persons who
are pregnant. They stated that “The American College
of Obstetricians and Gynecologists endorses equitable
treatment for lesbians and bisexual women and their
families, not only for direct health-care needs, but also
for indirect health-care issues.”23 Since the release of
that statement, new issues that have emerged for the
LGBTQ+ community include pregnancy and transgen-
der persons who may become pregnant.

Mortality Rate for Children Under
the Age of 5
Great strides have been made over the past 3 decades
to reduce the rates of mortality for children under the
age of 5. Since 1990, there has been a drop in the child
mortality rate from 12 million to 5.6 million in 2016.1
One of the objectives under the SDG 3 is to reduce the
rate of child mortality under the age of 5 to at least as
low as 25 per 1,000 live births by 2030.17 As mentioned
earlier, the leading causes of death for children under
the age of 5 that are not birth-related are pneumonia,
diarrheal diseases, and malaria.1 By contrast, in the

C H A P T E R 1 7 n Health Planning for Maternal-Infant and Child Health Settings 425

high blood pressure during pregnancy (pre-eclampsia
and eclampsia), complications from delivery, and
unsafe abortion. The other 25% of maternal deaths are
caused by or associated with diseases such as malaria
and AIDS during pregnancy. Every day around the
world, 830 women die from these preventable causes
related to pregnancy and childbirth.2 Worldwide, since
2000, the MMR dropped by 37%.18 However, even
though 99% of all maternal deaths occur in developing
countries, maternal mortality remains a challenge in the
United States, where about 700 women die each year
from complications during pregnancy or childbirth.24

In addition, in the U.S., severe maternal morbidity
(SMM), defined as the most severe complications of
pregnancy, annually affects more than 50,000 women
every year.25

Based on recent trends, the global burden of
maternal mortality continues to be recognized as a
public health problem. The Years of Life Lost (see
Chapters 3 and 9) is an issue because mothers are rela-
tively young.26, 27 These maternal deaths impact the
community not only as a loss to the workforce but as
providers of child care. Addressing the primary causes
of maternal mortality at the individual level across
the continuum of prevention requires improving access
to care from preconception through the postpartum
period.26 This often requires changes at the policy
level. Nurses and midwives have continued to be an
important part of the strategy to promote maternal
health and optimal pregnancy outcomes. Nurses and
midwives not only provide direct services to pregnant
women, they also serve as advocates for universal ac-
cess to prenatal care, for training to increase the num-
ber of skilled birth attendants at every birth, and for an
increase in policies that support safe motherhood and
baby-friendly hospitals.2,17

n CELLULAR TO GLOBAL:
MATERNAL HEALTH

The SDG 3.1 target is aimed at reducing the global ma-
ternal mortality ratio to less than 70 per 100,000 births
by 20302; under the HP 2020 topic of Maternal Child
Health, the MICH 5 objective is to reduce the maternal
mortality to 11.4 per 100,000 births by 2020.11 Not
only did the U.S. fail to meet the target of 11.4, but the
MMR rose to 18 by 2014 (Fig. 17-3).24 To help reduce
the MMR requires a population approach as outlined by
the United Nations in SDG 3. According to the WHO,
75% of maternal deaths globally are caused by prevent-
able causes including severe bleeding (mostly bleeding
after childbirth), infections (usually after childbirth),

7711_Ch17_420-446 28/08/19 9:16 AM Page 425

United States, the leading causes of death in children
between the ages of 1 and 4 are unintentional injury,
developmental/genetic conditions present at birth, and
assault (homicide) (Table 17-1).8

serious condition caused deaths among 30% of those
women who delivered their newborns in the hospital.
He observed that women who delivered their babies at
home where a midwife assisted with the birth had
better outcomes than those who delivered in the hospital.
Noting that the medical students came to the delivery
ward directly from the autopsy room at the hospital
without washing their hands, Semmelweis ordered a
change in hand washing policy. Once the policy change
took place, the maternal death rate decreased from 12%
to 1% within 2 years.29 His work is an early record of
the importance of epidemiology for improving health
outcomes.

Sudden unexpected infant death (SUID) is defined
as a sudden unexpected death in a child less than 1 year
of age in which the cause is not evident without further
investigation. It usually occurs in or around the infant’s
sleep area. The four main causes of SUID are (1) Sudden
Infant Death Syndrome (SIDS), (2) accidental deaths
(such as suffocation and strangulation), (3) sudden nat-
ural deaths (such as those caused by infections, cardiac
or metabolic disorders, and neurological conditions),
and (4) homicides.30 SIDS is defined as an infant death
that cannot be explained after an extensive examination
that includes a review of the clinical history, a complete
autopsy, and complete assessment of the site where the
death occurred. SIDS is the third leading cause of death
for all infants in the United States and the leading cause
of death for infants from 1 to 12 months of age.13 In the
U.S. in 2016, there were approximately 3,600 SUIDs with
SIDS the most common type of a SUID.30

The results of initial population-based studies con-
ducted in the late 1980s and 1990s established that babies
placed on their backs were at a lower risk of SIDS
than those placed on their stomachs.30-33 In response to
these findings, in the United States, a national Back to
Sleep campaign was instituted in 1992 that encouraged
parents to place infants in the supine position. The cam-
paign, now referred to as the Safe to Sleep Campaign, is
an excellent example of a universal prevention program
(see Chapter 2) using a public service approach. The
campaign also demonstrates the power of collaboration
between agencies. Safe to Sleep is a public education
campaign supported by the Eunice Kennedy Shriver
National Institute of Child Health, and Human Devel-
opment, the Maternal and Child Health Bureau, the
American Academy of Pediatrics, the SIDS Alliance, and
the Association of SIDS and Infant Mortality Programs
(see Box 17-1).34 It is also an example of how these type
of primary prevention programs can be effective. The
SUID rate fell from 154.6 deaths per 100,000 live births

426 U N I T I I I n Public Health Planning

n HEALTHY PEOPLE
HP 2020 Maternal Infant Child Health
Objectives

Objective: MICH 9.1 Reduce total preterm births.
Baseline: 12.7% of live births were preterm in 2007.
Target: 11.4%
Target-Setting Method: 10% improvement11

Midcourse Review: Between 2007 and 2013, total
preterm live births decreased from 12.7% to 11.4%,
meeting the target.12 According to the Centers for
Disease Control and Prevention (CDC), although the
preterm birth weight again dropped in 2014, it then
rose in 2015 and 2016 to approximately 1 in 10 births.
Differences between groups remained in 2016 with a
preterm birth among African American women (14%)
about 50% higher than the rate of preterm birth among
white women (9%).28

Population Focus on Maternal, Infant,
and Child Health
A population focus to improve the health of mothers, in-
fants, and children under the age of 5 is essential. The fol-
lowing examples are reminders of the importance of this
perspective for maternal, infant, and child health. Using
principles of epidemiology, changes in clinical practice
and policies greatly reduced the leading causes of death
for pregnant women and infants. In the first example,
during the 1840s, Dr. Ignaz Semmelweis, a Hungarian
working in Austria, discovered that hand washing re-
duced the incidence of puerperal fever (also called
childbed fever) or septicemia that follows delivery. This

TABLE 17–1 n Leading Causes of Death in Children
Aged 1 to 4

United States Worldwide

Unintentional Injury Pneumonia

Congenital malformations, deformations, Diarrhea
and chromosomal abnormalities

Assault (Homicide) Malaria

Sources: (1) and (25)

7711_Ch17_420-446 28/08/19 9:16 AM Page 426

in 1990 to 91.4 deaths per 100,000 live births in 2016 with
the majority of the decline occurring from the start of the
Back to Sleep campaign and 2000. Since then, the rate
has leveled off.35 During the same time period, SIDS rates
declined from 130.3 deaths per 100,000 live births to
38.0 deaths per 100,000 live births in 2016.35 Unfortu-
nately, accidental suffocation and strangulation in bed
(ASSB) mortality rates increased with a rate of 21.8 per
100,000 births in 2016.35

In the U.S., disparities have persisted along racial lines
with regard to SUID over the past 3 decades. American
Indian/Alaskan Native and non-Hispanic black infants
were more than twice as likely to die of SUID than His-
panic and Pacific Islanders, who hold the lowest rates of
SUID.36 Underlying reasons for this disparity are
not clearly understood. Parks, Lambert, and Shapiro-
Mendoza (2017) suggested that public health campaigns
aimed at reducing SUID may not be “… reaching certain
races/ethnicities, not addressing the most important risk
factors for these groups, or not being framed in the most
effective way to ensure uptake among diverse popula-
tions.”36 For example, one of the main risk factors of
SUID is preterm birth. With the preterm birth rate
highest in both American Indian/Alaskan Native and
non-Hispanic black infants than other racial/ethnic
groups,37 a Safe to Sleep campaign may not adequately

address underlying risks across all populations. Preventing
preterm births in at-risk populations may be needed as well.

Upstream to Prevention Across
the Maternal-Child Health Continuum
An important aspect of a population focus is the
upstream approach, a metaphor for looking at factors
that contribute to illness and disease (see Chapter 2). It
is based on the idea that if one only focuses on pulling
drowning people out of the river, one may miss the fact
that they are falling off the bridge upstream. If they are
prevented from falling off the bridge in the first place, no
one will have to save them from drowning further down
stream. Nurses and other health providers are urged to
focus upstream on the social, political, economic, and
behavioral causes of disease and unhealthy health events
to prevent disease in the first place and potentially poor
health outcomes for mother and child.

The health and safety of the mother, the health of
the developing fetus, safe birth for the newborn, and
continued healthy development of the child are the top
priorities for nurses who work in maternal-child health.
If the mother is healthy throughout the pregnancy and
delivers a healthy child, the nurse working in the hospi-
tal only interacts with the mother/child dyad (group of
two) for a brief time along this continuum. Therefore, it
is essential for nurses to think upstream about the root
causes of health problems and to prepare new mothers
and families for their future health back in the commu-
nity. The maternal-child health continuum spans the
time from preconception and continues as the child
develops. The health and well-being of the woman
throughout her pregnancy and perinatal period, and the
healthy growth and development of the fetus and child
continue for decades. The potential impact of upstream
approaches to health and safety for the maternal-child
health continuum is significant in health, social, and
economic terms, particularly for children. For this
reason, nurses use public health approaches to ensure
adequate nutrition, appropriate prenatal care, safe
delivery for the newborn, and care of mother and child
during the postpartum period.

Review of Assessment and Planning in
Maternal, Infant, and Child Health Settings
Nursing approaches to improve health for maternal-
child populations often involve interdisciplinary teams
that bring the breadth of expertise necessary for strong
programs. As a key member of that team, the nurse
is vital for creating successful and effective programs.
Assessment at the population level involves analysis of

C H A P T E R 1 7 n Health Planning for Maternal-Infant and Child Health Settings 427

There are ways parents and caregivers can reduce the
risk of Sudden Infant Death Syndrome (SIDS) and other
sleep-related causes of infant death. Learn how to create
a safe sleep environment for the baby.

• Select the crib.
• Always place the baby on his or her back to sleep, for

naps and at night, to reduce the risk of SIDS.
• Use a firm sleep surface, such as a mattress in a safety-

approved crib, covered by a fitted sheet, to reduce
the risk of SIDS and other sleep-related causes of infant
death.

• Give the baby a dry pacifier—not attached to a
string—for naps and at night to reduce the risk
of SIDS.

• Do not let the baby get too hot during sleep.
• Have the baby share your room, but not your bed.
• Keep soft objects, toys, crib bumpers, and loose

bedding out of the baby’s sleep area to reduce the
risk of SIDS and other sleep-related causes of infant
death.

BOX 17–1 n Safe to Sleep Campaign Parental
Guide

Source: (34)

7711_Ch17_420-446 28/08/19 9:16 AM Page 427

data from national, state, and local data sources (see
Chapters 4 and 5). Such data allow the nurse planner to
identify risks and protective factors related to maternal-
child health. International, national, state, and local
data that track risks and adverse outcomes are available
through numerous governmental and nongovernmen-
tal agencies such as the CDC, the National Center for
Health Statistics, and the Office of Minority Health.
Another excellent source of data at the state level is
the Pregnancy Risk Assessment Monitoring System.38

These data help nurses identify risks related to the
population for which they are caring. Another useful
example is the PeriStats data supported by the March
of Dimes Foundation.39 Once risks are identified, other
assessment strategies such as interviews, community
forums, and identification of local resources can follow
to aid in the planning process.

Models for community assessment, discussed in
Chapter 4, illustrate the need to include social, political,
economic, and cultural contextual perspectives in epi-
demiological investigations. In addition, the strengths
or assets are always identified in any population-level
assessment. Data collected for the assessment can
include archival data, health indicator data, interviews,
observational surveys, formal surveys, focus groups,
and community forums. Other sources of local data in-
clude hospital records, local health surveys, and agency
records.

Health problems, as well as community or organiza-
tional assets, can be identified from the analysis of the
data collected in the community assessment. A variety of
methods for prioritization exist. Most are based on the
perceived severity of the health problem and the impor-
tance placed on the problem by the community or or-
ganization. In the case of maternal-child health, serious
immediate risks for maternal or infant mortality often
rank higher than long-term morbidity risks. Although
obesity is a significant risk factor related to maternal,
neonatal, and child health,40 other immediate risks can
take priority. For example, in the fall and winter of 2009–
2010, the H1N1 pandemic became the immediate prior-
ity because of the high risk to the health of pregnant
women and their fetuses, resulting in a nationwide effort
to immunize pregnant women.41 Despite continued sub-
optimal vaccination rates, research demonstrates the
safety of the influenza vaccine in pregnancy.42 Another
example is the pertussis outbreak that began in 2012 that
was responsible for 18 deaths as of January 2013.43 This
has resulted in pertussis immunization becoming a pri-
ority for infant and child health and in a reduction of
pertussis cases from 48,277 in 2012 to 17,972 in 2016.43

In addition, the feasibility and likelihood of positive
change as a result of the planned interventions is impor-
tant for prioritization. Short-term programs with a
greater likelihood of success often receive a higher pri-
oritization ranking for funding.

Once the priority needs for the maternal-child population
of interest are identified, planning can begin (Chapter 5).
As explained in Chapter 5, program goals and objectives
are created. The goals must be both long- and short-term
and must address positive health outcomes; the objectives
must be measurable. The identified goals guide the evalu-
ation process. Planning must include the exploration of re-
sources as well as constraints to the planned interventions,
which include political, economic, and time constraints.
Before any interventions can begin, a budget must be de-
veloped; staffing needs must be met; supplies, equipment,
and space need to be obtained; required protocols must be
followed; and permissions must be granted. Interventions
that are well planned can be completed successfully. Clear
evaluation plans that include both process and outcome
measures document the success of the program.

In maternal-child health, the challenge is to identify
significant health risks in maternal-infant populations
across different health settings, set priorities for planning,
suggest strategies for interventions to address the risks,
and discuss evaluation plans for the selected interven-
tions. For the nurse working in maternal-child health
acute care and primary care settings, this requires build-
ing alliances with other disciplines, agencies, and mem-
bers of the community. There are a variety of risks for
the mother and child across the continuum from precon-
ception to childhood.

Health promotion with this population begins with
prevention of high-risk pregnancy and reduction of
shared exposures to risk for both the pregnant mother
and the developing fetus. These efforts to promote the
health and safety of mother and developing fetus can re-
duce the incidence of preterm birth, LBW, birth defects,
and IMR. Nurses who seek to address health risks for
maternal-infant settings must apply assessment and
planning strategies of public health science.

428 U N I T I I I n Public Health Planning

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Teenage Pregnancy
Epidemic
Public Health Science Topics Covered:

• Assessment
• Program development
• Program evaluation

7711_Ch17_420-446 28/08/19 9:16 AM Page 428

C H A P T E R 1 7 n Health Planning for Maternal-Infant and Child Health Settings 429

Nurses in the local hospital in City A, a moderate-
sized city in an economically depressed area, re-
sponded to a state health department call for funding
for teen pregnancy prevention and the initiation of a
community program to address the growing teen preg-
nancy rate. Teen pregnancy is defined as a pregnancy
in which the mother is between 15 and 19 years of
age, and the teen pregnancy birth rate is calculated
as the number of births per 1,000 women in this age
group.44 The nurses felt they could contribute to the
development of a teen pregnancy program because of
their expertise in working with pregnant teens who
came to their hospital for care across the perinatal pe-
riod and through their infants’ first year of life. These
nurses included those working in the labor and delivery
room, the hospital-run prenatal clinic for teens, the
neonatal unit, and the pediatric unit. They felt that
addressing teen pregnancy would also address the
larger issue of the high IMR in the community as
recommended by authorities in the field.44

The nurses began by reviewing the literature re-
lated to teen pregnancy. They found that commonly
reported teen pregnancy adverse outcomes increased
the risk for both the mother and infant. These ad-
verse outcomes included maternal death, risk for
sexually transmitted infections, and greater risk for
cephalopelvic disproportion, wherein the infant’s
head is too large to fit through the mother’s pelvis. In
addition, they found that teen mothers are less likely
to seek prenatal care early and more likely to deliver
low birth weight infants.44 Based on these national
statistics, the team became curious about the teens
who were served by their hospital and decided fur-
ther assessment was needed.

The team also recognized the importance of the
various legal and ethical concerns when working with
adolescents who are minors in the eyes of the law.
Nurses who work with programs to prevent teen
pregnancy face several ethical concerns. Because teens
are often under the age of 18 and must have parental
consent for most of their interactions with health-care
providers, the nurse must consider whether a planned
intervention will require parental consent. In addition,
many school settings where teens spend most of their
days also control the content of the information made
available to students. Various issues should be ad-
dressed up front from an ethical perspective to best
protect this vulnerable population (Box 17-2).45,46

To begin the work, these nurses created an interdis-
ciplinary team of key stakeholders to help identify

critical issues related to teen mothers in the community
they served and to develop a program based on those
findings. These stakeholders included key personnel
from the hospital’s maternal-child health services and
community-based health service providers such as the
federally qualified community health center, the direc-
tor of the teen clinic at the health center, the director
of the Planned Parenthood center, and the nursing di-
rector from the local department of public health. They
also felt it was essential to invite representatives from
the public and private schools in the community, the
director of immigrant services, leaders of the four
ethnic/cultural groups in the community, and the direc-
tor of the U.S. Department of Agriculture’s Women,
Infants, and Children nutrition program. In addition,
the nurses reached out to the community and invited
women living in the community to join the nurse team
to help complete the assessment and create a program
based on their findings.

The team believed that they needed to begin with
a focused assessment to identify the risk factors asso-
ciated with the problem of teen pregnancy specific
to their community (see Chapter 4). Their approach

Individuals under the age of 21 come under the defini-
tion of a vulnerable population. In addition, women
who are pregnant are also considered vulnerable.
Caution must be taken to protect their privacy and the
confidentiality of their information. There are differing
laws concerning the emancipation of minors and the dis-
pensing of information related to pregnancy. Pediatric
obstetrical ethics represents the intersection between
pediatric/adolescent ethics and obstetrical ethics and
includes ethical decisions made by, with, and for pregnant
adolescents. Community buy-in presents another impor-
tant issue because various community groups, including
parents, political bodies, and religious groups, have
differing opinions on:

• Sexual behaviors
• Abstinence
• Safer sexual practices
• Use of illegal substances
• Use of tobacco and alcohol products
• Contraception options
• Abortion counseling
• Birth options

BOX 17–2 n Legal and Ethical Issues Related
to Preventing Teen Pregnancy

Sources: (45) and (46)

7711_Ch17_420-446 28/08/19 9:16 AM Page 429

430 U N I T I I I n Public Health Planning

included a mapping of community assets related to
maternal, infant, and child health, and identification of
adolescent programs that included females.

They began their assessment using a technique re-
ferred to as fishboning, also known as the Ishikawa
cause-and-effect diagram, which provides an easy and
fast method of identifying root causes of a complex
issue or problem. This technique begins with the form-
ing of a root cause diagram (Fig. 17-4).47 The planning
team assembled their diagram with a facilitator leading
the process. In this case, the team identified social
causes such as poverty, minority status, and access to
adequate prenatal care. They also identified maternal
behavioral risk factors, including substance use and ma-
ternal stress. Finally, they identified issues related to
teen maternal health and pregnancy outcomes, includ-
ing nutrition and prior birth history.48 The outcome
they wished to address was preterm birth and LBW,
with teen pregnancy as one of the root causes.

Using the results of the fishbone diagram process
based on national data, the team then searched the
epidemiological data from their community to identify
whether the issues they found were significant in
their community. First, they reviewed the overall
demographics of the city. They found that, in City A,

50.1% of the residents had less than a high school
education compared with 20% of the state residents.
The city reported that 25.7% of the households were
below the poverty line, whereas in the state in general,
only 13.2% of households were below the poverty line.
Thirty percent of high school female teens reported
using tobacco in City A, compared with 17.5% at the
national level, and 28% met the definition for obesity,
compared with 20.9% nationally. Next, they looked at
the publicly available birth data and discovered that the
teen birth rate was 35.5 per 1,000 births, compared
with 20.3 at the national level and 25.2 at the state
level. Also, teen mothers in City A had a preterm birth
rate of 17.8%, which was significantly higher than the
11.6% rate for all pregnancies at the national level.
Another critical issue was access to prenatal care, with
teen mothers 20% less likely to receive adequate
prenatal care or breastfeed their babies than women
in the state overall.

They then requested information from the city
health department on the rates of LBW, IMR, prenatal
care, maternal obesity, prematurity, and tobacco
use among teen moms based on the birth certificate
data. The city agreed to provide this information and
reported back that the IMR for teen mothers overall

Poverty
Health

Disparities

Minority
Status

Teen
Pregnancy

Substance
Use

Tobacco
Use

CAUSES

EFFECT

Low Birth Weight
Preterm Birth

Drugs and
Alcohol Nutrition

Birth
History

Maternal
Stress

Physical
Factors

Adequate
Prenatal Care

Figure 17-4 Ishakawa fish-
bone template for low birth
weight and prematurity
outcomes.

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C H A P T E R 1 7 n Health Planning for Maternal-Infant and Child Health Settings 431

was 8.7 per 1,000 births, and for African American
teen mothers it was 16.8 per 1,000 births. The health
department reported similar disparities in relation to
preterm birth and LBW. Tobacco use in white teen
mothers (25%) was higher than in African American
teen mothers (10%), compared with 23.8% and 8.4%,
respectively, of female teens at the national level.
There was a slight difference in the initiation of prena-
tal care between the two groups, with 71% of white
teen mothers and 68% of African American teen
mothers initiating prenatal care in the first trimester.
The percentage of obese teen moms was similar in
both groups, with a 27.5% prevalence of obesity in
white teen mothers and 29.3% in African American
teen mothers.

Based on the data they gathered, the team concluded
that, for their community, City A, the teen pregnancy
rate was the highest in the state and represented a sig-
nificant health problem. In addition, tobacco use and
obesity among adolescent females during pregnancy was
a problem. The team decided that obesity and tobacco
use would be the target of their program.

Obesity and Pregnancy

Based on these facts, the team next took a closer look
at the link between maternal obesity and neonatal out-
comes. Based on the studies they read, they found that
obesity has been linked to multiple adverse outcomes
for both the mother and the baby. Researchers have
demonstrated that babies born to obese mothers are
at greater risk for mortality during their first month
and during their first year of life.49 Infants born to
obese mothers were more likely to have macrosomia,
that is, they have an excessive birth weight.50 This
often resulted in higher rates of maternal birth canal
trauma, shoulder dystocia, and perinatal asphyxia.50,51

Mothers who were obese during pregnancy were also
found to be at greater risk of developing gestational
diabetes, hypertension, and preeclampsia.50 Children
born to mothers with gestational diabetes were found
to have an elevated body mass index (BMI) during their
lifetime. Additionally, women who were obese during
pregnancy were also more likely to use medical serv-
ices, have longer hospital stays, and were twice as likely
to have a cesarean section delivery with an increase in
health-care costs.50,51

Tobacco Use and Pregnancy

They next examined the issue of tobacco use among
pregnant teens. Smoking poses risks for both the

mother and the infant. Women who smoke during
pregnancy, when compared to women who do not
smoke, are at increased risk for premature rupture of
membranes, placenta previa, or placental abruption.52

Further, among pregnant nonsmokers, those who are
exposed to secondhand tobacco smoke are more likely
to give birth to a low birth weight baby than are those
pregnant mothers who are not exposed to secondhand
tobacco smoke during pregnancy.52 Secondhand
smoke includes side-stream smoke, which is
defined as smoke from the lighted end of a tobacco
product, and mainstream-smoke, which is defined
as smoke exhaled by the smoker.

Tobacco use poses a significant health risk for the
baby.52 E-cigarettes pose a threat as well because they
contain nicotine, and nicotine is a known reproductive
toxicant that has adverse effects on fetal brain devel-
opment.53 Babies born to women who use tobacco
are more likely to be born prematurely and are more
likely to be born with LBW (less than 2,500 grams
or 5.5 pounds).53 Overall, babies born to mothers
who use tobacco weigh 200 grams less on average
than babies born to nonsmoking mothers.52 In addi-
tion, babies born to mothers who smoke are likely
to die of SIDS.53

Infants and children exposed to secondhand smoke
related to tobacco use are more likely to experience
adverse health issues.55,56 Exposure to secondhand
smoke causes premature death and disease in children
exposed in their home or daycare environment. These
children experience higher rates of ear infections and
respiratory problems that include bronchitis, asthma,
and pneumonia.

Based on their findings, the team decided on a
multifaceted approach. Programs that address issues
such as teen pregnancy, healthy weight preconception,
appropriate weight gain during pregnancy, and tobacco
use generally focus on outcomes such as a reduction in
number of pregnant teens, reduction in the rate of obe-
sity among childbearing women, recommended weight
gain during pregnancy, and reduction in tobacco use by
pregnant mothers. Achieving the target measures for
these outcomes should improve the health of teenage
mothers and infants in City A. A more significant
outcome would be the actual decline in the maternal
mortality or IMRs.

In the case of City A, the team considered a vari-
ety of approaches that had been successful in other
locations, such as community programs that strength-
ened parent-child communication and school-based

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432 U N I T I I I n Public Health Planning

programs.57 From their assessment, they elected to
work with the hospital outreach program and the
local neighborhood health center. The nurses at the
hospital would serve as the hospital’s representatives
on the team. The nurses’ role included two aspects.
First, they provided nutrition education to pregnant
teens attending the teen pregnancy clinic based in
their hospital, with a focus on healthy eating and
achieving a healthy weight gain over the course
of the pregnancy. They also put together a smoking
cessation program that included the development
of a smoking cessation peer-led support group. The
hospital provided space for the teens to meet, and
the nurses filled the role of facilitator. Once again,
the support program was put in place in conjunction
with the teen pregnancy clinic. The hospital agreed
to give the nurses time within their workweek to
provide this service. In addition, the nurses worked
with community members and stakeholders on the
team to look for opportunities to extend the nutri-
tional education program out into community settings
and link it back to the care given in the prenatal
clinics. Finally, the nurses agreed to take the responsi-
bility for collecting the needed evaluation data to
establish whether the program was successful. They
collected baseline and outcome data using specific
outcome measures. For the teens who participated
in the program, the nurses collected data on overall
weight gain during the pregnancy, the percentage of
participants who smoked and were able to quit, as
well as recording maternal birth outcomes such
as pregnancy complications, birth weight, gestational
age, and other physical outcome measures related
to maternal and neonatal outcomes chosen by
the team.

Based on the statistics for City A, the team decided
that they should also seek funding to expand the pro-
gram to address other key areas they had identified
during their assessment. They hoped by demonstrating
success with their teen pregnancy clinic program,
they would be able to secure funding to expand the
program and thus have a more significant impact on the
problem of teen pregnancy in City A.

Before submitting a grant, the nurses reconvened
the larger team and discussed the need for community
buy-in and consensus to expand the program. After
demonstrating the success of their original program,
they received funding from the hospital and some of
the stakeholders to support a communitywide forum
to be held at the city high school. The team held five

work meetings prior to the community meeting, in
which logistics and format were planned, donated
refreshments were solicited, and meeting details and
advertising were arranged. Representatives of all
community service agencies were invited to the
planning meeting.

During the community forum planning, the team
scheduled the mayor to speak to the assembly of
110 attendees, followed by local politicians at the state
and national levels. This confirmed the importance of
the work. Then, the audience broke into five small
workgroups. Members of the planning team who were
skilled in consensus building used the nominal group
process.56 Nominal group process or technique refers
to the process wherein a larger group can come to a
consensus for prioritizing needs in a brief meeting time.
To be successful, all participants must agree that they
will accept the results of the group process to repre-
sent their position for program planning. The first step
is often called brainstorming, in which each participant
is given a pad of paper and instructed to write down
every important issue he or she can think of related
to the broad topic of the forum. After about 5 to
8 minutes for this brainstorming, the participants post
their written papers in clusters on a whiteboard.
With input from the group, the facilitator arranges the
clusters into smaller categories. In this community
forum, the smaller groups contained about 22 partici-
pants. Next, the 90 ideas that were generated were
consolidated into 12 categories. Through a process of
voting to rank the order of the topics/categories, the
group was able to identify their top three concerns or
problems:

1. Teen pregnancy prevention
2. High rates of smoking by pregnant adolescents
3. Obesity among adolescent females

They also concluded that LBW was an issue, but
it was being addressed in another program. Based on
the initial success of the nurses’ tobacco cessation and
healthy nutrition program with pregnant teens, the
community felt the team had the experience to take
on a more comprehensive primary prevention program
that focused on preventing pregnancy, tobacco use, and
obesity in females under the age of 20.

The nurses were now working with a larger com-
munity team. They were able to secure support from
the chief nursing officer at their hospital by demon-
strating the value of the potential program to the hos-
pital and its community outreach initiative. Together

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C H A P T E R 1 7 n Health Planning for Maternal-Infant and Child Health Settings 433

with the community team, the nurses developed the
following goals for females aged 12 to 19 in City A:

1. Reduce the number of pregnancies.
2. Reduce the rate of obesity.
3. Reduce the initiation of tobacco use.

For both goals 1 and 2, the team developed a
healthy living program that used the school-based
health clinic system. They based the program on evi-
dence from other programs.58,59 The nurses on the
team brought the school nurses into the planning
process. The program extended over the academic
year and included support groups for female students
aimed at building self-esteem and healthy lifestyles with
a focus on healthy sexual practices and healthy eating.
There was some resistance from individual members of
the community related to the information that might
be provided in the support groups, so materials
used in the program were developed in conjunction
with parent groups. The program was expanded to
include faith-based settings for alternative support
groups that would provide the same intervention but
with an emphasis on abstinence from sexual relations
for parents and teens who were only willing to con-
sider abstinence-based approach.

The nurses established three measurable outcome
objectives:

• 75% of the teens who participate in the healthy
lifestyles program will demonstrate an increase in
self-esteem.

• 75% of participants who report they are not
sexually active at the beginning of the program
will report they are still abstinent at the end of
the program, and 75% of those who report that
they are sexually active will report that they are
practicing safe sex.

• 75% of the participants will demonstrate healthy
eating habits and daily exercising; 50% of participants
with a BMI above normal will have a BMI within
the normal range within 5 months of starting the
program.

When developing the nutrition intervention, they
considered the fact that there may be cultural issues
that should be addressed in the program. Food is
fundamental to a person’s social and racial identity.
In many parts of the world, health is determined by
traditional dietary rules and practices. Recommenda-
tions given by a nurse or health-care provider are
often in direct conflict with cultural rules. As a result,

women make food choices before conception, during
pregnancy, when planning feedings for their newborn,
and during their postpartum period based on their
cultural and social history. To address this, they in-
cluded an assessment of the cultural context related
to the nutritional aspect of their program prior to
implementing the program.

For goal 2, the community team chose to take a
universal approach and target enforcement of
existing laws in City A. The nurses helped the team
develop a campaign to stop sales of tobacco products
to underage customers, targeting stores selling to-
bacco located close to schools and playgrounds.
The team’s objectives were that 100% of all these
stores in City A would comply with laws that
prohibit sales of tobacco products to minors. The
community team also decided to initiate a media
campaign aimed at female middle school children,
using social networking sites at the beginning of the
school year. Their objective was that there would
be no change in the percentage of students who re-
ported they did not use tobacco from the beginning
of the school year to the end.

During the entire process, the nurses who had
initiated the project had the opportunity to work
with an interdisciplinary team that included key
stakeholders and members of the community. They
personally implemented the team’s first intervention
because of their expertise and their ability to evalu-
ate the success of the program. They were then able
to work with a larger community team to develop a
more ambitious primary prevention program titled
the Healthy Teens and Healthy Families program.
They were able to partner with nurses in a school
setting to deliver part of the program. They had ac-
tively advocated for their patients and helped fill a
gap in their community while building on available
community resources, such as the hospital-affiliated
prenatal clinic for teens and the school-based health
clinics.

n EVIDENCE-BASED PRACTICE
Culture and Nutrition During
Pregnancy

Practice Statement: Food is fundamental to a
person’s social and racial identity. In many parts of
the world, health is determined by traditional dietary
rules and practices. Recommendations given by a

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434 U N I T I I I n Public Health Planning

nurse or health-care provider are often in direct
conflict with cultural practices. As a result, women
make food choices during the preconception period,
during pregnancy, for feeding for their newborn, and
during their postpartum period based on their cultural
and social backgrounds.
Targeted Outcome: Healthy nutrition throughout
pregnancy that is congruent with cultural practices.
Evidence to Support: Development of a nutritious
diet plan for pregnant women requires that nurses
learn about and respect the food practices of the
diverse clients with whom they work. Strong evi-
dence exists that early nutrition has a positive effect
on the growth and development of the fetus and the
child. However, limited nursing research has been
conducted on the cultural aspect of nutrition during
pregnancy. Nurses who plan health promotion
programs for maternal-infant settings must consider
race, ethnicity, and sociocultural influences to plan
culturally appropriate interventions. Differences
exist from a cultural perspective in relation to weight
gain and nutrition. Cultural issues were seen as both
support for and barriers to healthy nutrition. Other
issues that emerged were economic disadvantage
and lack of food security. Studies have shown the
impact of cultural practices on food consumption
during pregnancy. A study performed by Santiago and
his associates of 200 predominately Hispanic women
in California revealed that the majority of the
women’s diets included fresh fruits, meat, milk and
juice, and prenatal vitamin supplements. However,
large percentages of the women reported eating
high-sugar sweet desserts, and high fat and salty
fast foods more than once a week. They also found
a high proportion of the women unknowingly con-
sumed foods with BPA, methylmercury, caffeine,
alcohol, and certain over-the-counter medications,
all of which have been shown to have adverse effects
on the developing fetus. In another study, Coronios-
Vargas et al. showed the effects of cultural choices
on food cravings and aversion of 160 women from
four ethnic groups: Black, Cambodian, Hispanic,
and White. Women were all enrolled in WIC pro-
grams and completed questionnaires about their
food preferences during pregnancy. The Cambodian
women craved more meat and spicy/salty foods
than the other three groups. Additionally, educational
level and number of years spent in the U.S. were
positively correlated with significantly more cravings
for traditional western American foods such as

chicken, peanut butter, and hotdogs. Aversions
for less typical American food such as fermented
fish and pigs’ feet also increased with higher educa-
tional level and more years of residence in the U.S.
Further evidence is needed that evaluates the
effectiveness of cultural tailoring of pregnancy
nutritional protocols and guidance for diverse
populations.
Recommended Approaches: Conducting a cultural
assessment prior to implementing a nutritional pro-
gram for pregnant women is a critical first step.
Understanding the cultural norms for nutrition can
help in the development of a pregnancy nutrition
curriculum that incorporates cultural supports and
addresses possible cultural barriers.

A comprehensive cultural assessment is essential
to developing a culturally appropriate plan and
guidance for pregnant women of diverse back-
grounds. The assessment should include collecting
information about all aspects of the woman’s back-
ground all of which may influence access to food,
patterns of consumption, and preference. Items to
assess include home/geographical setting (e.g.,
urban, rural, tribal), race and ethnicity, language,
gender, age, spiritual/religiosity/faith beliefs, disability
status, immigrant or refugee status, educational and
literacy levels, health literacy level, sexual orientation,
socioeconomic status, and military status. Under-
standing how each of these may influence nutrition
during pregnancy, as well as developing a plan that
incorporates these influences, is critical to adequate
nutrition during pregnancy. Linguistic considerations
should also be accommodated both in verbal and
written communications. Providers should also
avoid bias, prejudice, and stereotypes in working with
diverse populations and their cultural and food
practices. The goal is to help women develop a
nutritional plan that recognizes their cultural prac-
tices as well as supports a healthy outcome for the
pregnancy and the developing fetus.

Sources:
1. Koletzko, B., Brands, B., Grote,V., Kirschberg, F.,

Prell, C., Rezehak, P., … Weber, M. (2017). Long-term
health impact of early nutrition: The power of
programming. Annals of Nutrition and Metabolism, 70,
161-169. doi.org/10.1159/000477781

2. Ramakrishnan, U., Grant, F., Goldenberg, T., Zongrone,
A., & Martorell, R. (2012). Effect of women’s nutrition
before and during early pregnancy on maternal and infant
outcomes: A systematic review. Paediatric and Perinatal

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C H A P T E R 1 7 n Health Planning for Maternal-Infant and Child Health Settings 435

Epidemiology, 26(Suppl. 1), 285–301. doi:10.1111/
j.1365-3016.2012.01281.x

3. Bravo, I., & Noya, M. (2014). Culture in prenatal develop-
ment: Parental attitudes, availability of care, expectations,
values and nutrition. Child and Youth Care Forum, 43(4),
521-538.

4. Whitaker, K., Wilcox, S., Liu, J., Blair, S., & Pate, R. (2016).
Patient and provider perceptions of weight gain, physical
activity and nutritional counseling during pregnancy:
A qualitative study. Women’s Health Issues, 26(1),
116-122.

5. Coast, E., Jones, E., Lattof, S., & Portela, A. (2016). Effec-
tiveness of interventions to provide culturally appropriate
maternity care in increasing uptake of skilled maternity
care: A systematic review. Health Policy and Planning,
31(10), 1479-1491.

6. Iwelunmor, J., Newsome, V., Airhihenbuwa, C. (2013).
Framing the impact of culture on health: A systematic
review of the PEN-3 cultural model and its application
in public health research and interventions. Ethnicity &
Health, 1(19), 20. DOI: 10.1080/13557858.2013.857768

7. Coronios-Vargas, C., Toma, R.V., Tuveson, R.V.,
Schultz, I.M., & Schutz, M. (2010). Cultural influences
on food cravings and aversions during pregnancy.
Ecology of Food and Nutrition, 27(1), 43-49. DOI:10.1080/
03670244.1992.9991224

8. Santiago, S.E., Park, G.H., & Huffman, K.J. (2013).
Consumption habits of pregnant women and implications
for developmental biology: A survey of predominantly
Hispanic women in California. Nutrition Journal, 12(91),
1-14.

9. Bronheim, S., & Goode, T. (2013). Documenting the
implementation of cultural and linguistic competence: Guide
for maternal and child health bureau funded training
programs. Washington, D.C.: National Center for
Cultural Competence, Georgetown University Center
for Child and Human Development.

Prematurity and Low Birth Weight
As discovered by the nurses in City A, preterm birth
and LBW are associated with increased morbidity
and mortality during the first year of life as well as
with developmental delays that can extend across
childhood. LBW is defined as a birth weight less than
5.5 pounds, or 2,500 grams, whereas very low birth
weight (VLBW) is defined as a birth weight less than
3.3 pounds, or 1,500 grams. Babies born with a LBW
have a variety of morbidities that correspond to the
severity of their LBW.59

Strongly associated with LBW is preterm birth.
Preterm birth is defined as the birth of a live infant
before 37 weeks of gestation, whereas a very preterm

infant is born at less than 32 weeks gestation (Fig. 17-5).
Frequently, babies born prematurely face health prob-
lems such as respiratory distress due to immature lungs
and respiratory system, problems with feeding, difficulty
with thermoregulation, jaundice, neurological problems
with brain development, cerebral palsy, and risk for
learning disabilities, blindness, and hearing loss. They
are also at a greater risk for death.59 In addition, there are
significant costs. In the United States, those costs amount
to approximately $26 billion per year.60

Most infants born prematurely meet the definition
of LBW, but not all infants with a LBW are premature.
A way to help separate the two terms is to evaluate
the infant’s weight, head circumference, and length
against standardized growth charts based on gesta-
tional age. An infant born at 30 weeks who weighs
1,490 grams may meet the definition of VLBW but is
actually close to the 50th percentile for his gestational
age. But an infant born at 38 weeks who weighs
2,400 grams not only meets the definition of LBW but
also is in the 5th percentile for his gestational age.
Therefore, there are differences between preterm birth
and LBW. From an epidemiological perspective, both
prematurity and LBW are used as measures of the
overall neonatal health of a population despite the
overlap between the two terms.

The difficulty is determining the risk factors associated
with each of these health indicators. In almost one-half
of all preterm births, the cause is unknown. Risks asso-
ciated with preterm labor include bacterial infection in
the mother. It is thought that the infectious process sets

Figure 17-5 Nurse caring for premature infant. (From
the CDC public health awareness campaign to promote prenatal
care; Centers for Disease Control and Prevention Public Health
Images Library #8291.)

7711_Ch17_420-446 28/08/19 9:16 AM Page 435

off an immune response in the body of the pregnant
mother that contributes to preterm labor and delivery.
Another risk is psychological stress in the mother
that results in fetal stress which triggers early uterine con-
tractions. Corticotrophin-releasing hormone (CRH), a
stress- related hormone, can be triggered by chronic
psychosocial stress in the mother or physical stress to the
fetus. The release of CRH is thought to precipitate uterine
contractions that lead to premature labor and delivery.
Maternal complications, such as placental abruption,
are also linked to prematurity. In response to the
bleeding, blood clotting stimulates uterine contractions.
When there are multiple fetuses or abnormalities of
the uterus or placenta, the uterus can become over-
stretched, and premature contractions may occur. In-
fants born as multiple births are about nine times more
likely to be premature and have an LBW than singleton
(one baby) births. Other medical risks include diabetes,
hypertension, mother being underweight before preg-
nancy, obesity, and a short time between pregnancies.
Finally, interventions such as inductions and cesarean
sections can also lead to preterm births.61

Vulnerable Populations and Low Birth
Weight Disparity
Differences exist in the risk of having an LBW infant
based on race and socioeconomic status. Globally
tracking LBW has been hampered as the LBW database
has not been updated since October 2014. According
to UNICEF, one of the problems is that “… nearly half
of all babies are not weighed at birth. Moreover, the
babies that are weighed are more likely to be born
in health facilities, urban areas and of better-educated
mothers, which can lead to an underestimation of
LBW incidence.”62 UNICEF, in collaboration with
other organizations, is working on updating the data
base and hopes to have LBW data in their 2019 re-
port.62 Based on data from 2014, approximately 22 mil-
lion, or 16%, of all babies fell into the LBW category.63

In 2016, the U.S. LBW rate was 8.17% percent, the
VLBW rate was 1.4%, and the percent of preterm
births was 9.85%.64

In the U.S., racial disparities exist with regard to the
incidence of LBW. The African American rate of LBW is
almost two times higher than that of non-Hispanic white
infants (13.7% vs. 7%).65 The temptation in the U.S. is
to ascribe this disparity solely to assumed genetic differ-
ences. Yet the role of environment, access to prenatal
care, and systematic issues of inequality all conspire to
create social determinants of health resulting in poor
outcomes for persons of color.

Global and National Initiatives to Reduce LBW

436 U N I T I I I n Public Health Planning

n HEALTHY PEOPLE
HP 2020 Maternal Infant Child Health
(MICH) Objectives Related to Low
Birth Weight

MICH objective 8.1: Reduce low birth
weight (LBW)
Baseline: 8.2%of live births were low birth weight in 2007
Target: 7.8%
Target-Setting Method: Projection/trend analysis
Source: National Vital Statistics System–Natality
(NVSS–N), CDC, NCHS

MICH objective 8.2: Reduce very low birth
weight (VLBW)
Baseline: 1.5% of live births were VLBW in 2007
Target: 1.4%
Target-Setting Method: Projection/trend analysis
Source: National Vital Statistics System–Natality
(NVSS–N), CDC, NCHS
Midcourse Review: In 2013, these objectives met
or exceeded the 2020 targets. LBW was 8.0% in 2013,
and VLBW 1.4% in 2013.12 In 2016, there was no
change in these rates.64

March of Dimes Prematurity Campaign
Building on their earlier Prematurity Campaign, “… In
2017, the March of Dimes began the Prematurity
Campaign Collaborative to address the persistent health
inequities and the rising rate of preterm birth in the
United States”.66 This campaign provides information
and services for families of newborns in neonatal inten-
sive care units, creates community intervention pro-
grams to increase awareness of the problem, and
includes funding for basic research to improve practice
both in the United States and globally. In addition, the
campaign helps health-care providers identify risks for
premature birth and increases their ability to detect
these risks in pregnant women. Since the initiation of
the campaign, the March of Dimes has funded research
and advocated for the PREEMIE Act (Prematurity
Research Expansion and Education for Mothers Who
Deliver Infants Early) that became law in 2006. The
Prematurity Campaign supports activities in five main
areas: research and discovery; care innovation and com-
munity engagement; advocacy; education; and family-
centered newborn intensive care units (NICUs).66

7711_Ch17_420-446 28/08/19 9:16 AM Page 436

Knowledge of strategies to effect change in the
modifiable risk factors for infant mortality, specifically
preterm birth and LBW, include education of women
about preconception health, and the risks of smoking,
alcohol use, and illegal drug use. In addition, all health-
care providers involved with pregnant women as well
as pregnant women themselves must be aware of the
signs of preterm labor, defined as the presence of uter-
ine contractions between 20 and 37 weeks that result in
progressive dilation and effacement of the cervix. Nurses
must reach out to diverse population groups and inte-
grate culturally-sensitive messages into their educational
materials and programs. Additionally, nurses must
advocate for legislation, support federal and state
legislation to increase research on prematurity, and
work to expand maternity care services.

C H A P T E R 1 7 n Health Planning for Maternal-Infant and Child Health Settings 437

provide some funding. They adopted a model of part-
nership proposed by two public health nurses (PHNs),
Leffers and Mitchell, that included the following
components:66

• Participation by multiple constituencies to strengthen
the community support for the interventions

• Collaboration because it is necessary to address health
problems and is fundamental to partnerships

• Issues of diversity that are addressed respectfully and
appropriately, with representation of the various
diverse groups in the community

• Expertise and resources that grow stronger with broad
partners working together

• Partnership relationships as they are essential for the
sustainability of interventions.

Another issue that the team addressed was dispar-
ities in preterm births and LBW related to ethnicity.
At the national level, both the LBW rate and the
preterm birth rate were higher for African American
mothers than they were for any other ethnic group,
with the LBW rate almost double in these mothers
compared with non-Hispanic white mothers (13.68
vs. 6.97 in 2016). When they examined the literature
to look for the underlying causes of the disparity,
two of the possible causes were limited or lack of
access to care and lower income. In a classic study,
researchers dispelled the notion of the likelihood of
genetic differences. The study’s findings indicate that
the rates of LBW and VLBW for first-generation
African American women were similar to the rates
for U.S.-born, non-Hispanic white women and were
significantly less than the rate for U.S.-born, African
American women.67 Since then, much of the evidence
supports a strong link between LBW and VLBW
infants and social determinants, poverty, racial
discrimination, and chronic stress.13 In addition,
African American mothers are at higher risk for
having LBW infants.13

Based on their analysis of the data that confirmed
significant disparities among racial and ethnic groups in
City A, the team developed a citywide Healthy Babies,
Healthy Families program that used the HP objectives
as goals:

• Goal 1. Reduce preterm births.
• Goal 2. Reduce the number of LBW and VLBW

infants.

The program included multiple interventions, includ-
ing a media campaign and an outreach to underserved

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Small Babies
Public Health Science Topics Covered:

• Epidemiology
• Focused assessment
• Health planning
• Coalition building

To determine additional priority areas for nursing
interventions, epidemiological and demographic data
should be used for assessment. In response to the
work begun with the Healthy Teens and Healthy Fami-
lies program, the nurse team from City A also worked
to obtain funding to address the preterm birth rate
in the city. They were aware that their city had not
met the HP 2020 objective to reduce LBW and
VLBW. To further evaluate the data, the nurse team
compared the local rates with the state’s, using the
national morbidity data set. Their findings confirmed
that the rate of preterm births exceeded the state and
national rates as well as the HP 2020 goals and had
increased over the past decade from 15.5% to 22.2%;
this was a little more than double the national rate.
The team decided to conduct a more in-depth epi-
demiological investigation to identify determinants of
this health issue as well as strategies for addressing the
problem in City A. To plan an intervention that would
address preterm birth and LBW, the team partnered
with the state department of maternal-child health and
the local chapter of the March of Dimes. Both entities
had a long-standing commitment to the improvement
of maternal and infant outcomes, and were able to

7711_Ch17_420-446 28/08/19 9:16 AM Page 437

and implemented a child passenger safety program based
on their exposure to severe trauma in children who were
not properly restrained in a car. The program was offered
to low-income families at 46 fitting stations located in
the community, including fire stations and health depart-
ments, so that parents could receive help on car seat
installation. In other cases, nurses implemented changes
in procedures within the hospital setting to help provide
better care, as illustrated in the use of an intensive care
approach to care for children with polio in the 1950s (see
Chapter 14). This requires applying public health science
to the problem and determining whether the interven-
tion was effective.

438 U N I T I I I n Public Health Planning

l APPLYING PUBLIC HEALTH SCIENCE
The Case of One State’s Approach
to Decrease Infant Mortality Rates
Public Health Science Topics Covered:

• Epidemiology
• Surveillance
• Infant Mortality Rates
• Health planning

The State of South Carolina, for many years, has
had an IMR higher than the U.S. rate of 5.8 deaths
per 1,000 live births.70 South Carolina’s IMR in 2005
was 9.5 – placing it among the highest rates in the U.S.
In 2009, the IMR had decreased to 7.1, and in 2017
South Carolina’s IMR was 6.7.71 The drops in the IMR
are impressive even though South Carolina’s rate is
still higher than the overall U.S. IMR of 5.8.15 South
Carolina adopted a new model of care that has had
a positive effect on the IMR both in terms of health-
care outcomes and the cost of health care.

South Carolina’s IMR, similar to other locations
in the U.S., was highest among African American
women and poor women. Across the state, health-care
providers, including nurse midwives, were concerned
about the persistently high IMR. This IMR placed the
state among the last out of all the states, and these
health-care providers wanted to determine what could
be done to address this health disparity and improve
birth outcomes for mothers and infants. Nurses,
nurse midwives, other health-care providers, and public
health MCH providers were aware of many of the risk
factors and barriers for many women that make it
difficult for them to engage in and remain in prenatal
care. Their needs assessment identified late entry into
prenatal care and inconsistent use of prenatal care.

neighborhoods within the community using trained
lay health workers, aimed at increasing prenatal care
and promoting healthy living. The risk factors targeted
by their program included the issues addressed in
their first program with pregnant teens, tobacco use,
and obesity, because these are associated with preterm
births and LBW, while adding an intervention aimed
at improving access to and utilization of prenatal
care. They planned to expand their intervention to all
women of childbearing age. In addition, to reach their
goals to reduce preterm births and LBW, they needed
to assess outcomes over an extended period to iden-
tify changes that could be attributed to the program in
City A. The goals and objectives for the prematurity
and LBW initiatives would be measured by both imme-
diate outcomes and long-term impact evaluation (see
Chapter 5).

In addition to the impact evaluation, the nurses were
involved with a process evaluation (see Chapter 5).
For the citywide Healthy Babies, Healthy Families
program, the team created an advisory committee to
strengthen the collaboration with the community and
provide feedback. In the process evaluation, issues of
implementation such as efficiency and effectiveness for
the components of the program were addressed. In
this case, the team evaluated the performance by
team personnel, the lay health workers, educational
resources and process, program participation and com-
pliance with program elements, degree of fidelity to
program interventions, timeliness, and budget expendi-
tures. They located resources for protocols and tools
for evaluation.69 The primary long-term outcome of the
Healthy Babies, Healthy Families program was a reduc-
tion in the number of preterm births, LBW infants, and
VLBW infants in City A, with a subsequent reduction in
IMR as well.

Applying Public Health Science to
Acute Maternal, Infant, and Child
Health Settings
The use of a population-level approach is helpful in acute
maternal-infant health settings as well. Often, the nurses
are the first to become aware of a trend in the health of
infants and small children, and reach out to the commu-
nity to implement a prevention program. For example, as
mentioned in Chapter 12, the trauma nurses at the
Cincinnati Children’s Hospital Medical Center developed

7711_Ch17_420-446 28/08/19 9:16 AM Page 438

C H A P T E R 1 7 n Health Planning for Maternal-Infant and Child Health Settings 439

To complete their assessment of barriers and risks,
state-level data from 2008 and 2009 were reviewed.
The leading causes of infant deaths (42.6%) were con-
genital malformation and deformation disorders related
to short gestation (premature birth), LBW, and SIDS.71

Although the number of deaths due to maternal com-
plications decreased by 47.2% between 2008 and 2009,
and deaths due to dental causes such as unintentional
suffocations and strangulations decreased, there was
almost no change in infant deaths due to disorders
related to short gestation and LBW.71

The state’s health-care providers, especially the
nurses and nurse midwives, believed a new model of
delivery of prenatal care was needed to address the
continued high rate of IMR. Some nurses and nurse
midwives had heard about group prenatal care and
the positive impact it was having on maternal and infant
pregnancy and birth outcomes. The group model for
prenatal care was known as CenteringPregnancy. The
model was initially developed and implemented in
the 1990s by Yale-trained nurse midwife Sharon
Rising, CNM, MSN, FACM. MCH care providers were
interested in exploring the model for potential
implementation in the state to address the perinatal
health disparities.72

The CenteringPregnancy model is an evidence-based
model built on findings from research that prenatal
education and social support have significant positive
effects on birth outcomes, such as reduced risk for
LBW babies and less substance use among at-risk
mothers. The findings from other studies provided
additional strong evidence about the benefits of the
CenteringPregnancy model, including a reduction in
the likelihood of preterm delivery, a reduction in the
risk of NICU admissions, and a reduction in fetal de-
mise.73,74 Additional benefits included improved mental
health for some participants and an increased likeli-
hood that they would engage in breastfeeding.73 The
CenteringPregnancy model is implemented with
groups of 8 to 12 women; groups are formed
around gestational age and due dates. The groups
meet around routine scheduled prenatal care visits
and involve 10 visits of 90 minutes to 2 hours duration.
Each session includes a physical assessment completed
by the providers and some self-assessments such as
weight, blood pressure, and recording their own health
data. The groups have informal discussions among the
participants and the facilitator. These discussions in-
clude educational content and provide an opportunity
to discuss a variety of topics and concerns that women

have about their pregnancy, their health, their infant,
and their family’s health. The model and published
research about positive impact on birth outcomes,
especially LBW, and women’s satisfaction with the
model of care convinced providers in South Carolina
to implement a CenteringPregnancy model of
prenatal care groups. During 2009, with a $1.7 million
grant, the South Carolina Department of Health and
Environmental Control (SCDHEC) implemented the
CenteringPregnancy model of care. The objectives
included:

• Reducing IMR disparities
• Reducing C-Section rates
• Reducing preterm births
• Increasing adequate prenatal care utilization
• Decreasing gestational diabetes

The CenteringPregnancy groups were imple-
mented across South Carolina at 24 sites, primarily
for women who were Medicaid recipients. Along
with implementing the CenteringPregnancy model,
South Carolina health-care providers implemented
increased access to long-acting reversible contracep-
tion (LARC) and targeted breastfeeding by encourag-
ing hospitals to achieve the Baby Friendly Hospital
designation.

There have been several state reports and presenta-
tions of the South Carolina CenteringPregnancy pro-
gram outcomes.74-76 Five years after the project was
implemented, an analysis of the data provided evidence
that there was increased prenatal care, decreased
preterm births, decreased gestational diabetes, de-
creased C-section rates, and increased breastfeeding
rates among the mothers who participated. Overall,
there was a 34% reduction in the odds of having a
preterm birth, and among African American women
there was a 60% reduction in the odds of having a
preterm birth. In terms of reducing the disparities in the
IMR, there was also a significant reduction in IMR. In
2011 the overall state IMR was 7.4/1,000 live births, and
for African American mothers it was 12.6/1,000 births.
By 2014, the state rate was 6.5/1,000 live births, and for
African American mothers it was 9.3/1,000 live births.76

A retrospective 5-year cohort study of women who
were recipients of Medicaid and who had participated
in the CenteringPregnancy programs showed significantly
improved outcomes.73 Findings revealed a 36% reduced
risk for preterm birth and a 44% decreased incidence
of delivering a LBW infant. Also, the infants of mothers
who had participated in CenteringPregnancy programs

7711_Ch17_420-446 28/08/19 9:16 AM Page 439

Maternal-Infant and Early Childhood
Home Visiting
Home visiting has been a key component of public
nursing since the turn of the last century, as exempli-
fied in work done by Lillian Wald in New York City in
the early 1900s (see Chapter 1). Nursing home health
visits have traditionally included the delivery of health
care in the home. It is not a specific, single intervention
but rather represents a systematic approach to the
delivery of services within the home setting that
combines resources and supports available in the com-
munity. Common elements across home visiting pro-
grams for mothers and children include provision of
social support to parents, connecting families to com-
munity services, and providing education to parents
on childhood development.77 The majority of home
visiting programs target at-risk pregnant women or
parents, or both, to assist them to engage in prenatal
care, which is associated with improved pregnancy and
birth outcomes, and to assist them to provide a home
environment that supports optimal infant growth and
development.77 Published research has provided evi-
dence that high-quality home visiting programs are as-
sociated with better maternal and infant outcomes,
increased school readiness for children, reduced rates
of child neglect and abuse, and higher levels of parent
education and income.78A rigorous study by the
RAND Corporation showed that high-quality home
visiting programs are a good investment.79 There is
$5.70 return for every tax dollar spent on a home visit
due to reduced expenditures for health care and wel-
fare services.

The Affordable Care Act and Maternal,
Infant, and Early Child Home Visiting
Prior to the implementation of the Affordable Care Act
(ACA), approximately 450,000, or about 2% of U.S. chil-
dren and their families, received home visiting services.
To help increase that number, the 2010 ACA authorized
federal funding for Maternal Infant and Early Child

Home Visiting (MIECHV) programs. These were
defined as programs that included home visiting as a pri-
mary service delivery strategy.80 These programs were set
up to be offered voluntarily to pregnant women with
children age 5 or under. The goal was to improve maternal-
child health outcomes.81 In 2012, $71,900,246 was
awarded to 10 state-level organizations. The purpose was
to implement home visiting programs to provide links
to services as well as early childhood education.82 As part
of the grant application process, organizations had to
conduct a needs assessment (Chapter 4) using a public
health approach to identify the needs of the population,
and then tailor the program to the specific needs of that
population.

Data from a FY2017 review of home visiting models
provides ample evidence of the effectiveness of the
MIECHV programs. Each year approximately 156,000
parents and children received services through 942,000
home visits. Services were provided in 27% of U.S. coun-
ties, (22% rural counties and 36% urban counties), and
72% of participating families had household incomes at
or below 100% of the federal poverty guidelines ($24,600
for a family of 4). More than 80% of all funded programs
showed significant improvements in the benchmarks,
which include improved maternal and child health out-
comes; improved school readiness and achievement; im-
proved family economics and sufficiency; reduced child
injuries, abuse, and neglect; reduced domestic violence;
and improved coordination for referrals for community
resources.81

Home Visiting Program Models: What
Works?
Astero and Allen pointed out that evidence is divided
over what works, but across studies there is evidence
that home visiting programs have resulted in positive
outcomes.80 Central to the effectiveness of programs
is the inclusion of a systematic approach to the delivery
of services. Kahn and Moore completed a systematic
review of 66 studies that included a home visiting
component. They found that high-intensity early
childhood programs were effective for one or more
childhood outcomes.81 The Health Resources and
Services Administration has compiled a list of home
visiting programs and encourages the collection of
further evidence to support the use of a home visiting
approach.82

Many of these interventions are delivered by PHNs.
For example, in Washington County, Oregon, the Web
site related to maternal-child home visits states that “the
Field Team consists of experienced PHNs who make

440 U N I T I I I n Public Health Planning

had a 28% reduced risk of a NICU stay. Gareau con-
cluded that the South Carolina’s $1.7 million investment
yielded an estimated $2.3 million return on their
investment. It was concluded that CenteringPregnancy,
a nurse-led model of care, was effective in reducing
perinatal health disparities, improving health outcomes,
and achieving cost savings.73

7711_Ch17_420-446 28/08/19 9:16 AM Page 440

home visits to pregnant or postpartum women and fam-
ilies with newborn infants or young children with special
health-care needs.”83 These nurses meet with families in
their homes, provide education, and help link the fami-
lies with needed resources. The focus is to help decrease
the disparity in childhood outcomes related to socioeco-
nomic status.83

The Health Resources Services Administration
(HRSA) published a list of evidence-based programs that
meet their criteria (Box 17-3). The benchmarks chosen

for the MIECHV programs are consistent with the
goal of the program to reduce disparity in health out-
comes in children. They include six areas (Box 17-4).
The evidence-based programs listed by the HRSA are,
for the most part, based on a developmental theoretical
framework. For example, the Child First program
is based on research related to early brain develop-
ment. The program focuses on building a nurturing
environment for at-risk children based on the hypoth-
esis that nurturing is protective in relation to brain
development.

PHNs providing maternal, infant, and child home
visits are actively engaged in prevention using a selective
approach (Chapter 2) providing interventions to mothers
and children at greater risk for more impoverished child-
hood outcomes. Recently HRSA has contracted with
Mathematica Policy Research to conduct a systematic re-
view of home visiting research. The HRSA HomVee re-
view included only program models that used home
visiting as the primary mode of service across eight do-
mains and aimed to improve outcomes in at least one of
the eight domains. The eight domains were: (1) maternal
health, (2) child health, (3) positive parenting practices,
(4) child development and school readiness, (5) reduc-
tions in child maltreatment, (6) family economic self-
sufficiency, (7) linkages and referrals to community
resources and supports, and (8) reductions in juvenile
delinquency.84 The study included 45 program models,
and among those programs, 20 met the DHHS criteria
for evidence-based early childhood home visiting

C H A P T E R 1 7 n Health Planning for Maternal-Infant and Child Health Settings 441

The eight domains (benchmark areas) in which to
demonstrate improvement among eligible families
participating in the Maternal, Infant, and Early Childhood
Home Visiting Program (MIECHV) are:

1. Maternal health
2. Child health
3. Positive parenting practices
4. Child development and school readiness
5. Reductions in child maltreatment
6. Family economic sufficiency
7. Linkages and referrals to community resources and

support
8. Reductions in juvenile delinquency, family violence

and crime

BOX 17–4 n Benchmark Areas to Demonstrate
Improvement to Reduce Health
Disparities in Children

Source: (84)

Home Visiting Evidence of Effectiveness (HomVEE),
a program within the U.S. Department of Health and
Human Services, has reviewed 45 home visiting models
that meet the DHHS criteria for evidence-based models,
including at least one high- or moderate-quality impact
study with favorable, statistically significant impacts in two
or more of the eight outcome domains; at least one of
the impacts is from a randomized controlled trial and has
been published in a peer-reviewed journal; and at least
one of the impacts was sustained for at least 1 year after
program enrollment. Of the programs reviewed, 20 met
the DHHS criteria for an evidence-based early childhood
home visiting program model.

• Attachment and Biobehavioral Catch-Up (ABC)
intervention

• Child First
• Early Head Start—Home Visiting
• Early Intervention Program for Adolescent Mothers
• Early Start (New Zealand)
• Family Check-Up
• Family Connects
• Family Spirit
• Healthy Access Nurturing Development Services
• Healthy Beginnings
• Healthy Families America (HFA)
• Healthy Steps (National Evaluation 1996 Protocol)
• Home Instruction for Parents of Preschool Youngsters

(HIPPY)
• Maternal Early Childhood Sustained Home Visiting

Program
• Minding Baby
• Nurse Family Partnership (NFP)
• Oklahoma Community-Based Family Resource and

Support Program
• Parents as Teachers (PAT)
• Play and Learning Strategies (PALS) Infant
• Safe Care Augmented

BOX 17–3 n Evidence-Based Home Visiting
Service Delivery Models

Source: (84)

7711_Ch17_420-446 28/08/19 9:16 AM Page 441

programs. In terms of program impacts, one program
model, Healthy Families, had one or more effects on
each of the eight domains. Healthy Families America
had the widest range of favorable impacts in all
eight domains using primary or secondary measures.
Nurse Family Partnership was next with favorable
outcomes in seven domains. Interestingly, none of the
20 evidence-based programs showed favorable impacts
on juvenile delinquency or family violence using a
primary measure.84

Programs receiving MIECHV funds have mandated
content that must be included in the home visit curricu-
lum. All home visits must include: (1) preventive health
and prenatal care practices, (2) assisting mothers with in-
fant care and to maintain breastfeeding, (3) increasing
parents knowledge and understanding of infant and
child development milestones and behaviors, (4) provid-
ing parents with techniques that promote their use
of praise and other positive parenting techniques, and
(5) helping mothers to set goals for the future, including
continuing their education, finding employment, and se-
curing appropriate, affordable child care solutions. The
home visitor provides knowledge and informational
resources, and demonstrates and models strategies for
maternal health practices, infant care, and parenting
techniques.

n Summary Points
• Maternal, infant, and child health is a major indicator

of the health of populations.
• Globally, the IMRs and MMRs continue to be major

health issues.
• Preterm birth is a leading cause of infant mortality

worldwide.
• Nurses working in maternal-child health settings

can actively engage in efforts to improve the health
of mothers and children through the implementation
of programs at the community level and within an
acute care nursing unit.

442 U N I T I I I n Public Health Planning

t CASE STUDY
Planning a Breastfeeding
Promotion Program

Learning Outcomes
At the end of this case study, the student will be able to:

1. Apply assessment strategies for accessing secondary
data.

2. Describe assessment strategies for obtaining
primary data.

3. Identify evidence-based practice relevant to perinatal
health promotion.
a. Describe the Ten Steps of the Baby Friendly

Hospital Initiative.
4. Describe strategies for the development of a

community support program.

The nurses in an urban hospital in Baltimore
attended a professional development in-service
regarding the newly updated WHO/UNICEF Baby
Friendly Hospital Initiative Ten-Steps (BFHI) (2018),
CDC Guide (2013), Surgeon General’s Call to Action
(2011), and the Healthy People 2020 Breastfeeding
goals (CDC, 2018). The in-service emphasized the role
of nurses working in perinatal, mother-baby unit, and
newborn nursery settings to promote breastfeeding
by applying the BFHI Ten-Steps to improve exclusivity
rates and durations.

On return to work, they decided to review their
current breastfeeding support program and identify:
opportunities for aligning with the updated BFHI Ten
Steps program, and ways to connect with resources in
the community. They invited lactation consultant
nurses from the Maryland Breastfeeding Coalition to
help them review the existing data about breastfeeding
and to discuss developing a community support
program or clinic and partnership.

The lactation consultants directed them to available
Web sites including:

• BFHI: http://www.who.int/nutrition/bfhi/ten-steps/en/
• Healthy People 2020 Breastfeeding Goals: http://

www.usbreastfeeding.org/p/cm/ld/fid=221
• CDC Breastfeeding Report Card: https://www.cdc.gov/

breastfeeding/data/reportcard.htm
• CDC’s Guide to Strategies to Support Breastfeeding

Mothers and Babies: https://www.cdc.gov/breastfeeding/
pdf/BF-Guide-508.PDF

• U.S. Breastfeeding Committee and Coalition: http://
www.usbreastfeeding.org/coalitions-support

• U.S. Surgeon General’s Call to Action to Support of
Breastfeeding: https://www.surgeongeneral.gov/
library/calls/breastfeeding/index.html

Using their approach, answer the following ques-
tions that apply to assessment and planning.

1. Review the CDC BF Report Card. How does Mary-
land and your own state’s current breastfeeding data
compare with other states and national data?

7711_Ch17_420-446 28/08/19 9:16 AM Page 442

C H A P T E R 1 7 n Health Planning for Maternal-Infant and Child Health Settings 443

2. Reflect on the BFHI Ten Steps and how these
steps can increase breastfeeding rates.

3. Which of the Ten Steps reflects community
support?

4. Review Healthy People Breastfeeding goals and
Maryland State BF rates (or choose your own
state). Does the data indicate a need for a breast-
feeding support program or clinic?

5. Reflect on national initiatives to improve commu-
nity breastfeeding support, such as the USBC,
CDC, and the U.S Surgeon General. What are
specific initiatives noted that aim to improve
community breastfeeding support?

6. What information is essential to develop a needs
assessment?

7. Consult nursing research to determine evidence-
based strategies for nurses working in maternal-
infant settings to improve breastfeeding support
in the community setting. Review the Kaiser
Permanente tool-kit (2013).

8. How will the problems, objectives, and goals be
prioritized?

9. Describe the process of partnership. Who
will be likely partners for the nurse team?
Any other additional community stakeholders
or agencies?

10. Develop a plan for one intervention, including
the objectives and outcome goal for a commu-
nity program or clinic in a chosen state or
region.

Resources
1. Centers for Disease Control and Prevention. (2013).

Strategies to prevent obesity and other chronic diseases:
The CDC guide to strategies to support breastfeeding mothers
and babies. Atlanta: U.S. Department of Health and
Human Services. Retrieved from http://www.cdc.gov/
breastfeeding

2. Centers for Disease Control and Prevention. (2018).
Breastfeeding report card: United States 2018. Retrieved
from: https://www.cdc.gov/breastfeeding/data/
reportcard.htm

3. Kaiser Permanente. (2013). Improving hospital breastfeeding
support: Implementation toolkit. Retrieved from http://kpcmi.
org/wp-content/uploads/2013/03/kaiser-permanente-
breastfeeding-toolkit

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library/publications/the-world-factbook/rankorder/
2091rank.html. Accessed June 27, 2018.

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16. World Health Organization. (2018). Preterm birth. Retrieved
from: http://www.who.int/news-room/fact-sheets/detail/
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17. United Nations. (2018). Sustainable development goals:
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18. Centers for Disease Control and Prevention. (2018).
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19. ACOG Committee. (2014). Opinion No. 586: Health
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20. Schroeder, S.A. (2016). American health improvement
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21. Alencar Albuquerque, G., de Lima Garcia, C., da Silva
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22. Manley, M.H., Goldberg, A.E., & Ross, L.E. (2018). Invisibility
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23. The American College of Obstetricians and Gynecologists,
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24. Centers for Disease Control and Prevention. (2018).
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26. GBD 2015 Eastern Mediterranean Region Maternal Mortality
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27. GBD 2015 Maternal Mortality Collaborators. (2016).
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28. Centers for Disease Control and Prevention. (2018).
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29. Potter, P. (2001). About the cover: Ignaz Philipp Semmelweis
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33. Mitchell, E.A., Tuohy, P.G., Brunt, J.M., Thompson, J.M.D.,
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34. U.S. Department of Health and Human Services, National
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35. Centers for Disease Control and Prevention. (2018). Sudden
unexpected infant death and sudden infant death syndrome.
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36. Parks, S.E., Erck Lambert, A.B., Shapiro-Mendoza, C.K.
(2017). Racial and ethnic trends in sudden unexpected
infant deaths: United States, 1995-2013. Pediatrics, 139(6),
pii: e20163844. doi: 10.1542/peds.2016-3844.

37. Raglan, G.B., Lannon, S.M., Jones, K.M., & Schulkin, J.
(2016). Racial and ethnic disparities in preterm birth among
American Indian and Alaska Native women. Maternal Child
Health Journal, 20, 16–24. doi: 10.1007/s10995-015-1803-1.

38. Centers for Disease Control and Prevention. (2018). What
is PRAMS? Retrieved from https://www.cdc.gov/prams/
index.htm.

39. March of Dimes Foundation. (2018). Peristats. Retrieved
from https://www.marchofdimes.org/peristats/
Peristats.aspx.

40. Meehan, S., Beck, C., Mair-Jenkins, J., Leonard-Bee, J.,
& Puleston, R. (2014). Maternal obesity and infant mortality:
A meta-analysis. Pediatrics, 133(5), 863-71.

41. Lieberman, R.W., Bagdasarian, N., Thomas, D., & Van De
Ven, C. (2011). Seasonal Influenza A (H1N1) infection in
early pregnancy and second trimester fetal demise. Emerging
Infectious Disease, 17(1). Retrieved from http://wwwnc.
cdc.gov/eid/article/17/1/09-1895_article.htm.

42. Hvid, A. (2017). Association between pandemic influenza
A (H1N1) vaccination in pregnancy and early childhood
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43. Centers for Disease Control and Prevention. (2018). Pertussis
outbreak trends. Retrieved from http://www.cdc.gov/pertussis/
outbreaks/trends.html.

44. Centers for Disease Control and Prevention. (2017).
Teen pregnancy. Retrieved from https://www.cdc.gov/
teenpregnancy/about/index.htm.

45. Mercurio, M.R. (2016). Pediatric obstetrical ethics: Medical
decision-making by, with, and for pregnant early adolescents.
Seminars in Perinatology, 40 (4), 237-246.

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46. Fischer, M., Shlomo, I.B., Solt, I., & Burke, Y.Z. (2015).
Pregnancy prevention and termination of pregnancy in
adolescence: Facts, ethics, law, and politics. Israel Medical
Association Journal, 17(11), 665-8.

47. American Society for Quality. (2018). Fishbone (Ishikawa)
diagram. Retrieved from http://asq.org/learn-about-quality/
cause-analysis-tools/overview/fishbone.html.

48. Center for Disease Control and Prevention. (2018).
Pregnancy complications. Retrieved from: https://www.
cdc.gov/reproductivehealth/maternalinfanthealth/
pregcomplications.htm#Research.

49. American College of Obstetricians and Gynecologists
(ACOG). (2016). Obesity and pregnancy. Retrieved from
https://www.acog.org/Patients/FAQs/Obesity-and-Pregnancy.

50. Vernini, J.M., Brogin Moreli, J., Garcia Magalhães, C.,
Araújo Costa, R.A., Cunha Rudge, M.V., & Paranhos
Calderon, I.M. (2016). Maternal and fetal outcomes in
pregnancies complicated by overweight and obesity.
Reproductive Health, 13, 1–8. https://doi-
org.ezp.welch.jhmi.edu/10.1186/s12978-016-0206-0.

51. Araujo Júnior, E., Peixoto, A.B., Zamarian, A.C.P.,
Elito Júnior, J., & Tonni, G. (2017). Macrosomia: Best
practice & research. Clinical Obstetrics & Gynaecology, 38,
83–96. https://doi-org.ezp.welch.jhmi.edu/10.1016/
j.bpobgyn.2016.08.003.

52. Centers for Disease Control and Prevention. (2018). Smoking
during pregnancy. Retrieved from https://www.cdc.gov/
tobacco/basic_information/health_effects/pregnancy/
index.htm.

53. Centers for Disease Control and Prevention. (2016).
Information for health care providers: Preventing tobacco
use and pregnancy. Retrieved from https://www.
cdc.gov/reproductivehealth/maternalinfanthealth/
tobaccousepregnancy/providers.html

54. Mohlman, M., & Levy, D. (2016). Disparities in maternal
child and health outcomes attributable to prenatal
tobacco use. Maternal & Child Health Journal, 20(3),
701–709. https://doi-org.ezp.welch.jhmi.edu/10.1007/
s10995-015-1870-3.

55. Centers for Disease Control and Prevention. (2017).
Health effects of second-hand smoke. Retrieved from
https://www.cdc.gov/tobacco/data_statistics/fact_sheets/
secondhand_smoke/health_effects/index.htm.

56. Hoyt, A.T., Canfield, M.A., Romitti, P.A., Botto, L.D.,
Anderka, M.T., Krikov, S.V., & Feldkamp, M.L. (2018).
Does maternal exposure to secondhand tobacco smoke
during pregnancy increase the risk for preterm or small-for-
gestational age birth? Maternal & Child Health Journal,
22(10), 1418–1429. https://doi-org.ezp.welch.jhmi.edu/
10.1007/s10995-018-2522-1.

57. Center for Disease Control and Prevention. (2016). Commu-
nitywide initiatives. Retrieved from https://www.cdc.gov/
teenpregnancy/projects-initiatives/communitywide.html.

58. Van de Ven, A.H., & Delbecq, A.L. (1972). The nominal
group as a research instrument for exploratory health
studies. American Journal of Public Health, 62(3), 336-342.

59. Center for Disease Control and Prevention. (2017). Preterm
birth. Retrieved from https://www.cdc.gov/reproductivehealth/
maternalinfanthealth/pretermbirth.htm

60. March of Dimes. (2015). March of Dimes prematurity
campaign: Activities and milestones. Retrieved from

https://www.marchofdimes.org/mission/march-of-
dimes-prematurity-campaign.aspx.

61. Wood, S., Tang, S., & Crawford, S. (2017). Caesarean deliv-
ery in the second stage of labor and the risk of subsequent
premature birth. American Journal of Obstetrics and
Gynecology, 217(1), 63.e1–63.e10.

62. UNICEF. (2017). Low birth weight. Retrieved from
https://data.unicef.org/topic/nutrition/low-birthweight/.

63. UNICEF. (2014). Low birth weight, current status and
progress. Retrieved from: https://data.unicef.org/topic/
nutrition/low-birthweight/.

64. Centers for Disease Control and Prevention, National
Center for Health Statistics. (2018). Birthweight and
gestation. Retrieved from https://www.cdc.gov/nchs/
fastats/birthweight.htm.

65. Martin, J., Hamilton, B., Osterman, M., Driscoll, A.,
& Drake, P. (2018). National Vital Statistics Report Vol 67,
No. 1. Hyattsville, MD: National Center for Health Statistics.

66. March of Dimes. (2018). Fighting premature birth: The
Prematurity Campaign. Retrieved from https://www.
marchofdimes.org/mission/prematurity-campaign.aspx.

67. Leffers, J., & Mitchell, E.M. (2011). Conceptual model for
partnership and sustainability in global health. Public
Health Nursing, 28(1), 91-102.

68. David, R.J., & Collins, J.W. (1997). Differing birth weight
among infants of U.S. born blacks, African born blacks and
U.S. born whites. New England Journal of Medicine, 337,
1209-1214.

69. McKenzie, J.F., Neiger, B.L., & Thackeray, R. (2017).
Planning, implementing & evaluating: Health promotion
programs: a primer (7th ed.). San Francisco, CA: Pearson/
Benjamin Cummings.

70. Mathews, T.J., & Driscoll, A.K. (2017). Trends in infant
mortality data in the United States, 2005-2014. NCHS Data
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71. SDHEC. (2011). At a Glance: 2009 Infant Mortality Statistics.
Division of Biostatistics, Pregnancy Risk Assessment System,
South Carolina of Health and Environmental Control.
Retrieved from: http://www.scdhec.gov.

72. South Carolina Healthy Connections. (2015). Centering
pregnancy: A successful model for group prenatal care.
Retrieved from: https://www.scdhhs.gov/boi.

73. Gareau, S. (2016). Group prenatal care results in Medicaid
savings with better outcomes: A propensity score analysis of
centering programs in South Carolina. Maternal and Child
Health Journal, 20(7). DOI: 10.1007/s10995-016-1935.

74. Trotman, G., Chhatre, G., Darolia, R., Tefera, E., Damle, L.,
& Gomez-Lobo, V. (2015). The effect of centering pregnancy
versus traditional prenatal care models on improved
adolescent health behaviors in the perinatal period. Journal
of Pediatric and Adolescent Gynecology, 28, 396-401. https://
doi.org/10.1016/j.jpag.2014.12.003.

75. Picklesimer, A.H. (2015). Centering Pregnancy: Healthy
communities- One group at a time. https://prezi.com/f0qev
54qopdj/the-south-carolina-centeringpregnancy-story/

76. Van De Griend, K., Billings, D., Marsh, C., & Kelley, S. (2015).
Centering pregnancy: Expansion in South Carolina process
evaluation: Final Report 2015. University of South Carolina.

77. Kahn, J., & Moore, K.A. (2010). What works for home visiting
programs: Lessons from experimental evaluations of programs
and interventions. Child trend fact sheets (Publication

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No. 2010). Retrieved from http://www.childtrends.org/
wp-content/uploads/2005/07/2010-17WWHomeVisit .

78. Child and Family Research Partnership. (2017). Retaining
families in home visiting programs by promoting father
participation. The University of Texas at Austin. Retrieved
from www.childandfamilyresearch.org.

79. Dodge, K.A., Goodman, W.B., Murphy, R.A., O’Donnell, K.,
Sato, J., & Guptill, S. (2014). Implementation and random-
ized controlled trial evaluation of universal postnatal nurse
home visiting. American Journal of Public Health, 104(51),
5136-2143. http://www.ncbi.nlm.nih.gov/pmc/articles/
PMC4011097/.

80. Astero, J., & Allen, L. (2009). Home visiting and young
children: An approach worth investing in? Social Policy
Report, 23(5), 3-21.

81. Health Resources and Services Administration. (n.d.). Mater-
nal infant and early childhood home visiting program. Retrieved
from http://mchb.hrsa.gov/programs/homevisiting/.

82. Health Resources and Services Administration, Maternal
Child Health. (n.d). Home visiting. Retrieved from https://
mchb.hrsa.gov/maternal-child-health-initiatives/
home-visiting-overview.

83. Washington County, Oregon. (n.d.). Maternal and
child health field team. Retrieved from https://www.co.
washington.or.us/HHS/PublicHealth/MCHFT/index.cfm.

84. U.S. Department of Health and Human Services. (n.d.).
Home visiting evidence of effectiveness. Retrieved from:
https://homvee.acf.hhs.gov/

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447

Chapter 18

Health Planning for School Settings
Donna Mazyck and Joan Kub

LEARNING OUTCOMES

After reading the chapter, the student will be able to:

KEY TERMS

1. Define school nursing.
2. Present the contribution of school health to the

achievement of Healthy People objectives.
3. Describe the components and tenets of the student-

centered Whole School, Whole Community, Whole
Child model.

4. Summarize the key principles of the 21st Century
Framework for School Nursing Practice.

5. Discuss the role of school nurses in addressing health
disparities and social determinants of health among
vulnerable students.

6. Describe the role of policy in understanding school
nursing practice.

7. Discuss challenges to school health nursing for the future.

Asthma action
plan

Body mass index
(BMI)

Cyberbullying
Delegation
Disabilities

Framework for
21st Century School
Nursing Practice

Individualized education
program (IEP)

Individualized family
service plan (IFSP)

Individualized Healthcare
Plan

Least restrictive
environment

National Health
Education
Standards

School-based health
center

School nursing
Title I
Whole School, Whole

Community, Whole
Child (WSCC)

n Introduction
Did you have a school nurse while going through K-12
education? School nurses provide health promotion
and disease prevention for student populations, which
in 2017 numbered 55.9 million students enrolled in
public and private U.S. schools.1 The opportunities and
rewards in school nursing include helping students
reach education goals while learning positive health
behaviors; seeing students with chronic health condi-
tions learn to manage their health; creating a culture
of health in the school community so that students are
healthy, safe, and ready to learn; and collaborating with
school staff and community members to reduce social
determinants that create barriers to student health and
learning. Challenges in school nursing include incon-
sistent fiscal investment in school nursing positions
and misconceptions about the role of school nurses as
health professionals in education settings.

For children and adolescents throughout the world,
attending school represents a foundational way in which
to enter adulthood; however, gender and disparities in
wealth keep about 263 million children and adolescents
between ages 6-17 years out of school.2 Students who are
in school benefit from school nurses providing disease
prevention and health promotion that facilitate student
access to learning.

The National Association of School Nurses (NASN)
defines school nursing as:

A specialized practice of nursing that protects and promotes
student health, facilitates optimal development, and ad-
vances academic success. School nurses, grounded in ethical
and evidence-based practice, are the leaders who bridge
health care and education, provide care coordination, advo-
cate for quality student-centered care, and collaborate to de-
sign systems that allow individuals and communities to
develop their full potential.3

7711_Ch18_447-478 21/08/19 11:11 AM Page 447

School nurses use the nursing process to provide
individual and population-based care in schools to
facilitate the school nurse’s goal of supporting the
health and academic achievement of students:

• Assessment
• Diagnosis
• Outcome identification
• Planning
• Implementation
• Evaluation

School nurses may be employed by local school dis-
tricts, health departments, hospitals, or other entities.
Health priorities and educational goals converge in
school nursing, requires the school nurse to under-
stand and function in two cultures: the worlds of health
and education. Translation of these two cultures is a
vital role for school nurses as they advocate for stu-
dents. The school nurse knows both education and
health priorities, goals, policies, and legal requirements
in the implementation of school health services. This
knowledge places school nurses in a central role as
coordinators and connectors in the school setting.
NASN published the Code of Ethics to set forth “a com-
monality of moral and ethical conduct” for school
nurses. The code of ethics for school nurses focuses on
three aspects: NASN core values, NASN Code of Ethics,
and professional standards of practice.4

448 U N I T I I I n Public Health Planning

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Weeping Student
Public Health Science:

• Screening
• Referral and Follow-up
• Collaboration

After the second full week of the new school year,
Mark, the freshman high school English teacher, visited
the school nurse after the students left the building.
Mark described a student who barely spoke in class
and often wiped tears from her eyes. He knew that the
student, Mary, and her family had settled in the U.S.
after her family arrived as refugees in early June. Pat,
the school nurse, agreed to meet with the student on
Monday during her English class time. Mary came to
the health room door and hesitated before entering.
Pat stood up to meet Mary at the door, inviting her to
come into the room. Pat and Mary sat in the private

room at the back of the office. Pat told Mary that her
English teacher was concerned because he saw her
crying during each class. Pat asked Mary what had
happened to her, and Mary talked about adjusting to a
new country after living for 2 years in a refugee camp
overseas. Pat understood that addressing “primary
areas of concern for refugee children, such as
mental health, nutrition, communicable and vaccine-
preventable diseases, and oral health, is paramount
to improving health care and learning outcomes”
for children and youth who came to the country as
refugees.5 Pat did a nursing assessment that included
Mary’s health history, refugee status, and journey.
Mary shared with Pat that, after she completed
screening at the refugee center, the center staff con-
nected her with a mental health therapist. Pat and
Mary developed a rapport where they connected
weekly. While reviewing literature on needs of stu-
dents who are refugees, Pat learned that access to
education is lower for children and youth who
are refugees as compared to children who are not
refugees.6 In the Student Services Team meeting, Pat
shared her concern about Mary’s lack of confidence in
certain school subjects with colleagues on the team
(school counselor, school psychologist, school social
worker, and school administrator) and her recommen-
dation that Mary may need educational assessments to
appropriately develop her schedule. The team agreed
to work with Mary to develop a plan for her high
school year.

Historical Foundations of School Nursing
School nursing has emerged as a specialty within the
broader field of public health nursing. In the beginning
of the 20th century, the convergence of compulsory
education laws in the United States and medical exclu-
sion of students with contagious diseases paved the
way for Lillian Wald to collaborate with the New York
City Board of Education and Board of Health to
hire a school nurse to work with students and families
in four schools where there were high numbers of
student absenteeism and medical exclusions.7 On
October 1, 1902, Lina Rogers Struthers’s work began as
a month-long experiment when she took the role of a
school nurse in those four New York City schools. By
December, Struthers’s use of school nurse assessments,
planning, interventions, evaluations, and documenta-
tion yielded increased school time for children and an

7711_Ch18_447-478 21/08/19 11:11 AM Page 448

expansion of the school nurse staff from one nurse to
12 nurses.

Struthers, who became the superintendent of school
nurses for New York City schools, and those who
worked with her were the first school nurses hired
by a municipality. The advent of school nursing
resulted in students being able to remain in schools if
possible and only excluded children with communica-
ble diseases.7 The presence of school nurses proved
effective. From October 1902 to October 1903, student
health-related exclusions from New York City public
schools decreased by more than 90%, from 10,567 stu-
dents to 1,101 students.8 Based on this groundbreaking
work by the New York City school nurse demonstration
project, school nursing spread throughout the United
States and Canada. From the inception of school nurs-
ing, school nurses focused on whole school populations
and individual student case coordination. School nurses
are an integral part of school-based health programs in
the 21st century.

Healthy People and School Nursing
Two new topics were identified in Healthy People 2020
(HP 2020) that have particular relevance to school
nursing—those of early and middle childhood and
adolescent health. Both of these topics emphasize the link
between behavioral patterns established in either early
childhood or adolescence to adult health and the role of
the school setting in promoting health. Thus, school
nurses have a very important role to play in influencing
health outcomes in children and adolescents as well as
the long-term health of these children in the future.

C H A P T E R 1 8 n Health Planning for School Settings 449

n HEALTHY PEOPLE
School Health

HP 2020 Topic relevant to School Health: Early and
Middle Childhood
Goal: Document and track population-based measures
of health and well-being for early and middle childhood
populations over time in the United States.
Overview: There is increasing recognition in policy,
research, and clinical practice communities that early
and middle childhood provide the physical, cognitive,
and social-emotional foundation for lifelong health,
learning, and well-being. Early childhood, middle child-
hood, and adolescence represent the three stages of
child development. Each stage is organized around the
primary tasks of development for that period.

Selected HP 2020 Objectives: Early
and Middle Childhood
EMC–1: (Developmental) Increase the segment of
children who are ready for school in all five domains
of healthy development: physical development,
social-emotional development, approaches to
learning, language, and cognitive development.
Midcourse Review: There is no data for this develop-
mental objective that had no national baseline value
(see Fig. 18-1).
Source: (9)
EMC–4: Increase the segment of elementary, middle,
and senior high schools that require school health
education.
Midcourse Review: Ten objectives check school
health education standards related to EMC-4. Three
out of the 10 objectives worsened as noted in the
following:
EMC-4.3.1: Between 2006 and 2014, the segment of
elementary schools requiring that cumulative health
education instruction meet the U.S. National Health
Education Standards decreased from 7.5% to 1.7%.
EMC-4.3.2: Between 2006 and 2014, the segment
of middle schools requiring that cumulative health

0
EMC-4.3.1

EMC-4.3.1: Elementary schools requiring cumulative health
education instruction

EMC-4.3.2: Middle schools requiring cumulative health
education instruction

EMC-4.3.4: Health education classes taught by an instructor who
had received professional development within the
past 2 years related to teaching skills or behavioral
development

EMC-4.3.2

P
er

ce
nt

o
f S

ch
oo

ls
M

ee
tin

g
S

ta
nd

ar
ds

EMC-4.3.4

2006
2014

Healthy People 2020 Midcourse Review:
National Health Education Standards

Figure 18-1 Healthy People 2020 Midcourse Review.

7711_Ch18_447-478 21/08/19 11:11 AM Page 449

HP 2020 also includes a topic on educational and
community-based programs. This topic includes
schools as one of the targeted settings for delivery of
these programs aimed at improving health.11 An impor-
tant objective under this topic is objective number 5:
“Increase the segment of elementary, middle, and
senior high schools that have a full-time registered
school nurse-to-student ratio of at least 1:750 per stu-
dent.”11 The midcourse status reveals that, between
2006 and 2014, the segment of schools with a registered
nurse to student ratio of at least 1:750 increased for all
schools (elementary, middle, and senior high schools—
ECBP-5.1: 40.6% and 51.1%); senior high schools
(ECBP-5.2: 33.5% and 37.9%); and elementary schools

450 U N I T I I I n Public Health Planning

education instruction meet the U.S. National Health
Education Standards decreased from 10.3% to 4.2%.
EMC-4.4: Between 2006 and 2014, the segment of
health education classes taught by an instructor who
had received professional development within the
past 2 years related to teaching skills for behavioral
development declined from 52.5% to 41.2%.
Source: (9)

HP 2020 Topic relevant to School Health:
Adolescent Health
Goal: Improve the healthy development, health, safety,
and well-being of adolescents and young adults.
Overview: Adolescents (aged 10 to 19) and young
adults (aged 20 to 24) make up 21% of the population of
the United States. The behavioral patterns established
during these developmental periods help determine
young people’s current health status and their risk for
developing noncommunicable diseases in adulthood.

Selected HP 2020 Adolescent Health
Objectives
AH–2: Increase the segment of adolescents who par-
ticipate in extracurricular and out-of-school activities.
Midcourse Review: From 2007 to 2011–2012, the
segment of adolescents aged 12–17 participating in
extracurricular and/or out-of-school activities demon-
strated little or no detectable change (82.5% in 2007
and 82.7% in 2011-2012).
Source: (10)
AH–5: Increase educational achievement of adoles-
cents and young adults.
Midcourse Review:
AH-5.1: The segment of students who graduated
from high school 4 years after starting the ninth
grade increased from 79% in 2010–2011 to 81% in
2012–2013. In 2012–2013, nine states met the national
2020 target.
AH-5.2: From 2007–2008 to 2012–2013, the segment
of students aged 14–21 served under the Individuals
with Disabilities Education Act (IDEA) who graduated
from high school with a diploma increased from
59.1% to 65.1%.
AH-5.5: The segment of adolescents aged 12–17 who
considered schoolwork meaningful and important in-
creased from 26.4% in 2008 to 27.7% in 2013. In 2013,
there were statistically significant disparities by race
and ethnicity and family income in the segment of
adolescents aged 12–17 who considered schoolwork
meaningful and important.

AH-5.6: There was little or no detectable change in
the segment of adolescents aged 12–17 who missed 11
or more days of school due to illness or injury from
2008 (5.0%) to 2014 (4.4%).
AH-5.3.1: The segment of fourth graders with reading
skills at or above grade level increased from 33.0% in
2009 to 35.2% in 2013.
AH-5.3.2: The segment of eighth graders with reading
skills at or above grade level increased from 32.4% in
2009 to 36.1% in 2013.
Source: (10)
Midcourse Review:
AH–6: Increase the segment of schools with a school
breakfast program.

The segment of public and private elementary,
middle, and high schools with a school breakfast
program increased from 68.6% in 2006 to 77.1% in
2014.
Source: (10)
Midcourse Review:
AH–7: Reduce the segment of adolescents who have
been offered, sold, or given an illegal drug on school
property.

There was little or no detectable change in the
segment of adolescents in grades 9–12 who have
been offered, sold, or given an illegal drug on school
property from 2009 (22.7%) to 2013 (22.1%).
Source: (10)
Midcourse Review:
AH–8: Increase the segment of adolescents whose
parents consider them to be safe at school.

The segment of adolescents aged 12–17 whose
parents considered them to be safe at school increased
from 86.4% in 2007 to 90.9% in 2011–2012.10

Source: (10)

7711_Ch18_447-478 21/08/19 11:11 AM Page 450

education, health, public health, and school health
sectors to develop the WSCC model (see Fig. 18-2).17

In the WSCC model, positioned in the center are five
tenets. That each student:

1. Enters school healthy and learns about and prac-
tices a healthy lifestyle.

2. Learns in an environment that is physically and
emotionally safe for students and adults.

3. Is actively engaged in learning and is connected to
the school and broader community.

4. Has access to personalized learning and is sup-
ported by qualified, caring adults.

5. Is challenged academically and prepared for success
in college or further study and for employment and
participation in a global environment.19

Between the Whole Child tenets and the components
of coordinated school health, the WSCC model calls out
the need to coordinate policies, processes, and practices
with collaborations in learning and health. Surrounding
the student, the WSSC model places the 10 components
of coordinated school health, which expanded from the
original eight.18

WSCC Components
Health Education
The health education component provides structured
learning for students with information and skills.19 The
goal is to motivate and assist students in maintaining and
improving their health, preventing disease, and reducing
health-related risk behaviors. The comprehensive health
education curriculum includes a variety of topics such as
personal health, family health, community health, con-
sumer health, environmental health, sexuality education,
mental and emotional health, injury prevention and
safety, nutrition, prevention and control of disease, and
substance use and abuse. According to the CDC,
National Health Education Standards “were developed
to establish, promote and support health-enhancing
behaviors for students in all grade levels—from pre-
kindergarten through grade 12.”20 These standards pro-
vide the framework for the curricula and the methods
used to deliver the curricula. They also provide guidelines
for assessing student progress as well as expectations for
school-based health education programs.20

Physical Education and Physical Activity
Physical education and physical activity comprise part of
a national framework: comprehensive school physical ac-
tivity program (CSPAP) with physical education being

C H A P T E R 1 8 n Health Planning for School Settings 451

(ECBP-5.4: 41.4% and 58.1%), exceeding their respec-
tive 2020 targets.12 Instead of ratios, NASN deems that
staffing for school nursing services must consider the
range of health care required to meet the students’
needs, including social determinants of health and stu-
dent health care needs.13 The educational and commu-
nity HP 2020 topic also includes objectives related to
the provision of health-related educational programs
including such topics as unintentional injury, violence,
suicide, tobacco use and addiction, alcohol or other
drug use, unintended pregnancy, HIV/AIDS and sexu-
ally transmitted infections (STIs), unhealthy dietary
patterns, and inadequate physical activity.11

Whole School, Whole Community,
Whole Child
With more than 55 million students spending a signif-
icant portion of their lives in school, schools are one
of the most powerful social institutions shaping the
next generation. The primary mission of schools is
education, but health is also important because educa-
tional outcomes are inextricably linked to health.
However, health and education sectors developed
their individual approaches to meeting the needs of
students. The Centers for Disease Control and Preven-
tion (CDC) promotes a systems approach for coordi-
nated school health. The coordinated school health
model is an integral set of planned, sequential, school-
affiliated strategies, activities, and services designed to
promote the optimal physical, emotional, social, and
educational development of students.14,15 The concept
of a comprehensive school health program is not new.
The model is built on the inclusion of four main
supportive structures:

• School health advisory council
• School health coordinator
• School-based health teams
• School board policy16

In the education sector, ASCD (formerly the Associ-
ation of Supervision and Curriculum) developed five
tenets for the development of the Whole Child: every
student will be healthy, safe, engaged, supported, and
challenged. In 2014, ASCD and CDC released the Whole
School, Whole Community, Whole Child (WSCC)
model, which expanded on the original eight compo-
nents of the coordinated school health model and incor-
porated the five tenets of the Whole Child initiative.17

ASCD and CDC collaborated with leaders across

7711_Ch18_447-478 21/08/19 11:11 AM Page 451

the foundation (see Fig. 18-3).19 CSPAP includes five
components: physical education, physical activity during
school, physical activity before and after school, staff in-
volvement, and family and community engagement.19,21

Physical education curricula should be based on national
physical education standards.21

Nutrition Environment and Services
School nutrition services promote access to a variety of
nutritious and appealing meals that accommodate the
health and nutrition needs of all students. School nutri-
tion programs reflect the U.S. Dietary Guidelines for
Americans and other criteria to achieve nutrition integrity.
The school nutrition services offer students a learning lab-
oratory for classroom nutrition and health education and
serve as a resource for linkages with nutrition-related com-
munity services. It is recommended that qualified child
nutrition professionals provide these services.16

School-based programs can influence the extent to
which youth eat breakfast. In 2016—2017, the nation-
wide School Breakfast Program provided breakfast for
approximately 12.2 million low-income children, repre-
senting a 0.6% increase over the previous school year 22

One of the factors thought to influence the growing
problem of obesity in children and youth is the availabil-
ity of junk food in vending machines and the lack of
nutritious foods in school lunches. The school nutrition
environment gives students “opportunities to learn about
and practice healthy eating through nutrition education,
messages about food in the cafeteria and throughout the
school campus, and available food and beverages, includ-
ing in vending machines, ‘grab and go’ kiosks, school
stores, concession stands, food carts, classroom rewards
and parties, school celebrations, and fundraisers.”19

In 2010, the Healthy Hunger-Free Kids Act was
signed into law. The bill allows the U.S. Department of

452 U N I T I I I n Public Health Planning

Figure 18-2 Whole School,
Whole Community, Whole
Child Model: A Collaborative
Approach to Learning and
Health. Retrieved from
https://www.cdc.gov/healthy-
schools/wscc/index.htm.

7711_Ch18_447-478 21/08/19 11:11 AM Page 452

Agriculture (USDA) to update nutritional standards for
all food sold in schools, including vending machines. It
also provided an increase in funding for school lunch
programs. The three broad initiatives of the bill are to
(1) improve nutrition with a focus on reducing child-
hood obesity, (2) increase access to healthy school meals,
and (3) increase program monitoring and integrity.23

School nurses played a significant role in advocating for
this law.

Health Services
The health services component is a service provided to
students that assesses, protects, and promotes health.
These services are designed to ensure access or referral
to primary care services, foster appropriate use of pri-
mary care services, prevent and control communicable
disease, provide emergency care for illness or injury, pro-
mote and provide optimal sanitary conditions for a safe
school facility and school environment, and provide ed-
ucational and counseling opportunities for promoting
and maintaining individual, family, and community
health.16 School nurses are leaders of school health serv-
ices, providing population-focused nursing care to all
students in schools.24 These health services include emer-
gency services, acute care evaluations, noncommunicable

disease management, health education, and preventive
services.

School nurses are primarily employed by education
entities and funded with general or special education dol-
lars. Other sources for school nurse funding include
health departments, and local and state organizations
(see Box 18-1).25 School nurses facilitate access to
providers (some providers may be in the building
through school-based health center [SBHC] services),
collaborate with community services, and work with
families to support a healthy and safe school environ-
ment.19 Details about school nursing in the 21st century
are discussed later in this chapter.

Counseling, Psychological, and Social Services
Counseling, psychological, and social services prevention
and intervention services seek to improve students’ men-
tal, emotional, and social health, as well as supporting
their learning process.19 Mental health disorders in chil-
dren include attention deficit-hyperactivity disorder
(ADHD), which is the most prevalent (11% among U.S.
children 4-17 years old) as well as mood disorders, anx-
iety disorders, behavioral disorders, major depression,
and eating disorders.26 Over a lifetime, approximately
22.2% of 13- to 18-year-olds will experience a severe
disorder.27 Services to address severe disorders include
individual and group assessments, interventions, and re-
ferrals. Organizational assessment and consultation skills
of counselors, psychologists, and social workers con-
tribute not only to the health of students but also to the
health of the school environment. Professionals such as
certified school counselors, psychologists, and social
workers provide these services.14

Counseling, psychological, and social services pro-
grams provide education, prevention, and intervention
services, which are integrated into all aspects of the stu-
dents’ lives. Early identification and intervention with
academic and personal/social needs are essential in re-
moving barriers to learning and promoting academic

C H A P T E R 1 8 n Health Planning for School Settings 453

Figure 18-3 Comprehensive School Physical Activity
Program (CSPAP). Retrieved from https://www.cdc.gov/
healthyschools/physicalactivity/index.htm.

35.3% of schools employ part-time school nurses
(< 35 hours) 39.3% of schools employ full-time school nurses (> 35 hours)

Across the country, 25.2% of schools did not employ
a school nurse.

BOX 18–1 n School Nurse Employed by Schools
in the United States

Source: (25)

7711_Ch18_447-478 21/08/19 11:11 AM Page 453

achievement. School-based mental health programs may
include collaborations with school-employed mental
health professionals and community-based mental
health professionals. In seeking optimum outcomes for
students, schools must focus on challenges to collabo-
ration in school-based mental health programs, which
include integrating education and mental health sys-
tems, coordinating staffing, and working with resources
from both systems.28

Social and Emotional Climate
The psychosocial environment in schools influences
the social and emotional development of students.19

Violence within schools is one factor that can undermine
academic learning within a school (see Chapter 12). In
some cases, children are exposed to extreme acts of
violence or trauma in homes, communities, or within
schools, as in Newtown, Connecticut, at Sandy Hook
Elementary School29 (see Chapter 12) and at Marjory
Stoneman Douglas High School in Parkland, Florida.
School shootings are an example of the trauma and
violence that can adversely impact student educational
outcomes.30 Violence can take the form of bullying be-
havior in schools but also includes other forms of peer
victimization. These include physical assault, physical
intimidation, emotional victimization, sexual victimiza-
tion, property crime, and internet harassment.31 This
victimization can also occur within the context of a dat-
ing relationship. Overt signs of violence within schools
can also include carrying weapons, an act that can intim-
idate students from attending school. Based on the data
collected from the Youth Risk Behavior Surveillance
System survey in 2017, 6.0% of high school students were
threatened or injured with a weapon, such as a gun,
knife, or club, on school property during the past year,
and 6.7% reported not going to school in the past 30 days
because of concern for safety.32 Some states and school
districts implement periodic climate surveys to assess
and examine school social and emotional climate. The
U.S. Department of Education (USDE) set forth three
factors of school climate: engagement, safety, and envi-
ronment; one study’s findings support the USDE’s three-
factor model of school climate.33 Increasingly, schools
provide for safe emotional environments by establishing
trauma-informed schools that consider any trauma that
children experience in and out of schools.34

Physical Environment
The healthy school environment is focused on provid-
ing the physical and aesthetic surroundings of the

school to promote an environment conducive to learn-
ing. Factors that influence the physical environment in-
clude the school building and the area surrounding it,
such as any biological or chemical agents detrimental
to health of students and staff as well as factors such as
temperature, noise, and lighting.16 To address a school’s
physical condition requires attention to everyday
operations as well as during renovation with the goal of
protecting staff and students in schools from physical
threats, biological, and chemical agents in the air, water,
or soil.19

Indoor air quality is one example of a physical con-
dition that has gained significant attention. The Envi-
ronmental Protection Agency (EPA) developed a tool
kit, the Indoor Air Quality Tools for Schools Action Kit,
which guides schools in developing a practical plan
to remediate air problems.35 Some of the sources of
problems are classroom pets and plants, water/moisture
accumulation, eating facilities attracting vermin, sec-
ondhand smoke, combustion problems from furnace
rooms and kitchens, and ventilation systems.32 Select
interventions have been outlined by the EPA.35 In
addition to the EPA toolkit, the Healthy Schools Cam-
paign, a national nonprofit organization advocating for
green cleaning in schools, publishes a guide focused on
the practical steps in implementing a green program.36

Another intervention aimed at providing a safe
environment for students is the Safe Walk to School na-
tional program, a federal safe route to school program
started in 2005. Then, in 2012, new transportation bill
MAP-21 combined this program with safe transporta-
tion programs related to walking and bicycle use, giving
more discretion to states for funding these programs.37

Thus, safety concerns for schoolchildren exist both
inside the school and in the community surrounding
the school.

Employee Wellness
The school community consists of employees as well
as students. Generally, employee policies and benefits
originate on the school district level, but employee well-
ness initiatives may also occur at individual schools. In
a coordinated school health initiative, the school nurse
provides opportunities, often through an interdiscipli-
nary team, for school employees to improve their health
status through health assessments, health education, and
health-related fitness activities through interdisciplinary
teams. A variety of tools and activities to engage school
employees can be used in health promotion activities.
Employee wellness programs and initiatives have the

454 U N I T I I I n Public Health Planning

7711_Ch18_447-478 21/08/19 11:11 AM Page 454

potential to reduce staff health risks and improve quality
of life.38

The value of encouraging school staff, especially
teachers, to pursue a healthy lifestyle that can contribute
to their improved health status and improved morale
has meaning in schools focused on climate. Teachers
experience stress and burnout, which can have implica-
tions in student outcomes.39

Family Engagement
A healthy school environment benefits from meaning-
ful engagement with parents (i.e., biological parents,
relatives, or non-biological parents or guardians). The
influence of parents on their children and adolescents
makes them ideal partners with schools in supporting
healthy school environments, especially in nutrition
services and environment, physical activity, and school
health services.40 The CDC sets forth three aspects for
school staff to consider with parent engagement: con-
necting with parents, engaging parents in school health
activities, and sustaining parent engagement in school
health.40

Building capacity for school staff and families to act
as partners requires more than programs. The Dual
Capacity-Building Framework for Family and School
Partnerships provides a compass for building family
and school partnerships that include relational, develop-
mental, interactive, and collective/collaborative learning
networks.41

Community Involvement
The 10th component focuses on involving and integrat-
ing the community with school efforts for the purpose
of enhancing the well-being of the students. Partner-
ships to promote school health and student learning
exist with community organizations, local businesses,
social service agencies, faith-based organizations, health
clinics, and colleges and universities.19 Schools and uni-
versity schools of nursing/colleges partner in ways that
enhance school health services policies, school nurse ed-
ucation, school nurse practice, and research that ulti-
mately benefits students.42

Framework for 21st Century School
Nursing PracticeTM

Looking more deeply into the school health services of
the WSCC model led the National Association of
School Nurses to develop the Framework for 21st
Century School Nursing PracticeTM (Framework),
which depicts student-centered school nursing practice

(see Figs. 18-4 and 18-5).43 The five key principles of
the Framework exist in a nonhierarchical and overlap-
ping structure that surrounds the student, family,
and school community; the key principles are stan-
dards of practice, care coordination, leadership,
quality improvement, and community/public health.
School nurses provide student-centered care within
these key principles while also connecting with other
WSCC components and community connections.
The Framework helps guide individual school nurse
practice as well as school district-level school health
services.

Population-Based School Nursing
Practice
School nurses care for individual students with acute and
chronic health concerns, and also provide population-
based interventions.47 These school nurse population-
based interventions can be clearly seen in the Framework
components and are also depicted in the interventions
outlined in the Minnesota model for public health nurs-
ing practice known as the Intervention Wheel or the
Minnesota Wheel (see Chapter 2).44 The Intervention
Wheel describes 17 public health interventions that are
population-based. A population-based approach con-
siders intervening at three possible levels of practice.
Interventions may be directed at one of the following,
or all three: the entire population within the school’s
community, the systems that affect the health of those
populations, or the individuals and families within
those populations known to be at risk.

Primary Prevention
School nurses have an important role to play in selecting,
implementing, and evaluating comprehensive educa-
tional efforts at the school level. At least four of the
HP 2020 Healthy Educational and Community-Based
Programs objectives addressed the provision of compre-
hensive health education in schools to prevent health
problems.11 Areas of importance to school health include
sexuality, mental health promotion, substance abuse/
violence prevention, and health education including
life skills.

Immunizations
Providing well-child services has been an important role
of school nurses since the development of the specialty.
Monitoring vaccinations among children and adolescents

C H A P T E R 1 8 n Health Planning for School Settings 455

7711_Ch18_447-478 21/08/19 11:11 AM Page 455

to assure compliance with state mandates is an important
school nurse role related to surveillance. School nurses
support the use of state immunization information sys-
tems to identify fully immunized children as well as those
who are not fully immunized and consequently at risk.
This also helps to prevent duplication of vaccinations.
The school nurse also increases student and family
awareness of other recommended vaccinations.

The CDC keeps an updated list on its Web site
of many resources related to vaccinations for both
health professionals and families.45,46 Other sources of
current vaccine recommendations include the National

Network for Immunization Information and the
American Academy of Pediatrics immunization sched-
ules, also available online. These recommendations are
updated annually because of changes in risk, changes
in pathogens such as the flu virus, and changes in the
evidence related to best practices for different vaccines.
School nurses play a crucial role in counseling families
and staff about immunizations across the life span. The
CDC urges school nurses to specifically promote
preteen vaccines.47

The seasonal influenza vaccine is of particular interest
in school nursing practice. The primary resource for nurses

456 U N I T I I I n Public Health Planning

Figure 18-4 Framework for 21st Century School Nursing PracticeTM [Venn Diagram].
NASN’s Framework for 21st Century School Nursing Practice (Framework) provides
structure and focus for the key principles and components of current day, evidence-based
school nursing practice. It is aligned with the Whole School, Whole Community, Whole
Child model that calls for a collaborative approach to learning and health (ASCD & CDC,
2014). Central to the Framework is student-centered nursing care that occurs within the
context of the students’ family and school community. Surrounding the students, family,
and school community are the nonhierarchical, overlapping key principles of Care Coor-
dination, Leadership, Quality Improvement, and Community/Public Health. These prin-
ciples are surrounded by the fifth principle, Standards of Practice, which is foundational
for evidence-based, clinically competent, quality care. School nurses daily use the skills
outlined in the practice components of each principle to help students be healthy, safe,
and ready to learn.

7711_Ch18_447-478 21/08/19 11:11 AM Page 456

is the Advisory Committee on Immunization Practices,
a division of the CDC. The committee periodically up-
dates the influenza vaccine recommendations, including
recommendations for school-age children.48 In 2017, the
committee recommended annual influenza vaccination
for everyone aged 6 months or older.48 School-located
vaccination programs have become a viable option
for reaching the target populations and are likely to

continue. The models for providing this care vary; in
some locales, school nurses lead school district vaccina-
tion programs and administer the vaccines, and in other
cases, public health department staff members admin-
ister the vaccine in the schools.49 The roles of school
nurses in school-located vaccination range from provid-
ing direct care to working at a community and systems
levels to assure coverage from a population perspective.

C H A P T E R 1 8 n Health Planning for School Settings 457

Figure 18-5 Framework for 21st Century School Nursing PracticeTM [Text & Categories]. NASN’s Framework for
21st Century School Nursing Practice (Framework) provides structure and focus for the key principles and components of
current day, evidence-based school nursing practice. It is aligned with the Whole School, Whole Community, Whole Child
model that calls for a collaborative approach to learning and health (ASCD & CDC, 2014). Central to the Framework is
student-centered nursing care that occurs within the context of the students’ family and school community. Surrounding
the students, family, and school community are the nonhierarchical, overlapping key principles of Care Coordination,
Leadership, Quality Improvement, and Community/Public Health. These principles are surrounded by the fifth principle,
Standards of Practice, which is foundational for evidence-based, clinically competent, quality care. School nurses daily use
the skills outlined in the practice components of each principle to help students be healthy, safe, and ready to learn.

7711_Ch18_447-478 21/08/19 11:11 AM Page 457

Sexuality and Sex Education
Nearly half of the most common STI, chlamydia, occurs
in young women aged 15 to 24.50 Primary prevention of
high-risk behaviors related to sexuality is a priority for
school populations. It is estimated that 39.5% of high
school students have had sexual intercourse, and most
adolescents who have ever had sexual intercourse remain
sexually active.51 About 9.7% have had multiple partners.
The prevalence of being currently sexually active (past
90 days) was 28.7%. Of the 28.7% of students who are
presently sexually active, 3.8% reported that neither they
nor their partner had used any method of contraception
to prevent pregnancy during their last sexual intercourse.51

One approach to prevention within a school setting is
sex education. The topic of sex education is controversial.
At the local, state, and national levels, educational experts
have discussed who should decide what would be taught
in schools. Factors that play into those decisions are
parental concerns, public health prevention concerns,
and the role the educational system plays in public health
prevention versus parental rights. School nurses can help
inform the discussion by presenting empirical data
related to the magnitude and consequences of teen births
and sexual activity among adolescents in their own
school district and by suggesting evidence-based prac-
tices related to prevention. In addition, the school nurse
must take into consideration cultural and environmental
issues specific to their school and the children who attend
their school. Standard 5 of the National Health Educa-
tion Standards from the CDC provides a sound basis for
curriculum development in this area. Standard 5 states:
“Students will demonstrate the ability to use decision-
making skills to enhance health.”52 Once general content
is outlined, there are many resources available to assist
local educators in selecting appropriate curricula to
promote healthy sexuality.53-54

Violence Prevention
Cyberbullying: Student-to-student violence takes var-

ious forms within the school setting. Bullying, defined as
unwanted aggressive behavior by one or more youth
toward another youth who is not a sibling or dating
partner, occurs in various contexts.55 Cyberbullying repre-
sents a context in which bullying occurs via electronic
methods using technology.55 Researchers note that bullying
in schools and cyberbullying combine to adversely impact
the student’s mental health.56 The school nurse has the
potential to play a role in the prevention and early identi-
fication of cyberbullying and in the provision of treatment
to victims of violence.

458 U N I T I I I n Public Health Planning

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Frequent Flyer
Public Health Science Topics Covered:

• Assessment
• Program planning
• Program evaluation

Carly, an eighth-grader, recently entered a new
middle school when her family moved midyear from
a rural area to a large urban center after her father
obtained a job transfer. Carly had spent her entire life
in the rural area and was apprehensive about the move.
For the first few weeks, things seemed to go well.
She was welcomed by a group of girls who were the
“popular” girls in the class. They offered to include her
in activities outside of class, including football games
and parties. To Carly’s surprise, within a month she
had received an upsetting e-mail from someone she did
not know accusing her of sexual behavior. She learned
that several derogatory remarks about her had
been posted on a social media site that left her feeling
alone and depressed. As these postings continued, her
enthusiasm about school decreased, and she became
more withdrawn. She was afraid to log on to her com-
puter for fear that she would be bullied or picked on
online.

Bob, the school nurse, began to suspect something
was going on when Carly kept showing up in the health
suite with nondescript, vague symptoms. Because he
had heard through the student grapevine that a new
girl was being bullied online, he wondered whether it
might be Carly. After some initial probing about her
adjustment to her new school, he learned about Carly’s
situation. Bob began to provide direct care to Carly
to help her address the bullying, and with Carly’s per-
mission included her parents. He also included the
school administration. Bob took this case very seri-
ously given the recent cases in the news in which
cyberbullying had resulted in the victim committing
suicide. Counseling was sought for Carly, and she
began to show improvement,

Helping Carly was only half of the problem; prevent-
ing further bullying was the other half. The school
administration asked Bob to spearhead a school
team charged with the task of finding an educational
program for the school. Bob found evidence-
based programs and decided to include students,
teachers, and parents on his team to help choose
the program most appropriate for his school. The

7711_Ch18_447-478 21/08/19 11:11 AM Page 458

Dating Violence: Dating violence is another form
of violence that is not unfamiliar to adolescents. Re-
sults from the 2017 Youth Risk Behavior Surveillance
System (YRBSS) indicated that, of the 68.3% U.S. high
school students who date, 6.9% described being forced
to perform sexual acts, which included touching, kiss-
ing, or being forced to have sexual intercourse.61 Also
in the 2017 YRBSS, of the 69% of U.S. high school
students who reported experiencing physical violence
while on a date, 8% were hurt on purpose; the hurt was
described as being hit, slammed into something, or
injured with an object or weapon.61 In the above
violent situations, the prevalence of experiencing sex-
ual dating violence at least once in the past 12 months
was higher in females: 9.1% versus 6.8% in males.61

There is a need to screen adolescents for teen dating
violence, especially those with certain high-risk behav-
iors, including alcohol use and drug use.62 Social-emo-
tional skills are particularly important in addressing
healthy relationships, and school-based interventions
are increasingly being designed and tested.62 Different
strategies and approaches to engage adolescents in
interventions are being explored, including treatment
to lessen harms of youth exposed to violence and
treatment to prevent problem behavior and further
exposure to violence.62

Outreach to Immigrant Populations
Student populations are becoming increasingly diverse
in the United States, given the growing number of
immigrant parents. The percentage of all children
living in the United States with at least one foreign-
born parent rose from 15% in 1994 to 25% in 2016.63

Children of immigrants often face many challenges,
including cultural differences, poverty, lack of health
insurance, lack of access to public assistance, limited
English proficiency, and high levels of psychological
distress in those who have experienced war and
other adverse events. Outreach to these populations is
one intervention in which school nurses can play
an integral part. The multiple roles connected with

C H A P T E R 1 8 n Health Planning for School Settings 459

team agreed that, in addition to putting an educational
program in place, they should also assess the extent
of the problem. Bob located a resource with tools
to measure bullying, published by the CDC.55 The
team conducted a survey of the students and discov-
ered that it was more widespread than they had
initially thought.

To help the team, Bob found a definition of bullying
that helped them understand the broad scope of the
problem. According to the CDC, bullying involves a
youth being bullied or victimized when he or she is
exposed, repeatedly and over time, to negative ac-
tions on the part of one or more students.55 Bob
explored the issue further and found that the
phenomenon of bullying includes three groups:
the bully, the victim, and persons who are both
bully and victim. He found that in 2015, 21% of
students ages 1–18 reported being bullied at
school, and in high schools alone, the prevalence
was 19%. Additionally, girls were bullied at a
greater percentage than boys.57,58

Because the school was specifically concerned with
cyberbullying, Bob looked for a clear definition. Based
on what he read, he reported to the team that cyber-
bullying is the purposeful and repeated harm inflicted
through the use of computers, cell phones, and other
electronic devices.55,56 To help the team understand
the seriousness of the problem, Bob explained to them
that bullying can result in severe consequences for the
victim, including elevated levels of depression, anxiety,
poor self-esteem, psychosomatic problems, suicide
ideation, suicide attempts, and suicide.56 Using an eco-
logical understanding of the bullying behavior and with
Bob’s help, the team concluded that whatever program
they implemented should be based on the components
of the Olweus Bullying Prevention Program. This
program consists of school-level, classroom-level,
individual-level, and community-level components.59,60

The principles guiding this evidence-based program are
that adults should:59,60

• Show warmth and positive interest in their students
• Set firm limits for unacceptable behavior
• Use consistent nonphysical, nonhostile negative

consequences when rules are broken
• Function as positive roles models

The team completed their assessment and, based
on their findings, put together an antibullying campaign
for the school. The campaign included educational
sessions for students, teachers, and parents; public

service announcements posted throughout the school;
an anonymous hotline for reporting suspected bullying;
and the institution of a bullying intervention program
to help with early identification of, and intervention
with, victims. Because the team had collected initial
assessment data, they were able to demonstrate
significant improvement over time after the implemen-
tation of the campaign.

7711_Ch18_447-478 21/08/19 11:11 AM Page 459

outreach might include: developing a welcoming
orientation for the students, developing student sup-
port teams, facilitating the integration of the students
into after-school activities, and serving as an overall
advocate for the families.

it is essential to assess the value of the screening
program, to estimate the costs versus the benefits, and to
assure that there is not any inadvertent harm that evolves
from the program. The sensitivity and specificity of
the screening tools are also critical to evaluate (see
Chapter 2).

Some screening procedures, such as screening for sco-
liosis, have fallen out of favor over the past decade in
some areas. In 2018, the U.S. Preventive Services Task
Force concluded “the current evidence is insufficient to
assess the balance of benefits and harms of screening
for adolescent idiopathic scoliosis in children and
adolescents aged 10 to 18 years.”67 Screening guidelines
can vary by state, and it is important for school nurses to
access information on requirements at both the national
and state levels.

Vision Screening: Vision screening in schools has
a history dating back to 1899, when the Snellen eye
chart was first used. Although the Snellen chart contin-
ues to be prominent in the toolbox of school nurses,
there is a need to evaluate the vision screening tools
used based on national and international eye chart
design guidelines and to apply best practices based on
research.68 It is equally important to use an eye chart
that matches the cognitive level of the child. States gen-
erally require only distance acuity screening; when
students do not meet the criteria to pass the screening,
school nurses refer for eye exams and follow-up as
directed by policy.69

Audiometric Screening: Screening for hearing prob-
lems is another vital school nursing activity. The Amer-
ican Academy of Audiology has specific childhood
hearing screening guidelines. Minimum grades for
screening include preschool, kindergarten, and grades 1,
3, 5, and either 7 or 9. It is also important to screen any
student who enters a new school system without evi-
dence of having had a previous hearing screening
(Box 18-2).70 Although these criteria are specific to hear-
ing screening, the principles of proper communication,
referral, follow-up, and effective treatment are equally
important.

Screening for Obesity: It is evident from the National
Health and Nutrition Examination Survey (NHANES)
that obesity is a significant problem among U.S. adoles-
cents and children. In 2015-2016, the prevalence of obe-
sity among U.S. youth was 18.5%. Overall, the prevalence
of obesity among adolescents (12–19 years) (20.6%) and
school-aged children (6–11 years) (18.4%) was higher
than among preschool-aged children (2–5 years) (13.9%).
School-aged boys (20.4%) had a higher prevalence of
obesity than preschool-aged boys (14.3%). Adolescent

460 U N I T I I I n Public Health Planning

n CULTURAL CONTEXT
School nurses work with a growing number of students
and families from varied cultures in the context of
school health services. NASN published survey results
that pointed to school nurses knowing the demograph-
ics, languages spoken, health disparities, social determi-
nants, and environment of the population they served.64

Survey respondents expressed their need for additional
knowledge and skills to provide culturally competent
care. Specifically, school nurses saw gaps in (1) their
ability to communicate health information in families’
language of origin, (2) the availability the of school
nurse-specific resources on the topic, and (3) their abil-
ity to navigate work barriers, such as time constraints
and lack of administrative support.64 Actions that
addressed the expressed needs included providing
school nurse education and a compilation of Web-based
resources on cultural competence. With increased
knowledge and skills, school nurses can provide cultur-
ally competent care for all students. A study demon-
strated that a health promotion intervention used by
school nurses and health teachers enabled secondary
school-age students in a migrant education program to
enhance their learning by developing student-made
videos.65 The study used a transcultural nursing frame-
work and tailored the curriculum to the ethnicity of the
student population.65 School nurses grow in their influ-
ence on positive outcomes for students when engaging
in understanding their identities and cultural differences,
being culturally responsive, identifying social injustices,
and committing to lifelong learning.66

Secondary Prevention
Health Screening of Children and Adolescents
Screening is another vital role of school nurses in
addressing the actual and potential health problems of
children. School nurses conduct vision and hearing
screenings as well as BMI screenings, depending on the
regulations within the jurisdictions. Other screenings can
include postural or scoliosis screening, blood pressure
reading, drug use screening, and screening for mental
health problems, type 2 diabetes, cholesterol level,
asthma, tuberculosis, and head lice. In all of these cases,

7711_Ch18_447-478 21/08/19 11:11 AM Page 460

girls (20.9%) had a higher prevalence of obesity than
preschool-aged girls (13.5%).71,72 In 2013-2014, the preva-
lence of obesity reported for all U.S. children aged
2 to 19 years was 17.2%.72

For non-Hispanic black (22.0%) and Hispanic
(25.8%) youth, the rate was higher than among
both non-Hispanic white (14.1%) and non- Hispanic
Asian (11.0%) youth. There were no significant
differences in the prevalence of obesity between non-
Hispanic white and non-Hispanic Asian youth or
between non-Hispanic black and Hispanic youth.72,73

This disparity in obesity rates is the result of a complex
set of risk factors including genetics, cultural nutritional
practices, environments, and socioeconomic differences,
Obesity adversely affects children and adolescents by
increasing the risk for type 2 diabetes, hypertension, and
depression, as well as increasing the possibility of arthri-
tis, cancer, and cardiovascular disease later in life. Pre-
vention and intervention efforts rely on multiple
partnerships using multiple angles.

The primary screening method for obesity in children
is the calculation of BMI. BMI is a number calculated from
a child’s weight and height, and is a reliable indicator of

body fatness. To screen for obesity in children, the BMI
by itself is not sufficient. The BMI number is plotted on
a growth chart specific to girls or boys, and a percentile
ranking is obtained. This percentile indicates where the
child is in relation to other children of the same age
and sex.73 The categories are further broken down into
underweight, healthy weight, overweight, and obese
(Box 18-3).73 School nurses can use the CDC Body Mass
Index Child and Teen Calculator to calculate the BMI
as well as the percentile ranking in children. In addition
to height and weight, the calculator uses information on
sex, date of birth, and date of measurement to calculate
the percentile.74 Communication of the results of the
BMI to the family as well as the child’s health-care
provider is important. It is a challenge to design effective
prevention and intervention programs, because cultural
norms and perceptions must be taken into considera-
tion.75 Examining obesity trends within a particular
school allows the school nurse to be an advocate at a
community and systems level through his or her in-
volvement in school wellness policies.

C H A P T E R 1 8 n Health Planning for School Settings 461

The position statement on early childhood and school-
age population screening is as follows:

“The American Academy of Audiology endorses
detection of hearing loss in early childhood and school-
aged populations using evidence-based hearing screening
methods. Hearing loss is the most common developmen-
tal disorder identifiable at birth, and its prevalence in-
creases throughout school age due to the additions of
late-onset, late-identified, and acquired hearing loss.
Under-identification and lack of appropriate management
of hearing loss in children has broad economic effects as
well as a potential impact on individual child educational,
cognitive, and social development. The goal of early de-
tection of new hearing loss is to maximize perception of
speech and the resulting attainment of linguistic-based
skills. Identification of new or emerging hearing loss in
one or both ears followed by appropriate referral for
diagnosis and treatment are first steps to minimizing
these effects. Informing educational staff, monitoring
chronic or fluctuating hearing loss, and providing educa-
tion toward the prevention of hearing loss are important
steps that are needed to follow mass screening if the
impact of hearing loss is to be minimized.”

BOX 18–2 n Position Statement: American
Academy of Audiology

Source: (70)

After BMI is calculated for children and teens, the BMI
number is plotted on the CDC BMI-for-age growth
charts (for either girls or boys) to obtain a percentile
ranking. Percentiles are the most commonly used indica-
tor to assess the size and growth patterns of individual
children in the United States. The percentile indicates
the relative position of the child’s BMI number among
children of the same sex and age. The growth charts
show the weight status categories used with children
and teens (underweight, healthy weight, overweight, and
obese). BMI-for-age weight status categories and the
corresponding percentiles are shown in the following
table:

Weight Status
Category Percentile Range
Underweight Less than the 5th percentile
Healthy weight 5th percentile to less

than the 85th percentile
Overweight 85th to less than the

95th percentile
Obese Equal to or greater

than the 95th percentile

BOX 18–3 n BMI-for-Age Weight Status
Categories and the Corresponding
Percentiles

Source: (71)

7711_Ch18_447-478 21/08/19 11:11 AM Page 461

Screening Vulnerable Populations and Social
Determinants of Health
School nurses work with a vulnerable population – chil-
dren and youth. The environment where students live,
play, and learn (social determinants) has an impact on
their health.76 Racial and ethnic diversity among
students is increasing, with the greatest growth in His-
panic children, 24.7% (2015) and 24.9% (2016).63 Stu-
dents who are or who have family members in
immigrant or refugee status represent a vulnerable
population; 25% of U.S. children ages 0–17 years have
one foreign-born parent. An increasing number of
children ages 5–17 speak a language other than English
at home: 21.9% (2014) and 22.2% (2015).63 Access to
health care and safe housing are social issues impacting
student health and learning. Children ages 0–17 with
no usual source of health care has increased 3.6%
(2014) and 4.4% (2015).63 In addition to social deter-
minants, vulnerable students have needs that require
support in school settings. Students might have com-
plex chronic health conditions, such as type 1 diabetes,
asthma, and undiagnosed mental health illness; these
complex health issues, along with social concerns, can
lead to chronic absenteeism, which in turn limits
school success.77 School nurses collaborate with other
school staff and community-based partners to provide
students with the support they need to attend and
complete school.

Tertiary Prevention
Life-Threatening Emergencies in the School
Setting
School nurses are a primary connection to medical and
public health entities when schools experience emergen-
cies.78 Following the Sandy Hook shooting in 2012,
there has been increased awareness of the potential
for school-based violence (see Chapter 12). The CDC
reports that less than 2.6% of child homicides occur at
school.79 Despite the low incidence rate, the school nurse
must be prepared for the potential of a life-threatening
violent act occurring at a school. These life-threatening
emergencies require well-equipped schools, staff trained
in first aid and cardiopulmonary resuscitation, and

462 U N I T I I I n Public Health Planning

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Student with
a Mysterious Growth
Public Health Science Topics Covered:

• Secondary prevention
• Referral and follow-up

Dana worked as a school nurse in a suburban high
school. In her role, she connected with students by
standing in the doorway of the health room during
change of classes. Some students walking down the
halls never came into the health room for services.
Dana and those students greeted one another simply
verbally or with a nod. Sue was one of the students
who did not come to see Dana but enjoyed sharing
brief verbal exchanges of greetings. After a semester
of observing Sue from the health room door, Dana
noticed Sue’s abdomen growing larger. One day, Dana
motioned to Sue to come near the health room door
as she walked down the hallway. The school nurse

asked Sue if she would stop by for a visit during her
study period, which Sue did the next day. When Sue
arrived in the health room, Dana asked her to come to
a quiet office area. After exchanging pleasantries, Dana
asked Sue how she was feeling. Sue mentioned that
she was fine. Dana shared her observations of Sue’s
growing abdomen over the past 4 months. Sue quickly
stated, “I’m not pregnant!” Dana assured Sue she was
not making any assumptions. Dana asked Sue if she
would mind answering health-related questions. Sue
replied no, so Dana asked, specifically “Do you have
abdominal pain?” and “Do you have constipation or
urinary frequency?” Dana explained that, after checking
Sue’s vital signs, she would call Sue’s mother to share
her recommendation for a medical referral.

On exam, Dana recorded the following: Vital Signs:
BP 130/70, P 80, R 20, Temp 97.8°F, BMI 33. Dana also
documented her observations and Sue’s self-report.
When Dana contacted Sue’s mother, she heard the
mother’s concern that Sue might be pregnant. Dana
referred Sue’s mother to Sue’s health-care provider.
The school nurse documented her call. On the next
school day, Sue popped her head into the office to say,
“I have a medical appointment in 3 weeks.” A month
went by, and Dana had not heard back from Sue after
her appointment. She also did not see Sue in the hallway.
Dana called the home and spoke with Sue’s mother.
The abdominal growth occurred because of a large sim-
ple ovarian cyst that had gone undetected. The cyst was
20×10×25 cm in size and benign. Sue had surgery, which
included removal of her right ovary and was at home
recovering. Sue’s mother thanked Dana for not ignoring
her observations of Sue’s growing abdomen. Dana in-
quired if Sue was in contact with the school counselor
to arrange for resuming her studies.

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lay-rescuer automated external defibrillators (AEDs) 79

One approach for emergency preparedness in schools is to
have a designated medical emergency response plan on
record. A recommendation is that schools practice the plan
a number of times each year. The other recommendation
is to identify who within the system is authorized to make
emergency medical decisions and make sure AEDs are
available to the staff.80

Food Allergies: Exposure to a food allergen is another
example of a potentially life-threatening event. Between
2009 and 2011 the reported prevalence of food allergies
was 5.1% among children under age 18 years.81 In a recent
national survey of U.S. households with children under
age 18 years, food allergy prevalence was 8.0%. The food
allergen most prevalent in this survey was peanuts (2.5%
of children) followed by milk, shellfish, and tree nuts.82

Prevention is crucial and demands adequate manage-
ment plans, successful food allergy avoidance, recogni-
tion of food allergy reactions, preparation for appropriate
treatment of acute allergic reactions, knowledge of treat-
ments, and access to autoinjectable epinephrine.83

Episodic Care in the School Setting: An important
role of the school nurse is to provide episodic care and
to conduct disease and health investigations. School
nurses provide care and care coordination for students
with chronic health conditions and students with
acute health concerns. Where SBHCs are located or
linked with schools, school nurses determine if a stu-
dent’s acute health condition will benefit from a primary
care referral to the SBHC. The School-Based Health
Alliance recognizes the critical and foundational role of
school nurses for the entire student population. SBHCs
enhance foundational school health services:

The school nurse is the building’s health ambassador, on the
frontline for day-to-day oversight and management of the
school population’s health. School-based health care com-
plements the work of school nurses by providing a readily ac-
cessible referral site for students who are without a medical
home or in need of more comprehensive services such as pri-
mary, mental, oral, or vision health care.84

School nurses spend a significant portion of their day
caring for acute injuries and illnesses as well as adminis-
tering medication and providing episodic care for minor
ailments, such as headaches, stomachaches, pain, and
hay fever. School nurses know the value of quality im-
provement, especially the collection, analysis, and use of
data to improve outcomes for students. The interprofes-
sional work of school nurses is noted when they partici-
pate in school team meetings as well as when they
collaborate with community partners.

Although 83% of U.S. children under 18 years of age
have very good or excellent health, noncommunicable
disease affects their well-being and has the potential to
have a great impact on school outcomes.85 Noncommu-
nicable diseases (see Chapter 9) include asthma, diabetes,
allergies, cancer, and other medical disorders. Fourteen
percent of children have asthma; 10% of children ages 3–
17 years have attention deficit hyperactivity disorder
(ADHD); and 6% of children have unmet dental needs
due to lack of family funds.85 Often, the health-care needs
of a child with a noncommunicable disease are complex
and require careful planning, appropriate referrals, safe
management, and delegation of nursing tasks to licensed
and unlicensed assistive personnel (UAP).86 Mental dis-
orders (see chapter 10) are also common among chil-
dren. The global prevalence of mental disorders among
children and adolescents is 13.4%.87

Noncommunicable diseases and mental health disor-
ders in children and adolescents require coordination
between family members, school personnel, and health-
care providers. Care coordination of noncommunicable
diseases and mental health disorders contributes to
positive academic and health outcomes. One systems-
level approach to care coordination sets forth a model
with a focus on access to care that is student- and
family-centered and is led by a school nurse whose initial
priority is to set up a channel of communication across
systems.88 A system of care coordination includes five
components:

1. School health-care teams that support and share
processes and forms for care planning, partner
agreements, tracking care, monitoring, evaluating,
and reporting.

2. Interagency partnerships that enable services and
solutions to assist students and families in care.
Partner agreements support ease of communication.

3. Documentation with electronic health records to
help with monitoring quality and efficiency of
school health services through surveillance and
tracking systems.

4. Clinical expertise and evidence-based guidelines
that provide tools to help the school nurse give
high-quality care.

5. Performance improvements and outcome evalua-
tions that call for systems-level analysis of the
care coordination implementation, and outcome
reports that are shared with the care team, including
families.88

Care coordination is based on a thorough assessment
by the school nurse and involves activities that not only

C H A P T E R 1 8 n Health Planning for School Settings 463

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help the child deal with problems but also prevent and
reduce their reoccurrence. Care coordination includes
nursing care directed toward the child and coordination
and communication with parents, teachers, and other
care providers. The interventions are goal-oriented,
based on the specific needs of the child, and evaluated
based on their impact.88

Case management begins when the primary care
provider (PCP) confirms a diagnosis, for example, of
ADHD. Symptoms of ADHD in school-age children can
be marked by academic difficulties, inattention, impul-
siveness, oppositional behavior, poor self-esteem, exces-
sive motor activity, low frustration tolerance, increased
risky behavior, aggressive and antisocial behavior, and
less adaptive behaviors.98 The overall prevalence in
school-age children is about 10%.85 The school nurse is
often the designated professional that helps bridge the
gap between teachers, who often first see the behaviors
suggestive of a diagnosis of ADHD, and the PCP, who
can make an appropriate diagnosis. The school nurse also
oversees the delivery of medications.89

In addition to providing individual care, the appli-
cation of a population perspective allows the school
nurse to develop programs at the school level to help
identify students with ADHD and provide evidence-
based options for care. The school nurse performs
behavioral classroom observations that focus on early
diagnosis and treatment of ADHD for purposes of
decreasing academic failure, social isolation, high-risk
behaviors, family conflict, and adversity later in life for
these children.90

Asthma: In 2011, 14% of children under 18 had been
diagnosed with asthma.85 Asthma is a significant non-
communicable disease among adolescents. Over the past
20 years, asthma in children has increased when meas-
ured by prevalence, ambulatory visits, morbidity, and
mortality.91 The presence of a full-time registered school
nurse is important to provide care and care coordination
for students with asthma. In addition, the school nurse
provides instruction to school staff concerning the
recognition of and action steps for severe respiratory
symptoms. School nurses often take the lead in providing
school-based education to improve asthma management.
School nurse leaders in one school-based asthma pro-
gram recognized the crucial role of school district readi-
ness to implement evidence-based asthma care.92

Diabetes: Diabetes is another noncommunicable dis-
ease that requires self-management and coordination of
care within the school setting. There are two types of
diabetes. Type 1 is an autoimmune disease in which the
body forms antibodies to insulin, thus affecting the

body’s ability to produce insulin; previously type 1
was known as insulin-dependent disease. Diabetes is
one of the most common noncommunicable diseases
in children younger than 20 years in the U.S.; approxi-
mately 30.3 million people or 9.6% of the U.S. population
over 18 years have diabetes.93 Type 2 occurs when cells
do not respond correctly to insulin, resulting in insulin
resistance. Type 2 diabetes is a complex metabolic disor-
der with social, behavioral, and environmental risk
factors including being overweight, a family history of
type 2 diabetes, or other conditions such as high
blood pressure, polycystic ovary syndrome, or abnormal
cholesterol. The increasing frequency of diabetes types 1
and 2 in children is concerning. About 17,900 children
under the age of 20 are diagnosed with type 1 every year,
and 5,300 children ages 10–19 years old already have type
2 diabetes.94

One of the roles of the school nurse is to identify chil-
dren with diabetes, or who are at risk of developing type
2 diabetes, and refer them to care. Once a diagnosis has
occurred, the school nurse has an important role in en-
couraging self-care, which includes increasing knowl-
edge and skills such as blood glucose testing, insulin
injection, preparation of the insulin, diet management,
and hypoglycemic treatment.95,96 Additionally, assessing
for signs of stress and providing needed support are im-
portant. The school nurse works closely with the student,
family, and community-based health-care providers to
develop a plan for managing children with diabetes.96

Disabilities: Students with disabilities represent an-
other population that requires case management from the
school nurse.97 The IDEA of 2004 provides a comprehen-
sive definition of a child with disabilities (Box 18-4).98

School health services enable students with disabilities
to attend school. Student needs may include medication
administration, treatments, emergency care plans, indi-
vidualized health-care plans, health teaching, and health
counseling.99 School nurses maintain referral sources so
that students and families may be appropriately referred
for care and services. In addition, the school nurse is re-
sponsible for providing a safe and healthy environment.
In the case of children with disabilities, this may mean
wheelchair access, special furniture, elevators, restroom
accommodations, or dedicated space in the health room
for diaper changes, tube feedings, medication adminis-
tration, or rest.

National policy has resulted in the integration of chil-
dren with disabilities into the school setting. These laws
help define the rights of children with disabilities as well
as define the role of the school nurse. One law that had a
significant impact on school nursing is the Education for

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All Handicapped Children Act (EAHCA) of 1975.100 The
ages covered under this law include birth to 2-year-olds
in infant and toddler programs, as well as 3- to 21-year-
old students. EAHCA appropriated federal funding to
states for the provision of free appropriate public educa-
tion in the least restrictive environment. The purpose
of a least restrictive environment is to provide disabled
students with the opportunity to be educated with their
nondisabled peers.100 This was followed by the IDEA,
passed in 2004.101 This law builds on the original 1974
legislation and provides a mechanism for continual up-
dating of available resources. It addresses the same issues
for children as the EAHCA does but encompasses the
issues for all individuals with disabilities. Thus, the needs
of people with disabilities are now covered across the life
span. IDEA has undergone several amendments, with the
most current in 2004. The current iteration of IDEA

specifies school nursing as one of the related services that
will meet the needs of the student.101

A central component of these laws is the individual-
ized education program (IEP). An individualized edu-
cation program is an individualized plan for a child with
a disability; the goal of the plan is to help the child meet
their educational objectives. School nurses are integral
members of the team. If the student’s disability requires
the services of a nurse, the school nurse contributes to
the individualized education program, which is both a
process and a plan. School nurses, as part of the team,
provide resources and information when transition plan-
ning begins for students with special educational serv-
ices. An individualized family service plan (IFSP) is
indicated for qualified birth to 3-year-old children. It is
similar to an IEP and is provided to children with devel-
opmental delays to help address their issues. Once a
child turns 3, an individualized education plan replaces
the IFSP.

Other laws that affect children with disabilities, such
as Section 504 of the Americans With Disabilities Act,
are seen in Table 18-1.102,103 Although school adminis-
trators are required to accommodate children with
disabilities, school administrators, faculty, and staff are
not required to accommodate limitations due to other
characteristics such as poor literacy skills (that are not
due to learning disabilities), low educational levels, in-
ability to meet the minimum entrance requirements of
the learning environment, or lack of credentials. Parents
and students can ask for reasonable accommodations
based on functional limitations secondary to a medical
condition. These accommodations are made by teachers
and other staff via adjustments to their standard practices
to meet specific needs of the student.

Mental Health Disorders: The prevalence of mental
health disorders in children and adolescents is, on average,
about 13%, with ADHD being the most common at around
10%.85,87 A comprehensive school-based health program
must incorporate mental health care. One approach is to
provide a minimum elementary school counselor-student
ratio to help improve the overall school climate; this helps
to reduce disruptions within classrooms that result from
fighting, cutting class, stealing, or using drugs.104

Integrating learning and behavioral health with an
overall focus on improving functioning and not just
symptom reduction is a topic receiving increased empha-
sis.104,105 Integrating social-emotional learning into
school health education is needed. This can be accom-
plished on an individual basis or by developing and
implementing school-wide programs to address positive
behavioral support.104,105

C H A P T E R 1 8 n Health Planning for School Settings 465

Child with a disability.—
“(A) In general.—The term ‘child with a disability’

means a child—
“(i) with mental retardation, hearing impairments

(including deafness), speech or language impairments,
visual impairments (including blindness), serious emo-
tional disturbance (referred to in this title as ‘emotional
disturbance’), orthopedic impairments, autism, traumatic
brain injury, other health impairments, or specific learning
disabilities; and

“(ii) who, by reason thereof, needs special education
and related services.

“(B) Child aged 3 through 9.—The term ‘child with a
disability’ for a child aged 3 through 9 (or any subset of
that age range, including ages 3 through 5), may, at the
discretion of the State and the local educational agency,
include a child—

“(i) experiencing developmental delays, as defined by
the State and as measured by appropriate diagnostic

Child Ages 3 Through 9 (or any subset of that age
range): May, at the discretion of the State and the local
educational agency, include a child (i) experiencing
developmental delays, as defined by the State and as
measured by appropriate diagnostic instruments and
procedures, in 1 or more of the following areas: physical
development; cognitive development; communication
development; social or emotional development; or adap-
tive development; and (ii) who, by reason thereof, needs
special education and related services.”

BOX 18–4 n Individuals with Disabilities Education
Act—Definitions of a Child With
a Disability

Source: (98)

7711_Ch18_447-478 21/08/19 11:11 AM Page 465

School nurses also have a significant role in the early
identification of mental health needs. Some children fre-
quently visit the school nurse’s office with unexplained
physical symptoms. These frequent visitors (“frequent
flyers,” or what some have called “somatizers”) account
for a disproportionate use of resources in the school.106

Once a physical etiology has been ruled out, somatization
should be recognized as an early identifier of potential
mental health needs and stress in school-age children. The
school nurse can (1) monitor school-based mental health
care; (2) act as a care coordinator; (3) advocate for the stu-
dent; and (4) act as a liaison between the family, school,
clinic, and primary provider for these children.107 In ad-
dition, the nurse develops the health portion of the indi-
vidualized education program and the Individualized
Healthcare Plan for children with identified mental health
needs. The nurse may be the first person to recognize the
need for counseling. Consider the following examples of
student visits to the school nurse:

Example 1: This first example illustrates how the
school nurse can identify a problem that can be

addressed with a simple solution. Jason came to the
health room on a regular basis with complaints of
coughing and shortness of breath due to asthma.
His physical examination often did not correlate
with his complaints. After recognition of a pattern
of these complaints, it was found that these visits to
the health room occurred only during math class.
During consultations with the counselor, family,
and his math teacher, it was learned that Jason was
not getting good grades and was anxious about not
doing well in class. Referral to tutoring services
recommended by the counselor was an acceptable
solution to this problem for all concerned, includ-
ing Jason. After a few weeks, Jason was better pre-
pared for class and did not complain of any more
asthma symptoms during class.

Example 2: The second example is more complex.
The PE teacher referred Annie, a 14-year-old
middle school student, to the school nurse. Annie
was at the point of failing PE; she could not partic-
ipate in the activities because she forgot to bring
her PE clothes to school. The PE teacher asked

466 U N I T I I I n Public Health Planning

TABLE 18–1 n Description of Federal Laws for Children With Special Needs

Law Description Special Considerations

Pub. L. No. 94-14. Education
for All Handicapped Children
Act (EAHCA) of 1975.

Renamed the Individuals with
Disabilities Education Act
(IDEA) in 1990.

Source: http://www.scn.org/
~bk269/94-142.html

Section 504 of the Rehabilitation
Act of 1973 and current
amendments (2008).
29 U.S.C. § 794.

Source: http://www2.ed.gov
/about/offices/list/ocr/
504faq.html

Americans With Disabilities Act
(ADA) 1990

Americans With Disabilities Act
(ADA) Amendment 2008.
P.L. 110-325.

Source: http://www.ada.gov/
pubs/adastatute08

This law appropriates federal
funding to states for the provision
of a free and appropriate public
education in the least restrictive
environment to those students
with disabilities who qualify.

This is a civil rights law that prohibits
discrimination based on disabilities
by entities receiving federal
funds, including local education
agencies; several amendments to
the law expanded provisions in
2008.

The ADA is another civil rights law
that prohibits discrimination based
on disability.

An individualized education program
(IEP) is mandated for each student in
special education. An individualized
family service plan (ISFP) is indicated
for qualified birth to 3-year-old
children.

Public elementary and secondary
schools must provide Free
Appropriate Public Education for
qualified students with a disability.30

A 504 plan is written by the child’s
treatment team.

Section 504 expands disabilities
beyond learning to a mental or
physical impairment that substantially
limits one or more life activities.

The provisions of this law apply to
agencies with or without the receipt
of federal funds.

7711_Ch18_447-478 21/08/19 11:11 AM Page 466

whether the nurse could talk to Annie. Annie
and the nurse talked in private to discuss PE.
Annie felt uncomfortable undressing and chang-
ing her clothes in front of other girls. There were
no private dressing areas. She was self-conscious
about her weight. When the nurse talked to
Annie’s mother, she discovered that Annie had
not asked her mother for money for the PE
clothes. Her mother did not have a lot of money,
and Annie did not want to be an additional finan-
cial burden. The final plan was to allow Annie to
change her clothes in the privacy of the health
room and then go to PE. There were extra used
but clean PE clothes available that were given to
Annie. When Annie got dressed, the nurse noted
healed and new linear wounds on both her upper
forearms. They sat and talked. The nurse shared
her assessment of the old scars and new wounds
as being self-inflicted. Annie agreed. She had not
wanted her classmates or teachers to know. The
school counselor, the nurse, the mother, and
Annie met to discuss the implications of the self-
inflicted wounds. Annie and her mother agreed
that Annie would see a psychologist, and she
would attend PE with a long-sleeved PE shirt.
The nurse met with Annie weekly to discuss
healthy eating habits and daily physical activity.
Along with counseling by a trained psychologist,
increased daily exercise, and a change in dietary
habits, Annie began to lose weight, passed PE,
and had a group of friends by the end of the year.

These two examples differ in the severity of the issues.
Jason did not have a mental health disorder, but Annie’s
symptoms were indicative of possible mental health
issues. The right decision was to refer her for further as-
sessment and possible treatment. Both examples exem-
plify a very important point. Although the mental health
field has traditionally focused on psychopathology, the
absence of mental illness does not necessarily equate with
positive mental health.108 Children who have low psy-
chopathology and low subjective well-being are also at
risk for academic and behavior problems, and can benefit
from counseling.

The links between mental health and academic
achievement have been well established.108 In addition,
the CDC has stated that, if mental health disorders are
left untreated, adolescents are more likely to experience
higher rates of suicide, violence, school dropout, family
dysfunction, juvenile incarceration, alcohol use, drug use,
and unintentional injuries.108 These examples support

the role of the school nurse in providing counseling and
in conducting programs focused on prevention.

Delegation: Delegation is an intervention that has
particular relevance to the school nurse in addressing
noncommunicable diseases and mental health disor-
ders in schools. According to the National Council
of State Boards of Nursing (1995), delegation is defined
as transferring the authority to perform a selected nurs-
ing task in a selected situation to a competent individ-
ual.109 Because of budgetary constraints resulting in the
lack of school nurses, delegation is given to UAPs to
meet the health needs of student populations. One of
the challenges of delegation is the fact that laws, regu-
lations, scopes of practice, and standards vary by state,
and there is a potential conflict between state laws
and nurse practice acts. Another challenge is that of
assuring safe and effective delegation in school settings.
The school nurse must consider “the needs of the stu-
dent, the stability of the student, the complexity of the
task, the competence of the UAP, the expected out-
comes, and the needs of other students in determining
the appropriateness of delegating a specific task to
a UAP.”110

C H A P T E R 1 8 n Health Planning for School Settings 467

n EVIDENCE-BASED PRACTICE
School Screening for Adolescent
Idiopathic Scoliosis

Practice Statement: Routine school screening for
adolescent idiopathic scoliosis is not recommended.
Targeted Outcome: School nurses advocate for
review of state law and regulations requiring school
scoliosis screening programs.
Evidence to Support: The most common form of
scoliosis is adolescent idiopathic scoliosis, which affects
2%-4% of youth ages 10-18 years old. The U.S. Preven-
tive Services Task Force (USPSTF) finds insufficient
evidence to recommend screening adolescents for
idiopathic scoliosis. From the current evidence, the
USPSTF cannot assess benefits or harms of screening.
School scoliosis screening programs are thought to
over-refer for follow-up care, which incurs costs in
dollars and anxiety. In addition, school screening may
be duplicative because pediatric primary care clinicians
screen for scoliosis in well-child visits. The majority
of states do not require school scoliosis screening
programs; 15 states have mandates for such school
screening. The question to answer is: Are school
scoliosis screening programs functioning out of tradi-
tion or evidence?

7711_Ch18_447-478 21/08/19 11:11 AM Page 467

Consultation
Because of health expertise, the school nurse is likely
to provide consultation within schools to address
health issues. This can be in the role of the school nurse
for individualized education program evaluations, in
which nurses have a critical role in determining stu-
dent eligibility for 504 plans. A 504 plan for a student
with a disability provides for reasonable accommoda-
tions that help a student to attend, participate in, and
be successful at school.103 ADA amendments went into

effect in January 2009, making more health-related
functions fit the criterion of major life activities. The
list now includes reading, concentrating, thinking,
sleeping, eating, performing manual tasks, and other
major bodily functions.111

In addition to local school nurses, there is a state
school nurse consultant in 39 states. This person pro-
vides consultation to nurses practicing in schools and is
in a position to advocate for state-level policies and local
school nursing practices.112 The National Association of
State School Nurse Consultants (NASSNC) has a posi-
tion paper that provides the rationale for having a state
school nurse consultant in every state. The NASSNC ra-
tionale for having a state school nurse consultant
(SSNC) is as follows: The SSNC “is responsible for pro-
moting statewide quality standards for school health
policies, nursing scope of practice and clinical proce-
dures, documentation, and for initiating and coordinat-
ing a quality assurance program for accountability. S/he
works in collaboration with the state board of nursing,
provides guidance in health program development and
planning, establishes a continuum of staff development,
and serves as a liaison and resource expert in school
nursing practice and school health program(s).”112 The
position paper goes on to outline the responsibilities of
the SSNC (Box 18-5).

Advocacy
Advocacy by the school nurse occurs on multiple levels.
The school nurse can advocate for the student popula-
tion and their families through efforts to influence
policy at the local, state, and/or national levels.113 The
school nurse also serves as a direct advocate for health-
care consumers, in this case, students, families, and
school communities. The role of advocate can include
advocating for culturally competent and developmen-
tally appropriate care, optimal utilization of resources,
and promotion of a healthy environment.114

468 U N I T I I I n Public Health Planning

Recommended Approaches: School nurses lead in
advocacy that results in optimum health for students.
School nurses, especially through state school nurse
organizations, can convene other groups of child and
adolescent health and education professionals, student
advocates, and families to:

• review current school scoliosis screening law and
regulations

• review current evidence-based guidance on the
topic

• discuss what is best for students
• advocate with one voice for the evidence-based

course to take

Sources
1. American Academy of Orthopedic Surgeons and

Scoliosis Research Society. (2015). Position statement:
Screening for idiopathic scoliosis in adolescents. Rosemont,
IL: American Academy of Orthopedic Surgeons. Re-
trieved from https://www.srs.org/about-srs/news-and-
announcements/position-statement—-screening-
for-the-early-detection-for-idiopathic-scoliosis-in-
adolescents

2. Dunn, J., Henrikson, N.B., Morrison, C.C., Blasi, P.R.,
Nguyen, M., & Lin, J.S. (2018). Screening for adolescent
idiopathic scoliosis evidence report and systematic
review for the U.S. Preventive Services Task Force.
JAMA, 319(2),173-187. doi:10.1001/jama.2017.11669

3. Horne, J.P., Flannery, R., & Usman, S. (2014). Adolescent
idiopathic scoliosis: Diagnosis and management. American
Family Physician, 89(3),193-198. Retrieved from https://
www.ncbi.nlm.nih.gov/pubmed/24506121

4. Jakubowski, T.L. & Alexy, E.M. (2014). Does
school scoliosis screening make the grade? NASN SN,
29(5), 258-265. https://doi.org/10.1177/1942602X
14542131

5. Mabry-Hernandez, I., & Tannis, C. (2018). Screening for
adolescent idiopathic scoliosis. American Family Physician,
97(10), 666-667.

w SOLVING THE MYSTERY
The Case of the Missing Student
Assessment
Public Health Science Topics Covered:
• Interdisciplinary collaboration
• Program planning

Tameka, the school nurse in a large inner-city
charter high school, served on the attendance review

7711_Ch18_447-478 21/08/19 11:11 AM Page 468

C H A P T E R 1 8 n Health Planning for School Settings 469

The responsibilities of the state school nurse consultant
include:

• Serving as liaison and resource expert in school nursing
and school health program areas for local, regional,
state, and national school health-care providers, and
policy setting groups;

• Providing consultation and technical assistance to local
school districts, parents, and community members;

• Coordinating school health program activities with
public health, social services, environmental, and
educational agencies as well as other public and
private entities;

• Monitoring, interpreting, synthesizing, and disseminating
relevant information associated with changes in health
and medical care, school nursing practice, legislation,
and legal issues that have an impact on schools;

• Facilitating the development of policies, standards,
and/or guidelines. Interprets updates and disseminates
policies, standards, guidelines, and/or procedures to
enhance coordinated school health programs;

• Fostering and promoting staff development for school
nurses. This may include planning and providing
orientation, coordinating, and/or providing educational
offerings and networking with universities and other
providers of continuing education to meet identified
needs;

• Promoting quality assurance in school health services
by initiating and coordinating a quality assurance
program that includes a needs assessment, data collec-
tion and analysis, and evidence-based practice;

• Participating in state-level public interagency/private
partnerships with statewide stakeholders to foster a
coordinated school health program, representing
school nurses in multidisciplinary collaborations;

• Initiating, participating in, and utilizing research studies
related to a coordinated school health program, the
health needs of children and youth, school nursing
practice, and related issues; and

• Serving as legislative liaison regarding school health
issues with the state department of health.

BOX 18–5 n Responsibilities of State School
Nurse Consultants

Source: (112)

convening the committee. The school administration
understood that academic achievement is linked to
students being present in class,115 and reduction of
absenteeism was a major strategic goal for the school.
The committee was composed of the vice principal,
two teachers, the school social worker, and Tameka.
During one meeting, the committee discussed one
student, Aisha, who was in danger of losing credits for
courses she was passing because of excessive absen-
teeism. Aisha had recently moved into the school
district and had no record of a health problem. The
committee decided that Tameka would contact
the student and parent or guardian for additional
information.

As a first step, Tameka asked Aisha to come to the
health suite. Aisha told Tameka that she was an only
child and her mother, Monique, was a single parent
who had a night-shift job that paid the minimum wage.
To make up for the low wages, Monique worked as
much overtime as she could get. They had moved to
the city to be closer to extended family. Aisha had
made a few friends in school and in her neighborhood.
She worked hard at staying current with her school-
work, despite school absences.

After some probing, Aisha explained that she had
juvenile rheumatoid arthritis (JRA), specifically, pol-
yarticular disease, but had not reported it because
she was sure she could cope with it on her own. She
was diagnosed with JRA 4 years ago. She described a
typical morning on school days; it took her about 2 to
3 hours to get dressed and ready for school because of
extreme discomfort in her joints. Her mother usually
did not return from her shift until after the time Aisha
needed to leave for school. Aisha sometimes gave up
trying to get ready in time to make the walk to school.
Although it was only four blocks, some mornings the
pain made it very difficult to walk.

When Tameka spoke with Aisha’s mother, Tameka
discovered that they did not have a car and traveling
on the city bus to see her PCP was difficult for Aisha
as it required two bus changes. The mother then
admitted that Aisha had not actually seen a PCP since
they had moved to the city. The prescribed medication
regimen was abandoned by the family because of a
lack of finances. Aisha primarily relied on over-the-
counter NSAIDs for pain relief, which she described as
“okay, sometimes.”

Tameka concluded that her priority regarding
Aisha was to help connect her with health care, includ-
ing support for medication costs. Tameka referred

committee. Because attendance in school is critical to
learning, the school administration had convened the
committee to include those who could provide the
most insight into underlying factors that might con-
tribute to attendance problems. The current emphasis
on educating the whole child by the Every Student
Succeeds Act (ESSA) furnished the initial rationale for

7711_Ch18_447-478 21/08/19 11:11 AM Page 469

Local Laws and Regulations
From a local school perspective, implementing wellness
policies and practices reflecting the goals of HP is one
example of how nurses intervene at this level. In Wiscon-
sin, a guide has been published titled What Works in
Schools: Healthy Eating, Physical Activity, and Healthy
Weight; the guide provides approaches that nurses can
perform for prevention of obesity.116 School nurses play
an important role on school health advisory councils
(wellness committees, school wellness advisory councils)
where they can advocate for comprehensive health pro-
grams and recommend, review, and facilitate the imple-
mentation of district policies.117 These policies relate to
key components that support school health including the
built environment, school wellness policies, or changing
longstanding policies that are no longer supported by ev-
idence. Changing practice involves changing beliefs,
which requires collaborative community relationships,
identification of hierarchy structures in school policy de-
velopment, and system education.113

State Laws and Regulations
Variations in legislative mandates for school nurses
occur within and among states in the United States.
School nurses practice under state nurse practice acts and
codes. That means nurses must not only understand the
scope and standards of school nursing practice but also
the specific state-level regulations related to their scope
of practice, the required level of education, and other rel-
evant laws. For example, school nurses need to know if
state nurse practice acts provide for delegation of certain
nursing tasks to UAPs, or the minimum level of educa-
tion required to practice as a school nurse.

State immunization regulations govern the criteria for
required vaccines for enrollment in schools. School nurses
must be alert to changes in immunization regulations and
requirements to inform parents and guardians of changes
and to review compliance.

States mandates vary with respect to student screening
for certain health conditions. More than 70% of states re-
quire hearing and vision screening to detect potential
hearing or vision problems.118 School nurses conduct
these screenings in schools. In some school districts, tech-
nicians, not school nurses, are responsible for conducting
hearing and vision screenings, and school nurses focus on
following up with those students referred for exams.

Federal Laws
School nurses also play a significant role in adhering to
federal laws and promoting the development of federal
policies. The laws with particular relevance to children

470 U N I T I I I n Public Health Planning

Monique to the local health department for assistance
with completing the state Children’s Health Insurance
Plan (CHIP) application. With approval of the applica-
tion, Aisha began visits to health-care providers.

The attendance review committee helped set up a
class schedule to allow Aisha a first period study hall
so that she could get to school in time for classes. The
social worker also worked with Aisha and Monique
to get documentation approved for the possibility of
Aisha receiving home instruction in the event of an
exacerbation of JRA. Tameka also arranged for Aisha
to receive transportation to school if needed. It was
hoped that, with proper management as well as accom-
modations within the school setting, Aisha would not
miss school.

Intervening on Aisha’s behalf was only the begin-
ning of Tameka’s job as an advocate. Through a
collaborative approach, the school team had helped
address an issue for Aisha and also identified a gap in
how they collected health information on new stu-
dents. Tameka proposed that they develop a new
student process that would help to identify students
at risk for adverse educational outcomes due to
health issues such as Aisha’s. The team identified
other team members who needed to be on their
committee, including the staff who did the initial
intake. In Aisha’s case, she had not reported the
problem, but when the team reviewed her transcript
form from the other school, they found a notation on
Aisha’s condition that had been missed. Changing
the intake process was a crucial step for the school
in the process of advocating for their students who
needed additional support services.

Tameka modeled the nurse’s role by illustrating
the importance of health services that support learning,
health, and student achievement. She began by focusing
on individual student advocacy and then helped lead
the team in advocating for the student body as a
whole.

Policy Development and Enforcement
Policy plays a significant role in influencing school health
and the health services provided to students. This role
can be seen in the Focus on School Health section of HP,
federal and state laws, and local regulations governing
services. The advocacy role of school nurses includes ad-
vancing school health policy, whether it is local school
policy, state policy, or national policy affecting children
and adolescents.113

7711_Ch18_447-478 21/08/19 11:11 AM Page 470

with disabilities were reviewed in preceding sections.
Other laws also important to the role of the school nurse
are discussed here.

Elementary and Secondary Education Act
School health services are influenced by a number of fed-
eral laws, beginning with the Elementary and Secondary
Education Act (ESEA), also referred to as ESSA (Public
Law 115).119 This legislation provides federal funding for
improved academic achievement for students, including
students with disabilities. ESSA sets the stage for educa-
tion policy and reform from the federal, state, and local
levels, and sets the atmosphere in which schools work,
including school health services. The act has come under
some criticism because it includes a requirement for
standardized testing. Under President Obama, the Act
was modified to allow states to apply for a waiver from
the requirements of the Act. States need to apply and
demonstrate how they will improve academic achieve-
ment.119 Title I of the ESSA is aimed at improving the
academic outcomes of the disadvantaged. It provides a
mechanism for state education agencies to provide fund-
ing to local education agencies that apply for grants to
resource programs aimed at improving the academic
achievement of students.

Child Abuse Prevention and Treatment Act
The Child Abuse Prevention and Treatment Act
(CAPTA) was first passed into law in 1974 as Public
Law 93-247 and has undergone numerous amendments
over the years. CAPTA includes provisions for funding
state child welfare agencies, among other provisions.120

School nurses, along with other school staff, are required
to report suspected child abuse and neglect according to
their state laws and regulations.

Family Educational Rights and Privacy Act
The Family Educational Rights and Privacy Act
(FERPA) provides for the protection of privacy for par-
ents and eligible students as related to education records
maintained by educational agencies and institutions that
receive funds from the U.S. Department of Education.
Because private and religious schools do not generally
receive funds from the U.S. Department of Education,
they would not be subject to FERPA. With FERPA, par-
ents and students have certain rights to review, inspect,
and request amendments to a student’s education record.
FERPA sets forth the parameters for educational agencies
and institutions for disclosure of personally identifiable
information from education records.121 For example,
student health records are often considered part of the

education record, and the school nurse must maintain
the privacy of the records under FERPA. According to
FERPA, “At the elementary or secondary level, a stu-
dent’s health records, including immunization records,
maintained by an educational agency or institution sub-
ject to FERPA, as well as records maintained by a school
nurse, are ‘education records’ subject to FERPA.”143

From this perspective, school health records are consid-
ered education records. HIPAA sets out requirements
for electronic health-care transactions to protect the
privacy and security of individually identifiable health
information.121 Thus, it is important for school nurses
to know which act applies in their school district.

Children’s Health Insurance Program
In 1997, the U.S. Congress passed legislation titled the
Children’s Health Insurance Program (CHIP), which
was reauthorized as the Children’s Health Insurance
Reauthorization Act of 2018 (Pub. L. 115-123).122 CHIP
provides health insurance to approximately 9.4 million
children whose family incomes are too high to qualify for
Medicaid and too low to afford health insurance. The
federal government provides matching funds to states.
The states can implement the program as an extension
of Medicaid, a separate program from Medicaid, or a
combined CHIP-Medicaid program.123 The reauthorized
Act extends the requirement that states maintain
coverage for children from 2019 through 2023; after
October 1, 2019, the requirement is limited to children
in families with incomes at or below 300% federal
poverty level (FPL).122 The reauthorization continues the
23 percentage point CHIP-enhanced federal match rate
established by the Affordable Care Act for FY2018 and
FY2019, decreases it to 11.5 percentage points in FY2020,
and returns to the regular CHIP match rate for FY2021
through FY2023. 122

School nurses serve a vital role in facilitating student
enrollment in CHIP. School nurses are often the only
health-care providers who see students on a regular basis.
They collaborate with local health departments to pro-
vide information and outreach to parents and families of
children about enrolling in CHIP. School nurses work
one-on-one with families with ill children who need to
seek primary health care but are hesitant to do so because
of a lack of or inadequate health-care insurance.

Healthy Hunger-Free Kids Act
Another example of a federal law that impacts schools is
the Healthy Hunger-Free Kids Act of 2010 (Pub. L. 111-
296), which was signed into law on December 13, 2010.
This law allows the USDA to update the school nutrition

C H A P T E R 1 8 n Health Planning for School Settings 471

7711_Ch18_447-478 21/08/19 11:11 AM Page 471

standards and provides funding to increase the national
school lunch program.124 School nurses have taken lead-
ership in testifying for and supporting this new law.

Challenges for the Future
Time spent in childhood poverty has been linked with
poor child health status, with African American chil-
dren disproportionately affected.125 Poor health status
plays a role in limiting educational achievement of
adolescents.126 Addressing health disparities that have
an impact on education, such as vision, asthma, teen
pregnancy, aggression and violence, physical activity,
lack of breakfast, and inattention and hyperactivity,
has a role in promoting educational attainment among
low-income and minority adolescents.127 School nurses
are in a position to lead health-promoting efforts and
reform to help address health disparities in school-age
children, and to transform educational and health
systems to achieve health and educational equity.

Health-Care Reform
With the passage of the federal ACA as Public Law 111-
148, school nursing has a role in certain provisions.
Highlights of those provisions of Public Law 111-148
include:128

• Access to health insurance for people with preexist-
ing conditions

• Streamlined enrollment procedures for Medicaid
and CHIP

• Development of standards and protocols for health
information technology

• Teen pregnancy prevention strategies and services
• Increased access to clinical preventive services

through school-based health centers
• Oral health-care prevention activities
• Funding for a childhood obesity demonstration

project

School nurses must remain aware of activities related
to health-care reform. Partnerships with local health de-
partments enable school nurses to know what resources
exist for children and families.

School Health Services Funding
With few funded mandates for school nursing, financing
school health services generally happens with local gov-
ernment dollars: either education or public health. What
would it take for both health and education to support
funding for school health services? The health needs of
schoolchildren must be met. The answer may require

building creative and collaborative linkages between
schools and community health services.91

Data on the cost-effectiveness of school nursing will
allow critical and strategic decision making related to
funding school health services. A study of the economic
value of hospital nurses indicates the need to look at the
broader values that nurses deliver in care and compassion
as well as economics.129 Demonstrating the economic
value of professional nursing in the school setting may
facilitate the provision of appropriate school nurse
staffing to meet the health needs of students.

472 U N I T I I I n Public Health Planning

n CELLULAR TO GLOBAL: WORLD
HEALTH ORGANIZATION
SCHOOL HEALTH INITIATIVE

According to the WHO:

WHO’s Global School Health Initiative, launched in 1995, seeks
to mobilize and strengthen health promotion and education
activities at the local, national, regional, and global levels. The
Initiative is designed to improve the health of students, school
personnel, families, and other members of the community
through schools.

The goal of WHO’s Global School Health Initiative is to
increase the number of schools that can truly be called “Health-
Promoting Schools”. Although definitions will vary, depending on
need and circumstance, a Health-Promoting School can be char-
acterized as a school constantly strengthening its capacity as a
healthy setting for living, learning, and working.

The general direction of WHO’s Global School Health Initiative
is guided by the Ottawa Charter for Health Promotion (1986); the
Jakarta Declaration of the Fourth International Conference on
Health Promotion (1997); and the WHO’s Expert Committee
Recommendation on Comprehensive School Health Education and
Promotion (1995).

The main strategies of this initiative are:

• Research to improve school health programs
• Building capacity to advocate for improved school

health programs
• Strengthening national capacities
• Creating networks and alliances for the development

of health-promoting schools130

According to the WHO, efforts to improve health
in school-aged children and adolescents will improve
health globally through the reduction of adverse health
behaviors. These include:

• tobacco use
• behavior that results in injury and violence

7711_Ch18_447-478 21/08/19 11:11 AM Page 472

n Summary Points
• School nursing provides care to individuals, families,

and communities within the educational system.
• HP sets specific goals related to promotion of optimal

health in school-age children and adolescents.
• The Whole School, Whole Community, Whole Child

model informs a collaborative way to address learn-
ing and health needs for children and adolescents
within a school setting. The Framework for 21st Cen-
tury School Nursing PracticeTM represents a student-
centered structure for school nursing practice based
on five key principles and is aligned with the WSCC
model.

• Public health science informs school nursing prac-
tice, especially in relation to levels of prevention.

• Specific federal, state, and local laws apply to school
nursing practice. School nurses serve as advocates for
students, their families, and their communities in ob-
taining resources, protecting rights, and promoting
reform.

REFERENCES

1. National Center for Education Statistics. (n.d.). Fast facts:
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C H A P T E R 1 8 n Health Planning for School Settings 473

• alcohol and substance use
• dietary and hygienic practices that cause disease
• sedentary lifestyle
• sexual behavior that causes unintended pregnancy

and disease131

t CASE STUDY
The Case of the New Nurse

Learning Outcomes
At the end of this case study, the student will be able to:

• Discuss how to prioritize steps for building a school
health program.

• Identify opportunities for collaboration.
• Apply evidence-based school health programs to a

specific population.
• Identify applicable education-related regulations.
• Apply components of health planning, assessment,

and program development to the school setting.

Nesrin started her new job as a school nurse in a
K–5 charter school in New York City that had just
been established and was due to open its doors in
3 months. The school was located in a district where the
population was 40% non-black Hispanic, 30% African
American, 10% non-Hispanic white, and had a growing

Arabic population. She took the job because the char-
ter schools in New York have more freedom to create
their own programs. She was included as part of the
leadership team charged with creating a healthy learn-
ing environment. Based on her recommendation, the
team decided to construct their program using the ele-
ments of the Whole School, Whole Community,
Whole Child (WSCC) model created in collaboration
with CDC.18

1. What would her first steps be from a public health
perspective?

2. Compare your answers with your classmates’
answers, make a master list, and prioritize the
steps.

3. Once you have completed these first steps, put
together a comprehensive health program for the
school.
a. Who would you put on your planning team?
b. What essential elements are needed for the

program?
c. What resources are needed?

4. Put together a draft program based on available
evidence of best practices.

5. Be sure to address the different developmental
needs of the students.

6. How will you address special health needs, including
accommodations for students with disabilities?

7. How will health education play a part in your plan?
8. What federal, state, and local regulations must you

include in the plan?

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and Human Services. Retrieved from https://www.cdc.gov/
diabetes/pdfs/data/statistics/national-diabetes-statistics-
report .

95. Patrick, K.A., & Wyckoff, L. (2017). Providing standards for
diabetes care in the school setting: A review of the Colorado
model. NASN School Nurse, 33(1), 52-56. doi.org/10.1177/
1942602X17725886.

96. National Diabetes Education Program. (2016). Helping
the student with diabetes succeed: A Guide for school
personnel. National Institutes of Health and Centers for
Disease Control and Prevention. Retrieved from https://
www.niddk.nih.gov/-/media/Files/Health-Information/
Communication-Programs/NDEP/health-care-professionals/
NDEP-School-Guide-Full-508 ?la=en.

97. Yonkaitis, C.F., & Shannon, R.A. (2017). The role of the
school nurse in the special education process: Part 1: Stu-
dent identification and evaluation. NASN School Nurse,
32(3), 178-184. doi.org/10.1177/1942602X17700677.

98. Individuals with Disabilities Education Act. (2006).
Individuals with Disabilities Education Act of 2004,
Pub. L. No. 108–446. Retrieved from http://idea.ed.gov/
download/statute.html.

99. Shannon, R.A., & Yonkaitis, C.F. (2017). The role of the
school nurse in the special education process: Part 2:
Eligibility determination and the Individualized Education
Program. NASN School Nurse, 32(4), 249-254. doi.org/
10.1177/1942602X17709505.

100. U.S. Government Publishing Office. (1975). Education for
All Handicapped Children Act of 1974, Pub. L. No. 94–142
(1975). Retrieved from https://www.govinfo.gov/content/
pkg/STATUTE-89/pdf/STATUTE-89-Pg773 .

101. U.S. Department of Education. (2013). Building the legacy:
IDEA 2004. Retrieved from http://idea.ed.gov/explore/
home.

102. Wrightslaw. (n.d.). Section 504, the Americans With
Disabilities Act, and Education Reform. Retrieved
from http://www.wrightslaw.com/info/section504.ada.
peer.htm.

103. Galemore, C.A., & Sheetz, A.H. (2015). IEP, IHP, and
Section 504 primer for new school nurses. NASN School
Nurse, 30(2), 85-88. doi.org/10.1177/1942602X14565462.

104. Cohen, J. (2014). School climate policy and practice trends:
A paradox. A commentary. Teachers College Record.
Retrieved from https://www.schoolclimate.org/themes/
schoolclimate/assets/pdf/policy/SCPolicy&Practice
Trends-CommentaryTCRecord2-28-14 .

105. Domitrovich, C.E., Durlak, J., Staley, K.C., & Weissberg,
R.P. (2017). Social-emotional competence: An essential
factor for promoting positive adjustment and reducing
risk and school children. Child Development, 88, 408-416.
doi:10.1111/cdev.12739.

106. Shannon, R.A., Bergren, M.D., & Matthews, A. (2010).
Frequent visitors: Somatization in school-age children
and implications for school nurses. The Journal of School
Nursing, 26(3), 169-182.

107. National Association of School Nurses. (2017). The school
nurse’s role in behavioral health of students (Position
Statement). Silver Spring, MD: Author. Retrieved from

https://www.nasn.org/nasn/advocacy/professional-
practice-documents/position-statements/ps-behavioral-
health.

108. Centers for Disease Control and Prevention. (2015). Mental
health basics. Healthy youth mental health. Retrieved
from http://www.cdc.gov/mentalhealth/basics.htm.

109. National Council of State Boards of Nursing. (2005).
Working with others: A position paper. Retrieved from
https://www.ncsbn.org/Working_with_Others .

110. Resha, C. (2010). Delegation in the school setting: Is it a
safe practice? The Online Journal of Issues in Nursing,
15(2), 5. doi:10.39 12/OJIN.Vol15No.02Man05.

111. U.S. Department of Education, Office for Civil Rights.
(2011). Protecting students with disabilities. Retrieved from
http://www2.ed.gov/about/offices/list/ocr/504faq.html.

112. National Association of State School Nurse Consultants.
(2008). State school nurse consultant position. Retrieved
from http://www.schoolnurseconsultants.org/wp-content/
uploads/2013/05/NASSNC-Position-Statement-Need-
for-State-School-Nurse-Consultants .

113. Hogan, J. (2018). Condom access for high school students:
The journey from data to policy. NASN School Nurse, 33(5),
284-287.

114. National Association of School Nurses & American Nurses
Association. (2017). School nursing: Scope and standards
of practice (ed 3). Silver Spring, MD: American Nurses
Association.

115. Jacobsen, K., Meeder, L., & Voscuil, V.R. (2016). Chronic
student absenteeism: The critical role of school nurses.
NASN School Nurse, 31(3), 178-185. doi.org/10.1177/
1942602X16638855.

116. Dworak, L.M. (2009). From paper to practice: A look at
Healthiest Wisconsin 2010 and the development of local
school wellness policies that aid in the prevention of child
overweight. NASN School Nurse, 24(2), 85-89.

117. Sheetz, A.H. (2011). Why is a school health (wellness)
advisory council important for school nursing practice?
NASN School Nurse, 26(5), 280-282.

118. Network for Public Health Law. (2017). School nursing
scope of practice: 50 state survey. Retrieved from https://
www.networkforphl.org/_asset/dx4pp2/50-State-Survey—
School-Nursing-Scope-of-Practice .

119. U.S. Department of Education. (2015). Every Student
Succeeds Act. Retrieved from https://www.ed.gov/essa.

120. U.S. Department of Health & Human Services, Administra-
tion for Children and Families, Administration on
Children, Youth and Families, Children’s Bureau. (2017).
Child maltreatment 2015. Retrieved from http://www.
acf.hhs.gov/programs/cb/research-data-technology/
statistics-research/child-maltreatment.

121. U.S. Department of Health and Human Services, U.S.
Department of Education. (2008). Joint guidance on the
application of Family Educational Rights and Privacy Act
(FERPA) and the Health Information Portability and
Accountability Act (HIPAA) of 1996 to student health
records. Retrieved from https://www2.ed.gov/policy/
gen/guid/fpco/doc/ferpa-hipaa-guidance .

122. Federation of American Scientists. (2018). Children’s
Health Insurance Program Reauthorization Act of 2009,
Pub. L. No. 115-123 (2018). Retrieved from https://fas.org/
sgp/crs/misc/R45136 .

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123. Medicaid.gov. (n.d.). Children’s Health Insurance Program
(CHIP). Retrieved from https://www.medicaid.gov/
chip/index.html.

124. U.S. Department of Agriculture Food and Nutrition Serv-
ices. (n.d.). Local wellness policy. Retrieved from http://
www.fns.usda.gov/tn/healthy/wellnesspolicy.html.

125. Malat, J., Oh, H., & Hamilton, M. (2005). Poverty
experience, race, and child health. Public Health Reports,
120, 442-447.

126. Hass, S.A., & Fosse, N.E. (2008). Health and the educational
attainment of adolescents: Evidence from the NLSY97.
Journal of Health and Social Behavior, 4(2), 178-192.

127. Basch, C.E. (2010). Healthier students are better learners: A
missing link in school reforms to close the achievement gap.
Equity Matters: Research Review No. 6. New York, NY:
Teachers College, Columbia University.

128. U.S. Department of Health & Human Services. (2010).
Patient Protection and Affordable Care Act of 2010, Pub. L.
No. 111-148. Retrieved from https://www.hhs.gov/
healthcare/about-the-aca/index.html.

129. Keepnews, D. (2013). Mapping the economic value of
nursing: A white paper. Seattle: Washington State Nurses
Association. Retrieved from https://www.wsna.org/
assets/entry-assets/Nursing-Practice/Publications/
economic-value-of-nursing-white-paper .

130. World Health Organization. (2018). School and youth
health. Retrieved from https://www.who.int/school_
youth_health/resources/en/.

131. World Health Organization. (2018). School health
and youth health promotion. Retrieved from
https://www.who.int/school_youth_health/en/.

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479

Chapter 19

Health Planning for Older Adults
Minhui Liu

LEARNING OUTCOMES

After reading the chapter, the student will be able to:

KEY TERMS

1. Describe the trend of aging population from a global
perspective.

2. Describe demographic and social trends in an aging
America.

3. Define successful aging and determinants of health in the
older population.

4. Describe the main health issues facing older adults.
5. Apply current frameworks related to prevention of

illness and injury in older adults.
6. Characterize priorities for chronic disease management

in the aging population.

7. Identify community resources for helping older adults
age in place.

8. Describe age-specific models of health-care delivery
across the continuum from wellness to end-of-life care.

9. Identify risk factors of successful aging in minority
populations.

10. Articulate key ethical issues related to aging in our
society.

Aged dependency ratio
Ageism
Aging
Baby boomers
Caregiver
Centenarians
Continuing care

retirement
communities (CCRCs)

Core end-stage indicator
Dependency ratio
Early onset at-risk

substance use
Elder maltreatment
Elderly
Elderly persons
Geriatrics
Gerontology

Hospice care
Health promotion
Late onset at-risk

substance use
Life expectancy
Life span
Naturally occurring

retirement community
(NORC)

Old-old
Older adult
Physical activity
Palliative care
Population aging
Rectangularization

of aging
Super centenarians

n Introduction
The world is facing a situation without precedent: globally,
the population aged 60 and over is growing faster than all
younger age groups. In 2017, the estimated number
of people aged 60 and over was 962 million, which com-
prises 13% of the global population. This group of people
is growing at a rate of about 3% per year. Globally,
the number of individuals aged 80 years and older is
projected to triple by 2050, from 137 million in 2017 to
425 million in 2050.1 In the first half of the last century, the
increase in older populations was largely due to improve-
ments in life expectancy. Life expectancy is the probable
number of years a person will live based on the birth
and mortality statistics of the population. The global life

expectancy at birth in 2016 was 71.4 years (73.8 years for
females and 69.1 for males), and global average life ex-
pectancy increased by 5.2 years between 2000 and 2015.2
In the United States, life expectancy increased from
47.3 years at the beginning of the 20th century to 78.8 years
in 2015.2 In 2012, 29 high-income countries had a life ex-
pectancy that exceeded 80 years of age.1 Factors that have
influenced this increase in life expectancy during the last
half of the 20th century include decreased fertility rates and
increased urbanization.1 The fact that we are living longer
has had a direct impact on public health, allocation of
health resources, and demand for nursing services. Under-
standing this phenomenon from a public health perspec-
tive provides nurses with the context in which aging
occurs and the factors that contribute not only to living

7711_Ch19_479-508 21/08/19 11:09 AM Page 479

longer but also to maintaining an optimal health-related
quality of life. This understanding, in turn, helps nurses
develop, implement, and evaluate nursing interventions
across settings from a public health prevention framework.
This will improve the health-related quality of life experi-
enced by older adults and reduce the need for more costly
tertiary care.

Health of Aging Populations
Who Is Old?
In the United States, the commonly accepted definition
of older adult is a person aged 65 or older. This defini-
tion is used in this chapter to be consistent with language
used in Healthy People.3 The age of 65 was chosen be-
cause, in high-income countries, most persons are eligi-
ble for retirement benefits at this age. The World Health
Organization (WHO) pointed out that this definition is
somewhat arbitrary and may not be applicable in lower-
income countries.4,5 The issue is that chronological age
may not accurately reflect a similar biological age of per-
sons living in a low-income country compared with
someone the same age living in a high-income country.
For example, the WHO argued that a person aged 50
or 55 living in a low-income country may be comparable
biologically with a person aged 65 living in a high-
income country. People who live in low-income coun-
tries age faster because of inadequate nutrition, exposure
to communicable diseases, and poorer living conditions.5
Thus, the aging process is a product not only of chrono-
logical age but also of biological age.

Aging occurs differently in individuals and popula-
tions. Rather than an inevitable decline, aging can in-
stead be viewed as the later stages of continuous growth
and development that occur across the life span. The
quality and length of life depend on factors that improve
the biological response to growth and development
experienced across the life span. The factors include not
only individual healthy habits embraced in youth and
followed across the life span, but also the environment
in which an individual lives. The term life span is used
to describe the measure of a life from birth to death. It
also refers to the genetically based limit to the length of
life. In humans, the documented maximum life span
achieved was 122 years.

Though chronological age as a marker for aging has
some limitations, it provides a way to compare popula-
tions. Other terms commonly used are elderly or elderly
persons, but the preferred term is older adult. These
terms are also defined using chronological criteria and
are typically used to describe persons aged 65 years
or older.5 There are also terms for subpopulations, as

evidenced by terms such as old-old (ages between
85 and 95) and oldest-old (95+). As life expectancy
lengthens, another chronological group is also emerging,
those over the age of 100.6 This population is referred to
as centenarians. Super centenarians are those who live
to be 110 years of age or older.

Nurses provide needed care for older adults and are
educated to view aging as a lifelong process, not simply
a particular chronological age or an end stage of life.
Understanding the specific needs of the older adult from
a population perspective provides nurses with an oppor-
tunity to actively participate in the public health initiative
reflected in HP: improve the quality of life for older
adults.3 For nurses providing care to older adults, there
is an opportunity to reduce risk and enhance function at
the individual level, even in the face of age-related
changes. When this is expanded to include groups of
individuals, communities, and populations, the impact
of nursing interventions is more significant.

Regardless of clinical practice settings, most nurses are
likely to provide care to older family members, friends,
or members of their communities. Providing care to
older adults requires examining the phenomenon of
aging from a population perspective that includes:

• The demographic, social, and health trends associated
with aging

• Public health issues
• Impact on individual care delivery systems
• Resources for health prevention and promotion
• Implications for policy and research

Thus, aging is not adequately measured by chronolog-
ical age. Instead, the quality of life experienced as individ-
uals age is a product of chronological and biological age
and is affected by the environments in which we live.5

An Aging America
In 2015, the U.S. Census Bureau estimated that 14.9%
(47.8 million) of the U.S. population was 65 years old or
older.7 By 2050, the estimated number of persons aged
65 or older will be 83.3 million, and 60% of these older
Americans will be over the age of 74.8 On average, those
who are presently 65 years of age will now live another
18 years, and those aged 85 years will live on average
into their early 90s.9 This phenomenon is referred to as
population aging, which is a shift in the distribution of
a country’s population toward older ages. In other
words, the proportion of the population that is older has
increased (Fig. 19-1). This is usually reflected in an in-
crease in the population’s mean and median ages, a de-
cline in the proportion of the population composed of
children, and a rise in the proportion of the older adult

480 U N I T I I I n Public Health Planning

7711_Ch19_479-508 21/08/19 11:09 AM Page 480

population (Fig. 19-2). Population aging is widespread
across the world and is most advanced in high-income
countries.10,11 This aging of the population globally, ac-
cording to the WHO, is a cause for celebration because
it reflects the positive effect of interventions aimed at
improving health. It also offers opportunities, as older
adults are a wonderful resource. However, this trend
puts strains on pension funds and the demand for
health-care services.11 It is imperative, then, to tailor
health-care resources and systems to the unique needs
of an aging population.

What accounts for the population aging in the
United States? One of the reasons is the improvement

in the environment. In the first half of the 20th century,
diseases that previously led to death in early life became
less threatening as a result of the development of antibi-
otics and other medications. In addition, improvements
in sanitation, diagnostic advances, the application of
technology, and improved prenatal and obstetrical care
contributed to longer living.1 Globally, improvements in
life expectancy are tied to increased child survival rates
and HIV/AIDS survival rates.12 Prior to these innova-
tions in the United States, nearly half of the people born
in the year 1900 died before they reached age 50. Con-
trast this with our current situation, wherein people born
today can expect to live beyond their 75th year, and an
increasing number are living to be 100. In 1900, about
1 in 25 Americans was over 65; today 1 in 8 are. The older
adult population in the United States is expected to in-
crease from 52.8 million in 2018 to 94.7 million in 2060.
Increases in longevity can also be seen in the fastest
growing age group in our society, the old-old. By 2035,
there will be 11.5 million persons over the age of 85. We
also can expect to see nearly a million centenarians, or
people 100 years or older.13,14

Along with changes in life expectancy, a main reason
for the dramatic increase in the number of older adults
in the United States is the effect of the baby boomer gen-
eration. Baby boomers are those members of the U.S.
population born between 1945 and 1964. In 2010, the
first of this generation turned 65. Growth in the number
of older adults will continue as this cohort moves
through the upper age groups and will begin to stabilize
after 2050.14 According to the U.S. Census Bureau, in
2010 a little more than 14% of the older population was
over the age of 85, but by 2050, when all of the baby
boomers are over the age of 85, that proportion is
expected to increase to over 21%.14 A good way to
visualize this cohort is through a comparison of popula-
tion pyramids over time. Figure 19-3 includes four pop-
ulation pyramids for the United States, 20 years apart,

C H A P T E R 1 9 n Health Planning for Older Adults 481

Figure 19-1 Increase in the number of U.S. older adults
expressed in millions, 2015–2060. (From the U.S. Census
Bureau.)

Figure 19-2 Distribution of U.S. older adults over age
groups, 1990–2050. (From the U.S. National Institutes of
Health, National Institute on Aging [2009]).

65–74

75–84

85–99

100+P
er

ce
nt

ag
e

(%
)

20
45

20
50

20
40

20
35

20
30

20
25

20
20

20
15

20
10

20
05

20
00

19
95

19
00

7711_Ch19_479-508 21/08/19 11:10 AM Page 481

482 U N I T I I I n Public Health Planning

Male Female

Population (in millions)

12 9 6 3 0

United States -1990
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0

0 3 6 9 12 15

Male Female

Population (in millions)

12 9 6 3 0

United States – 2000
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0

0 3 6 9 12 15

Male Female

Population (in millions)

12 9 6 3 0

United States -2030
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0

0 3 6 9 12 1515

Male Female

Population (in millions)

12 9 6 3 0

United States – 2050
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0

0 3 6 9 12 15

Figure 19-3 Comparison of population pyramids 1990–2050. (From U.S. Census Bureau, International Programs U.S. Retrieved
from http://www.census.gov/population/international/data/idb/informationGateway.php/)

starting with 1990. The 1990 pyramid shows the baby
boomer bump clearly. This was when the baby boomers
were between 25 and 45 years old. By 2050, this cohort
is 85 years of age or older, and this accounts for the
change in the top of the pyramid.14

Another term that describes the shift in our popula-
tion toward the older ages is the rectangularization of

aging. This describes the population trend toward in-
creased numbers of healthy years before decline or, more
exactly, a reduction in variability of the age of death.15

With a steady or slightly declining birthrate and reduc-
tions in early deaths, a population’s tendency to move
toward older ages emerges, which is what we are seeing
in the United States today.

7711_Ch19_479-508 21/08/19 11:10 AM Page 482

The face of aging in the United States is changing dra-
matically. People are living longer, achieving higher levels
of education, living in poverty less often, and experiencing
lower rates of disability.13 Even with this positive outlook,
there are still significant public health challenges. For
example, the old-old age group is not only increasing in
numbers but is also prone to the development of serious
chronic conditions, such as dementia. This creates a great
impact on both older adults and their caregivers.16 This
group is also more likely to be living in poverty and to
experience functional declines. Also, the epidemic of obe-
sity will have an impact on the development of cardiovas-
cular disease and diabetes, with implications not only for
longevity but also for health-care utilization and quality
of life. Today, more than a third of persons over the age
of 59 (41.0%) are obese.17

Aging and the Workforce
In our daily lives, our joint activities and interactions
with older adults demonstrate their valuable contribu-
tions to family life, workplaces, and communities.
Consider the greeter at Walmart, the volunteer at the
library, and our elected officials serving as senators
and representatives well into their 70s and sometimes
80s. As more people over the age of 65 participate in the
workforce,9,18,19 we encounter more and more persons
actively contributing to the health and well-being of our
communities.

From 1977 to 2007, the number of persons over
the age of 65 increased by 101%. This graying of the
workforce is not just the result of the increase in the
numbers of older adults staying in the workforce;
younger Americans are entering the workforce at an
older age.19 Older adults are staying in the workforce for
a variety of reasons. One factor was the economic reces-
sion of 2008 to 2010 that reduced the savings of older
adults. More than half of those 62 and over in 2009 cited
the recession as their reason for staying in the workforce.
Other reasons included a desire to feel productive,
a need for social interaction, and the wish for something
to do.19

One of the things the increased life expectancy of a
population affects is the dependency ratio. The depend-
ency ratio is the proportion of dependents (those aged
0 to 14 years plus those 65 years of age and older) per
every 100 members of the population aged 15 to 64. In
relation to the older population, the ratio is referred to
as the aged dependency ratio and it reflects the ratio of
the number of persons age 65 and older per every
100 members of the population aged 15 to 64 (Box 19-1).
Because of the aging population, there is an expected rise

in the dependency ratio as well.19 Factors that may im-
prove the aged dependency ratio include the increased
age of full retirement for Social Security benefits for baby
boomers rising from 65 to 67 and the graying of the U.S.
workforce. As the number of those who live past the age
of 65 increases, any possible benefits from the increased
number of those over 65 who work may be wiped out
by the increasing number of persons aged 75 and older.19

Healthy People and Older Adults
As life expectancy increases along with the proportion
of the population living over the age of 85, society is
confronted with both challenges and opportunities for
people of all ages. The challenge for the 21st century is
to make these added life span years as healthy and pro-
ductive as possible and to continue the current trend of
decline in disability across all segments of the population.
Many older adults experience hospitalizations, nursing
home admissions, and low-quality care, and may lose the
ability to live independently at home. Chronic conditions
are the leading cause of death and disability among older
adults. Because of these concerns, HP 2020 added a new
topic area, Older Adults.3

C H A P T E R 1 9 n Health Planning for Older Adults 483

n HEALTHY PEOPLE
Older Adults

Healthy People Topics Relevant to Health
Planning for Older Adults
Targeted Topic(s): Older adults
Goal: Improve the health, function, and quality of life
of older adults.
Overview: Older adults are among the fastest growing
age groups, and the first baby boomers (adults born
between 1946 and 1964) turned 65 in 2011. More
than 37 million people in this group (60%) will manage
more than one chronic condition by 2030. Chronic

Total Dependency Ratio =

Number of people aged 0 to 14+
number of people aged 65 and older × 100

Number of people aged 15 to 64

Aged Dependency Ratio =

Number of people aged 65+ × 100
Number of people aged 15 to 64

BOX 19–1 n Aged Dependency Ratio

7711_Ch19_479-508 21/08/19 11:10 AM Page 483

• Research and analyze appropriate training to equip
providers with the tools they need to meet the needs
of older adults4

The Changing Diversity in the Older Adult
Population
Another changing demographic for older adults in the
United States is the evolving ethnicity of this population.
Although those over 64 are less ethnically and racially di-
verse compared with younger groups, this is projected to
change over the next 4 decades dramatically. The number
of white older adults is projected to decrease by 10%, and
all other ethnic/racial groups will increase, with 42% of
older adults being members of a minority population by
2050. The number of persons of Hispanic origin aged
65 years or older will nearly double from 37.4 million
in 2010 to 71 million in 2050.21 This increasing ethnic
diversity of the older adult population has implications
for the development of culturally relevant interventions
that consider the diverse cultural heritage of this group.
Thus, conducting a cultural assessment and maintaining
cultural competency is an essential skill for nurses work-
ing with older adult populations.

Determinants of Aging and Health
To begin to think about the public health implications of
an aging population, it is essential to understand what
it means to age. Aging is the process of becoming

484 U N I T I I I n Public Health Planning

Target met
or exceeded
20.0% (n=3)

Improving
6.7% (n=1)

Little or no
detectable

change
20%
(n=3)

Getting worse
33.3%
(n=5)

Baseline only
20%
(n=3)

Measurable
78.9%
(n=15)

Archived
10.5%
(n=2)

Developmental
10.5%
(n=2)

Total Objectives: 19

Measurable Objectives: 15

Healthy People 2020 Midcourse Review:
Older Adults

conditions can lower quality of life in older adults and
can be leading causes of death in this population.
HP 2020 Midcourse Review: Of the 19 objectives for
this topic area, 2 were developmental and 15 were
measurable (Fig. 19-4). For 3 of the measurable
objectives, the target was met or exceeded, and 1 was
improving. For 3, there was little or no detectable
change, and 5 were getting worse. Three of the
objectives had baseline data only.20

Source: See HP 2020 for background, objectives,
interventions, and resources.3

Why Is the Health of Older Adults Important?
According to HP, more than 60% of older adults manage
two or more chronic conditions. To address this growing
burden on our health-care system, population-level ap-
proaches are needed to reduce the morbidity and mortality
associated with chronic diseases (see Chapter 9), and to
improve the health-related quality of life experienced by
older adults. HP supports population approaches that
will increase prevention initiatives while improving access
to services. Emerging issues for improving the health of
older adults include efforts to:4

• Coordinate care
• Help older adults manage their own care
• Establish quality measures
• Identify minimum levels of training for people who

care for older adults

Figure 19-4 Healthy People 2020 for Older Adults Midcourse Review.

7711_Ch19_479-508 21/08/19 11:10 AM Page 484

chronologically and biologically older. This process is de-
termined by genetics and is modulated by the environ-
ment. It can also be viewed from a perspective that moves
beyond the physiology of aging. As noted by the WHO,
aging is a concept that encompasses more than counting
years or the physiological and psychosocial features that
change over time.4,5 It is often defined as a feeling, a state
of mind, or a product of what an individual is able to
do—in other words, a functional definition of aging.
Simply viewing aging in terms of the number of years
lived or specific age-associated signs limits a true defini-
tion of an older adult, for individuals of any given age
may exhibit widely varied characteristics. Older adults
are a diverse group of people moving across the life
course with many heterogeneous and unique features.
Indeed, there are more and more differences among in-
dividuals as they grow older. Important indicators of age
are physical health, psychological well-being, socioeco-
nomic factors, functional abilities, and social relations.
Goals of nursing care are to modify physiological and
psychological changes and help people stay healthy,
functional, and independent longer.

Theories of Aging
The processes of aging have long intrigued scientists and
philosophers. However, finding an explanation for the
many complex changes associated with aging, both pre-
dictable and random, has presented a formidable chal-
lenge. Many ideas have been proposed and tested, but
the only certainty is that no single theory can explain
everything about the process of aging. Theories encom-
pass biological, immunological, psychological, and de-
velopmental realms. Even these widely ranging ideas
about aging have some key features in common.

One theoretical approach to aging is that signs of
aging emerge when demands exceed resources, that is,
the person no longer independently has the resources
needed to meet the demands of everyday life. Some of
the biological theories provide examples of this imbal-
ance. Another theory is that aging occurs when there is
a loss of effectiveness in maintaining equilibrium at the
biological level, such as what occurs in heart failure.
Other theories are based on the loss of the ability to adapt
to change, which becomes more pronounced with the
advance of time.22

Biological Theories of Aging
The biological theories of aging regard the body as a col-
lection of cells and materials subject to mechanical or ar-
chitectural failure as they grow older. Biological breakdown
with aging may result from genes, such as when harmful

genes “turn on” and become active in later life, or when
some older adults exhibit youthful vigor and well-being
in older adulthood, which seems to run in their families.
It is also thought that some genes actually promote func-
tional decline and structural deterioration, thereby pro-
ducing the outward and organic signs of aging. In genetic
studies of worms, scientists have been able to isolate the
specific gene that controls longevity, and by manipulat-
ing that gene, can cause the worms to live a greatly ex-
tended life span.22 The excitement that accompanied the
mapping of the human genome was coupled with the
hope that, by decoding genetic material, we would be
able to understand and ultimately influence health and
longevity. However, many more questions have devel-
oped from our knowledge thus far, including the myste-
rious forces that cause a gene to turn on or turn off.

Another theoretical viewpoint of aging suggests that
aging occurs as a result of the accumulation of errors in
protein synthesis over time, leading to impaired cell
function. In aging, it is thought that successive genera-
tions of faulty cells eventually lead to impaired biolog-
ical function. However, despite evidence of declines in
cell replication, amino acid sequencing does not change
with age, and there is no evidence that RNA becomes
defective with age. Once again, this biological theory
cannot fully explain the dynamics and differences of
aging organisms.22

An additional theory is that aging is related to muta-
tions that occur when cells are exposed to environmental
factors, such as radiation or chemicals; this exposure
causes the DNA to be damaged and altered. Thus, genet-
ics are modulated by the environment. This is based on
the observation that accumulations of mutations are
time-dependent, and it is possible that faulty cells from
youth are replicated and harbored, increasing in num-
bers with age. This is one explanation for the deleterious
effects that can show up later in life.22

The free-radical theory is another major idea in the
biological realm, stemming from the observation that
older adults are more prone to the damaging effects of
free radicals, that is, molecules with unpaired electrons.
They also have lower levels of protectant free-radical scav-
engers, such as vitamin A, vitamin C, and niacin. Free-
radical damage to cells and organs occurs as a result of
oxidative stress and is thought to have cumulative effects.
There are both internal and external sources for oxidative
stress, as free radicals are a by-product of oxygen metab-
olism. Some research into the effects of free-radical
damage has uncovered the accumulation of harmful pig-
mented proteins called lipofuscins that are associated with
aging. The key idea is that cells are repeatedly aggravated

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by harmful stressors that may be metabolic by-products.
In aging, the DNA cannot keep up with needed
repairs, resulting in a decline in function and number
of cells. Serious problems occur when nonreplaceable
cells are damaged, such as muscle, heart, nerve, and brain
cells.24

Yet another major biological theory of aging is the
cross-linkage or connective tissue theory, which describes
the chemical reactions that create strong bonds among
molecular structures that are normally separate, partic-
ularly in collagen, elastin, and ground substance. In-
creased numbers of cross-links in collagen yield stiffness
and loss of resilience. In elastin, cross-links affect move-
ment and elasticity. Evidence of these processes might
be seen in stiffening of blood vessels or skin changes
associated with aging. One of the reasons that caloric
restriction and steroids have been associated with the
slowing of the aging process may have to do with the for-
mation of fewer cross-linkages on a molecular level.24

Some of the physiologically based theories of aging
describe relatively random events, but there are also
some key ideas about programmed aging, or a biological
or genetic clock that determines how an individual’s
original pool of genetic material is played out in an or-
derly manner. Examples of this can be seen in human de-
velopment, maturation, and the expected cessation of
certain body functions, for example, menopause, graying
of hair, or thymus atrophy. The programmed aging the-
ory is based on the concept that cells double a limited
number of times before they die, or that there is an
expected life span for every cell.

Psychosocial Theories of Aging
Psychosocial theories of aging revolve around three
major and somewhat conflicting ideas: disengagement,
activity, and continuity. Early theorists offered the
observation that older adults tend to disengage from
pursuits and roles that they enjoyed in earlier life and
suggested that this process was a mutual withdrawal
of the individual from society. In a classic article,
Cumming25 proposed that this process of disengagement
was accepted and actually desired by older adults, and
that it was a natural and universal feature of a long life.
From their perspective, disengagement was the “correct”
way to age.

However, a clearly opposing theory was at work. Older
adults who resisted withdrawal and remained active and
engaged in life were observed to age more optimally. In
fact, the more active they were, the greater satisfaction
they expressed with the quality of their lives. They were
more likely to be able to substitute new roles for those lost

through changing function or social circumstances. Many
community-based programs for older adults are based on
the activity theory and offer many activities that help
older adults to keep busy and socially engaged. For many
older adults, activity is a vital coping strategy, as they face
inevitable losses and changes in their lives.

Perhaps strongest of all is the theory that people are
basically consistent throughout their lives, and their per-
sonalities remain constant through the passing years.
This is described as continuity26 and can be an important
consideration for nurses as we assist individuals in man-
aging health issues or dealing with new challenges asso-
ciated with aging. We can help older adults use their past
experiences to frame new situations and work from the
strengths within their perspectives and personalities.

Key Aging Research
Despite the fact that we live in a rapidly aging society, the
truth is that many people have a limited understanding
of what it means to grow older. Some people may have
misconceptions about the natural processes of aging and
may view the world of aging according to their own ex-
periences and even prejudices. Some may lack under-
standing of the trials and triumphs that older adults
experience in their everyday lives. It is imperative that
nurses be open in their views of aging. Older adults are
not “the other;” they are a preview for those who are
younger, moving along life’s continuum ahead of them.

Formal study of the aging process has developed over
the past several decades. With a growing population of
aging adults, the National Institutes of Health established
the National Institute of Aging specifically to conduct re-
search about the processes of aging. Research projects
range from examinations of minute molecular, genetic,
and biochemical mechanisms, all the way to entire popu-
lations, and every aspect in between. Exciting discoveries
and insights that are revealed today will inform nursing
practice as nurses care for older adults in our society. In
the following sections, three major longitudinal studies are
discussed that have shaped our understanding of the
processes and challenges of aging, have helped to define
the determinants of health in aging, and have helped to
identify health priorities for an aging population.

Baltimore Longitudinal Study of Aging
The Baltimore Longitudinal Study of Aging (BLSA)
began in 1958 and is the longest-running scientific study
of human aging.27 It is an excellent example of a longi-
tudinal cohort study (see Chapter 3). The focus of this
study is to discover what happens as people age and to
distinguish changes that are due to natural aging from

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those that are due to diseases or other causes. This study
has followed more than 1,400 individuals from age 20
to 90 and older. Over the course of the study, important
aspects of the aging process and determinants of health
have been uncovered, including:

• Normal age-related circulatory system changes and
the development of cardiovascular disease

• Impact of lifestyle choices on the development of
disease

• Brain and memory changes that predict declines
• Stability of personality in older years, coping strate-

gies, and perceived happiness
• Organic changes, such as prostate enlargement and

diagnostic parameters for disease
• Sensory changes, such as alterations in hearing and

taste
• Metabolism and nutrition in aging, including body

composition, predictors for the development of
diabetes, and age-related changes in renal function

A fundamental aim of the BLSA is to differentiate
which changes are a normal part of aging and which are
the result of disease processes. The study has been able
to demonstrate that slower reaction speed and some
changes in short-term memory are associated with aging
in the absence of disease. However, sudden losses, such
as those that accompany heart attacks or strokes, are
clearly the result of disease but can be worsened by the
changes that occur naturally with aging. The good news
is that lifestyle decisions can affect the occurrence or
progression of age-associated disease.

New England Centenarian Study
One fascinating way to look at aging is through the
extremes of longevity, for example, by examining the
features of very long-lived individuals or the super cente-
narians. The oldest documented living person was Jeanne
Calment of Arles, France, who attained the age of
122 years. Her extremely long life span was carefully stud-
ied, as it pushed the boundaries of what we thought could
be possible in human survival and suggested some traits
and behaviors that might contribute to longevity.28

For example, Madame Calment remained physically
active through most of her life. She kept a lean weight.
But contrary to the accepted wisdom about healthy be-
haviors, she smoked cigarettes from the age of 21 until
the age of 117. She ascribed her longevity and relatively
youthful appearance to olive oil, wine, and chocolate.

Serious research about the features and commonali-
ties of people who live to 100+ years is reflected in the
ongoing New England Centenarian Study. Scientists

have observed that individuals who age well into the
extremes of the life span have a marked delay in the de-
velopment of age-associated disability. Among the study
subjects, about 15% have no significant disease at age
100, and these people are characterized as “escapers.”
About 43% of the group has age-related disease that did
not show up until around age 80, and these are called the
“delayers.” The remaining people can be described as
“survivors,” as they have clinically demonstrable disease
prior to age 80, but they manage to survive and continue
to live even with these diseases.28 Basically, longevity
trends support a hypothesis of compression of morbidity,
wherein older adults experience more years of health
prior to the development of disease. Researchers suggest
that in aging, as stated by Hilt, Young-Xu Silver,
and Perls, “… the older you get, the healthier you’ve
been.”29–31

Normative Aging Study
The Normative Aging Study began in 1963 and has fol-
lowed male veterans longitudinally to evaluate changes
in their physical health, health-related behaviors, such as
smoking and dietary intake, and other factors that may
influence health.32 For example, during certain years of
the study, measurements were collected of lead and cad-
mium content in participants’ bodies. Neurocognitive
tests have been tracked, along with tests of motor func-
tion, memory, and learning. Other psychosocial variables
that can have a substantial effect on aging and health
include depression, adverse life events, optimism, and
perceived stress. This study also has a large bank of DNA
samples to look at genes associated with the development
of Alzheimer’s disease.32 With such a wide range of vari-
ables collected over a long period of time, investigators
may be able to identify specific relationships among
genetic, environmental, physiological, and psychosocial
variables.

These ongoing studies and many others continue to
reveal important information about the normal processes
of aging and to identify important roles for nurses in the
community to promote health, reduce risk factors for dis-
ease, and support and enhance optimal management of
chronic conditions associated with aging.

Program Planning and Health
Promotion in Aging
As demonstrated in the major aging research studies,
longevity and health are influenced by complex interac-
tions among biological, psychological, and sociological

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factors. Past research about aging has often emphasized
the extent to which health problems, such as diabetes
or osteoporosis, could be attributed exclusively to age.
Such research tended to exaggerate the homogeneity
of older adults. However, researchers are now reporting
some essential elements that contribute to healthy
aging overall and have helped to identify preventive
health-care goals for older adults and 10 keys to healthy
aging (Box 19-2).33

Changing demographic trends related to an aging
population have driven many changes in health care,
requiring specialized knowledge and application of
gerontology (the study of the effects of time on human
development or the study of the aging process) and
geriatrics (specialized medical care of older adults).
Nursing has been a leader in the field of gerontology,
as it was the first profession to offer advanced certifica-
tion recognizing the specialized skills and knowledge
required in caring for older adults.34

There are a few considerations we need to keep in
mind when promoting successful aging in older adults.
The first consideration is the importance of enhancing
and encouraging healthy life choices at all ages. Nurses
may be involved in health promotion initiatives at any age
that may protect health, reduce risk factors, and lay the
groundwork for optimal health in aging. For example, the
health programs focused on eliminating childhood obe-
sity, promoting physical activity, and stopping smoking
may have far-reaching effects on the aging process. This
is because healthy weight is associated with less hyperten-
sion and healthier glucose metabolism, activity is associ-
ated with strength and mobility, and smoking cessation
reduces the risk of developing respiratory and cardiovas-
cular disease. Thus, healthy and/or unhealthy behaviors
practiced during the younger years contribute to the
health, function, and well-being of the older adult.

Many of the risk factors for the development of dis-
ease and disability in aging can be modified through
changes in behavior or changes in environment.3 Such
modifications are a key focus for public health nurses
working with older populations, whether in the form of
public health education, screening programs, surveil-
lance, exercise, diet, immunization programs, and sani-
tation, as well as for nurses who provide individualized
care. Stages of Change (Transtheoretical) Model devel-
oped by Prochaska and DiClemente is one of the most
commonly used theories in health behavior change
(Table 19-1).35 The basic premise of this model is that be-
havior change is a process, not an event. When a person
attempts to change a behavior, he or she moves through
five stages (precontemplation, contemplation, prepara-
tion, action, and maintenance).

Finally, when we look at risk factors for the develop-
ment of disease and disability in aging, we recognize that
most can be modified through changes in behavior or
changes in environment. Such modifications are a key
focus of community health nursing, whether in the form
of public health education, screening programs, surveil-
lance, exercise, diet, immunization programs, sanitation,
or individualized care.

488 U N I T I I I n Public Health Planning

1. Controlling hypertension
2. Stopping smoking
3. Screening for cancer
4. Keeping current on immunizations
5. Regulating blood glucose
6. Lowering cholesterol
7. Being physically active
8. Preventing bone loss and muscle weakness
9. Maintaining social contact

10. Combating depression

BOX 19–2 n Ten Keys to Healthy Aging

Source: (33)

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the CAPABLE Study
Public Health Science Topics Covered:

• Community Assessment
• Face-to-face motivational interview
• Health assessment

• Health planning:
• Applying health-related conceptual models
• Patient-centered care approaches

Nancy is an 80-year-old retired teacher who has no
children and lives alone. After being discharged from
the hospital, she found she was too weak to use her
front steps, which, without a railing, were unsafe. She
lives in a townhouse with a bedroom upstairs, but she
has difficulty using the stairs because of the absence of
railings and her osteoarthritis pain. Most of her days
were spent alone, and many of her routine activities
such as getting in and out of the bathtub were impossi-
ble. She had fallen several times when trying to get
into bed. And although skilled home care assisted her
in understanding her medications, her environmental
and physical functioning were not addressed.

On the community center bulletin board, Nancy
saw a flyer for Community Aging in Place – Advancing

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C H A P T E R 1 9 n Health Planning for Older Adults 489

TABLE 19–1 n Stages of Change Model

Stage Definition Potential Change Strategies

Precontemplation

Contemplation

Preparation

Action

Maintenance

Has no intention of taking action within the
next 6 months

Intends to take action in the next 6 months

Intends to take action within the next 30 days
and has taken some behavioral steps in this
direction

Has changed behavior for less than 6 months

Has changed behavior for more than 6 months

Increase awareness of need for change; personalize
information about risks and benefits

Motivate; encourage making specific plans

Assist with developing and implementing concrete
action plans; help set gradual goals

Assist with feedback, problem-solving, social
support, and reinforcement

Assist with coping, reminders, finding alternatives,
avoiding slips/relapses (as applicable)

Source: (35)

Better Living for Elders (CAPABLE) which is a home-
based program of an interprofessional team – an occu-
pational therapist (OT), a registered nurse (RN), and a
handyman (HM) – who work with low-income older
adults for 5 months on what they identify as their most
important goals.36 This program is based on an overar-
ching mode––Society to Cells Resilience Framework––
and three other models: person-environment fit,
disablement process, and control. The Society to
Cells Resilience Framework emphasizes intervening
on more than one socioecological domain, such as
physiologic, individual, and built environment. It also
posits that there are critically resilient times, such as
post-hospitalization.37 Person-environment fit is crucial
depending on the number of activity of daily living
(ADL) challenges a person has. If someone has recently
been hospitalized, their new deficits may change the
extent that they “fit” their environment because
they may have new demands of that environment
(e.g., may not be able to rise from a low toilet any-
more).38 The individual and home environment focus
is used from Verbrugge and Jette’s Disablement
Process.39 Individualizing fit between the person and his
or her environment (increasing P/E fit) should result in
better functioning within that environment. Verbrugge
and Jette use the Life Span Theory of Control,40 which
proposes that progression of disability increases
the threat to personal control, which in turn may
result in negative health consequences. Synthesizing
these frameworks, the goal of CAPABLE is to enhance
resilience (improve ADLs and mobility) by increasing
control (e.g., problem- solving and reframing), and
improving factors that relate to ADL difficulty and

undermine control (e.g., pain, depression, and environ-
mental hazards).

In the first two sessions, the OT met with Nancy
and conducted a semistructured clinical interview using
the Client-Clinician Assessment Protocol (C-CAP).
This tool provides a systematic approach to identify
and prioritize patient-centered performance areas
problematic to Nancy (e.g., she cannot use the front
steps due to her low physical function). For each area
identified, the OT observed Nancy’s performance and
evaluated safety, efficiency, difficulty, and presence of
environmental barriers and supports. The OT provided
a notebook with evidence-based educational materials,
contact information, and a calendar to integrate the
sessions by the RN and HM that Nancy kept for refer-
ence. Based on the environmental assessment, observa-
tion of ADLs, and identification of Nancy’s goal, the
OT and Nancy discussed possible environmental
modifications. In sessions 3 to 5, the OT taught Nancy
problem-solving skills to identify behavioral and envi-
ronmental contributors to performance difficulties.
They also discussed strategies for attaining function
goals. For example, the OT trained Nancy to use spe-
cific strategies such as energy-saving techniques, simpli-
fying tasks, using assistive devices, and skills in keeping
balance to reduce fear of falling. In each session, the
OT reinforced strategy use, reviewed problem-solving,
refined strategies, and provided education and re-
sources to address future needs. Home modifications
were coordinated with the HM to assure that
they were provided in a timely manner and met
Nancy’s needs. The OT followed up with training
in their use. In the final (6th) OT session, the OT

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and there was little focus on prevention. Today, there is
clear evidence that healthy behaviors across the life span,
beginning in utero, increase the chances of a longer life
with reduced disease and disability. Because of this, the
older adult was added to the Healthy People topics in
2020.3 From 2000 to 2011, heart disease was the leading
cause of death for those 65 years of age or older, account-
ing for a little under a third of all deaths in this age
group.41

Communicable Disease
Older adults are more vulnerable to acquiring a commu-
nicable disease and at higher risk for morbidity and mor-
tality from it. (See Chapter 8 for more information on
communicable diseases.) There are three main reasons
for increased vulnerability to communicable diseases in
the older adult:

• Decreased immunity
• Existence of comorbid illness
• Undernutrition

All of these reasons are host-specific. Decreased im-
munity occurs as a result of the aging process and poor
antibody production. Alteration in skin integrity because
of drying and thinning of the epidural layer can also de-
crease immunity. The existence of comorbid conditions
has a greater impact on the immune function than
does aging, leading to more complex infections and re-
duced ability of the body to recover from infection.
Finally, undernutrition has an impact on the body’s de-
fense system. Undernutrition in the older adult occurs
for various reasons, including psychosocial issues and
medication side effects.

The primary communicable diseases of concern in
the older adult are influenza, pneumonia, shingles with
influenza symptoms, and tuberculosis. For 2000 to
2010, influenza with pneumonia was the sixth leading
cause of death in adults 65 years or older and the fifth
leading cause of death for those 85 years of age or older.
Pneumonia and influenza infection occurs due to
exposure to the pathogen.42 On the other hand, shingles
occurs from the reactivation of the varicella zoster virus
years after initial exposure. Any adults who have had
chickenpox are at risk for shingles, because the virus re-
mains in a dormant state in the body following a case
of chickenpox. About 25% of all healthy adults will get
shingles during their lifetimes, usually after age 40. This
risk increases with age, with adults over 60 being 10 times
more likely to have shingles than children under 10.43

Mycobacterium tuberculosis (TB) can occur in older
people from either exposure to a person with an

490 U N I T I I I n Public Health Planning

reviewed all techniques, strategies and devices, and
helped Nancy to generalize success to other situations.

The RN met with Nancy for up to four sessions
during the same five months as the OT sessions. The
first RN session started within ten days after the first
OT session. In this session, the RN assessed Nancy
using C-CAP for RN in which the RN focused on how
and whether Nancy’s pain, depression, strength,
balance, and medication management impacted daily
function. In this assessment, the RN and Nancy identi-
fied and prioritized goals, such as reducing pain and
improving depression, and made plans to achieve those.
The RN also added educational resources to the
CAPABLE notebook to reinforce its use as a resource.
In RN visits 2 and 3, the RN and Nancy worked on the
goals identified through the C-CAP RN. In each session,
the RN reinforced strategy use, reviewed problem-
solving, refined strategies (e.g., doing exercise, pain
management), and provided education and resources
to address future needs (e.g., pill box for medication
management). In the final (fourth) session, the RN
reviewed Nancy’s strategies and helped to generalize
them to other possible challenges.

The HM coordinated the ordering of the assistive
devices like the walker as well as the repair and
modification supplies. The HM used the prioritized
work order to provide the modifications that the OT
ordered (e.g., installing railings to stairs, adding grab
bars in bathtub, adding bath mat). The HM had exten-
sive experience working with older adults and their
needs for home modification.

After CAPABLE, Nancy can safely use her front
steps and stairs with newly installed railings. She can
safely get into and out of bed and her shower with
the aid of assistive devices and training. She can
engage socially by going on excursions now that
strength and balance training allows her to get in
and out of cars. Improved mobility has led to mood
improvement, and she adheres to her simplified
medication regimen.

Aging, Health, Disability, and Disease
As we age, our risk for development of disease and dis-
ability increases. Aging decreases the ability to ward off
communicable diseases and increases the likelihood of
developing a noncommunicable disease (NCD). For ex-
ample, as we age, our risk increases for diabetes mellitus,
arthritis, heart failure, and dementia.3 Prior to World
War II, this was accepted as part of the aging process,

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active TB infection or reactivation of the mycobac-
terium related to an earlier exposure. In addition to
increased susceptibility, older adults living in group
living facilities such as long-term care facilities are at
increased risk for exposure.

Emerging Communicable Disease Issues
in Older Adults
There are three emerging issues for the baby boomer gen-
eration and older adults related to communicable dis-
eases. These are the increase in human immunodeficiency
virus (HIV) infection, sexually transmitted infections
(STIs), and the increased prevalence of chronic hepatitis
C (HCV) in those over 50.44,45 These issues will take
on increased importance as more of the baby boomer
generation passes the 65-year milestone.

The increase in the number of older adults diagnosed
with an STI is attributed to two issues: changes in sexual
activity in this population and the increased vulnerability
to exposure to the pathogens. In today’s society, there is
a higher rate of divorce and an increase in partner
changes among older adults. Also, older adults are less
apt to use condoms based on decreased perception of
risk. There is no evidence to support discontinuation of
screening for STIs at any specific age, as individuals are
at risk for an STI regardless of age.44 The reported in-
creased prevalence in HIV among older adults includes
those 50 and older, and as this population ages, there is
a predicted increased prevalence of the disease. In addi-
tion to the increase in at-risk sexual activity among the
older adult population, the other issue is that patients
with HIV infection are living longer.

In 2012, the Centers for Disease Control and Pre-
vention (CDC) released recommendations for screen-
ing for chronic HCV in those born between 1945
and 1965. Over the next two decades, this population
will meet the current definition of older adult. Cur-
rently, three-quarters of all persons diagnosed with
chronic HCV are over the age of 50.45 The CDC used
epidemiological data to develop their recommenda-
tions for this targeted cohort. They considered the
weighted, unadjusted anti-HCV prevalence, the size of
the population, and the differences in prevalence
among racial/ethnic groups.45 Based on their extended
analysis of the data, the CDC made the following
recommendations:

In addition to testing adults of all ages at risk for HCV infec-
tion, CDC recommends that:

• Adults born between 1945 and 1965 should receive
one-time testing for HCV without prior ascertainment of

HCV risk (Strong Recommendation, Moderate Quality of
Evidence).

• All persons identified with HCV infection should receive
a brief alcohol screening and intervention as clinically
indicated, followed by referral to appropriate care and
treatment services for HCV infection and related condi-
tions (Strong Recommendation, Moderate Quality of
Evidence).45

Prevention of Communicable Diseases
in Older Adults
Based on the epidemiology triangle (see Chapter 3), pub-
lic health interventions for preventing communicable
diseases in older adults, for the most part, focus on
primary prevention through vaccination. This includes
vaccination for prevention of pneumonia and shingles.
For that reason, there are specific recommendations for
vaccination in the older adult population to prevent these
infections (Table 19-2).46

An example of this primary prevention focus is the
public health campaign to have all adults over the age
of 64 vaccinated for influenza. This campaign is aimed
at reducing the burden of disease related to influenza.
Annually, there are approximately 90,000 hospitaliza-
tions and 5,000 deaths among older adults related to in-
fluenza.47 Although the influenza vaccine rate has
increased from 15% to 65% over the past few decades,
there has been no significant decrease in the death rate
during this period. To address this, new flu vaccines
for older adults are now available with increased
immunogenicity (the ability of a substance to provoke
an immune response needed for the vaccine to be
effective).47

Population-level initiatives aimed at reducing
communicable disease in the older adult population
require a broad perspective. If vaccines alone are not
effective in reducing morbidity and mortality, then
other strategies to improve an older adult’s resistance
are needed. As previously noted, the older adult is
at increased risk for communicable diseases. Efforts
aimed at decreasing vulnerability include better
self-management of NCD, improved nutrition, and
physical exercise.

For communicable diseases such as influenza, pneu-
monia, and shingles, the rapid progression from infec-
tion to disease requires a primary prevention focus. For
other communicable diseases, a secondary prevention
approach should also be implemented. For example, the
new recommendation to screen all those born between
1945 and 1965 for HCV underlines the importance of
identifying subclinical cases of the chronic infection.

C H A P T E R 1 9 n Health Planning for Older Adults 491

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Identification allows treatment to begin, thus reducing
the morbidity and mortality associated with HCV, espe-
cially liver disease. Increased screening for STIs could
also result in earlier identification of these communicable
diseases, earlier initiation of treatment, and subsequent
reduction in morbidity and mortality.

Noncommunicable Diseases
The risk for developing an NCD increases over the life
span because of genetics, the physiology of aging, health
behaviors, and the environment. Most older adults
(80%) have at least one NCD and 77% live with more
than one.48 Thus, a single disease approach to care may
not work. Instead, the challenge is to develop programs
for older adults that address a combination of NCDs.
Risk factors associated with cardiovascular disease, the
leading cause of death in older adults, include obesity
and hypertension (Table 19-3). These risk factors also
increase the risk for diabetes and other NCDs. The
prevalence of these risk factors increases with age. More
than a quarter of the older adult population is obese,
and the prevalence of hypertension ranges from 64% to
over 81%.41

In addition to vaccination, primary prevention mod-
els focus on reduction of behavioral risk factors associ-
ated with obesity and hypertension. These include
improving nutrition, increasing physical activity, and
social support. HP has a link to community approaches

for addressing these issues with older adults.3 Second-
ary prevention approaches for older adults focus on
screening and early intervention. Of the 14 key indica-
tors in the CDC’s report on promoting preventive serv-
ices in persons aged 50-64, 4 include disease screening
(Box 19-3).49 (For more information on screening for
NCDs, see Chapter 9.)

Evidence-based tertiary prevention programs include
those aimed at self-management of NCDs. Healthy Peo-
ple has a link to community preventions aimed at the
self-management of diabetes.3 According to the chronic
disease self-management model discussed in Chapter 9,
the basic elements of self-management include the ability

492 U N I T I I I n Public Health Planning

TABLE 19–2 n Vaccine Recommendations for Older Adults

Vaccine Age Dose and Schedule

Zosters: RZV or ZVL

Pneumococcal vaccines: PCV13
and PPSV23

50 yr or 60 yr and older

65 yr and older

Get two doses of RZV at age 50 years or older
(preferred) or one dose of ZVL at age 60 years
or older, even if the individual had shingles before

Get one dose of PCV13 and at least one dose of
PPSV23 depending on age and health condition

Source: (46)

TABLE 19–3 n Health Risk Factors for Older
Adults—2017

Obese Hypertension

Men 65–74 41.5% 64.1%

Men 75+ 26.6% 71.1%

Women 65–74 40.3% 69.3%

Women 75+ 28.7% 81.3%

Source: (41)

Eight indicators that provide a baseline of data through
which to monitor progress in ensuring that recommended
services reach this key population:

1. Vaccinations that protect against influenza
2. Vaccinations that protect against pneumococcal

disease
3. Screening for early detection of breast cancer
4. Screening for colorectal cancer
5. Screening for diabetes
6. Screening for lipid disorders
7. Screening for osteoporosis
8. Counseling service for smoking cessation

Recommended services for older adults:

1. Alcohol misuse screening and counseling
2. Aspirin use
3. Blood pressure screening
4. Cervical cancer screening
5. Depression screening
6. Obesity screening and counseling
7. Zoster vaccination

BOX 19–3 n Centers for Disease Control and
Prevention: Clinical Prevention
Services for Older Adults

Source: (49)

7711_Ch19_479-508 21/08/19 11:10 AM Page 492

to communicate with a health-care provider, proper use
of medications, nutrition, regular exercise, and disease-
specific activities such as foot care for those with diabetes.
Management of NCDs can become a challenge for the
older adult. Older adults may be homebound, no longer
able to drive, or both, resulting in difficulty getting to
their health-care provider or obtaining resources. If they
have more than one NCD, such as heart failure and dia-
betes, they may need to access two separate providers
located in two separate practices. Grocery stores are in-
creasingly located in areas that require access by car. Reg-
ular exercise may be challenging for the city-dwelling
older adult because of a potentially unsafe environment.
The lack of safety can include lack of sidewalks and/or
street crime, and some neighborhoods are generally un-
safe for regular exercise.

Injury and Violence in the Older Adult
Injury and violence are issues for the older adult and in-
clude both unintentional and intentional injury. In 2013,
unintentional injuries were the eighth leading cause of
death among U.S. adults aged 65 and over, resulting in
nearly 46,000 deaths.50 Accidental injuries that pose
the greatest threat include falls, motor vehicle crashes,
and residential fires. Intentional injuries include elder
maltreatment and suicide. Reducing injury in older
adults is a national public health priority as defined
by the CDC National Resource Center for Safe Aging,
the National Center for Injury Prevention and Control,
and others (Box 19-4). These resources focus not only on

C H A P T E R 1 9 n Health Planning for Older Adults 493

w SOLVING THE MYSTERY
The Case of the Failing Hearts
Public Health Science Topics Covered:
• Focused assessment
• Chart review
• Geographic information systems
• Health planning
• Adapting interventions to the population being

served

Cathy worked as a nurse at the heart failure clinic
for a few months and was becoming increasingly frus-
trated with the patients at the clinic who also had type
2 diabetes. She had spent time doing health education
with them and had even developed a pamphlet on
managing your diabetes, to no avail. They were missing
their appointments at the diabetes clinic and continued
to have elevated blood sugars. She explained to them
that tight glucose control was essential to the manage-
ment of their heart failure, but week after week these
patients were not following through with what she had
mapped out for them.

In desperation, she contacted her friend Adele, a
family nurse practitioner who specialized in diabetes
and also had completed a public health nursing master’s
program. Adele came to the clinic and asked her to
explain the problem. After listening to Cathy, Adele
suggested that they do a focused assessment of the
patients who were not following through with their
diabetes care. Adele explained the importance of doing
assessments prior to implementing an intervention.
Together they conducted a chart review of the patients
that Cathy identified as having difficulty. Most of them

were over the age of 60, and all of them had limited
transportation options. They plotted the addresses of
these patients on a city map. They then located the
heart failure clinic on the map as well as the diabetes
clinic. These two clinics were located a number of
miles apart. The heart failure clinic was close to a bus
route, but the diabetes clinic was a few blocks from the
nearest bus stop. By tracing the travel routes, they
found that the effort needed to make two appoint-
ments in the same week for the majority of the
patients was a main barrier for Cathy’s patients.

Together, Cathy and Adele developed a one-stop
approach for the patients at the heart failure clinic who
also had diabetes. Adele arranged to be present at the
heart failure clinic one day a week, and Cathy sched-
uled the patients with type 2 diabetes for that day.
Adele developed a special diabetes self-management
program for these patients who, for the most part,
were over 65 years of age and had decreased access
to transportation. This program included aspects of
case management (see Chapter 9). With her knowl-
edge of the resources in the community, Adele was
able to assist these patients in various aspects of
diabetes management. For example, for some of the
patients she contacted Meals on Wheels to deliver
meals that fit within the patients’ dietary restrictions.

These two nurses used basic public health skills to
identify an older population at risk for increase morbid-
ity and mortality including assessment and health plan-
ning. Their intervention reduced the number of clinic
visits these patients needed to make and, over time,
Cathy and Adele saw an improvement in the majority
of these patients. They also were able to demonstrate
a decrease in hospitalizations. Their decision to not
take a one-disease approach but rather incorporate
two specialties had positive results.

7711_Ch19_479-508 21/08/19 11:10 AM Page 493

reducing the morbidity and mortality related to injury in
the older adult but also on helping older adults maintain
an independent lifestyle.

Unintentional Injury
Falls are the most common form of unintentional injury
and one of the leading causes of injury and death in the
older population. More than one out of four older adults
fall every year.51 The risk factors associated with falls in
the older adult are well understood and help in the design
of prevention activities. Risk factors include muscle
weakness, unsteady gait, osteoporosis, failing eyesight,
and hypotension. Based on the key risk factors, the CDC
has dedicated a whole website to the prevention of falls.52

Many of these risk factors are associated with NCDs.
Other risk factors are associated with the home and
community environments. Within the home there are is-
sues such as scatter rugs, lack of grab bars in the bath-
room, and other hazards that contribute to falls. In the
community, sidewalk safety, well-lit streets, and other
factors are crucial to prevention of falls. Prevention
strategies are aimed at these risk factors and can be
applied at the individual, group, or community level.53

Intentional Injury: Elder Maltreatment
Intentional injury is also a concern for the older adult
population. Elder maltreatment is a substantial global
health issue. It is a violation of a human being’s basic
fundamental right: to be safe and free of violence. Older
adults are often victims of abuse and neglect that can
result in serious injury and debilitation. An estimated
2.1 million older Americans are victims of physical,
psychological, or other forms of maltreatment. The ac-
tual incidence of elder maltreatment is likely to be un-
derestimated. It is thought that for every case of
maltreatment reported to the authorities, as many as five
cases have not been reported. In addition, estimates of
the prevalence of maltreatment vary due to differing re-
search methods and operational definitions used in stud-
ies. Although there is legitimate concern about the
direct effects of abuse or neglect, there are also health-
related consequences that place victims at high risk.
Elder maltreatment and self-neglect are associated with
shorter lifespans after adjusting for other factors associ-
ated with increased mortality.55,56 Various terms are
used in the literature, including elder abuse, elder mis-
treatment, and elder maltreatment. For this chapter, the
term elder maltreatment is used and refers to both abuse
and neglect.

In the U.S., self-neglect, which is defined as “inability,
due to physical or mental impairment or diminished ca-
pacity, to perform essential self-care,” accounts for a
majority of elderly maltreatment cases reported to Adult
Protective Services (APS).57 Self-neglect is associated
with devastating outcomes, not only on physical and
psychological well-being, but also on higher mortality
rates and increased health care use. The CDC has com-
piled a comprehensive definition of elder maltreatment

494 U N I T I I I n Public Health Planning

• Falls
• Older adult drivers
• Elder abuse and maltreatment
• Residential fire
• Sexual abuse
• Suicide

BOX 19–4 n Injury and Violence That Pose the
Greatest Threat to Older Adults
in the United States

Source: (50)

n EVIDENCE-BASED PRACTICE
Fall Prevention for Older Adults

Practice Statement: Improve the gait and balance
of older adults through a regular exercise program.
Targeted Outcome: Decrease the number of falls.
Evidence to Support: According to the CDC, there
are interventions that can reduce falls and help older
adults live better and longer.53 Based on evidence,
exercise is one of the possible approaches because
it appears to have statistically significant beneficial
effects on balance ability in the short term. However,
there is less evidence to support long-term balance
because many of the studies they reviewed were small

studies and often had methodological weaknesses.
They recommend further research to help standardize
the timing of outcome assessments and more long-
term follow-up of outcomes.
Recommended Approaches: The CDC has two
downloadable guides that provide in-depth review of
population-level strategies:

• Preventing Falls: What Works; A CDC Compendium
of Effective Community-based Interventions From
Around the World

• Preventing Falls: How to Develop Community-based
Fall Prevention Programs for Older Adults

Sources: (53, 54)

7711_Ch19_479-508 21/08/19 11:10 AM Page 494

and different forms of elder maltreatment are listed
below:

Elder maltreatment is any abuse and neglect of per-
sons aged 60 and older by a caregiver or another person
in a relationship involving an expectation of trust. Forms
of elder maltreatment include:

• Physical abuse occurs when an elder is injured (e.g.,
scratched, bitten, slapped, pushed, hit, burned, etc.),
assaulted, or threatened with a weapon (e.g., knife,
gun, or other object), or inappropriately restrained.

• Sexual abuse or abusive sexual contact is any sexual
contact against an elder’s will. This includes acts in
which the elder is unable to understand the act or is
unable to communicate. Abusive sexual contact is
defined as intentional touching (either directly or
through the clothing), of the genitalia, anus, groin,
breast, mouth, inner thigh, or buttocks.

• Psychological or emotional abuse occurs when an
elder experiences trauma after exposure to threaten-
ing acts or coercive tactics. Examples include humili-
ation or embarrassment, controlling behavior (e.g.,
prohibiting or limiting access to transportation, tele-
phone, money or other resources), social isolation,
disregarding or trivializing needs, or damaging or
destroying property.

• Neglect is the failure or refusal of a caregiver or other
responsible person to provide for an elder’s basic
physical, emotional, or social needs; in other words,
it is a failure to protect them from harm. Examples
include not providing adequate nutrition, hygiene,
clothing, shelter, or access to necessary health care;
or failure to prevent exposure to unsafe activities and
environments.

• Abandonment is the willful desertion of an elderly
person by a caregiver or other responsible person.

• Financial abuse or exploitation is unauthorized or
improper use of resources of an elder for personal
benefit, profit, or gain. Examples include forgery,
misuse or theft of money or possessions, use of coer-
cion or deception to surrender finances or property, or
improper use of guardianship or power of attorney.58

Risk Factors for Elder Maltreatment
Elder maltreatment is a complex problem that affects
more than 500,000 older adults each year in the
United States.59 There is no single pattern of elder mal-
treatment. Elder maltreatment is an equal opportunity
issue that crosses all walks of life and social strata.
Victims are not just infirm or mentally impaired people
who are vulnerable to abuse. Elder maltreatment can

occur in situations such as the case of Mickey Rooney, a
movie actor who testified before Congress in 2011 that
he was the victim of maltreatment from his son.

A combination of individual-, relationship-,
community-, and social-level factors are associated with
increased risk for elder maltreatment.60,61 Individual-
level risk factors include both the perpetrator and the
victim. The interaction of these individual risk factors
occurs at the relationship level. However, both commu-
nity and societal factors influence risk. On the flip side,
there are protective factors as well (Box 19-5).60 These
protective factors provide areas through which nurses
can work to strengthen their relationships not only with
individuals and their families but in combination with
the community.

Primary, Secondary, and Tertiary Prevention
For Elder Maltreatment
It is essential that nurses identify those who may be vic-
tims of elder maltreatment and provide evidence-based
interventions at the individual and community levels.
Perel-Levin argues that prevention efforts should include
two levels of intervention: screening as a routine part of
primary care and working with the community to pro-
vide services. Interventions should seek to decrease the
incidence of elder maltreatment, improve early identifi-
cation, and ensure proper management of those who
were victims of maltreatment. According to Perel-Levin,
interventions should be interdisciplinary and consider
the context of the person. Key components for overcom-
ing barriers to prevention are building trust and effective
communication among all persons involved.62

Several screening tools are available, such as the
geriatric assessment instrument (GAI).63 The challenge
for the nurse is to build a screening program that in-
cludes not only training in the use of the screening tool
but also establishing links with resources for those who
screen positive for elder abuse.64 Another approach at
the community level is providing information both to
professional health-care providers and to members of
the community. For example, the Florida Department
of Elder Affairs has a website dedicated to prevention
of elder abuse. Another resource is the information
available through the U.S. Administration on Aging
National Center on Elder Abuse (NCEA).65 Community
initiatives to address elder abuse and neglect include
programs to:

• Increase public awareness and shift public attitudes
toward recognizing and reporting abuse

• Improve identification and triage of cases

C H A P T E R 1 9 n Health Planning for Older Adults 495

7711_Ch19_479-508 21/08/19 11:10 AM Page 495

• Increase integrated service models
• Improve justice system response
• Leverage and utilize emerging and untapped

resources

Other community-based activities focus on dissem-
inating promising practices in the courts, creating elder
law clinics, educating older adults about such things as
predatory mortgage lending, building new response
systems for complaints of abuse and neglect, and con-
vening clergy and lay leader groups to work within faith
communities to make a difference in elder abuse and
neglect.66

Policy
Policy-level interventions have been undertaken to pre-
vent and address elder maltreatment. The Elder Justice
Act of 2010 (Pub. L. 111-148) is part of the Affordable

Care Act and provides specific benefits to elders.67 In
addition, at the state level is Adult Protective Services
(APS) that facilitates the protection of vulnerable adults,
including the older adult (Box 19-6). The role of APS is
to prevent, correct, or discontinue maltreatment.68

Reporting suspected elder abuse or neglect cases to
APS agencies provides access to services that address the
social, medical, and legal needs of older persons.66,67

Once a report is made to APS, a process of investigation
and support begins. Based on the information APS re-
ceives, caseworkers determine whether there is imminent
danger. They contact the victim and further evaluate
the situation, looking at the risk factors and the victim’s
capacity to understand. They develop a care plan that
may include services provided directly by caseworkers,
through arrangements with community-based resources,
or contracted by APS on a short-term emergency basis.
Victims of abuse may receive short-term services, such

496 U N I T I I I n Public Health Planning

A combination of individual, relational, community, and
societal factors contribute to the risk of becoming a per-
petrator of elder maltreatment. They are contributing fac-
tors and may or may not be direct causes. Understanding
these factors can help identify various opportunities for
prevention.

Risk Factors for Perpetration
• Individual Level

• Current diagnosis of mental illness
• Current abuse of alcohol
• High levels of hostility
• Poor or inadequate preparation or training for care-

giving responsibilities
• Assumption of caregiving responsibilities at an early age
• Inadequate coping skills
• Exposure to maltreatment as a child

• Relationship Level
• High financial and emotional dependence upon a

vulnerable elder
• Past experience of disruptive behavior
• Lack of social support
• Lack of formal support

• Community Level
• Formal services, such as respite care for those providing

care to elders, are limited, inaccessible, or unavailable
• Societal Level

• A culture where:
• There is high tolerance and acceptance of aggressive

behavior

• Health-care personnel, guardians, and other agents
are given greater freedom in routine care provision
and decision making

• Family members are expected to care for elders
without seeking help from others

• Persons are encouraged to endure suffering or re-
main silent regarding their pains

• There are negative beliefs about aging and elders.

Protective Factors for Elder Maltreatment
Protective factors reduce risk for perpetrating abuse and
neglect. Protective factors have not been studied as exten-
sively or rigorously as risk factors. However, identifying and
understanding protective factors are equally as important
as researching risk factors. Several potential protective
factors are identified below. Research is needed to deter-
mine whether these factors do indeed buffer elders from
maltreatment.
Relationship Level
• Having numerous, strong relationships with people of

varying social status
Community Level
• Coordination of resources and services among commu-

nity agencies and organizations that serve the older
population and their caregivers

• Higher levels of community cohesion and a strong sense
of community or community identity

• Higher levels of community functionality and greater
collective efficacy

BOX 19–5 n Centers for Disease Control and Prevention: Elder Maltreatment—Risk and Protective Factors

Source: (60, 61)

7711_Ch19_479-508 21/08/19 11:10 AM Page 496

as emergency shelter, home repair, meals, transportation,
help with financial management, home health services,
and medical and mental health services. The APS case-
worker may continue to monitor the service provision to
make sure that victim risk is reduced or eliminated.66

A geriatric interdisciplinary team can be involved to
provide a comprehensive medical, functional, and social
assessment. Based on the findings of the assessment
and in collaboration with the APS team, an individual-
ized intervention plan can be formulated. Some cases
of elder abuse or neglect may require intervention
from the criminal or civil justice system for serious legal
issues such as sexual assault, financial exploitation, or

guardianship. Coordination with other agencies such as
Area Agencies on Aging, local women’s shelters, and the
National Center for Elder Abuse, are available to help
manage elder abuse and neglect cases in the community,
and other professionals such as social workers can
provide a broad community-based approach.67,69

Substance Use in Older Adults
Obtaining an accurate picture of substance use in the
older population is difficult. Of concern is the baby
boomer cohort that has a higher rate of substance use
compared with other cohorts. The concern is that as this
cohort ages, there will be a substantial increase in the
number of older adults with health problems associated
with substance use. It is projected that there will be a
doubling of the prevalence of substance use disorders in
those over age 50 by 2020.70 This increase includes alco-
hol, legal, and illegal drugs. However, we know little
about age-specific interventions to promote recovery and
reduce morbidity and mortality. Population-level ap-
proaches are required to address this issue rather than
relying on individual behavior modification. This re-
quires population-level interventions based on a clear
picture of the problem (Box 19-7).71

For older adults, there are two separate issues related
to substance use disorders: early onset and late onset sub-
stance misuse, clearly defined in the 1990s.72 Early onset
at-risk substance use reflects older adults who have a
history of regular alcohol consumption above the recom-
mended limits or problem drug use that began early in
their adult lives. This group of older adults is often re-
ferred to as hardy survivors. Late onset at-risk substance
use is defined as at-risk substance use that began later in
life, often triggered by a sentinel event such as loss of a
spouse or partner.72

Alcohol and Older Adults
Although heavy alcohol use was reported by only 2.1% of
those over 65 in 2013,73 these figures may not be the
true picture because of underreporting of alcohol use
in this population.74 As the baby boomer generation
continues to turn 65, there may be a cohort effect in re-
lation to the prevalence of risky drinking, because more
than 60% of baby boomers (aged 45 to 64) are current
drinkers. Therefore, the prevalence of alcohol use dis-
orders in the older population may increase over the
next few decades.

Alcohol use disorders are not the only issue. As we
age, our ability to metabolize alcohol also changes. Alco-
hol has a more potent effect due to the physiological

C H A P T E R 1 9 n Health Planning for Older Adults 497

• Freedom Over Safety: The client has a right to choose
to live at risk of harm, providing she or he is capable
of making that choice, harms no one else, and does not
commit a crime.

• Self-Determination: The client has a right to personal
choices and decisions until a time that she or he
delegates, or the court grants, the responsibility to
someone else.

• Participation in Decision Making: The client has a right
to receive information to make informed decisions and
to participate in all decision making affecting his or her
circumstances to the extent able.

• Least Restrictive Alternative: The client has a right to
service alternatives that maximize choice and minimize
lifestyle disruption.

• Primacy of the Adult: The worker has a responsibility
to serve the client, not the community’s, family
members’, or landlord’s concerns.

• Confidentiality: The client has a right to privacy and
secrecy.

• Benefit of Doubt: If there is evidence that the client is
making a reasoned choice, the worker has a responsi-
bility to see that the benefit of doubt is in his or her
favor.

• Do No Harm: The worker has a responsibility to take
no action that places the client at greater risk of harm.

• Avoidance of Blame: The worker has a responsibility
to understand the origins of any maltreatment and to
commit no action that would antagonize the perpetra-
tor and so reduce the chances of terminating the
maltreatment.

• Maintenance of the Family: The worker has a responsi-
bility to deal with the maltreatment as a family prob-
lem, if the perpetrator is a family member, and to
try to find the necessary family services to resolve the
problem.

BOX 19–6 n Principles of Adult Protective Services

Source: (68)

7711_Ch19_479-508 21/08/19 11:10 AM Page 497

changes of aging. As we age, a decrease in the ratio of
body water to fat, a decrease in the hepatic blood flow,
and a reduction in the efficiency of liver enzymes, all re-
sult in a decreased ability to metabolize alcohol. This, in
turn, affects the duration of elevated blood alcohol and
increases the risk of liver damage.75 Another issue for the
older adult is medication interactions with alcohol. Use
of drugs that interact with alcohol is common among
older adults, which increases the potential alcohol-
related risks.76

As explained in Chapter 11, the recommended drink-
ing limits are less than five standard drinks per day or
fourteen per week for men, or less than four standard
drinks per day or eight per week for women. However,
healthy people aged 65 and older should consume no
more than three standard drinks per day and no more
than seven drinks per week.77 As discussed earlier, older
adults who exceed the recommended daily limits are at
increased risk for alcohol- related problems due to differ-
ences in metabolism and physiology.72

Medication Interactions
The issue of adverse interactions between alcohol and
prescribed medications are of particular concern in

older adults, because about 62.5% are using medications
with potential alcohol interactions.76 Two types of inter-
actions occur: pharmacokinetic interaction, wherein
alcohol interferes with the body’s ability to metabolize
the medications, and pharmacodynamic interaction,
wherein alcohol enhances the effects of the medication.72

The growing recognition of the potential harm related to
alcohol and medication interactions in older adults
underscores the need for a population perspective. Al-
though both the National Institute on Alcohol Abuse and
Alcoholism and the Substance Abuse and Mental Health
Services Administration have highlighted the issue, few
public health approaches are available for increasing
awareness of the problem leaving the burden on the in-
dividual practitioner to inform individual adults.

Substance Use and Physical Health
Both legal and illegal drug use increases the risk for ad-
verse health outcomes. Alcohol consumption in older
adults increases their risk for injury, NCDs, and com-
municable diseases. Alcohol may be the underlying
cause for up to half of older trauma patients. Early onset
substance users, even those who are currently abstinent
but have a history of consuming alcohol or other drugs
above the recommended limits for a long period of
time, often have serious health problems that may be
mistaken for symptoms of aging, such as dementia or
depression.72

An example of how important it is to evaluate early
onset users for physical complications is the negative
impact of long-term alcohol use on the ability to ab-
sorb thiamine (vitamin B1), an essential, water-soluble
vitamin. Untreated thiamine deficiency in older adults
with a history of early onset alcohol use may result in
Wernicke-Korsakoff syndrome, a brain disorder. Unfor-
tunately, the prevalence of Wernicke-Korsakoff syn-
drome at autopsy exceeds recognition during life.78 Thus,
clinicians may fail to screen for long-term alcohol use in
this population. Because of the long-term impact on the
human body, alcohol use above the recommended limits
increases the risk for other adverse outcomes that occur
as the person ages, including alcohol-related cardiomy-
opathy, liver cirrhosis, pancreatitis, various cancers
(including cancers of the liver, mouth, throat, larynx
[the voice box], and esophagus), high blood pressure,
and psychological disorders.72

One possible public health intervention might be to
initiate a universal screening approach aimed at helping
clinicians identify both early and late onset alcohol use
that places the older adult at increased risk for alcohol-
related NCDs as well as injury. A five-step process was

498 U N I T I I I n Public Health Planning

Informed and active policy will require new approaches
and investment in the following:

• Data and analysis, with increased emphasis on docu-
menting substance abuse in the elderly, in addition to
the historical emphasis on alcohol abuse and mental
health problems

• Expanded literature review that encompasses studies
not considered in this report,* some of which may
not be specific to substance abuse but can offer new
conceptual and methodological insights

• Prevention, treatment, and management strategies
specifically tailored for older adults from different
ethnic, gender, and racial groups, including immigrant
populations

• Monitoring of demographic shifts in heterogeneous
older populations

• Long-term projections of the demand for expanded
clinical and public health services for substance abusers

• Traumatic brain injury

BOX 19–7 n Public Policy Recommendations to
Prevent Licit and Illicit Substance Use
in Older Adults

*Report by the Substance Abuse and Mental Health Services Administration that
addressed the projected demand for substance abuse services over the next
20 to 30 years for those born during the baby boomer years.

Source: (73)

7711_Ch19_479-508 21/08/19 11:10 AM Page 498

recommended by Savage that includes information not
only on current use but also on prior use and duration
of use over the lifetime.79

Aging in Place
During the past three decades, there has been an increase
in the emphasis of an aging-in-place approach. This ap-
proach includes implementation of community-based
programs that include health promotion, prevention of
disease, improvement of functioning, and enhancement
of quality of life in older adults while maintaining them
in their homes.80,81 This emphasis mirrors a decline in
the percentage of the population 65 years of age or older
living in skilled nursing facilities. Based on the 2010 cen-
sus data, the percent of persons living in nursing homes
fell from 5.1% in 1990 to 3.1% in 2010. The decline was
also seen in the population 85 years of age or older. In
1990, almost 25% were living in skilled nursing facilities.
That dropped to 10.4% in 2010.82

Barriers to aging in place include funding for home
modifications, availability of needed services, and con-
sumer awareness.81 Because of changing health status,
some older adults need special services beyond the basics
to maintain themselves safely in their own home settings.
Likewise, issues of environmental safety and security can
impinge on aging successfully in place. One community-
based approach is the CAPABLE program developed by
a team of nurse researchers from Johns Hopkins Univer-
sity School of Nursing. This innovative program com-
bines health-care services with home modifications and
links to services within the community to meet the needs
of disabled older adults so that they can remain in their
homes.83

Aging in place requires an understanding of the com-
munity in which older adults live.83 The built environ-
ment surrounding the older adult has a direct impact on
their quality of life. Changing lifestyles for older adults
mean that they may have more time to enjoy amenities
in the community, such as recreation facilities. However,
biological changes, such as decreases in vision and
mobility, alter their ability to enjoy these facilities. To
achieve aging in place, the CDC stated:

Affordable, accessible, and suitable housing options can allow
older adults to age in place and remain in their community
all their entire lives. Housing that is convenient to commu-
nity destinations can provide opportunities for physical ac-
tivity and social interaction. Communities with a safe and
secure pedestrian environment, and near destinations such
as libraries, stores, and places of worship, allow older adults

to remain independent, active, and engaged. Combined
transportation and land-use planning that offers convenient,
accessible alternatives to driving can help the older adults
reach this goal of an active, healthy lifestyle.84

The concept of aging in place is growing in popularity.
There is now a National Aging in Place Council, and the
American Association of Retired Persons has a guide
to livable communities and a webpage dedicated to the
subject. The process includes a match among affordable
housing, access to services, and a healthy built environ-
ment. Housing options for older adults span a contin-
uum from complete independence to dependence, with
many gradations in between. Many people can remain at
home completely independent throughout a long life, or
with just a little help getting around or keeping house.
Care ranges from help with household tasks and running
errands to round-the-clock care for someone who is
seriously ill.

Naturally Occurring Retirement Community
With the aging of the American population, a new
phenomenon is emerging: the naturally occurring
retirement community (NORC). Federal funding was
established in 2010 for NORCs with more than $25 mil-
lion in federal and matching funds that have resulted
in the establishment of more than 50 supportive service
programs.85 A NORC is defined as a community that
provides:

• Residential housing with supports
• Transportation for appointments and shopping
• Individual assessment of those at risk, followed by

referral and follow-up of service
• Coordination of nonprofessional services85

NORCs take many different forms. They can exist
in subsidized housing complexes, condominiums, apart-
ments, or single-family neighborhoods. Closed or
vertical NORCs are geographically confined, such as
apartment buildings or complexes. The open or hori-
zontal form of NORC refers to one- and two-family
homes in age-integrated neighborhoods. By capitalizing
on the valuable contributions of experience and skill
from older residents and making use of the density and
proximity of older adults in NORCs, resources and
economies of scale (factors that cause the average cost
of producing something to decrease as its output in-
creases) make it possible to organize and deliver services
that promote healthy aging in place. Instead of service
delivery that is reactive to a crisis, is time limited, and
is disconnected from the communities in which older

C H A P T E R 1 9 n Health Planning for Older Adults 499

7711_Ch19_479-508 21/08/19 11:10 AM Page 499

residents have built their lives, NORC programs seek to
deepen the connections that older adults have to their
communities before problems arise.

Continuing Care Retirement Communities
In anticipation of changing needs, some older adults
arrange to become part of continuing care retirement
communities (CCRCs), a relatively new phenomenon
in the United States that has appeared during the past
three decades. A CCRC is defined as a community that
provides housing and health care across the continuum
from independent living, to assisted living, to skilled
nursing care. Residents are required to sign a contract on
entrance into the community. They are charged an entry
fee as well as a monthly maintenance fee but may differ
on their affordability with some available to higher in-
come older adults.86 The advantage of such communities
is the ability for older adults to remain within the CCRC
over the long term. The disadvantage is the costliness of
such facilities. Entrance into these communities requires
the financial ability to pay the entrance fee and the
monthly payment. In the 1990s and early 2000s, approx-
imately 10 to 20 units were established per year. After the
2008 recession, there was a sharp decline in the industry,
because many older adults could not sell their homes and
therefore did not have the money necessary to pay the
entrance fee.

All of these models are aimed at keeping the older
adult in a community setting and as independent as
possible as long as possible. With the aging of the popu-
lation, the need for viable community-based living for
older adults will increase. Nurses such as the researchers
at Johns Hopkins School of Nursing are vital to helping
this population achieve optimal health within their own
communities.

Ageism in Our Society
Ageism describes bias toward older adults based on
stereotypes.87 Ageism, like racism and sexism, is a way
of judging or categorizing people and not allowing them
to be individuals with unique ways of living their lives.
It is a set of beliefs, attitudes, norms, and values used to
justify age-based prejudice and discrimination.87,88 It can
have an impact on patient outcomes, and can affect their
feelings of self-worth and their ability to make au-
tonomous decisions about their health care.88

Ageism may occur when health-care providers
incorrectly attribute pathology to normal aging. These
assumptions can influence screening procedures, infor-
mation exchanges, and treatment decisions. Ageism

may manifest itself through the use of patronizing
language, or by dismissing symptoms as “all part of
growing older.” Even unintentionally, health-care
providers may hold attitudes, beliefs, and behaviors as-
sociated with ageism against older patients. This is why
it is so important to have a good working knowledge of
age-related physiological and psychological changes, so
that signs of disease or disability can be differentiated
and treated appropriately.

Dementia and Alzheimer’s Disease:
Impact on the Older Adult Population
Alzheimer’s disease and related dementias (ADRD) are
the sixth leading cause of death for all adults in the U.S.
and the fifth leading cause of death in people over the
age of 64.89,90 Globally, approximately 50 million people
have dementia, with nearly 10 million new cases a
year.90 It is the most common form of dementia. In
the U.S., in 2014 alone, 5 million people were diagnosed
with ADRD (1.6% of the population). By 2050 in the
U.S. it is estimated that number will rise to 13.9 million
(3.3% of the population).89 Other dementia diagnoses
include vascular dementia, mixed dementia, dementia
with Lewy bodies, and frontotemporal dementia. The
central issues for those with ADRD or other forms
of dementia are the problems with memory and the
impact on cognition. Both Alzheimer’s disease (AD)
and dementia severely affect people’s ability to work,
care for themselves, and engage in social activities. AD
is the sixth leading cause of death in adults in the
United States.90,91

Prevention
Primary prevention of AD and other types of dementia
is challenging because there is no clear evidence that
specific interventions actually prevent AD or cognitive de-
cline.93 However, secondary prevention through memory
screening programs has helped to identify those people
in the early stages. Early identification has the potential
to slow the progression of the disease with emerging
pharmaceutical treatments for those with AD and de-
mentia. There are currently five drugs approved by the
Food and Drug Administration for the treatment of
AD (donepezil, galantamine, memantine, rivastigmine,
and tacrine) that have shown a temporary slowing of the
progression of the disease over 6 to 12 months although
there is no clear evidence on when to stop the treatment.94

These treatments also provide the opportunity for the per-
son with AD to plan for the future while they are still able

500 U N I T I I I n Public Health Planning

7711_Ch19_479-508 21/08/19 11:10 AM Page 500

to do so. Tertiary prevention focuses on active manage-
ment of AD with the goal of achieving an optimal quality
of life within the realities of the disease.93,94

Centers for Disease Control and Prevention’s
Healthy Brain Initiative
Another element in health promotion/prevention is the
Healthy Brain Initiative: The Public Health Road Map
for State and National Partnerships, 2018–2023, which
was jointly developed by the Alzheimer’s Association and
the CDC Healthy Aging Program to advance cognitive
health as a public health goal.95 Specific actions are high-
lighted and addressed in four domains of public health:
educate and empower the nation, develop policy and
mobilize partnerships, assure a competent workforce,
and monitor and evaluate. See Box 19-8 for details of this
program.

Caregiving
One of the primary challenges facing the older popula-
tion, especially those with AD, dementia, or a chronic
NCD, is the need for caregiving when physical and or
mental disorders decrease the ability to perform ADLs.
A caregiver is anyone who assists someone else who is
incapacitated in some way and needs help. Family care-
givers are defined as “an adult family member or other

individual who has a significant relationship with, and
who provides a broad range of assistance to, an individ-
ual with a chronic or other health condition, disability,
or functional limitation.”96 Formal caregivers are vol-
unteers or paid caregivers associated with a service sys-
tem. For many older adults, family members become the
primary caregivers providing unpaid care resulting in a
financial, physical, and psychosocial burden on the fam-
ily.95 To help provide more assistance to family care-
givers in 2017 congress passed the RAISE Family
Caregivers Act.96 The purpose of the act is to help address
the estimated $470 billion cost of unpaid care and the
$7,000 in out-of-pocket expenses incurred annually by
family caregivers.97

There can be significant consequences to caregivers’
health.95 The long hours, physical tasks, stress, and re-
lentless responsibility can take a toll on caregivers, and
can manifest in health problems such as increased blood
pressure, hyperinsulinemia, impaired immune system
function, and cardiovascular disease. Health conse-
quences relate to the number of hours spent providing
care. Two-thirds do not take advantage of preventive
health services for themselves. Twenty-five percent of
caregivers have health problems, such as back injuries,
resulting directly from caregiving activities. They may
also experience mental and emotional effects as a result

C H A P T E R 1 9 n Health Planning for Older Adults 501

The role of public health in enhancing the physical
health of older adults is well-known. Public health’s role
in maintaining cognitive health, a vital part of healthy
aging and quality of life, is emerging. The need for a
delineated public health role comes at a critical time
given the dramatic aging of the U.S. population,
scientific advancements in knowledge about risk behav-
iors (e.g., lack of physical activity, uncontrolled high
blood pressure) related to cognitive decline, and the
growing awareness of the significant health, social, and
economic burdens associated with cognitive decline.
The Healthy Brain Initiative provides 25 specific actions
in four domains that state and local public health
agencies and their partners can pursue. These four
domains include the following:

• Educate and empower
• Develop policies and mobilize partnerships
• Assure a competent workforce
• Monitor and evaluate

The lack of cognitive health—from mild cognitive
decline to dementia—can have profound implications for
an individual’s health and well-being. Older adults and
others experiencing cognitive decline may be unable to
care for themselves or conduct necessary ADLs, such as
meal preparation and money management. Limitations
with the ability to effectively manage medications and
existing medical conditions are particular concerns when
an individual is experiencing cognitive decline or dementia.
If cognitive decline can be prevented or better treated,
lives of many older adults can be improved.

Opportunities for maintaining cognitive health are
growing as public health professionals gain a better un-
derstanding of cognitive decline risk factors. The public
health community should embrace cognitive health as a
priority, invest in its promotion, and enhance our ability
to move scientific discoveries rapidly into public health
practice.

BOX 19–8 n Healthy Brain Initiative: The Public Health Road Map for State and National Partnerships,
2018–2023

Source: (95)

7711_Ch19_479-508 21/08/19 11:10 AM Page 501

of their caregiving, which can include depression and
isolation.

Because of the toll that caregiving exacts from the
caregivers, the CDC has declared caregiving a public
health priority. To address this priority, the CDC devel-
oped the Reach Effectiveness Adoption Implementation
Maintenance (RE-AIM) framework.98 The framework is
intended to help communities and organizations develop
programs for caregivers. The RE-AIM website provides
case examples for interventions aimed at assisting the
caregiver. This is an example of how evidence can be
translated into practice at the population level to address
an important public health issue.

The caregiving relationship can be a complicated one
and often requires engaging the community to help plan
interventions. Nurses should recognize the warning signs
of caregiver stress early. Nurses can help caregivers look
at the sources of stress, identify what they can and cannot
change, and identify resources within the community
that can relieve the pressure, such as respite care for the
caregiver. The RE-AIM website provides case studies
that can help nurses build programs for caregivers and
underlines the importance of working at the population
level to help individuals deal with the enormous task of
caring for a loved one.98

Hospice and End-Of-Life Care
Traditionally, hospice care has been under the domain
of community health care, because the goal is to provide
care to persons at the end of life within the community
setting. Many older adults have an ideal picture of the
way that they would choose to die. Unfortunately, frank
discussions about these wishes and preferences are far
too rare, and specific actions that will assure those wishes
are respected are sometimes difficult to articulate and
communicate. Common descriptions of the preferred
circumstances of death include being free of pain and
suffering, being in the company of loved ones, and being
in one’s own home. Hospice care was formally developed
to address this need. It is usually defined as the provision
of care to persons who have less than six months to live
the goal of which is to provide care and comfort not cure
or treatment.

Originally the term hospice was used to describe a
place of shelter for weary and sick travelers returning
from religious pilgrimages. During the 1960s, Dr. Cicely
Saunders began to develop hospice care in the United
Kingdom and was invited by the dean of the Yale School
of Nursing to become a faculty member and help build
hospice care in the United States. There, an organized
professional team approach to end-of-life care was estab-
lished, the first program to formalize the use of modern
pain management techniques to care for the dying. The
first hospice in the United States was established in New
Haven, Connecticut, in 1974, and now there are many
thousands of such programs across the country.99

Hospice is not a physical place but rather a philosophy
of care. Eighty percent of hospice care is provided in the
patient’s home, a family member’s home, or in nursing
homes. Specialized inpatient hospice facilities are also
available to assist with end-of-life care. If a person has a
terminal illness or disease that is no longer responding
to treatment, the person is eligible for hospice care. Two
physicians must certify that the person has a terminal ill-
ness and that if the disease were to run its normal course
survival would be 6 months or less.100 In 2016, 1.4 million
Medicare recipients received hospice care. The majority
(64%) were 80 years of age or older. The most frequent
principal diagnosis was cancer (27.2%) followed by car-
diovascular disease (18.9%) and dementia (18%). The
mean length of stay in hospice care was 71 days.101

Unique to the hospice philosophy is the recognition
that there is potential for growth for the patient and fam-
ily, even at the end of life, and that there is such a thing
as a good death. Hospice programs seek to support living
through the dying process and include family as part of

502 U N I T I I I n Public Health Planning

n CELLULAR TO GLOBAL
Dementia in older adults has a substantial impact
from the cellular to global level.91 Although specific
causes for dementia are still unknown, the disease in-
volves damage of nerve cells in the brain, which can
occur in several brain areas. Worldwide, around
50 million people have dementia, and there are nearly
10 million new cases every year.95 Lives of patients
with dementia are impacted at the individual level
due to cognitive changes (e.g., memory loss, difficulty
in communicating, reasoning and handling complex
tasks) and psychological changes (e.g., personality
changes, anxiety, agitation). The impact of these
changes extends to the interpersonal level due to the
heavy care burden of patients with dementia. Given
the increasing number of older adults worldwide,
dementia care has received much attention globally
and become a public health priority of the WHO.95

Nurses who understand this impact from cellular to
global level are more likely to have the capacity to
provide a comprehensive care to the patients and also
the family caregivers as well as advocate for services
and resources to help support older adults and their
families living with ADRD.

7711_Ch19_479-508 21/08/19 11:10 AM Page 502

this process. Hospice programs provide state-of-the-art
palliative care and supportive services according to
unique individual and family needs.

Palliative Care
A key component of hospice is the use of palliative care.
At some point in life, it becomes unreasonable to expect
cure or reversal of disease processes or to restore a
previous level of functioning and independence, and it
is clear that life is nearing its end. Death is a natural
process, and older adults go through developmental tasks
as they approach death, with the goal of life closure. As
death approaches, adaptation to a new state allows beings
to remain whole: to interact with their environments, to
experience human relationships, and to achieve person-
ally meaningful goals.

The WHO defines palliative care as “an approach that
improves the quality of life of patients and their families
facing the problems associated with life-threatening
illness, through the prevention and relief of suffering by
means of early identification and impeccable assessment
and treatment of pain and other problems, physical,
psychosocial and spiritual.”102 According to the WHO,
palliative care has specific aspects (Box 19-9).

End-of-life nursing care may focus on symptom con-
trol and solving functional, physical, or psychological
problems to optimize the older adult’s quality of life,
regardless of the amount of time that remains. Patient/
family-centered care is clearly appropriate for the unique
experience of dying. Many nursing actions center on
supporting physiological function and preventing com-
plications, goals that are still appropriate at the end
of life. Appreciating each person as a unique individual is
extremely important in assuring optimal care at the end of
life. Although it may be evident to health-care providers
that certain goals and interventions would suit the pa-
tient’s needs, even more important is finding congruence
with the patient’s own perceived and stated goals and val-
ues and upholding his or her rights to self-determination.
For example, the presence and involvement of family and
friends may have great importance at the end of life.
Family members may seek involvement in the caring
activities as an expression of feelings of closeness and
love. They may try to find understanding of, resolution
to, or closure of past issues. For the person nearing the
end of life, the presence of family, friends, and even pets
may be a powerful affirmation of the continuity of life.103

Palliative care for older adults focuses on issues sur-
rounding the geriatric syndromes and on the provision
of care in a variety of long-term care settings. Common
geriatric syndromes occurring at the end of life include

dementia, delirium, urinary incontinence, and falls.101

The decision to initiate palliative care in geriatrics is
based on the presence of several markers that indicate
that curative approaches are no longer appropriate. Core
end-stage indicators that characterize the terminal
phase of a chronic NCD include physical decline, weight
loss, multiple comorbidities, a serum albumin of less
than 2.5 g/dL, and ADL dependence.104 Nondisease-spe-
cific indicators for palliative care include frailty or ex-
treme vulnerability to morbidity and mortality as a result
of a progressive decline in function and physiological
reserve. Frequent falls, disability, susceptibility to acute
illness, and reduced ability to recover are examples of
frailty. Issues such as functional dependence, cognitive
impairment, and family/caregiver support needs can
enter into the decision to take a palliative approach
to care.

C H A P T E R 1 9 n Health Planning for Older Adults 503

By the WHO definition, palliative care:

• Provides relief from pain and other distressing
symptoms

• Affirms life and regards dying as a normal process
• Intends neither to hasten or postpone death
• Integrates the psychological and spiritual aspects of

patient care
• Offers a support system to help patients live as actively

as possible until death
• Offers a support system to help the family cope during

the patient’s illness and in their own bereavement
• Uses a team approach to address the needs of patients

and their families, including bereavement counseling,
if indicated

• Will enhance quality of life and may also positively
influence the course of illness

• Is applicable early in the course of illness in conjunction
with other therapies intended to prolong life, such
as chemotherapy or radiation therapy, and includes
those investigations needed to better understand and
manage distressing clinical complications

BOX 19–9 n WHO Components of Palliative Care

Source: (102)

n CULTURAL CONTEXT
End-of-life decisions provide a good example of why
we need to understand the cultural context in which
older adults live. A key issue in end-of-life decisions is
the cultural perspective of the patient and family mak-
ing the decision.106,107 As one set of researchers found

7711_Ch19_479-508 21/08/19 11:10 AM Page 503

Life Closure
At the end of a long life, the personal experience of death
can be viewed as an opportunity or even an achievement.
Older adults in the dying process may examine their lives
outwardly and deal with their worldly affairs as a way to
interface with the world and find some meaning from their
lives. The outward aspects of their lives include their rela-
tionships with their community, organizations, and other
social groups. Older adults may take actions to assure they
leave a legacy. They also may reflect on the impact their
lives have had on others. They may make choices and
plans about how they are leaving this world.

As they move further into the process of life closure,
they step into an inner world, where they seek to derive
meaning, affirm love of self, love of others, and complete
family and friend relationships. This may involve some
form of saying goodbye, knowing this is the last time, and
accepting the finality of life. Surrendering to the un-
known and letting go may be very difficult, but it is part
of achieving a peaceful death.

As nurses involved in end-of-life care, we are faced
with the fact that there are some things we cannot fix. We
cannot stop death. We cannot find the perfect words,
erase the anguish, or take away the depth of loss. But it

may be enough to be present for the person and the fam-
ily, respond with compassion and kindness, and keep a
realistic perspective that to everything there is a season.

n Summary Points
• The aging population is growing globally with an

increased need for health-care services.
• Both biological and psychosocial factors play a role

in healthy aging.
• More than 50% of older adults experience more than

one NCD, resulting in a new focus in Healthy People
2020 that included the improvement of the ability of
the older adult to self-manage NCDs.

• Older adults experience issues related to communi-
cable diseases and substance use.

• Health planning for older adults is key to meeting
Healthy People objectives.

• Substance use is a growing issue among the older
population.

• Alzheimer’s disease and dementia have an impact on
the quality of life for the older population and their
families.

• The hospice model allows for the delivery of compas-
sionate end-of-life care for the older adult population.

504 U N I T I I I n Public Health Planning

“… clashes between biomedical and ethnocultural
realms of care that led to cultural insensitivity.”107 In
other cultures, such as Hispanic cultures, there is a
preference for nondisclosure of terminal prognosis,
which is not always in line with traditional hospice
practice. Language is also important. In Spanish,
“hospicio” has negative connotations related to the
abandonment of loved ones.106 When planning and
implementing end-of-life policies and procedures in
any setting caring for the older adult, it is important to
know the culture of the population receiving care. The
health-care provider who expresses an interest in the
cultural heritage of the older adult receiving care will
be able to establish rapport and assist the family and
the patient in making end-of-life decisions that match
their cultural perspective and beliefs.

As mentioned earlier, the U.S. is facing an increasing
diversity of race and ethnicity groups, which suggests a
more diverse culture than before. To better serve the
patients, nurses must strive to understand the diverse
culture. For researchers, including nurse scientists,
more culturally relevant interventions and treatments
should be developed or adapted to reach the maximum
benefit for the patients.

t CASE STUDY
Health Planning to Improve
Physical Activity in Older Adults

The members of the nursing department in a large
urban public health department were challenged with
developing a program to improve physical activity level
in older adults given the established benefits of physical
activity. To complete this case study, do the following:

1. Access the HP website related to objectives for
older adults and physical activity.

2. Examine the literature and determine what baseline
data are available related to the objective from a
national perspective.

3. Critique possible population-level approaches in
relation to their utility in meeting the objectives
including but not limited to:
a. Policy initiatives
b. Development of a health program
c. Public service announcements

4. Determine what data are available in the city
nearest you that would help determine the level of
physical activity in that city among older adults.

7711_Ch19_479-508 21/08/19 11:10 AM Page 504

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C H A P T E R 1 9 n Health Planning for Older Adults 505

5. Determine how the nurses can complete the
assignment. Be sure to include in your conclusion
the following:
a. Assessment needs
b. Types of population-level interventions best

suited to meet the objective
c. Health-planning steps needed specific to the

chosen intervention(s)

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70. Mattson, M., Lipari, R.N., Hays, C, & Van Horn, S.L. (2017).
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71. Substance Abuse and Mental Health Services Administration.
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72. Blow, F.C. (1998). Substance abuse among older adults. Treat-
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74. Savage, C.L., & Finnell, D. (2015). Screening for at-risk
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75. National Institute on Aging. (n.d.). Health and aging.
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76. Holton, A.E., Gallagher, P., Fahey, T., & Cousins, G. (2017).
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78. Chandrakumar, A., Bhardwaj, A., ‘t Jong, G.W., (2018).
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79. Savage, C.L. (2008). Screening for alcohol use in older
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80. Wick, J.Y. (2017). Aging in place: Our house is a very,
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81. Park, S., Han, Y., Kim, B.R., & Dunkle, R.E. (2017). Aging
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509

Chapter 20

Health Planning for Occupational
and Environmental Health
Gordon Gillespie, Cynthia Betcher, and Sheila Fitzgerald

LEARNING OUTCOMES

After reading the chapter, the student will be able to:

KEY TERMS

1. Define occupational health and occupational and
environmental health nursing.

2. Describe the relationship between the work
environment, workplace exposures, and worker health
and safety.

3. Discuss the concept of toxicology and the relevance to
understanding and preventing occupational diseases.

4. Discuss controlling hazards and reducing injuries in the
workplace.

5. Identify vulnerable worker populations.
6. Explain the role of the occupational and environmental

health nurse in the development, management, and
evaluation of occupational health programs.

7. State methods of worker protection and safety as
well as health promotion strategies in the occupational
health setting.

Case management
Disability
Employee assistance

program (EAP)
Engineering controls
Environmental monitoring
Epidemiological triangle
Ergonomics
Hazard Communication

Standard
Health risk appraisal

(HRA)

Hierarchy of controls
Material safety data sheet

(MSDS)
National Institute for

Occupational Safety
and Health (NIOSH)

National Occupational
Research Agenda
(NORA)

Occupational and
environmental health
history

Occupational and
environmental health
nurse (OEHN)

Occupational and
environmental health
nursing

Occupational Safety
and Health
(OSH) Act

Occupational Safety and
Health Administration
(OSHA)

Personal protective
equipment (PPE)

Total Worker
Health®

Toxicology
Vulnerable worker

populations
Workers’ compensation
Work-family interface
Workplace assessment/

workplace walkthrough

n Introduction
Every week, 257 million Americans go to work.1 Con-
struction workers can be seen during the day at a new
building site or doing repairs on a busy highway in the
middle of the night. Health-care providers are present
around the clock in hospitals and emergency depart-
ments. Behind the scenes are nutrition services, plant
facilities staff, laundry workers, and hazardous waste
workers. In an office building, top executives are in
the boardroom, while administrative assistants spend

hours in front of a computer, telephones ringing in
the background. When the workday is over, the house-
keeping staff cleans bathrooms, polishes floors, and
removes trash for another new day. The goal of occu-
pational health is to ensure each worker returns home
safely at the end of the workday. Unfortunately, not all
workers do. Fatalities and injuries occur: mine explo-
sions, deaths of truckers, collapses at construction
sites, loss of limbs among soldiers, and violent inci-
dents in the workplace. Every work setting presents its
own unique exposures and hazards and its own mix of

7711_Ch20_509-536 21/08/19 11:09 AM Page 509

worker demographics that may affect the health and
well-being of employees. The occupational and envi-
ronmental health nurse (OEHN) is a key member of
the interprofessional team responsible for the assess-
ment and detection of occupational hazards and the
implementation of interventions to protect the health
of worker populations (Box 20-1).

Focus of Occupational Health
The Joint International Labour Organization/World
Health Organization indicates that the focus of occupa-
tional health should:

• Follow a systems approach to promoting safe and
healthy work environments

• Afford prevention the highest priority
• Develop work cultures in a direction supporting

health and safety at work while preventing and con-
trolling hazards and risks, and in doing so promoting
a positive social climate and smooth operation that
may enhance productivity and quality2

The Occupational Safety and Health Administra-
tion (OSHA) is a federal agency formed in 1970. OSHA
is charged with protecting coworkers, family members,
employers, customers, suppliers, nearby communities,
and other members of the public affected by the work-
place environment.3

The Workplace and the Epidemiological
Triangle
The workplace is only one component of the overall en-
vironment, but it is where adults spend approximately
one-third of their time.4 The epidemiological triangle
(Chapter 3) provides a framework to describe the com-
plex relationships among an agent (the exposure[s] in
the workplace), the host (worker/employee), and the en-
vironment (workplace)—the setting in which the agent
and host come together.5 This chapter clarifies how these
three components relate to one another.

Occupational and Environmental
Health Nursing
The specialty of occupational health nursing evolved dur-
ing the 19th century, when industry leaders hired nurses
to decrease the spread of communicable disease among
workers, reduce injury, and promote safety. The land-
mark events in the evolution of the specialty are de-
scribed in Box 20-2. Today’s OEHN has expanded this
specialty practice into management areas, consultation
with government and industry, policy setting at the local,
state, and national levels, education, and research. Nev-
ertheless, a major role for the OEHN is providing direct
care to employees in the workplace.

510 U N I T I I I n Public Health Planning

Occupational Health Professionals
Occupational and environmental health nurse

Occupational health physician
Occupational and environmental hygienist

Ergonomist

Occupational psychiatrist/psychologist

Toxicologist

Injury prevention/safety specialist

Health promotion educator

BOX 20–1 n Members of the Interprofessional Occupational and Environmental Health Team

Primary Focus
Prevention of occupational disease and injury, restoration of employee

health and return to work, protection from occupational hazards
Diagnose, treat, and manage occupational disease and injury
The recognition, evaluation, and control of chemical, biological, or

physical factors or stressors arising in the workplace; and the use of
analytical techniques to detect exposures and implement engineering
controls to correct, reduce, or eliminate exposure

Evaluate, design, and promote the interface between the worker, tools
used, and their work

Diagnose, treat, and manage mental and behavioral disorders
secondary to exposures in the workplace

Evaluate and describe the toxic properties of chemical and physical
agents used during work

Develop procedures, standards, or systems to achieve the control or
reduction of hazards, injuries, and exposures

Develop educational strategies and methods to promote the health of
worker(s) in the occupational setting

7711_Ch20_509-536 21/08/19 11:09 AM Page 510

In 1993, the Institute of Medicine (now known as the
Health and Medicine Division of the National Acade-
mies of Sciences, Engineering, and Medicine) conducted
a workshop to discuss the growing need to enhance oc-
cupational and environmental health content in the
practice of nursing. The workshop resulted in the estab-
lishment of the Committee on Enhancing Environmen-
tal Health Content in Nursing Practice and competencies
for this nursing specialty.6 Today, the importance of oc-
cupational health is evident in the Healthy People (HP)
objectives.7

C H A P T E R 2 0 n Health Planning for Occupational and Environmental Health 511

n HEALTHY PEOPLE
Targeted Topic: Occupational Safety and Health
Goal: Promote the safety and health of people at
work through prevention and early intervention.
Overview: The intent behind the occupational safety
and health topic area is to prevent diseases, injuries,
and deaths that result because of working conditions.
Work-related illnesses and injuries include any
illness or injury incurred by an employee engaged in
work-related activities while at or away from the
worksite. With the advent of Total Worker
Health®, there is now a focus on the activities and
behaviors occurring outside of the workplace that may
impact the overall health of the worker and ultimately
worker safety and productivity.8

Workplace settings vary widely in size, sector,
design, location, work processes, workplace culture,
and resources. In addition, workers themselves are

different in terms of age, gender, training, education,
cultural background, health practices, and access to
preventive health care. These activities translate to
great diversity in the safety and health risks for each in-
dustry sector and the need for tailored interventions.

Occupational safety and related HP objectives are
primarily addressed through the National Occupa-
tional Research Agenda (NORA). NORA was
established by the Centers for Disease Control and
Prevention (CDC), National Institute for Occupa-
tional Safety and Health (NIOSH), and its partners
to stimulate research and improve workplace practices.
Now in its third decade (2016–2026), NORA focuses
on occupational safety and health in 10 sectors:

1. Agriculture, Forestry, and Fishing
2. Construction
3. Health Care and Social Assistance
4. Manufacturing
5. Mining
6. Oil and Gas Extraction
7. Public Safety
8. Services
9. Transportation, Warehousing, and Utilities

10. Wholesale and Retail Trade7

HP 2020 Midcourse Review: There are 16 measura-
ble objectives for this topic area. Thirteen of the
objectives met or exceeded their target with 2 of the
objectives improving. For 1 objective, there was little
or no detectable change.
Source: (7, 8, 9)

1888 Betty Moulder of Pennsylvania was the first reported occupational health nurse who cared for coal miners and
families.

1942 American Association of Industrial Nurses established.
1970 The Occupational Safety and Health Act is passed creating the Occupational Safety and Health Administration

(OSHA) and the National Institute for Occupational Safety and Health (NIOSH).
NIOSH Occupational Safety and Health Education and Resource Centers are created to educate occupational
health professionals (nurses, physicians, industrial hygienists, and safety specialists), now called NIOSH Occupa-
tional Safety and Health Education and Research Centers.

1972 The Accreditation Board for Occupational Health Nursing is established, creating certification of nurses in the
specialty practice of occupational and environmental health nursing.

1977 The American Association of Industrial Nurses name changed to the American Association of Occupational
Health Nurses.

1993 The Office of Occupational Health Nursing (OOHN) was established at OSHA.
1997 AAOHN releases first edition of AAOHN Core Curriculum for Occupational Health Nursing.

BOX 20–2 n Landmark Events in the Evolution of Occupational and Environmental Health Nursing

Source: Adapted from Institute of Medicine. Committee to Assess Training Needs for Occupational Safety and Health Personnel in the
United States, 2000.

7711_Ch20_509-536 21/08/19 11:09 AM Page 511

Occupational and environmental health nursing is
defined by the American Association of Occupational
Health Nursing (AAOHN) as “the specialty practice that
provides for and delivers health and safety programs and
services to workers, worker populations, and community
groups.”10 The AAOHN is the professional organization
that develops and approves standards of practice,
supports education and research, and provides political
consultation to state and national legislators related
to OEHN. The Accreditation Board for Occupational
Health Nursing certifies nurses in the specialty practice
of occupational and environmental health nursing.

The practicing OEHN focuses on promotion and
restoration of health, prevention of illness and injury,
and protection from work-related and environmental
hazards. The specialty is guided by a code of ethics
(Box 20-3) that provides an ethical framework for
decision making and nursing actions.11 Another im-
portant document developed by the AAOHN is the
Standards of Occupational and Environmental Health
Nursing.12 The standards include a definition of and

scope of practice for OEHNs. Because OEHNs fre-
quently have a combined knowledge of health and busi-
ness, they are equipped with the skills to incorporate
their experience in health care with their knowledge of
establishing safe and healthy work environments.

Key Agencies in Occupational Health
The passage of the Occupational Safety and Health
(OSH) Act in 1970 created two government organiza-
tions: OSHA and NIOSH.3 The work of both agencies
has a profound effect on the work environment and the
safety and health of workers in the United States.

Occupational Safety and Health
Administration
OSHA, which is part of the Department of Labor, is the
main federal agency charged with the regulation and
enforcement of the OSH Act. The mission at OSHA in-
volves the development and enforcement of safety and
health standards to assure safe and healthful working

512 U N I T I I I n Public Health Planning

Preamble
The American Association of Occupational Health
Nurses, Inc. (AAOHN) Code of Ethics has been devel-
oped in response to the nursing profession’s acceptance
of its goals and values and the trust conferred upon it by
society to guide the conduct and practices of the profes-
sion. As a professional, occupational and environmental
health nurses (OHNs) accept the responsibility and inher-
ent obligation to uphold these values.

The Code of Ethics is based on the belief that the
goal of occupational and environmental health nurses is to
promote the worker, worker population and community
health and safety. This specialized practice focuses on
promotion and restoration of health, prevention of illness
and injury and protection from occupational and environ-
mental hazards. The occupational and environmental
nurse has a unique role in protecting the integrity of the
workplace and the work environment.

The client can be workers, workers’ families/significant
others, worker populations, community groups, and em-
ployers. The purpose of the AAOHN Code of Ethics is
to serve as a guide for registered professional nurses to
maintain and pursue professionally recognized ethical be-
havior in providing occupational and environmental health
and safety services.

Ethics is synonymous with moral reasoning. Ethics is not
law, but a guide for moral action. Professional nurses, when
making judgments related to the health and welfare of the
client, utilize these significant universal moral principles.

These principles are:

• Right of self-determination
• Confidentiality
• Truth telling
• Doing or producing good
• Avoiding harm
• Fair and nondiscriminatory treatment

Occupational and environmental health nurses recog-
nize that dilemmas may develop that do not have guide-
lines, data or statutes to assist with problem resolution;
thus, occupational and environmental health nurses use
problem-solving, collaboration and appropriate resources
to resolve dilemmas.

The Code is not intended to establish nor replace stan-
dards of care or minimal levels of practice. In summary, the
Code of Ethics and Interpretative Statements provide a
guiding ethical framework for decision-making and evalua-
tion of nursing actions as occupational and environmental
health nurses fulfill their professional responsibilities to
society and the profession.

BOX 20–3 n Code of Ethics and Interpretive Statements for the American Association of Occupational
Health Nurses

Source: From the AAOHN, used with permission.

7711_Ch20_509-536 21/08/19 11:09 AM Page 512

conditions for working men and women. The OSH Act
includes the General Duty Clause, which requires an em-
ployer to “furnish to each of his [sic] employees employ-
ment and a place of employment which are free from
recognized hazards that are causing or are likely to cause
death or serious physical harm.” Most employees who
work for private employers in the United States are pro-
tected by federal OSHA or through an OSHA-approved
state program. Federal agencies must have a safety and
health program that meets the same standards as re-
quired under federal OSHA. The self-employed, family
members of family farms, employers who do not employ
outside employees, and workers protected by regulations
of another federal agency (for example, the Mine Safety
and Health Administration, the Federal Aviation Admin-
istration, and the Coast Guard) are not covered by the
OSH Act.13 Additionally, the Act requires businesses with
more than 10 employees to keep records of fatalities, in-
juries, and illnesses on the OSHA 300 form. This record-
keeping is critical to an employer’s safety and health
program for several reasons. Identification and descrip-
tion of the causes of work-related illness and injury assist
in identifying problem areas that need corrective action
to reduce hazardous workplace conditions. The data col-
lected on these logs are used by the Department of Labor
and OSHA to develop workplace statistics, including
fatality, morbidity, and incidence rates for workplace
illnesses and injuries for U.S. industries. These statistics
are available to the public and provide a yearly accounting
of the injuries and illnesses occurring among U.S. worker
populations. The data in OSHA 300 logs provide infor-
mation for OSHA to monitor the progress being made to
reduce workplace safety and health problems.14 OSHA
also uses these logs to target the need for enforcement
activities in industries in which the majority of workplace
injuries and illnesses occur.

National Institute for Occupational Safety
and Health
The second agency created by the OSH Act was NIOSH,
an agency of the Department of Health and Human
Services, whose mission is to conduct research and pro-
vide information, education, and training in the field of
occupational safety and health. In 1996, NIOSH created
NORA.7,15 NORA is a partnership program between gov-
ernmental agencies, large and small businesses, universi-
ties, worker organizations, and professional groups that
work in collaboration to develop innovative research with
the ultimate goal of improving workplace practices.7,16

Ultimately, these research partnerships seek to provide
recommendations for safer, healthier workplaces.

Occupational Safety and Health Program
A formal OSH program is an essential tool for the
OEHN. Employers are encouraged to develop an OSH
program to manage the safety and health at the worksite
to reduce injuries, illnesses, and fatalities by complying
with OSHA standards and the General Duty Clause.17

An additional recommendation for an OSH program is
to address the unique hazards and conditions found at
each worksite.

An OSH program provides a systematic process that
evaluates the workplace, recognizes the exposures and
hazards found in each area of the worksite, provides a
plan to control these exposures and hazards, and evalu-
ates the effectiveness of these controls through routine
environmental monitoring of the worksite and routine
medical screening to assess for any adverse health con-
ditions of the workforce. Environmental monitoring is
the assessment of the workplace to identify risks and
other hazards, whereas screening refers to identifying in-
dividual risks within individual workers such as heart
disease and high blood pressure. The OEHN is a member
of an interprofessional team that provides information
on the health data collected during the medical screening
process to assist in the evaluation of the effectiveness of
the OSH program. If a problem is found with program
effectiveness, corrective action is taken, and workers are
re-evaluated.

Primary, Secondary, and Tertiary Prevention
In most workplaces, an occupational safety and health
program focuses on primary, secondary, and tertiary
prevention of occupational illnesses and injuries, and
promotes worker health. Through primary prevention,
workers are protected from exposure to hazards, or ex-
posures are limited to levels considered safe. Examples
of primary prevention interventions in the workplace in-
clude engineering controls, such as the use of less
hazardous chemicals, or personal protective equipment
(PPE), such as masks, gloves, or hearing protection, or
tethering a roofing worker to prevent a fall.

Secondary prevention requires early recognition
of a disease before the disease becomes irreversible or
is no longer easily treatable. Screening and monitoring
of workers are examples of secondary prevention activ-
ities designed to detect early signs of disease (e.g.,
audiometric screening to detect hearing loss for work-
ers in a noisy environment or spirometry screening to
detect a reduction of lung function due to work in
a closed, dusty environment). Tertiary prevention in-
volves the treatment of the disease. The diagnosis of an

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occupational illness, such as work-related asthma, may
require that the worker be removed from the exposure
and transferred to another job. For nonoccupational ill-
nesses that occur, the OEHN must coordinate with the
worker’s family physician or nurse practitioner regard-
ing the timing of work return, particularly if accommo-
dations in the workplace are needed. For example, an
employee recovering from a myocardial infarction may
require a gradual return to physically demanding work
or an employee being treated for cancer may require a
flexible work schedule to accommodate chemotherapy
or radiation.

Worker Populations
The demographic characteristics of workers vary by age,
race, gender, culture, ethnicity, and sensory/functional
ability. These factors may influence a worker’s vulnera-
bility and susceptibility to exposures in the workplace
and must be incorporated into an OSH program. In the
United States, employment is often begun during ado-
lescence and young adulthood. Approximately 43% of
teenagers are employed in their first job by age 19 years.
As the U.S. workplace becomes more diverse, OEHNs
must focus on the vulnerable worker. The U.S. workforce
is changing in a variety of ways. As many traditional serv-
ice and manufacturing jobs migrate to other countries,
the workforce is becoming much more dependent on
“knowledge” workers.18 Occupational health providers
also need to pay attention to this rapid movement toward
a knowledge-based economy that relies heavily on the
creativity, mental stamina, and intellectual capacity of
workers. This trend will likely change the pattern of dis-
ease and injuries that occur. For example, fewer physical
injuries such as falls and crush injuries are likely to occur
as factory worker jobs (and related injuries) are relocated
to other countries. A higher rate of sedentary lifestyle dis-
eases such as high blood pressure, diabetes, and obesity
may occur as employees spend more time sitting at a
computer versus physically moving during the course of
their workday.

Emerging issues in the workplace are tied to the trend
of longer working hours, greater participation of women
in the workforce, couples having children later in life, in-
creasing responsibility for the care of aging family mem-
bers, and dual-career families. More and more workers
find themselves sandwiched between work and domestic
responsibilities.19-21 Today, researchers at NIOSH are fo-
cused on the associations between work-life balance,
well-being, and functioning.22 Examples of research
needed in this field include the effects of telecommuting
and other organizational practices that meld work and

family life, and the benefits of increased job flexibility and
control over family obligations.

Unions
Unions have played an essential role in the evolution of
occupational safety and health in the United States. In
1890, the United Mine Workers of America (UMWA)
was formed with the primary purpose of preventing
miner deaths.23 The UMWA’s constant effort taken to
describe the dangerous conditions in coal mines that lead
to black lung disease and fatalities was instrumental in
the passage of the Coal Mine Health and Safety Act of
1969.23 Over the years, labor unions have used collective
bargaining agreements to help improve worker health
and safety at union worksites. An example of this type of
initiative is the 1974 contract agreement between the U.S.
Steel Corporation and the United Steel Workers of
America, which addressed the adverse health effects
caused by exposure to coke oven emissions during steel
production.23 Unions assist their members with day-to-
day issues at work, participate in legislative and regula-
tory policy-making, and conduct collective bargaining
for workers over wages, working conditions, and bene-
fits. Unions also conduct education and training pro-
grams for their members. They provide workers with a
voice in workplace decisions and provide a mechanism
for resolving workplace issues unavailable to workers in
a nonunionized workplace.

Over the years, the number of union members in the
United States has fallen dramatically, from 20.1% of
American workers in the private sector in 1983 to 10.7% of
wage and salary workers in 2017.24 Yates discusses sev-
eral reasons for the decline of U.S. unions. External
forces include the shift of the economy from the produc-
tion of goods to a service economy and the lack of de-
mand by workers for the services offered by unions.23 A
2018 ruling by the Supreme Court of the United States
removing the requirement of “fair share” of union dues
is likely to further reduce union participation. An inter-
nal force that has affected unions is the way union leaders
are chosen. They are no longer selected from rank-and-
file members, but from delegates far removed from the
average rank and file union member.23

The OEHN must establish a working relationship with
a union that has a presence in the workplace. Health and
safety meetings should involve the union so trust and mu-
tual respect are developed among members of the safety
and health program. Despite the fact their numbers have
decreased in the United States, unions such as the Service
Employees International Union, the American Federa-
tion of Labor-Congress of Industrial Organizations, and

514 U N I T I I I n Public Health Planning

7711_Ch20_509-536 21/08/19 11:09 AM Page 514

others remain important organizations representing
workers in many high-risk industries.

C H A P T E R 2 0 n Health Planning for Occupational and Environmental Health 515

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Contaminated Home
Public Health Science Topics Covered:

• Epidemiology and biostatistics

Juan, a Mexican immigrant to the United States,
works in California and Oregon during the harvest
season as a migrant/seasonal farmworker. His 8-month
work experience includes harvesting strawberries, as-
paragus, and navel oranges in California. In Oregon, he
works in the berry and celery fields, usually for 6-week
periods and often for many different owners. In one of
these jobs, he experienced a puncture wound to his
foot, resulting in the need for a tetanus immunization,
after which he traveled back to California to work in
the raisin grape harvest.

Depending on the season, Juan spends up to
12 hours per day working in the fields, planting or
harvesting crops, and unloading trucks. At the end of
the day, his clothes are often covered with dust. He
sometimes brings his wife and children into the field to
assist him with the picking of fruit or vegetables.

Juan and his family are often provided substandard
housing with a communal bathroom and shower, and a
shared kitchen in the local shantytowns. The location
of the housing is often directly across from the fields,
and inhabitants may be exposed to the pesticides with
which the fields are sprayed.

The public health nurse (PHN) from the local health
department provides care to the migrants. As a part of
this role, the PHN sees Juan in the nearby free clinic as
a follow-up to his foot injury. The puncture wound to
his foot has healed and has no signs of infection. The
PHN realizes exposures in the worksite are critical to
Juan’s health and interviewed him about his work and
current health status. Juan reports leaving the fields late
every day and eating dinner before removing his work
clothes or taking a shower. He also complains of slight
abdominal discomfort and diarrhea that has lasted for
the past 7 days. After further inquiry, the PHN learns
that, although 1,3-dichloropropene is the most com-
mon pesticide used locally to control pests from eating
the roots of grape plants, local farmers may be spraying
several other pesticides and fungicides.

The pesticide 1,3-dichloropropene is a sweet-
smelling, colorless liquid that dissolves in water and
evaporates quickly.25 The pesticide released into the

atmosphere takes several days to break down. After
learning of the proximity of Juan’s home to the fields,
the PHN develops an exposure risk-reduction plan in
collaboration with Juan. The plan includes Juan wearing
a facemask and dusting off his clothing before entering
his home. He will remove his clothing at the door and
put them in a bag to keep them from contaminating the
rest of the home. Juan then will shower before eating.
When the fields are being sprayed, Juan’s children
will wait 5 days before playing outside near the fields
or their home. The PHN asks Juan to return in 2 to
3 weeks for a re-evaluation of his symptoms and po-
tential referral to industrial medicine and potentially
pulmonary function testing. The PHN provides Juan a
summary sheet with his nursing diagnosis, agreed-upon
plan, and notes for the next PHN in case he relocates
before his next clinic appointment. The treatment plan
is provided in both English and Spanish.

Exposures in the Workplace
Exposures for any worker can include physical, chemical,
biological, or psychological hazards. These hazards may
have a profound effect on the short- and long-term
health of workers. It is important for OEHNs to identify
hazards in their work environment so mitigation plans
can be implemented to reduce the potentially harmful
effect on workers.

Physical Exposures
Physical hazards in the workplace, such as noise, exces-
sive hot or cold temperatures, vibration, and nonionizing
and ionizing radiation, cause harm or injury to body tis-
sues through energy transfer.

Noise is an exposure frequently found in workplaces
where construction, welding, or work with heavy ma-
chinery or power tools is performed. After years of ex-
posure to loud noises, hearing loss can occur due to
damage of the hair cells in the inner ear and failure of
sound wave transmission to the auditory nerve. Loud-
ness and duration of noise exposure are two important
factors that affect hearing loss. Nonwork exposure to
loud noise can occur at music concerts, in sports such as
hunting or target practice, and without the use of hearing
protection such as ear buds, all of which may lead to
hearing loss. OSHA has developed a standard that reg-
ulates noise exposure and requires a hearing protection
program in the workplace.26 This standard requires
monitoring of noise levels within the work environ-
ment, use of hearing protection, training and education

7711_Ch20_509-536 21/08/19 11:09 AM Page 515

of employees in the proper use of hearing protection,
creation of baseline audiograms for each employee, and
annual hearing tests.

Excessive heat exposure can be found in foundries,
pottery-making plants with kilns, and in the road con-
struction and fishing/agriculture industries during the
summer months. For migrant workers like Juan, health
outcomes of working in hot environments can be debil-
itating and potentially life-threatening when heat stress,
heat exhaustion, and heat stroke occur. Industries that
require outdoor work during the summer months also
expose workers to nonionizing radiation from the sun
and increased risk for skin cancer.27 Jobs with winter-
month cold exposures include construction and police
and fire service work, although food industry workers
may spend time in freezers or stock frozen foods year-
round. Cold exposure results in stimulation of the sym-
pathetic nervous system, potentially resulting in frostbite
and hypothermia.28

Workers are exposed to vibration in manual tasks that
involve two main mechanisms: hand-arm vibration, in
which the main exposure is associated with power tools,
such as a jackhammer; or whole-body vibration trans-
ferred to the body by large machinery, such as a bulldozer.
These types of vibration exposures place workers at risk
for acute and chronic musculoskeletal disorders.29

The Agency for Toxic Substances and Disease Registry
defines ionizing radiation as any one of several types of
particles and rays given off by radioactive material, high-
voltage equipment, nuclear reactions, and stars. The types
of ionizing radiation normally important to health are
alpha particles, beta particles, x-rays, and gamma rays.27,30

Ionizing radiation can have significant health effects, in-
cluding skin burns, hair loss, nausea, birth defects, illness,
and death. Certain types of cancer have been associated
with ionizing radiation, although a person’s risk may be
influenced by dose and the age of the person when ex-
posed.27,30 For example, hospital x-ray technicians can be
exposed to ionizing radiation during radiological proce-
dures. However, most hospitals employ comprehensive
safety protocols to prevent ionizing radiation exposure.

Chemical Exposures
According to OSHA, there are approximately 650,000 ex-
isting chemical products and hundreds of new products
being introduced into the workplace annually. These
chemical exposures can cause health effects to our body
systems and act as carcinogens. As a result of these
findings, OSHA issued the Hazard Communication
Standard.31 This policy requires both employers and em-
ployees to be knowledgeable about hazards and to protect

themselves from illness or injury. This policy also requires
the producers of chemicals to be responsible for reviewing
the scientific evidence related to chemical hazards, and
generating and communicating information to chemical
users in the form of a material safety data sheet (MSDS).
An MSDS accompanies the hazardous chemical and de-
scribes the physical and chemical properties (e.g., acid,
solvent) and health hazards, routes of exposure, safe han-
dling and use, emergency and first aid procedures, and
control measures.

Heavy Metals
Lead, mercury, cadmium, beryllium, nickel, and alu-
minum are examples of heavy metals that may be found
in an occupational environment.32 Information on
chemical exposures may be obtained at the Agency for
Toxic Substances and Disease Registry’s website. An ex-
ample of a chemical hazard in the workplace is beryllium,
a metal naturally found in mineral rocks, coal, soil, and
volcanic dust. Beryllium compounds are mined and pu-
rified for use in nuclear weapons and reactors, aircraft,
satellites, and x-ray machines. Workers exposed to beryl-
lium may develop an inflammatory respiratory condition
known as chronic beryllium disease years after exposure.
Lung cancer screening for these workers is also recom-
mended because beryllium is a human carcinogen.33

516 U N I T I I I n Public Health Planning

w SOLVING THE MYSTERY
The Case of the Toxic Exposure
Public Health Science Topics Covered:
• Screening
• Surveillance
• Environmental assessment

Ken is a 45-year-old male working for a large
manufacturing company that produces lead-acid stor-
age batteries for electric automobiles. He works the
night shift, sweeping floors and cleaning offices in the
company’s administration building. He arrives at the
occupational health clinic at the end of his shift report-
ing persistent abdominal pain over the previous
6 weeks. During the clinical assessment, Ken also
reports intermittent headaches, vomiting, and general
fatigue. The occupational health physician requests a
serum lead level to screen for lead toxicity. Ken
ultimately is diagnosed with lead poisoning and an
environmental assessment of the administration
building is requested. The assessment finds no environ-
mental lead present in the administration building.
The clothing and shoes of plant employees are

7711_Ch20_509-536 21/08/19 11:09 AM Page 516

hospitals, clinics, and community health settings can be ex-
posed to bloodborne pathogens such as HIV and hepatitis
B and C. OSHA’s Bloodborne Pathogen Standard, first in-
troduced in the early 1990s, provides strict regulations for
health-care settings to prevent and manage exposures by
use of needleless devices, sharps containers, non-recapping
of needles, and proper disposal of body fluids.

OSHA also provides guidelines for the protection of
employees exposed to tuberculosis. Employees must have
a respiratory protection program outlining when an
employee needs to use a respirator as protection against
tuberculosis, the proper selection and fit of respirators,
fit testing and medical evaluation of workers who use res-
pirators, and training for respirator use.39 A respirator is
a personal protective device (PPD) worn on the face and
covers at least the nose and mouth. It is used to reduce
the wearer’s risk of inhaling hazardous airborne particles
(including dust particles and infectious agents such as
tuberculosis), gases, and vapors.40 Prior to using a respi-
rator, a worker must have a medical evaluation to ensure
he or she is able to use the respirator; a fit test must be
done to determine the proper dimensions of the respira-
tor on the worker; and the worker must be trained in the
proper use and handling of a respirator.

Biological exposures are common among workers
who provide animal care in zoos, farms, or research
facilities where studies are completed on animals such as
rats, mice, and monkeys. Work in wet environments
(such as chicken- or meat-processing facilities) may in-
crease exposure to fungal diseases.

Psychological Exposures
Work has changed dramatically in the United States as a
result of greater competition for goods and services.
Globalization is increasing the speed and demand
for products, and the information technology field has
altered communication practices. Outsourcing of jobs to
developing countries, layoffs, and downsizing have
changed job security. These changing trends affect the
physical and psychological well-being of workers, and
outcomes may include hypertension, cardiovascular
disease, gastrointestinal disease, substance use disorder,
difficulty sleeping, workplace violence, hostility, depres-
sion, low productivity, and absenteeism.41

Job Stress
Job stress is the harmful physical and emotional response
that occurs when the requirements of the job do not
match the capabilities, resources, or needs of the worker.22

Two job-stress models demonstrate strong associations
between work stress and disease: the Demand Control

C H A P T E R 2 0 n Health Planning for Occupational and Environmental Health 517

screened for lead that could have been tracked into the
administration building; no lead was found. The OEHN
conducts an in-depth history to identify Ken’s recre-
ational activities. The OEHN learns that Ken goes to an
indoor firing range on the weekends spending about
1 hour shooting his firearm at a target. When fired,
bullets release lead particulates into the air that were
likely inhaled by Ken leading to his lead toxicity.
Because the toxicity was identified at work, Ken was
entered into a lead exposure program where his lead
levels will be monitored, and he will not be permitted
to pick up extra shifts within the plant to prevent addi-
tional lead exposures. In addition, Ken was advised to
switch to an outdoor shooting range where he can still
enjoy his hobby while reducing his lead exposure.34,35

Pesticides
Migrant/seasonal farmworkers such as Juan and pest
control workers are exposed to pesticides when they
enter fields where pesticides have been applied or when
they mix or apply them. Organophosphates, one type
of pesticide, are powerful cholinesterase inhibitors.
Cholinesterase is an enzyme important for the proper
functioning of the nervous system in humans, other ver-
tebrates, and insects.36 Inhibition of this enzyme can
cause a buildup of acetylcholine within nervous and
skeletal smooth muscle systems, leading to signs and
symptoms affecting the respiratory system, cardiovascu-
lar system, central nervous system, eyes, and skin.

Organic Solvents
Organic solvents (e.g., benzene, toluene, carbon disulfide,
carbon tetrachloride, trichloroethylene or TCE) are volatile
hydrocarbons found in a variety of industries. These chem-
icals are used in degreasing and dry-cleaning operations
and in the manufacturing of paints, paint strippers,
lacquers, rubber products, plastics, and textiles. Health
effects of these agents include central and peripheral nerv-
ous system damage, kidney and liver damage, reproductive
effects, as well as skin lesions and cancer. An example is
benzene, a known carcinogen and product derived from
coal and petroleum and found in gasoline. Chronic expo-
sure to benzene affects bone marrow and blood production
and can lead to leukemia. Short-term exposures may cause
drowsiness, unconsciousness, dizziness, and death.37

Biological Exposures
Biological agents include bacteria, viruses, and other
microorganisms that can be transmitted by air, food,
water, soil, or direct contact.38 Health-care providers in

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Model and the Effort-Reward-Imbalance Model. The
Demand Control Model developed by Karasek and col-
leagues describes the relationship between job demands
and job control.42 The job demands variable examines
the pace and intensity of work, and job control relates to
the ability of the worker to direct and manage work.
When work involves a high level of demand with low level
of control, job strain can result in physiological and psy-
chological changes in the worker, particularly increased
cardiovascular disease risk.42-44

A third variable, social support at work, added to the
Demand Control Model by Johnson and Hall, affirms
that the level of job strain may be reduced by the protec-
tive effect of social support from coworkers and super-
visors.45 Examples of stressful situations include the
employee in a supermarket who must check and bag gro-
ceries quickly and efficiently (high demand) under the
watchful eye of a supervisor, who records the number of
customers assisted without the development of long lines
(control). Another example is the catalog “800” operator,
who is recorded and timed for speed and courtesy when
taking orders (high demand/low control).

A second work stress model, the Effort-Reward-
Imbalance Model, builds on the concept of job demands
and includes the amount of effort invested by a worker
in the job.46 It is hypothesized that the inequity of re-
wards contributes to negative mental health outcomes
through a process of devaluation related to recognition,
promotion, and job security.

To assist workers in coping with stressful conditions at
work or within the family, workplaces may employ psychol-
ogists, social workers, counselors, or psychiatric-mental
health clinical nurse specialists, or they may contract with
an employee assistance program (EAP).47 The benefit of
an EAP is it allows employees to discuss work, financial, or
social issues in a confidential setting. EAPs also can refer
workers for further evaluation and treatment by a licensed
therapist (e.g., psychiatrist, psychiatric-mental nurse prac-
titioner). Health promotion programs may assist the worker
in coping with stressful situations by encouraging regular
physical exercise, relaxation, or meditation to reduce work-
ers’ psychosocial stress.48

Routes of Exposure
There are three body systems that can serve as routes of
exposure to hazardous substances found in the workplace:

• Respiratory system
• Integumentary system
• Gastrointestinal system

Inhalation of substances (i.e., gases, particles, carbon
monoxide, solvents) into the lungs may cause local or
systemic effects. The upper respiratory tract protects
the lungs by filtering large particles in the nose and via
the cilia, but respirable particles that range from 1 to
10 microns in diameter still can be inhaled into the lower
respiratory tract. Factors that may increase the absorp-
tion of respirable particles include faster respiratory rate
and greater depth of respiration.

Pesticides, solvents, and cleaning agents are exam-
ples of agents absorbed through inhalation as well as
through the skin (dermatological absorption). Damage
to the epidermis or exposure to a lipid soluble substance
(solvent) increases absorption. Ingestion of particles
into the gastrointestinal tract may occur by eating or
smoking in the workplace. Providing a separate loca-
tion for workers to consume meals and take breaks re-
duces this exposure. Although ingestion is the least
common source of exposure, transfer of toxins by
hand-to-mouth activity can be reduced by proper hand
hygiene.

Controlling Hazards and Injuries
in the Workplace
An effective OSH program can be accomplished by con-
trolling hazards and preventing injuries in the workplace.
Two strategies to achieve this goal are incorporating
principles of ergonomics and adopting a hierarchy of
controls.

Ergonomics
One approach to reducing injuries is to apply the field
of ergonomics, which incorporates the science of bio-
mechanics, to design work that is less demanding of a
worker’s joints, back, and muscles to prevent injury. An
ergonomist designs the job to fit the worker, rather than
physically forcing the worker’s body to fit the job. There
is increased ergonomic risk associated with jobs that
require repetitive, forceful, or prolonged exertions of
the hands; frequent heavy lifting, pushing, pulling, or
carrying of heavy objects; or prolonged awkward pos-
tures. Workers with these types of jobs have a greater
risk of developing musculoskeletal problems such as
back pain, carpal tunnel syndrome, and tendonitis. Ex-
amples of workers who may have ergonomic risks are
meat and poultry processors, grocery store checkout
personnel, and nursing home staff whose jobs involve
bathing, turning, and walking patients. Workstations,
tools, and equipment can be adapted to fit the worker

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and reduce the physical stress on a worker’s body.
Additional examples of tasks that have ergonomic risks
include the following:

• Lifting heavy or awkward items
• Placing or extracting items from high shelves
• Pushing or pulling heavy loads without assistance
• Being exposed to excessive vibration
• Using excessive force to perform tasks
• Repeating the same motion throughout the workday
• Working in awkward or stationary positions
• Maintaining the same posture for long periods of

time
• Using the body or a body part to press against hard

or sharp edges
• Cold temperatures
• Combined exposures to several risk factors49

In addition to chemical, psychological, and physical
exposures for our case study individual, Juan, ergonomic
issues also are of concern. Repeatedly lifting heavy bas-
kets of fruits and vegetables can result in musculoskeletal
problems, possibly leading to long-term problems.

Hierarchy of Controls
Occupational health providers can use a systematic
process known as the hierarchy of controls to control
workplace hazards. There are five levels of control:
(1) elimination or substitution, (2) engineering controls,
(3) warning, (4) administrative controls, and (5) PPE.50

The most effective level of control is the elimination
or substitution of a hazardous material, task, or process.
For example, benzene is an aromatic solvent used in
many industrial products such as glues, paints, gasoline,
and rubber, and can cause changes in the production
of white cells in the bone marrow, leading to leukemia.
Benzene can be eliminated by substituting toluene, a less
toxic solvent.

If elimination or substitution is not possible, the next
most effective strategy is the implementation of engi-
neering controls. Isolation of a hazard is an example of
an engineering control. For example, in the past, nurses
at workstations without ventilation hoods mixed anti-
neoplastic agents. Based on research findings that cited
reproductive effects and recommendations from occu-
pational safety and health engineers, these agents are
now mixed in the pharmacy under properly ventilated
hoods. An additional strategy is closed system transfer
devices.51

A third-line strategy is providing warnings. OEHNs can
coordinate with industrial hygienists to have warning signs
placed in higher risk areas. For example, a yellow-taped

walkway on the floor of a bottling plant can remind fork-
lift operators of the potential for employees to be walking
along a given path. Another example is a mandated
sign that warns of radioactive exposures found in hospi-
tals where radioactive isotopes or radiation producing
machines are located.

Use of administrative controls is a fourth strategy of
hazard control. Job rotation is an example of how one
may reduce the overexposure of workers in the nuclear
power industry to radiation. Hygienic work practices and
good housekeeping, such as frequent floor washing in
dust-producing industries, reduce the hazard of res-
pirable particles from entering the air. The most impor-
tant administrative control may be the training and
education of workers, so they are knowledgeable about
hazards present in the workplace. Educational materials
must be culturally sensitive and produced at an appro-
priate cognitive and literacy level for workers. In addi-
tion, materials may need to be provided in multiple
languages.

The least effective level of control, yet still important,
involves the use of PPE. Hard hats, masks, respirators,
gloves, hearing protection (ear muffs or ear plugs),
gowns, metal-toed shoes, and headgear are examples of
PPE. In the hierarchy of controls, PPE is least effective,
primarily because worker compliance is difficult to en-
sure. Equipment may interfere with movement, hearing,
and comfort, and may be cumbersome and hot if worn
properly for 8 hours, leading workers to use PPE incor-
rectly or not at all. Therefore, close supervision of worker
compliance with PPE and supervisors’ role-modeling the
use of PPE are important.

Workplace Assessment (Workplace
Walkthrough)
As an OEHN, regularly scheduled assessments with
members of the occupational health team are impor-
tant. The purpose of the workplace assessment or
workplace walkthrough is to observe the operations
taking place in a facility, observe workers performing
their jobs, identify the use of engineering controls, view
the use of equipment (moving and stationary) in work
areas, and observe the physical layout and cleanliness
of the facility including locker rooms, hand-washing
stations, changing facilities, and break and lunch
rooms. During the walkthrough, the OEHN also should
engage managers, supervisors, and individual workers
in discussions about their work and safety and health
issues.

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520 U N I T I I I n Public Health Planning

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Pottery Factory
Walkthrough
Public Health Science Topics Covered:

• Epidemiology and biostatistics

John is an OEHN at a large pottery-making facil-
ity with 452 workers. The building is located in a
rural area and is the size of three football fields.
It includes the kiln, storage space for sand and silica,
machines for pottery production, paints and glazes,
heavy equipment, workstations, and an inventory
of finished pottery. The occupational health clinic is
located in a separate administration building adjacent
to the main facility.

As he walks through the plant on a beautiful
summer day, John observes a truck being loaded
with boxes of pottery. At the plant, the kiln is in
use and the plant temperature is 91°F. Machines
are mixing the clay, and workers are providing the
materials for this process. (Many of the materials
are stored in 50-pound bags.) The clay then is trans-
ferred to machines that form plates, cups, and other
items, which then are stored on drying racks. Once
the pottery is dry, small teams of four to six workers
stand at a workstation and manually place handles
on the cups or smooth the edges of the pottery to
prepare the items for glazing. The last process he
observes is the decoration of the pottery in a clean
room where workers sit at large tables applying
decals or painting the pottery with small brushes.
As John walks through the plant, he observes contin-
uous activity and notices that a pathway is painted
to denote safe travel routes by machinery and
walkers. Small electric carts transfer materials to
workstations throughout the plant and honk their
horns at workers on foot. The plant is noisy and
not air conditioned; John can hear the loud ventila-
tion system.

Production in this plant occurs around the clock.
However, the night shift employs only 25 workers to
repair equipment in the plant. Workers on the day
and evening shifts are allowed 30 minutes for lunch
or dinner and an additional 20-minute break.

Following the walkthrough, management requests
John write a summary report of his findings (Box 20-4).
The report would consist of a summary and recom-
mendations regarding the strengths and weaknesses
of the OSH program, medical surveillance, emergency

response, and recordkeeping. It would be followed by
an action plan for management.

A summary of John’s report and action plan follows:

No obvious hazardous substances were identified. There is a
risk that small molecules known as particulates are being
released into the air during the manufacturing process of the
pottery. Measurements need to be taken by the industrial
hygienist to determine whether employees are inhaling the
particulates. If particulates are found, masks will need to be
fitted to and worn by workers to prevent the inhalation of
particulates. Employees are at risk for low back injuries while
lifting bags of pottery materials. Optimally, 25-pound bags will
be purchased in the future. Workers with lifting responsibilities
need to start an exercise program to strengthen their lower
back muscles and undergo education on proper body mechan-
ics when lifting to prevent a lower back injury. The industrial
hygienist also needs to take noise measurements to determine
whether the noise is excessive and places workers at risk for
noise-induced hearing loss. Based on literature reported on by
the OEHN, 72% of all hearing-related illnesses occur in the
manufacturing sector, so a hearing protection program may
need to be implemented.52

The OEHN report needs to address the following
questions:

1. What are the hazardous exposures (physical,
biological, chemical, and psychosocial) present in
the worksite?

2. What are the specific mechanisms of exposure
(inhalation, ingestion, dermal) in the worksite?

3. What physical and chemical exposures should be
evaluated by the occupational/environmental
hygienist who accompanied the OEHN on the
walkthrough?

4. What types of accidents and injuries would the
OEHN anticipate in this worksite? What are the
potential causes?

5. Are hierarchies of control followed in this worksite?
What PPEs are appropriate?

6. What is the level of housekeeping within the work-
site? (For example, are floors wet or cluttered? Are
there other fall hazards?)

7. Are workers provided training and information re-
garding the hazards of their work? Do employees
demonstrate the safety practices they received
training on?

BOX 20–4 n Guide to Preparing Workplace
Assessment Report

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Occupational and Environmental History
Another tool used by the OEHN is a comprehensive
occupational and environmental health history. An
occupational nurse practitioner or physician conducts
a history and physical assessment on an employee after
a formal offer of employment is made. The results of
this assessment are reviewed by the OEHN. The objec-
tive of the assessment and history is to identify factors
that would increase the health or safety risk of the new
employee in performing the new job. Findings from the
assessment and history may require work accommoda-
tions and/or further physical exam and screenings.
For example, a new employee who worked in a plant
assembling small toys by hand for the past 15 years is
at risk for carpal tunnel syndrome. Further assessment
of carpal tunnel syndrome and job rotation may be nec-
essary to prevent the onset or worsening of the disorder.
The health history must remain confidential and acces-
sible only to the occupational health team.

To perform an adequate history, the OEHN needs a
formal job description that identifies the job tasks re-
quired of the employee and the job exposures that the
worker will have. A careful analysis of the job description
and the worker’s capabilities and current health status
facilitates the proper placement of the new employee. For
example, an individual who had a prior back injury
should not be placed in a position requiring heavy lifting.
An individual with well-controlled diabetes may not do
well with frequent alternating shift work. An individual
with cardiovascular disease should avoid work in con-
fined spaces as well as exposure to carbon monoxide and
solvents. When a worker returns to work after an injury
or the diagnosis and treatment of an acute or chronic
disease, a new history and assessment are necessary to
determine fitness for duty and the potential need for
accommodation.

Key components of the history are:

• Review of systems
• Personal and family health history
• Psychosocial history
• Past medical history
• List of hobbies

Following the occupational history, a licensed occu-
pational health practitioner performs a physical assess-
ment. Specialized exams may be required for different
job descriptions. For example, if a worker drives trucks
across the country, the Department of Transportation
requires an annual exam that includes an audiometric
exam, vision testing, depth perception, a complete blood

count, blood chemistry, urine drug screening, and
electrocardiogram.

Finally, when the history and physical exam are
completed, a discussion of the results with the em-
ployee should occur and recommendations regarding
safety and health practices should be provided. The
new employee should be encouraged to use the re-
sources provided by the occupational health program
to maintain, protect, and promote his/her health dur-
ing employment.

Vulnerable Workers
With the increasing diversity in the U.S. workforce, not
everyone goes to work healthy, not everyone goes to
work free of stress, and not everyone goes to work in a
friendly, accepting environment. Certain vulnerable
worker populations may be affected by demographic,
social, physical, psychological, and economic factors that
lead to potential susceptibility and health disparities in
the workplace.

C H A P T E R 2 0 n Health Planning for Occupational and Environmental Health 521

l APPLYING PUBLIC HEALTH SCIENCE
The Case of Adolescent Workers
Public Health Science Topics Covered:

• Social sciences

Stephen is a 17-year-old employed by a heavy equip-
ment rental agency on weekends. He is a reliable and
hard-working adolescent, and his employer regularly
requests him to return equipment to the storage lot
and to service and prepare it for re-rental. At times,
Stephen also drives large tractors and feels privileged
to be given the responsibility to do so. Two questions
to think about in this case are: Is Stephen’s employer
compliant with the Fair Labor Standards Act (FLSA),
and what developmental issues should the employer
consider when assigning Stephen to these more
complex tasks?

Adolescence is commonly the first time an individual
becomes employed, unless he or she works on a
family farm or for a family business. The U.S. Congress
passed the FLSA in 1938, which governs the number of
hours an adolescent can work and what types of jobs
adolescent workers can safely perform.53 Despite these
regulations, approximately 70 adolescents die every
year in work-related situations, which are the result
of adolescents performing tasks not in compliance with
the FLSA, including operating hazardous equipment,
such as motor vehicles or meat slicers; working late at

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Exposures to hazardous agents (e.g., carcinogens, noise,
or heavy physical labor) early in life may have acute or
long-term (latent) effects on disease development later
in life. For the OEHN, communicating with employers,
parents, school personnel, and the teen can facilitate
education and training of working adolescents. OSHA
developed a website for teen workers that promotes
safety and health and provides information regarding
hazards, PPE, and details of the FLSA.58

Older Adults in the Workforce
The baby boomer generation, those individuals born
between 1946 and 1964, are contributing to the aging
pool of workers. The healthy lifestyles of many of these
workers has improved life expectancy and extended
working life. The trend of working beyond age 65 years
also is influenced by the 1983 Social Security Amendment,
which raised the full retirement age (eligibility for 100%
Social Security benefits) beginning with individuals born
in 1938 or later. For example, an individual born in 1960
would not be eligible for full Social Security retirement
until age 67.61,62

Older workers may be motivated to remain employed
due to various factors such as financial need, family re-
sponsibilities, a sense of job satisfaction and purpose,
productivity, social engagement, and ability to use skills
and knowledge developed over the years. Alternatively,
an individual with fewer years of education may select
retirement at an earlier age because they began working
in their early teens and twenties and have saved for re-
tirement. A physically demanding job (such as construc-
tion, mining, or farming) also may have resulted in
musculoskeletal injury or the development of a chronic
disease that stimulates early retirement.63

The physical and psychological changes that occur with
the aging process may have an impact on the duration of
work life, such as decreased physical strength, endurance,
balance, visual acuity, and hearing ability; loss of flexibility;
and reduced aerobic capacity and immune response.64

In addition to the normal anatomical and physiological
changes of aging, older workers may have a chronic disease
as a result of their past work exposures or lifestyle behav-
iors, which may limit their employment opportunities.
Older workers may be more vulnerable to falls and trauma.
Frequently among injured older workers, recovery time
for an injury is lengthened, and return to work is delayed.
The OEHN needs to assess the risk of injury and recom-
mend ergonomic changes that adjust the work environ-
ment to the aging worker’s capability, such as the use of
adjustable-height work benches, reducing need to lift
objects, and eliminating repetitive tasks and use of force.65

522 U N I T I I I n Public Health Planning

night or alone; handling hot liquids and grease; and lift-
ing heavy objects.54,55 In Stephen’s case, is his employer
compliant with the FLSA? In actuality, this type of work
is considered hazardous work and restricted by the
FLSA until a worker is 18 years old.

A cross-sectional study conducted by Runyan and
colleagues documented risks to adolescents that in-
cluded exposures to chemical, physical, and biological
agents.56 Of note in this study are significant findings
related to noncompliance with the use of PPE, even
after work orientation and training of the adolescents.57

In general, adolescents are employed in part-time,
temporary, low-paying jobs in the service sector. As
new workers, they often are inexperienced, unfamiliar
with job tasks, lack knowledge of workplace hazards,
and frequently unaware of their rights as workers.
Assessment of the physical characteristics of an
adolescent is an important consideration, because
growth spurts occur between the ages of 14 and 17,
especially among males. Taller and more muscular
males may be given adult tasks with minimal regard to
experience or maturity. The common psychological
characteristics of the adolescent include enthusiasm;
however, a sense of invulnerability may increase the
risk for injury. Communication skills and self-esteem
also may be underdeveloped, and interactions with
customers and supervisors may be challenging.58,59

Stephen’s physical size, coordination, sense of invul-
nerability, and responsible demeanor may give his
employer a false sense of security. Stephen may not
have the skills and decision-making ability to work
with heavy equipment, even though it may seem like
an exciting opportunity to him.

The benefits of employment for adolescents include
the development of self-reliance, self-esteem, and disci-
pline as well as organizational and communication
skills. However, research by educators has demonstrated
that negative effects occur when an adolescent works
more than 20 hours per week and has less time for par-
ticipation in extracurricular school activities and limited
time for interaction with peers and family activities.60

Educators also have found work among adolescents
leads to fatigue and inadequate time for completion of
homework.58

It has been documented that working adolescents may
not enroll in rigorous courses such as math and science
because busy work schedules or long work hours may re-
sult in absenteeism. Increased disposable income may
promote the use of alcohol, illicit drugs, and smoking.

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Enrollment of older workers in fitness programs pre-
serves and builds muscle strength, prevents loss of bone
density, and improves aerobic capacity and cardiopul-
monary function. Workplace health promotion pro-
grams can provide nutrition education, weight control
instructions, stress management, and risk factor reduc-
tion guidelines for cardiovascular disease and diabetes.66

Women in the Workforce
Approximately 51% of workers in the United States are
women, of whom 75% work full-time. Median earnings
of women are gradually increasing; however, on average
their salaries are 80% of a man’s earnings. The number
of working women with college degrees has more than
tripled since 1970, allowing women to enter professional
and management positions.67 The majority of women are
employed in the service and health-care sectors, where
multiple hazards exist, including ergonomic (lifting),
chemical (antineoplastics, anesthetic gases, latex), bio-
logical agent (bloodborne pathogens), and psychosocial
hazards (stress, violence).

As women have entered nontraditional employment,
such as construction, engineering, and forestry, their
vulnerability to injury has increased. PPE is often de-
signed for the average-sized man, so fit of the equipment
often becomes an issue for women workers. In addition,
a woman’s total body strength is generally two-thirds of
a man’s (being lower than a man’s in the upper extrem-
ities and similar to a man’s in the lower extremities),
placing many women workers at risk for musculoskele-
tal injuries. Women workers are often employed in
sedentary jobs with computer and keyboarding respon-
sibilities. Proper ergonomic assessment of a workstation
and encouraging physical activity during the workday
can prevent musculoskeletal and repetitive motion
disorders.68 Social stressors such as sexual harassment
and gender-based discrimination may exist causing
additional problems.

Finally, as with all workers, the work-family interface
must be considered. Women workers, in particular, re-
main the predominant individuals balancing work and
family life. As such, shift work, weekend work, and the
total number of hours worked frequently present chal-
lenges. Women may also need an opportunity to express
breast milk following the birth of a child.

Fair Labor Standard Act (FLSA) Regarding
Workers Who Are Nursing 69

“Section 7 of the FLSA requires employers to provide
reasonable break time for an employee to express breast
milk for her nursing child for 1 year after the child’s birth

each time such employee has need to express the milk.
Employers are also required to provide a place, other
than a bathroom, that is shielded from view and free
from intrusion from coworkers and the public, which
may be used by an employee to express breast milk.”

Members in the Workforce With a Disability
The Americans with Disabilities Act (ADA) of 1990
(amended in 2008) is landmark legislation that prohibits
workplace discrimination of a qualified individual with a
disability.70 The ADA has promoted the hiring of indi-
viduals with disabilities and mandated accommodations
for disabled workers. The ADA defines disability using
three criteria.70 First, there must be a physical or mental
impairment that substantially limits one or more major
life activities of such individual. For example, military
personal returning from war may have one or more am-
putated extremities that prevent them from performing
activities of daily living independently. Second, there
needs to be a record of such impairment. Records can be
obtained from the worker’s personal physician, nurse
practitioner, or from a state agency that certified the dis-
ability. Third, the person needs to be regarded as having
impairment, meaning that the disability would affect the
person’s ability to perform a job without accommodation.

According to the U.S. Bureau of Labor Statistics,
approximately 6.2 million people with disabilities were
employed in 2017.71 These workers represent about
4% of the employed population and are employed
predominately in the service sector and in professional
occupations.

Work eligibility for an individual with a disability is
defined as the ability to perform the essential functions
of the job. These functions must be defined by each
workplace and be on record. After a job offer is made, a
disabled individual may request accommodations from
the employer. Examples include job restructuring, so that
long periods of standing do not occur, or the provision
of a large computer monitor for an individual with visual
impairments. The ADA also provides for workers who
become disabled during the course of employment, after
which the worker may request an accommodation (e.g.,
change in hours worked).

A primary role of the OEHN is to support an individ-
ual with a disability to maintain work and to assist the
worker who has developed an acute or chronic injury or
illness to return to work. Assessing the social, demo-
graphic, occupational, clinical, and psychological factors
unique to the worker will facilitate the maintenance of em-
ployment. For example, an individual with diabetes and
hypertension recovering from a myocardial infarction

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may need an accommodation to participate in a cardiac
rehabilitation program. A worker may require assistance
with lifting and walking duties following a hip replace-
ment, or a worker with a leg thrombosis might be al-
lowed to telecommute 2 to 3 days per week to reduce
commuting time.

Immigrant or Foreign-Born Persons
in the Work Force
In 2017, the U.S. labor force included 27.4 million im-
migrant workers who made up 17.1% of the labor force.72

These workers are predominately men and foreign born
(47.9% Hispanic and 25.2% Asian). In addition, immi-
grant workers earned about 18% less than native-born
workers, and about 21.8% of these workers are not high
school graduates.

Individuals and families migrate for many reasons:
to provide a better life for their family, escape war, seek
political asylum, or to obtain a job as a scientist or
health-care provider. Approximately 22.6% of working
immigrant men work in agricultural, construction, or
maintenance jobs, and 33.1% of working immigrant
women are employed in service sector occupations
(hotel workers, cooks, servers, dry-cleaning workers).
These workers are a vital part of the labor force in the
United States, although there has been a trend toward
returning to Mexico during periods of U.S. economic
decline and violence toward immigrants.73

As members of the U.S. labor force, immigrant
workers often have physically demanding jobs that ex-
pose them to hazards such as pesticides, cleaning
agents, farm animals, infectious diseases, or excessive
heat or cold, which place them in jeopardy of sustaining
poisonings, disease, and physical injuries.74 In general,
immigrants are poorly paid, and many live below the
poverty level. For further investigation of the factors
that influence immigration, see the U.S. Department of
State, U.S. Citizenship and Immigration Services, and
the U.S. Department of Labor websites. Having the
knowledge to assist immigrants with the basic needs of
shelter, food, health care, and employment helps with
major issues related to this worker population.

Minority Members in the Workforce
In general, workers of minority, ethnic, and racial popu-
lations are disproportionally exposed to poor working
conditions, limited health-care access, and reduced ca-
reer opportunities.76 Factors associated with such disad-
vantages include lack of educational and economic
opportunities as well as the unfortunate persistence of
discriminatory practices by some employers. There are
greater proportions of minority workers in some of the
most dangerous industries, such as construction and
agriculture, where there is a heavy reliance on the labor
of recent immigrants. Additionally, there are several his-
torical and current examples of manufacturing settings
that pose greater risks to minority worker populations.
Examples from the past include textile factories in which
cotton dust caused increased rates of byssinosis in work-
ers who were primarily African-American, and uranium
mining, which placed Native American miners at risk for
pulmonary cancer.

Even within a single industry, it is often the minor-
ity workers who hold the dirtiest, highest risk jobs. An
example comes from the hospitality industry, a work
setting that may not immediately come to mind as one
risky to a worker’s health. But if one looks at the
demographic distribution of hotel workers by job title,
minority workers are overrepresented in the lowest
paid jobs with the highest exposures to hazards. The
tasks of a hotel housekeeper include handling trash
and working with cleaning products as well as the
ergonomic stressors of lifting, bending, and working
in awkward postures to change linen and exposure to
marijuana smoke.77 Furthermore, these job activities
must be carried out under working conditions that
impose even more stress—time pressures related to
meeting quotas, questionable social support, and
threatened job security—with little power to advocate
for an improved working environment.77

524 U N I T I I I n Public Health Planning

n CULTURAL CONTEXT
There are special considerations for OEHNs when
working at organizations employing immigrants. First,
safety and health outreach training programs need to
comply with OSHA standards for immigrant workers.
Outreach training programs educate workers on their
rights and responsibilities for helping create a safe

workplace.75 Programs also show workers how to file
complaints. Education and signage in the workplace
need to be provided in the native languages of workers
for whom English is a second language. In addition, any
education and signage should be culturally appropriate.
Assessment of understanding may need to be con-
ducted through the use of interpreters, language phone
lines, written or oral surveys written in the workers’
native languages, and observation of adherence to safe
work practices. Ideally, bilingual coworkers will con-
duct education and on-the-job training.

7711_Ch20_509-536 21/08/19 11:09 AM Page 524

Workers of minority groups also are disproportion-
ately represented among those unable to find employ-
ment. The unemployment rates in the United States vary:
6.5% for African Americans, 4.6% for Hispanics, 3.5%
for whites, and 3.2% for Asians.78 There is a clear need
to promote fair employment practices and safe and
equitable working conditions for all who are eligible to
be part of the workforce.

Roles of the OEHN
Occupational Disease Surveillance
The OEHN has important responsibilities for assessing,
monitoring, and providing surveillance for occupational
diseases. A working knowledge of toxicology, “the study
of harmful effects of substances on humans or animals”,
and the common diseases unique to the specific occupa-
tional health settings are essential.79 Tables 20-1 and 20-2
provide descriptions of common occupational and envi-
ronmental exposures, the organ systems affected, signs
and symptoms, and diseases caused by these agents.
Latent and long-term effects of these exposures and the
organ systems involved are described.

Preventing Injuries and Fatalities
Approximately 3.9 million workers are injured on the
job annually and about 12 to 13 workers die each day as
a result of traumatic injuries they have sustained.80 More
than 2 million of these injuries require a job transfer,
work restriction, or time away from the job. Among all
workers, 2.6 million are treated in emergency depart-
ments annually, and approximately 110,000 of these
workers are hospitalized. Fatalities among workers result
from transportation incidents, contact with objects and
equipment, assaults and violent acts, falls, and exposure
to harmful substances or environments.

Figure 20-1 displays the causes of nonfatal injuries in
the private industry in 2011 and shows that the leading
sectors where injuries occur are manufacturing, health
care, the retail trade, and construction. In Figure 20-2,
fatal work injuries are described by cause, with trans-
portation incidents being the highest source of fatality.

Case Management
Case management is an approach to managing health
care in a cost-effective manner.81 After an employee
is injured or recovering from an acute or chronic

C H A P T E R 2 0 n Health Planning for Occupational and Environmental Health 525

TABLE 20–1 n Examples of Occupational Exposures and Effects

Symptoms and Diseases Agent Potential Exposures

Immediate or Short-Term Effects

Dermatoses (allergic or irritant)

Headache

Acute psychoses

Asthma or dry cough

Pulmonary edema, pneumonitis

Cardiac arrhythmias

Angina

Abdominal pain

Hepatitis (may become a
long-term effect)

Metals (chromium, nickel),
fibrous glass, solvents,
caustic alkali, soaps

Carbon monoxide, solvents

Lead, mercury, carbon
disulfide

Formaldehyde, toluene
diisocyanate, animal dander

Nitrogen oxides, phosgene,
halogen gases, cadmium

Solvents, fluorocarbons

Carbon monoxide, methylene
chloride

Lead

Halogenated hydrocarbons
(e.g., carbon tetrachloride)

Electroplating, metal cleaning, plastics, machining,
leather tanning, housekeeping

Firefighting, automobile exhaust, wood finishing,
dry cleaning

Removing paint from old houses, fungicide, wood
preserving, viscose rayon industry

Textiles, plastics, polyurethane kits, lacquer, animal
handling

Welding, farming, chemical operations, smelting

Metal cleaning, solvent use, refrigerator
maintenance

Car repair, traffic exhaust, foundry, wood finishing

Battery making, enameling, smelting, painting,
welding, ceramics, plumbing

Solvents use, lacquer use, hospital workers

Continued

7711_Ch20_509-536 21/08/19 11:09 AM Page 525

526 U N I T I I I n Public Health Planning

TABLE 20–1 n Examples of Occupational Exposures and Effects—cont’d

Symptoms and Diseases Agent Potential Exposures

Latent or Long-Term Effects

Chronic dyspnea, pulmonary
fibrosis

Chronic bronchitis,
emphysema

Lung cancer

Bladder cancer

Peripheral neuropathy

Behavioral changes

Extrapyramidal syndrome

Aplastic anemia, leukemia

Source: Adapted from the Agency for Toxic Substances and Disease Registry. (2008). Case studies in environmental medicine: Taking an
exposure history. Retrieved from http://www.atsdr.cdc.gov/csem/exphistory/docs/exposure_history

Asbestos, silica, beryllium,
coal, aluminum

Cotton dust, cadmium, coal
dust, organic solvents,
cigarettes

Asbestos, arsenic, nickel,
uranium, coke oven
emissions

β-naphthylamine, benzidine
dyes

Lead, arsenic, hexane, methyl
butyl ketone, acrylamide

Lead, carbon disulfide,
solvents, mercury,
manganese

Carbon disulfide, manganese

Benzene, ionizing radiation

Mining, insulation, pipefitting, sandblasting,
quarrying, metal alloy work, aircraft or electrical
parts

Textile industry, battery production, soldering,
mining, solvent use

Insulation, pipefitting, smelting, coke ovens,
shipyard workers, nickel refining, uranium mining

Dye industry, leather, rubber-workers, chemists

Battery production, plumbing, smelting, painting,
shoemaking, solvent use, insecticides

Battery makers, smelting, viscose rayon industry,
degreasing, manufacture/repair of scientific
instruments, dental amalgam workers

Viscose rayon industry, steel production, battery
production, foundry

Chemists, furniture refinishing, cleaning, degreasing,
radiation workers

TABLE 20–2 n Organ Systems Often Affected by Toxic Exposure

Organ/System Exposure Risks

Respiratory

Skin

Liver

Kidney

Cardiovascular

Reproductive

Hematological

Neuropsychological

Asbestos, radon, cigarette smoke, glues

Dioxin, nickel, arsenic, mercury, cement (chromium), polychlorinated biphenyls (PCBs), glues,
rubber cement

Carbon tetrachloride, methylene chloride, vinyl chloride

Cadmium, lead, mercury, chlorinated hydrocarbon solvents

Carbon monoxide, noise, tobacco smoke, physical stress, carbon disulfide, nitrates, methylene
chloride

Lead, carbon disulfide, methylmercury, ethylene dibromide

Arsenic, benzene, nitrates, radiation

Tetrachloroethylene, mercury, arsenic, toluene, lead, methanol, noise, vinyl chloride

7711_Ch20_509-536 21/08/19 11:09 AM Page 526

disease, some OEHNs will assume a case management role
in assessing the worker’s disability and rehabilitation needs
to promote a return to work or will coordinate with a case
management vendor. The case manager assists with the
transition from hospital to home and works with the

employee, family members, and rehabilitation specialists
(if applicable) in the coordination of the employee’s
successful return to work. Additional case management
services include arranging transport, providing health ed-
ucation, ordering durable medical equipment, and making
referrals and recommendations for care. The care manager
also works with employers to arrange for modified duty if
approved by treating provider for work restrictions.

Workers’ Compensation
Workers’ compensation provides income benefits, med-
ical payments, and rehabilitation payments to workers
injured on the job, as well as benefits to surviving families
of fatally injured workers. Workers’ compensation laws
are considered to be no-fault laws. Because these laws en-
sure employees who suffer injuries or fatalities as a result
of work are provided fixed monetary awards, they elim-
inate the ability for employees to sue employers for pain
and suffering, even if the employer was negligent.82

However, not all injuries may be identified in workers’
compensation laws and some may require filing suit
to determine reasonable compensation. Each state work-
ers’ compensation law regulates the amount and dura-
tion of compensation for workers injured or who die. In
general, most state workers’ compensation laws cover
medical expenses related to a disability and the cost of
job retraining following an injury. A disabled worker re-
ceives two-thirds of the normal monthly salary during
the disability and may receive more salary for permanent
physical injuries, or if the worker has dependents.83 The
act provides compensation for survivors of employees
who die. Although workers’ compensation laws are

C H A P T E R 2 0 n Health Planning for Occupational and Environmental Health 527

Health care and social assistance

Manufacturing

Retail trade

Transportation and warehousing

Leisure and hospitality

Construction

Professional and business services

Wholesale trade

Financial activities

Other services

Agriculture, forestry, fishing, and hunting

Information

Educational services

Mining

Utilities

0 20 40 60 80 100 120 140 160 180

Violence and
other injuries by

persons or
animals, 16.9%

Transportation
incidents, 41.3%

Falls, slips, trips,
14.5%

Exposure to
harmful substances

or environments, 8.9%

Fires and
explosions, 3.1%

Contact with
objects and

equipment, 15.1%

Figure 20-1 Number of nonfatal
occupational injuries and illnesses
involving days away from work in
the private industry (in thousands).
(Data from the Bureau of Labor Statistics, U.S.
Department of Labor. [2012, November 8].
News release: Nonfatal occupational
injuries and illnesses requiring days away
from work, 2011. Retrieved from http://
www.bls.gov/news.release/archives/osh2_
11082012 )

Figure 20-2 Fatal occupational injuries by industry and
event or exposure, all U.S., 2011 (total 4,693). (Data from
Bureau of Labor Statistics, U.S. Department of Labor. [2013,
April 25]. Fatal occupational injuries by industry and event or
exposure, all U.S., 2011. Retrieved from http://www.bls.gov/
iif/oshwc/cfoi/cftb0259 )

7711_Ch20_509-536 21/08/19 11:09 AM Page 527

complex, OEHN case managers frequently assist injured
workers and families in negotiating the laws.

Workplace Health Promotion
Health promotion programs in the workplace are de-
signed to identify and prevent both occupational and
nonoccupational disease and injury, and to educate
workers about behaviors that influence health and well-
ness. The goals of health promotion are designed to:

• Reduce absenteeism
• Increase productivity
• Sustain or increase the level of well-being, self-

actualization, and personal fulfillment of a given
worker or worker group

The OEHN plays an important role in initiating, con-
ducting, and evaluating health promotion programs.
Both employees and employers derive benefits from
participation in and initiation of a health promotion
program, including:

• Reduction in health-care costs and improved injury
care

• Increased productivity
• Reduced absenteeism and presenteeism
• Improved sense of well-being among workers
• Improved impression of management as proactive

and invested in workers84

The number of health promotion programs being
developed by corporations and industries has grown
considerably. This increase is believed to be associated
with the rising cost of health benefits and services that
employer-based health-care programs have experienced
over the past decade. Many of these programs are
designed to manage noncommunicable health condi-
tions that workers may bring to the workplace. It also is
important to educate employers that the top reasons
leading to mortality (cardiovascular, cancers, cerebrovas-
cular, chronic respiratory, and unintentional injuries) are
preventable and responsive to behavior change.85,86

The workplace provides a stable and captive audience
(workers) for health promotion programs. In addition,
the workplace can serve as a source of coworker and
supervisor social support for positive behavior change.87

The CDC’s report The National Healthy Worksite Pro-
gram strongly asserts that reducing morbidity associated
with behavioral and biological risk factors is a public
health priority for the country.88 The majority of studies
completed to date show positive health and financial
impacts of worksite health promotion programs over the
past 3 decades.89-91

528 U N I T I I I n Public Health Planning

n EVIDENCE-BASED PRACTICE
Assaults by Patients/Visitors Against
Health-Care Workers

Registered nurses and other health-care workers are
at increased risk for being assaulted while performing
their work.1 These exposures to physical violence
impact the physical and mental health of workers as
well as their ability to practice safely.
Practice Statement: Health-care workers need to
be proactive with their efforts to prevent assaults.
Targeted Outcome: Prevent and mitigate acts of
workplace violence (i.e., assaults) as they occur without
experiencing personal physical or emotional injuries.
Supporting Evidence: Health-care workers experience
approximately half of all occupational assaults.1 Factors
associated with this workplace violence include providing
care to persons with a history of violence against others
or under the influence of drugs or alcohol, working alone
or understaffed, working in settings with inadequate
security or prolonged wait times, and believing that
violence is part of the job. The primary prevention of
assaults can be attempted through de-escalation; how-
ever, efforts are not always successful. When assaults
do occur, health-care workers have reported somatic
complaints, posttraumatic stress symptoms, and
decreased work productivity.2,3

Recommended Approaches: The OEHN needs to
design, modify, implement, and evaluate a workplace
violence prevention program. Key components of the
program need to include management commitment
and employee participation, worksite analysis, hazard
prevention and control, safety and health training, and
recordkeeping and program evaluation. Specific strate-
gies within these components will vary by work setting.
For example, management commitment and employee
participation in the home health-care setting could be
operationalized through a workplace violence safety
committee. The manager would convene the initial
committee and turn over responsibilities to the com-
mittee members while providing sufficient resources
based upon members’ requests. Membership on the
committee can include nurses, physicians, chaplains,
social workers, patient care assistants, physical thera-
pists, patients, and other key stakeholders responsible
for the delivery of home health care.

References:
1. Occupational Safety and Health Administration, U.S.

Department of Labor. (2016). Guidelines for preventing
workplace violence for healthcare and social service workers

7711_Ch20_509-536 21/08/19 11:09 AM Page 528

A health risk appraisal (HRA) is frequently the initial
component of many successful health promotion pro-
grams in the workplace. HRAs are questionnaires com-
pleted by employees to assess personal health habits and
behavioral risk factors, such as smoking, alcohol, or seat
belt use. An individual’s actual age is compared with an
estimate of their risk age, an overall measure of risk for
morbidity and mortality as identified by epidemiological
research. An example of an individual with a decreased
risk age is one who maintains a healthy body mass index,
exercises regularly, does not smoke tobacco products,
drinks moderately, and complies with an age-appropriate
screening schedule as defined by a health-care provider.
A worker with an increased risk age may not exercise,
is overweight, drives without a seat belt, and does not
have a health provider. If a worker is identified with a
high-risk age, and he or she incorporates healthy lifestyle
behavior changes, such as physical exercise or weight
reduction, a reduced risk age could be achieved. It is
essential that the HRA results be communicated to em-
ployees by the OEHN. The worker with the reduced risk
age should be commended and encouraged to maintain
a healthy lifestyle. The worker at increased risk will need
a health assessment, education, and counseling to assist
with behavior change, if desired.92 Effective workplace
health promotion programs require a strong leadership
and management team committed to initiating an effec-
tive, evidence-based educational program focused on an
individual or worker group. Resources to run an effective
program, educators, incentives, and equipment also are
essential. Finally, outcome evaluations of the efficacy of
the program must be conducted.92

Because the occupational health provider is working
with adult learners, several important concepts should
be considered:93,94

• Respect during the learning experience should be
demonstrated to workers.

• Provide opportunities for workers to be actively
engaged in their learning.

• Incorporate workers’ previous experiences into the
context of the health promotion activities.

• Apply the learning to the self-identified needs of the
workers.

• Be present during learning encounters through
active listening and change talk.

• Provide programming in a setting that accommo-
dates the schedule of the worker and eliminates
distractions.

• Repeat important content to facilitate learning.
• Present information from the simple to the complex,

and pace the content appropriately with examples.

C H A P T E R 2 0 n Health Planning for Occupational and Environmental Health 529

(OSHA Publication No. 3148-06R). Washington, DC:
Author.

2. Gillespie, G.L., Bresler, S., Gates, D.M., & Succop, P.
(2013). Posttraumatic stress symptomatology in
emergency department workers following workplace
aggression. Workplace Health & Safety, 61(6),
247-254.

3. Gillespie, G.L., Gates, D.M., Kowalenko, T., Bresler, S.,
& Succop, P. (2014). Implementation of a comprehensive
intervention to reduce physical assaults and threats in the
emergency department. Journal of Emergency Nursing,
40(6), 586-591.

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Ethical Dilemma
Public Health Science Topics Covered:

• Health service systems

Jorge is a 45-year-old man with a history of diabetes,
cardiovascular disease, and obesity. He was recently
hospitalized for a myocardial infarction. During his
return-to-work assessment, the occupation physician
instructed Jorge to begin light exercise daily and start
a low-fat, low salt, 2,000 calorie per day diet. Jorge
comes to the OEHN clinic for guidance on exercise
and diet. The OEHN negotiates with the plant manager
to allow Jorge to return from his lunch period 20 min-
utes late each day so he can walk on the trail next to
the plant. Jorge also is permitted to be “on the clock”
during his walks. Several times during the past week,
the OEHN sees Jorge sitting on a bench playing games
on his telephone and not walking.

• What is the ethical dilemma posed in this case study?
• What options does the OEHN have to resolve this

dilemma?
• What is the best option? Provide a rationale for this

option.

OEHNs have a responsibility to their employers to
manage employees’ illnesses and injuries while reducing
overall health-care expenditures. Once the OEHN be-
comes aware that Jorge is not using the time away from
the plant as agreed to by Jorge and the plant manager,
the OEHN has a responsibility to notify the plant man-
ager. Prior to notifying the plant manager, the OEHN
reviews the American Association of Occupational Health
Nurses’ Code of Ethics and Interpretive Statements. The
code has six principles: (1) right of self-determination,

7711_Ch20_509-536 21/08/19 11:09 AM Page 529

Emergency Preparedness and Disaster
Management
Frequently, a business will ask its OEHN to prepare an
emergency response plan to respond to human-created
and natural disasters. In large corporations, a committee
that includes the OEHN as well as management, human
resources, safety officers, security, and other support
services staff usually does this planning. Whether the
OEHN works at a large company or small business,
emergency preparedness or “all hazards” preparedness
is a continuous and coordinated process that must be
constantly evaluated and redefined as needed to ensure
the safety of the workforce in case of a disaster.98

Knowledge of the five components of disaster pre-
paredness is an essential element for planning a disaster
response. Four of the five components include (1) pre-
paredness (occurs pre-impact and is a proactive process
for putting in place the structure needed for a disaster
response); (2) mitigation (primarily occurs during the

530 U N I T I I I n Public Health Planning

(2) confidentiality, (3) truth-telling, (4) doing or produc-
ing good, (5) avoiding harm, and (6) fair and nondiscrimi-
natory treatment.11 The OEHN realizes there is an
ethical dilemma resulting from being aware that Jorge
is not taking the walks. The dilemma results from the
employer’s right to cancel the walk periods if they are
not being used appropriately and Jorge’s rights to self-
determination and confidentiality.

The OEHN considers several options in this case.
First, the OEHN could notify the employer that Jorge
is not taking the walks. This option violates Jorge’s
confidentiality. Second, the OEHN could follow Jorge
to the walking trail daily and instruct him that he needs
to take the walk. This option violates Jorge’s right of
self-determination. Third, the OEHN could meet with
Jorge in the clinic and discuss the current treatment
and options. The third option is chosen by the OEHN.
During the discussion, the OEHN asks Jorge about his
adherence and barriers to walking each day while at
work. The OEHN openly shares the rationale for the
conversation: They are talking precisely because the
OEHN saw him sitting on a bench and not walking.
Speaking privately with Jorge also provides for his
confidentiality. A new treatment plan is devised that
allows for Jorge’s right of self-determination. Jorge
reports it is too hot for him in the afternoon to walk.
He has agreed to arrive to work early and take his
walk before his shift starts. The OEHN will follow up
with him in 2 weeks to evaluate his progress.

consider that the flavoring in their microwave popcorn
has made some workers very sick. In 2000, the
Missouri Department of Health and Senior Services
received a report about eight cases of lung disease in
workers who had formerly all worked in the same
microwave popcorn factory between 1992 and 2000.
Four of these workers were on waiting lists for lung
transplants.95 After a Health Hazard Investigation by
NIOSH, it was determined that the fixed obstructive
lung disease, or bronchiolitis obliterans (BO), was
caused by exposure to the food flavoring diacetyl.

Diacetyl is a water-soluble di-ketone found naturally
in butter, coffee, wine, and beer. The chemical diacetyl
has butter-flavored characteristics and is used in can-
dies, pastries, and frozen foods. The problem occurs in
the manufacturing of the microwave popcorn, because
diacetyl easily vaporizes when heated. The workers
with the highest rates of BO were the mixers and
microwave-packaging workers. The mixers worked
around large mixing tanks where visible dust, aerosols,
and vapors were produced. The microwave packers
worked within 5 to 30 meters from the mixing tanks.
On inspection, NIOSH required both groups of
workers to use respirators leading to improvements
in their lung function.95,96 In December 2003, a NIOSH
alert was sent to more than 4,000 businesses that
use food flavorings in their manufacturing processes,
advising employers to reduce vapors in the mixing
room and warn workers of the hazard.97

Emerging Issues in Occupational Health
Emerging issues in occupational health highlight the
need for the OEHN to remain current and knowledge-
able about the ever-changing trends in the field. OEHNs
can remain up to date on emergency issues by joining
professional societies, belonging to occupational-focused
online mailing lists, and attending professional confer-
ences dedicated to emerging issues in occupational
health. Following the next case study, two significant
issues for the future are discussed.

l APPLYING PUBLIC HEALTH SCIENCE
The Case of Popcorn Lung
Public Health Science Topics Covered:

• Epidemiology and biostatistics

Many people like eating microwave popcorn when
watching movies at home. Most people would never

7711_Ch20_509-536 21/08/19 11:09 AM Page 530

pre-impact phase as a means to limit adverse effects of
the disaster; (3) response (activation of the various pro-
cedures planned prior to the event); and (4) recovery
(stabilizing the community through both reconstruction
and rehabilitation) (Chapter 22).99 The following ques-
tions serve to provide basic assessment information:

• How will the OEHN communicate with onsite and
offsite employees?

• Are there employees with disabilities, and what are
their needs in an emergency situation?

• What types of emergency supplies are needed and for
what period of time?

• If everyone must leave the site, how will the OEHN
evacuate the area?

• If it is necessary for everyone to shelter in place, what
supplies are needed to accommodate everyone?

• Are fire plans up to date?
• Is the OEHN prepared for all types of medical

emergencies?
• Has the OEHN coordinated plans with other

businesses and residents in the area?

The fifth component is evaluation. At the conclusion
of a disaster event, it is critical to conduct a formal eval-
uation to identify areas for further improvement and
preparedness prior to another disaster.

An OEHN should review and evaluate an emergency
preparedness plan at least once every year and ensure
employees’ families have a plan for their home. The
OEHN also will consult and coordinate with local emer-
gency medical services that will assume the role of
incident command upon their arrival. It is often neces-
sary for employees to remain at the worksite as a result
of an emergency, and fear for the location of and safety
of family members is often of concern. Another impor-
tant component of the disaster is the psychological effect
that each employee may experience, and awareness that
symptoms of acute anxiety and posttraumatic stress
may be outcomes for workers providing disaster care to
victims. The U.S. Federal Emergency Management
Association offers a comprehensive guide for businesses
that want to develop a preparedness plan.100 An addi-
tional resource for the OEHN is Al Thobaity et al.’s
review of common domains of the core competencies of
disaster nursing.101

“Green” Jobs
The term “green jobs” represents the effort to create
employment in the field of renewable and efficient en-
ergy production. The topic of green jobs has evolved
from two important issues facing the United States in

the 21st century: (1) the need to rebuild the economy
after the worst economic crisis since the Great Depres-
sion and (2) the need to develop strategies that will
respond to the threat of global climate change. Green
jobs are designed to preserve or enhance environmental
quality and build a clean energy environment, but green
jobs are not always new jobs. The goal of this movement
is to build a clean energy environment by several meth-
ods: (1) to invest in sources of renewable energy, such
as wind turbines and solar power generation, and (2) to
increase energy efficiency by investments in mass tran-
sit and modern infrastructure. Because many of the
concepts previously described must be done locally
by local workers, another important goal of the clean
energy economy is to prevent jobs from moving out of
the United States. The most important goal of the clean
energy economy is sustainability through social, envi-
ronmental, and economic strategies ultimately leading
to job creation, economic growth, the growth of new
industries, and innovation that will end the dependence
of the United States on polluting and costly fossil fuels,
as well as creating strategies for solving global climate
change.102 Many of the occupational risks associated
with green jobs may not be known for years, indicating
the need for the OEHN to be vigilant in risk assess-
ments of the worker population and remaining current
with notices on new risk patterns.

C H A P T E R 2 0 n Health Planning for Occupational and Environmental Health 531

n CELLULAR TO GLOBAL
Silica is a naturally occurring substance and by-product
that becomes aerosolized when working with stone,
rock, concrete, and bricks. The silica becomes
aerosolized and finer than grains of sand when people
perform activities such as sanding concrete, cutting
granite for kitchen counters, manufacturing brick, and
making ceramic products. Workers in certain industries,
particularly construction and hydraulic fracturing, have
greater exposure to respirable crystalline silica. At the
cellular level, this exposure can lead to chronic obstruc-
tive pulmonary disease, lung cancer, and kidney disease.
To prevent exposure and reduce the prevalence of
silica-related disease, companies can provide workers
with saws equipped with a system that continuously feeds
water to the blade; companies can also reduce the
number of hours employees work directly with silica-
based products. These modifications will help reduce
aerosolized dust exposure, thus reducing respirable crys-
talline silica. On a national level, OSHA established new
regulations governing exposure limits to silica in con-
struction and general industry. The regulations, phased

7711_Ch20_509-536 21/08/19 11:09 AM Page 531

n Summary Points
• Occupational health is focused on the maintenance

and promotion of workers’ health, improving work-
ing environments, and developing work organiza-
tions and cultures to support health and safety.

• Occupational and environmental health nursing is a
specialty nursing practice focused on health and
safety programs and services to workers.

• Two federal agencies that have had an impact on
worker health are the National Institute for Occupa-
tional Safety and Health (NIOSH) and Occupational
Safety and Health Administration (OSHA).

• The OEHN has a responsibility for promoting health
within the workplace by conducting workplace as-
sessments and occupational and environmental
health histories.

• Preventing injuries and hazards is dependent on
knowledge of exposures, vulnerable worker popula-
tions, and using a hierarchy of controls.

• Toxicology is the study of adverse effects of chemical,
physical, or biological agents on living organisms
and the ecosystem.

• The roles of the OEHN include disease surveillance,
preventing fatalities and injuries, case management,
and health promotion within the workplace.

• Emerging issues in occupational health include
emergency preparedness and disaster management
and the creation of green jobs.

532 U N I T I I I n Public Health Planning

in during 2017 and 2018, are now in full effect. During
OSHA visits, inspectors will monitor for compliance
to the standard to assure workers are adequately
protected from silica exposures. At the global level,
the International Labour Organization/World Health
Organization created the Global Programme for the
Elimination of Silicosis for use by developed and devel-
oping nations. The program provides outlines for host
countries to establish a national silicosis program, action
plan to implement the program, and guidelines for
epidemiological data and programmatic changes for
the national silicosis program.

t CASE STUDY
The Case of Tidy Cleaners

Learning Outcomes:
• Discuss ways to conduct an employee health assess-

ment of the workplace environment.

• Identify potential physical and chemical hazards in the
workplace.

• Identify potential peer assistance issues.
• Apply components of health planning, assessment,

and program development to the occupational health
setting.

As a member of an interprofessional occupational
health team, an OEHN, Nancy, was asked to assess the
employees working for a well-respected dry-cleaning
business in a large metropolitan area. Initially, Nancy
consulted with the manager to obtain the list of chemi-
cals used in the dry-cleaning process and to ascertain
the demographics of the employees. During a workday,
Nancy then conducted a walkthrough of the site. There
were 22 workers who have worked for Tidy Cleaners
for an average of 15 years and ranged in age from 18 to
54 years; the workers were predominantly female. The
women frequently sort garments, remove stains, and
repair and press clothing after the dry-cleaning process.
The males were responsible for the operation (loading
and emptying machines) and repair of the dry-cleaning
equipment. One to two employees were available to
assist customers when they dropped off or picked up
their cleaning and to manage the cash registers. The
workforce was composed of both Hispanics, many of
whom spoke Spanish only, and whites. The hours of
operation were from 9 a.m. to 8 p.m., 6 days a week,
and employees worked rotating shifts. Ladders were
used to transfer cleaned clothing from overhead elec-
tric racks when being claimed by customers. The build-
ings were windowless, except for the entrance, and a
series of powerful stationary fans supplemented an old
ventilation system.

The manager of the dry-cleaning business reported
the most effective dry-cleaning solvent used in his
business was perchloroethylene (“perc”), along with
carbon tetrachloride.103 As a conscientious business
owner, the manager stated he would like Nancy to do
an occupational assessment of the plant and to assess
the workers for occupational exposures and risks.
He stressed that prior to conducting an assessment,
consent from each employee must be obtained in
writing, and the data remain confidential. Nancy also
was requested to make recommendations to improve
the health and safety in the plant.

• Describe the roles of the following persons who would
consult with the OEHN for worker safety: industrial
hygienists, safety manager, occupational safety and
health engineers, and occupational medicine.

7711_Ch20_509-536 21/08/19 11:09 AM Page 532

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• Identify:
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chemical, and psychosocial) present in the plant.
• Potential mechanisms of exposure (inhalation,

ingestion, dermal) in the plant.
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further evaluated by an occupational/environmental
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workers.
• Persons Nancy could consult with concerning

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• Alterations in the work environment and work
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537

Chapter 21

Health Planning, Public Health Policy, and Finance
Christine Vandenhouten and Derryl Block

537

LEARNING OUTCOMES

After reading the chapter, the student will be able to:

KEY TERMS

1. Discuss the role of policy in optimizing health for
populations.

2. Describe the role of policy in the delivery of health care
in the United States.

3. Apply public health principles to public health policy
planning.

4. Identify ethical issues related to public health policy.
5. Examine the role of nurses in public health policy.
6. Describe U.S. governmental policies related to the

financing of health care.

Advocacy
Affordable Care Act (ACA)
Children’s Health

Insurance Program
(CHIP)

Culturally acceptable
health policies

Economics
Effectiveness

Efficiency
Equity
Grants
Health economics
Market economy
Medicaid
Medicare
Policy
Public health economics

Public health finance
Public health policy
Social Security Disability

Insurance (SSDI)
Supplemental Nutrition

Assistance Program
(SNAP)

Supplemental Security
Income (SSI)

Temporary Assistance for
Needy Families
(TANF)

Woman, Infants, and
Children (WIC)

n Introduction
“Health policy refers to decisions, plans, and actions that
are undertaken to achieve specific health care goals within
a society. An explicit health policy can achieve several
things: it defines a vision for the future, which in turn
helps to establish targets and points of reference for the
short and medium term. It outlines priorities and the ex-
pected roles of different groups; and it builds consensus
and informs people.”1 Public health policy refers to poli-
cies specifically intended to direct or influence actions,
behaviors, or decisions that influence the health of popu-
lations. Stakeholder groups including lobbyists, grant fun-
ders, and nongovernmental organizations all influence
public health policy.

For public health nurses, health policy is an explicit
part of professional life. As noted in Chapter 1, nurses
are responsible for advocating for, identifying, interpret-
ing, and implementing public health laws, regulations,

and policies.2 Public health policy activities by nurses in-
clude actively engaging in strategies to change or enact
policies that improve the health of populations, especially
populations experiencing disparity. Public health policy
activities also include educating the public on relevant
laws, regulations, and policies. A nurse working in a col-
lege health clinic is required to report a case of mumps
to the local public health department and can help mon-
itor for additional cases to help determine whether there
has been an outbreak (see Chapter 8). Knowledge of pub-
lic health policy is necessary for the nurse to facilitate iso-
lation of affected students, to educate them (and their
families, if given permission to communicate with them),
and to collaborate with the public health department’s
outbreak investigation aimed at reducing the spread of
the disease.

Nurses are affected by state-level nurse practice acts
that determine the scope of practice for registered nurses
(RNs) and Advanced Practice Registered Nurses

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(APRNs). These policies come under the umbrella of
public health policy because they are designed to protect
the recipients of nursing care. Nurses who provide direct
care to patients are affected in their day-to-day life by
public health policies designed to protect both them and
the patients they care for. These policies include man-
dated and recommended vaccines that nurses and other
health-care workers should receive,3 the use of personal
protective equipment, and procedures for handling and
disposing of sharps such as hypodermic needles or blades.

Public health policy includes local and county policies
mandating recycling of certain materials and special re-
cycling procedures for hazardous materials and medica-
tions that hold special pollution risks in an effort to
reduce environmental health risks. Other examples of
public health policies include the fluoridation of water to
prevent dental caries, school nutrition policies, regula-
tions related to the distribution of pharmaceuticals dur-
ing an emergency, and sales of tobacco and e-cigarettes
to minors. Public health policies may involve mandating
single interventions or comprehensive programs. For ex-
ample, a school district might set a policy that all seventh
graders attend a specific educational session about at-risk
drug use. A comprehensive policy may include mandat-
ing educational sessions for various grades, mandatory
drug testing for student athletes, community-based pro-
grams for parents, and the presence of school resource
police officers in the school.

We are all affected by certain governmental policies,
such as taxes that fund government including the federal
income tax, payroll taxes, and state and local taxes. Al-
though taxes are not regularly thought of as public health
policy, the policy of exempting employer-sponsored health
benefits from income and payroll taxes has influenced
employers to offer health benefits in lieu of increased
salaries. Since the 2010 health care reform law, to im-
prove access to health care, large employers were re-
quired to provide health-care coverage. From a public
health perspective, a broad range of policies are instituted
to directly or indirectly protect or promote the health of
populations through the passing of laws and the setting
of regulations based on the greatest good for the greatest
number of people.

Public Health Policy and the U.S.
Health-Care System
Public health policies directly affect our health-care sys-
tem and its underlying philosophies. The U.S. health-care
system is a complex combination of privately funded and

provided, publicly funded and provided, and publicly
funded and privately provided services. Why is our
health-care system so complex? In part, it is complex be-
cause of the economic culture within the United States
that supports an open market for the exchange of
goods/services and payments, including health-care serv-
ices. When the government attempts to intervene in the
market system to promote quality, supply, and equity/
fairness, a tension is created between those principles
and allowing or even facilitating an open market sys-
tem. This tension has been evident in ongoing debates
in the United States over health-care reform despite
the fact that all other developed countries offer univer-
sal health coverage. According to the World Health
Organization, universal health coverage occurs when
all individuals and communities receive essential
health services, including health promotion, treatment,
rehabilitation, and palliative care without financial
hardship.4

In a market economy, the prices of goods and serv-
ices are set by supply and demand. A well-functioning
market economy is one in which there are many buy-
ers, many sellers, and complete information about the
goods and services being exchanged. In many ways, the
U.S. health-care market does not meet the criteria of a
free market. Buyers often do not have complete infor-
mation about goods and services. For instance, after an
auto crash, injured persons or their families do not
have time to evaluate the quality and cost of ambulance
and emergency room services in the area. In addition,
because health-care decisions, such as whether to un-
dergo a screening exam or what kind of cancer treat-
ment to initiate, are often based on interpretation of
technical information, individuals rely on advice given
by health-care providers, the media, and significant
others. In some areas, there are few “sellers” of specific
services. For example, almost 9 out of 10 counties
in the United States did not have an abortion provider
in 2014,5 and more than half of rural counties had no
hospital-based obstetric services during the period
2004-2014.6

Whereas government intervenes in the market
economy to ensure quality, supply, and equity/fairness,
the U.S. governmental role in the health-care market
has been restrained because of cultural factors that
emphasize individual rights and a relatively unfettered
market system. Early government intervention in-
cluded conducting research into the adulteration
and misbranding of food and drugs, providing health
care to the merchant marines, and developing and
enforcing quarantine laws.

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The idea of health insurance took root in the 1930s in
the private market whereby individuals could take out an
insurance policy to defray the cost of health care if they
became ill or suffered an accident.7 Today, employer-
based health insurance is the norm. Internal Revenue
Service (IRS) rulings (i.e., policies) since the 1940s allowed
for health insurance expenses to be tax favored, thus
encouraging businesses to offer it and individuals to seek
it out.8 An employer-based model was retained in the
Affordable Care Act (ACA).

In the 1960s, federal health insurance programs and
related policies became the norm with the development
of Medicare to aid older adults and Medicaid to aid the
poor and disabled. These two groups were generally not
covered by employer-based health care. Despite the ex-
istence of these large programs, and with limited move-
ment toward health reform, in 2014, the United States
mandated that individuals have health insurance. Since
then, however, exemptions to the comprehensiveness of
health insurance to fulfill the mandate have been passed,
and the penalty for not having health insurance has been
eliminated.

Health expenditures in the United States are far above
those of other industrialized countries, and health out-
come performance lags behind those countries in many
areas.9 For example, in 2016 the United States ranked
12th in the world for the prevalence of adult obesity rates
with 36% of adults having a Body Mass Index (BMI)
greater to or equal to 30.0.10 Despite the high expenditure
on health care, in 2017 the United States ranked 43rd in
life expectancy.11

Within the United States, there are great disparities
in quality indicators such as access to care and immu-
nizations.12 According to Healthy People, “If a health
outcome is seen to a greater or lesser extent between
populations, there is disparity.”13 Health disparities
are linked to social determinants of health such as
living conditions and socioeconomic status (income,
education, and occupation). The ACA was an attempt
to decrease disparities by assuring individual insurance
coverage. In 2010, prior to the ACA, 82% of persons
under 65 years had medical insurance compared with
89% in 2015.

Health disparities are also linked to demographic vari-
ables such as race, ethnicity, and age.13 Take colorectal
screening as an example. Although initiation of the ACA
resulted in increased colorectal cancer screening rates in
adults aged 50-75, from 52% in 2008 to 62% in 2015, dis-
parities among ethnic and racial groups continue.14 In
2015, 49% of American Indian/Alaska Native and His-
panic adults aged 50-75 were screened compared with

C H A P T E R 2 1 n Health Planning, Public Health Policy, and Finance 539

53% of Asian adults; 61% of Black, non-Hispanic adults;
and 65% of White, non-Hispanic adults. There were also
disparities in colorectal screening rates based on educa-
tion and income.14

In 2015, disparities in insurance coverage among U.S.
ethnic and racial groups persisted. Only 80% of Hispanic
people of any race, 88% of Blacks, 91% of Asians, and
92% of White, non-Hispanic had insurance.15

Likewise, there are disparities in morbidity and mor-
tality rates among people of different racial and ethnic
groups. In 2015, African Americans were more likely to
die from heart disease, stroke, cancer, asthma, HIV/AIDS,
homicide, and influenza and pneumonia than non-
Hispanic whites.16,17 An important intervention to de-
crease mortality from influenza is the flu vaccine, often
provided free or at a reduced cost through local public
health departments. African Americans aged 65 and older
were less likely (61%) to have received a flu shot in the last
12 months than their non-Hispanic white counterparts
(73%).18 Infant mortality rates show dramatic disparities
related to maternal race and ethnicity. In 2014, the infant
mortality rate among Black or African Americans was
10.7 deaths/1,000 live births, compared with 7.6 among
American Indian or Alaska Natives, 5.0 among Hispanic
or Latina Americans, and 4.9 among non-Hispanic
whites.19

Although some might suggest that race and ethnic-
ity are the primary reasons for the dramatic disparities
in health indicators, current research suggests that
socioeconomic status plays a more significant role.20–22

The relationship between health and socioeconomic
status is complicated. Individuals living at or below
the federal poverty level may qualify for public insur-
ance programs, but they also frequently lack other
resources, such as transportation or flexible working
hours, making access to health-care services challeng-
ing. Lack of resources, whether financial, educational
(literacy), or health care related, and even social mar-
ginalization can result in chronic stress. Additionally,
exposure to chronic stress is linked to a higher inci-
dence of certain illnesses such as cancer, heart disease,
and other chronic diseases. This, combined with an ab-
sence of insurance and reduced access to quality health
care, results in increasing mortality among minority
groups and all individuals living in poverty.23

National Health Policy
There are many laws and regulations that guide health
policy at the national level. Article 1, Section 8, of the
U.S. Constitution provides the federal government with
certain authority, including providing for the general

7711_Ch21_537-568 21/08/19 11:09 AM Page 539

welfare and regulating commerce among the states. This
section has been interpreted as the basis for a variety of
powers and activities including federal involvement in
health care.

In the United States, most health-care goods and serv-
ices are exchanged in the private market with individuals
choosing their care provider and directly or indirectly
paying for services. Often, the type of indirect payment
(e.g., particular health insurance policies that pay for
medical or health-related expenses) affect individual
choices regarding care. For instance, the contractual
agreement between an individual or group and a health
insurer may not cover particular screenings such as den-
tal checkups. The extent of coverage of a specific insur-
ance policy is in itself a policy that affects health-care
choices. Individual health insurance is regulated prima-
rily at the state level, and most states have a specialized
office for insurance matters which is led by a state insur-
ance commissioner.

Although some states use model acts and model reg-
ulations as guides, policies that govern private health in-
surance vary significantly from state to state. For
instance, inclusion of mental health services in private
insurance policies varies greatly. Some states prohibit
insurers from discriminating in coverage for mental
health and other health problems, some states require a
minimum level of coverage of mental health expenses,
and some do not require insurance companies to cover
mental health services at all.24

In addition to the publicly funded programs that
cover older adults and the poor through Medicare and
Medicaid, respectively, the U.S. government both pro-
vides and pays for care for certain specific populations.
The federal government is deemed to have responsibil-
ity for providing and paying for services for soldiers,
veterans, prisoners in federal facilities, and American
Indians/Native Americans.

Social Security, Medicare, and Medicaid
Social Security, a composite of social welfare and
social insurance programs, was first signed into law in
1935 as part of a plan to alleviate poverty and end the
Great Depression.25 Social security benefits, benefici-
aries, payroll taxes, and wage caps have undergone
a series of modifications since that time and now
cover the following: Federal Old-Age (Retirement),
Survivors, and Disability Insurance; Temporary Assis-
tance for Needy Families; Health Insurance for Aged
and Disabled (Medicare); Grants to States for Medical
Assistance Programs for Low Income Citizens (Medicaid);

State Children’s Health Insurance Program for
Low Income Citizens (SCHIP); and Supplemental
Security Income. Payroll taxes, split between the
employer and the employee, are funneled by the In-
ternal Revenue Service into the Federal Old-Age and
Survivors Insurance Trust Fund and the Federal
Disability Insurance Trust Fund to fully or partially
pay for these programs.

Since 1965, Medicare has provided payment for hos-
pital care; long-term care; and pharmaceutical, physi-
cian, and other services to individuals 65 and older,
and specified groups of people with disabilities under
65 including individuals with end-stage renal disease.
Medicare is not a care delivery system, but rather a so-
cial insurance system administered by the Centers for
Medicare & Medicaid Services (CMS), a federal gov-
ernmental agency within the U.S. Department of
Health and Human Services. Concerns about financial
viability of Medicare have led to discussions about
funding, eligibility, and fraud reduction.26

Medicaid, another national health program admin-
istered by the CMS, provides financial assistance
to states and counties for low-income families with
dependent children, low-income older adults, and
disabled individuals. Unlike Medicare, a strictly federal
program, Medicaid is jointly financed by matching
funds from federal and state governments. Medicaid
is described in more detail in the State Health Policy
section.

Healthy People
At the national level, Healthy People is a prevention
policy agenda to guide interventions for the improve-
ment of health outcomes in areas such as infant mor-
tality, years of healthy life, and racial and ethnic health
disparities.27 Federal, state, and local health officials to-
gether with health-care providers and consumers de-
veloped national health goals and objectives for the
United States. Since 1979, goals and objectives have
been reevaluated about every 10 years.27 Healthy People
includes targets that are examples of federal health
policy. Healthy People also includes specific goals and
objectives for policy changes (see Chapter 1). It is an
example of setting policy agendas at the national level
using a consensus-building approach. That is, the
agenda was built based on the input from numerous
stakeholders. The Healthy People 2030 framework
builds on lessons learned in previous Healthy People
iterations and emphasizes reducing preventable deaths
and injuries.28

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Patient Protection and Affordable
Care Act of 2010
The passage and enactment of the ACA in 2010 by the
federal government was the most significant overhaul of
the U.S. health care regulatory system since the passage
of Medicare and Medicaid in 1965. The purpose of the
ACA was to improve access to affordable health coverage
for everyone, including the most vulnerable, to provide
ways to bring down health-care costs, and to improve
quality of care by improving health outcomes. Some key
components of the law are as follows:

• Denial of coverage for preexisting conditions was
prohibited.

• Young adults could stay on their parents’ plan until
age 26.

• Originally, the ACA required that most U.S. citi-
zens and legal residents have health insurance. Op-
ponents of the ACA challenged the constitutionality
of the individual insurance mandate, suggesting it
amounted to a tax; however, the U.S. Supreme
Court upheld the legislation.29 However, in 2019,
the tax penalty associated with not having insurance
was repealed.

• Employers with 50 or more employees were required
to offer insurance coverage or pay a fine.

• Medicaid coverage for most non-elderly low-income
adults was expanded to 138% of the federal poverty
level, but after a Supreme Court decision in 2012,
states could opt in to adopt this expansion or choose
not to.

• State-based health-care marketplaces were created
for individuals and small businesses to compare and
enroll in health insurance plans. Governmental sub-
sidies for health insurance companies to participate
in the marketplaces were intended to reduce out of

pocket costs to individuals. Those subsidies have
been reduced and health insurance premiums will
likely continue to increase.

• Preventive health care was provided at no additional
cost (e.g., annual exams, flu shots, cancer screen-
ings).30 Covered preventive services for adults
include risk-based screenings for abdominal aortic
aneurysm, at-risk alcohol use, hypertension, high
cholesterol, colorectal cancer, depression, HIV,
obesity, tobacco use, and syphilis. Additional
preventive services include access to aspirin therapy,
diet counseling, and immunizations.31 A series of
judicial decisions have allowed some employers to
exempt birth control coverage from their insurance
plans.

• Insurance was required to cover essential health
services including ambulatory patient care, emer-
gency services, hospitalization, maternity and
newborn care, mental health and substance use
disorder services, prescription drugs, rehabilitation
and habilitation services and devices, lab services,
preventive and wellness services, chronic disease
management, and pediatric services, including oral
and vision care. After passage of the bill, efforts to
reduce costs centered on proposals to limit the
essential health services that insurance must include,
especially in the realm of maternity and infant
care, and mental health and substance use disorder
services.32

There are components of the ACA with significant po-
tential implications for public health nursing.33 Some of
these are authorized, mandatory funds for evidence-
based early childhood home visitations; an authorized
CDC national diabetes prevention program; loan repay-
ment to increase public health workforce; programs to
help educate more public health professionals; school-
based health centers; public/private partnerships for
education and outreach campaigns; community health
centers and nurse managed clinics; workplace wellness
programs; and national quality improvement strategies
to improve population health.34

The ACA also established the Prevention and Public
Health Fund. It provides increased and sustained
national resources for prevention and public health,
improves health outcomes, and enhances health-care
quality. The U.S. Department of Health and Human
Services summarized the investments as a “broad range
of evidence-based activities including community and
clinical prevention initiatives; research, surveillance and
tracking; public health infrastructure; immunizations

C H A P T E R 2 1 n Health Planning, Public Health Policy, and Finance 541

n HEALTHY PEOPLE
History of Healthy People

• 1979 Surgeon General’s Report, Healthy People:
The Surgeon General’s Report on Health Promotion
and Disease Prevention

• Healthy People 1990: Promoting Health/Preventing
Disease; Objectives for the Nation

• Healthy People 2000: National Health Promotion
and Disease Prevention Objectives

• Healthy People 2010: Objectives for Improving Health
• Healthy People 2020
• Healthy People 2030

7711_Ch21_537-568 21/08/19 11:09 AM Page 541

and screenings; tobacco prevention; and public health
workforce and training.”34

Occupational Safety and Health Administration
The Occupational Safety and Health Administration
(OSHA), part of the U.S. Department of Labor, regu-
lates safety and health for workers (see Chapter 20).
“OSHA’s mission is to prevent work-related injuries,
illnesses, and deaths.”35 Since the agency was created
in 1971, occupational deaths have been cut by 62% and
injuries have declined by 42%. For example, OSHA’s
bloodborne pathogens standard requires an exposure
control plan that includes components such as obser-
vance of universal precautions to prevent contact
with blood or other potentially infectious body fluids;
engineering and work practice controls to minimize
exposure; and vaccination, postexposure evaluation,
and follow-up.

Special Populations
As mentioned earlier, the U.S. government directly
provides health care for soldiers, veterans, members
of federally recognized American Indian/Native
American tribes, and inmates of federal prisons. Spe-
cial agencies are charged with providing health care to
these populations. For instance, the Department of
Veterans Affairs provides health care for veterans
through the Veteran’s Administration (VA) hospitals
and programs. Indian Health Services (IHS) is a
federally funded program to provide health services to
Native American populations based on treaties estab-
lished during the early development of the United
States. Nurses who work in the armed forces, VA, IHS,
and federal prisons are usually employees of the federal
government.

State Health Policy
States and Medicaid
Medicaid is jointly financed and administered by fed-
eral and state governments. States set their own guide-
lines for eligibility and services but must include certain
federally mandated basic services: inpatient and outpa-
tient hospital care; laboratory and radiology services;
skilled care at home or at a long-term care facility; early
periodic screening, diagnosis, and treatment for those
younger than 21 years of age; and family planning serv-
ices.36 The federal government mandates that partici-
pating states include federally determined categories
(low-income families with dependent children, low-
income older adults, and disabled individuals) in their
Medicaid eligibility criteria. Participating states may

choose to provide Medicaid coverage to other groups
such as the medically needy or individuals with income
levels above Medicaid cut-offs but who have extraordi-
nary medical costs. Many states have received waivers
from the federal government to use Medicaid funds in
a different way.37,38 For instance, Wisconsin used Med-
icaid funds in a demonstration project, BadgerCare
Plus, to pay for health-care services for low-income
adults without dependent children.

A related federal/state program is the Children’s
Health Insurance Program (CHIP) (see Chapter 18).
The federal government provides matching funds to
states for coverage of children in families whose incomes
are too high to qualify for Medicaid, yet they remain
unable to afford private insurance. States have some
latitude in determining covered services and eligibility
levels. Additionally, as of April 2018, 32 states and the
District of Columbia adopted the Medicaid expansion
as part of the ACA.39

Some states have decided on policies that incremen-
tally moved toward universal health-care coverage
for their residents. For instance, Oregon initiated
a plan to provide health insurance to low-income
residents while holding down costs through explicitly
rationing certain services.40 Ballooning costs resulted
in limitation of services, severe limitations to eligibility,
and even the institution of a lottery for remaining
spots in the plan. In 2006, Massachusetts passed a
statute requiring all state residents to obtain health
insurance coverage.41 Free and subsidized health in-
surance was made available to low-income residents.
States are experimenting with a variety of policies
to address health insurance coverage, especially for
low-income people.

Another important health policy at the state level is
the establishment of predetermined criteria for both
health-care providers and facilities. For example, in
Wisconsin, the Department of Regulation and Licens-
ing is responsible for ensuring the safe and competent
practice of licensed professionals in health care and
other professions.42 The department sets licensing
requirements, establishes professional practice stan-
dards, and enforces occupational licensing laws.
The department also regulates educational programs
for licensed professionals. The Wisconsin Division of
Quality Assurance is charged with, among other re-
sponsibilities, assuring the safety and quality of health-
care facilities. This division is also responsible for
ensuring that hospitals meet Centers for Medicare and
Medicaid Services (CMS) standards for receiving re-
imbursement from Medicare and Medicaid. Each state

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takes responsibility for ensuring the safe regulation of
health-care services.

Each state has an official state public health agency
headed by a chief executive officer, often called the state
health commissioner.43 These agencies, funded by state
legislatures, monitor health status, enforce public health
laws and regulations, and distribute federal and state
funds for public health activities to local public health
agencies. The form and structure of state public health
agencies vary greatly from state to state, with some
states merging the state public health agency with social
services.

Almost all state-based public health agencies partici-
pate in the U.S. Centers for Disease Control and Preven-
tion (CDC) Health Alert Network (HAN). According to
the CDC, the vast majority of those agencies have more
than 90% of their population covered by the HAN system.
The HAN includes a secure website and emergency
messaging system for sharing reputable information
about urgent public health events such as bioterrorism,
communicable diseases, and environmental threats.44

Statewide HAN initiatives, funded by grants from the
CDC, connect local health departments with hospitals,
clinics, law enforcement, firefighters, and emergency
medical providers. The HAN incorporates various levels
of messages ranging from time-sensitive information that
necessitates immediate action to general public health
information.

HAN archives from 2017 include messages about in-
fluenza surveillance and treatment recommendations;
advice for providers treating patients returning from
hurricane-affected areas; Brucella incidence and expo-
sure related to the consumption of raw milk; a reminder
to clinicians of the dangers, symptoms, and treatment
of carbon monoxide poisoning related to the use of gen-
erators during power outages; and information about a
Seoul virus outbreak associated with home-based rat
breeding in Wisconsin and Illinois. In that same year,
the Texas Department of State Health Services commu-
nicated a Zika virus health alert regarding enhanced
surveillance and modified testing guidelines of symp-
tomatic and asymptomatic pregnant women in certain
counties.

Local Health Policy
Local public health agencies derive their authority from
state and local laws and regulations. They deal with issues
such as water safety and fluoridation, sanitation, com-
municable diseases, and sanitary food and beverages, and
they sometimes regulate and/or own health-care facilities
such as hospitals, clinics, or nursing homes.45 The form

and structure of local public health agencies vary with
centralized models operated directly by the state or de-
centralized models under county, city, or other local ju-
risdictions. Local public health agencies have a chief
executive officer who generally works with local boards
of health that are appointed or elected (see Chapter 13).

Local Health Department Personnel
Health department personnel are influential in devel-
oping, monitoring, and enforcing local health laws and
regulations (see Chapter 13). For instance, local health
agency advocacy has resulted in many local jurisdic-
tions passing ordinances restricting the use of tobacco
in public settings. Local health agencies have policies
whereby sanitarians inspect restaurants, convenience
stores, food vendors at county fairs, and other public
facilities that serve food to enforce guidelines such as
food holding temperatures. The local health depart-
ment can close these establishments if they do not meet
certain standards. Another example of health-related
policy at the local level involves zoning ordinances. A
community in need of a shelter for homeless families
was having difficulty securing a permit to open a shel-
ter in a residential area because of zoning laws and
property owners’ fear of decreasing property values.
Advocates for the homeless along with public health
representatives met with residents to determine a plan
for the shelter that would minimally affect the neigh-
borhood. Advocates also petitioned the elected city
board for a change in the zoning laws to allow a home-
less shelter in that area of the city.

To promote equity and efficiency, a local health
agency may have a policy about services offered to resi-
dents. For instance, one local health agency may decide
to offer free home visits to families of newborns who
meet certain risk criteria, whereas another local health
agency decided to offer one free home visit to all families
of newborns. As public health agency budgets are re-
duced, it is important to base local policy decisions on
scientific evidence.

Likewise, local health agencies need to determine poli-
cies for payment for services such as immunizations or
for clinics that treat sexually transmitted infections.
Should clients pay the full or partial (sliding fee) cost of
each unit of service, should the agency request a dona-
tion, or should these services be free of charge? Some-
times, state or federal policy influences these decisions,
but often these kinds of policy decisions are left to the
local health agency. These decisions potentially affect
access to care, utilization rates of the service, and resources
available for other services.

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Local jurisdictions or even regions need to coordi-
nate emergency services such as 911 call centers; am-
bulance, fire, and rescue dispatch; and routing to local
hospitals. Development of policies regarding emer-
gency response services requires extensive coordination
of multiple stakeholders within multiple jurisdictions.
With the increasing incidence of opioid use, many lo-
calities are adopting policies to combat the morbidity
and mortality associated with opioid use (Box 21-1)
(Fig. 21-1).46

Preparing for emergencies involving disasters, such as
a flood, collapse of a bridge, chemical spill, or act of
bioterrorism, requires extensive planning. Public health
agencies are often involved in primary prevention, but
some disasters cannot be prevented, such as a tornado.
Public health agencies work cooperatively with other

agencies and community stakeholders to develop an
emergency management plan that includes prepared-
ness, mitigation, response, recovery, and evaluation
(Chapter 22). An emergency management plan is an
example of a policy. Many counties and other jurisdic-
tions hold disaster drills to test aspects of their emer-
gency disaster plans.

Local health departments can choose to undergo a
voluntary accreditation process. Since 2013, the Public
Health Accreditation Board has run a national voluntary
accreditation program for local health departments in
addition to state, tribal, and territorial health depart-
ments. Accreditation helps assure and improve the qual-
ity and performance of health departments.50

Business/Organizational Health Policy
Federal, state, and local laws affect health, but so do poli-
cies of businesses and organizations. Organizations and
businesses may choose to develop policies for their em-
ployees or customers, such as hospitals and universities
that establish smoke-free campuses. Legally, sometimes
organizational policies clash with state or local policies.

For instance, in 2018, cannabis was illegal at the fed-
eral level, but almost two-thirds of states had legalized
medical use, and almost half had legalized or decrimi-
nalized recreational use.51 In general, employers can
prohibit cannabis use at work or employees from com-
ing to work under the influence of drugs or alcohol, but
employers also need to attempt to comply with contra-
dictory laws while assuring employee and public safety.

544 U N I T I I I n Public Health Planning

More than 42,000 Americans died of opioid overdoses
in 2016, a 28% increase over 2015. With the increase
in opioid use, abuse, and related mortality related to
overdose, there is a need to develop and test policies
to reduce morbidity and mortality associated with opi-
oid abuse. At the national level, the CDC has increased
funding for states to assess policy interventions regard-
ing opioid abuse. At the state level, prevention includes
implementing and evaluating universal prescription drug
monitoring programs that allow pharmacists to deter-
mine if a patient has obtained prescriptions opioids
elsewhere. At the local level, interventions include
providing technical assistance to communities and juris-
dictions with high rates of at-risk opioid use and death.
Insurers and health systems are educating providers
and facilitating the use of evidence-based prescribing
guidelines such as using nonpharmacologic therapies
and nonopioid pharmacologic therapies when possible
and prescribing the lowest possible dose and quantity
for expected level and duration of severe pain. For ex-
ample, one Wisconsin county implemented a nonopi-
oid dental pain protocol for patients seeking care at local
emergency departments. These policy interventions
need to be evaluated to determine what works.46,47

Other local interventions include the wide distribution
of overdose-reversing agents and programs that provide
supervised consumption of opioids including methadone
at specialized community facilities. In 2018, the U.S. Sur-
geon General suggested that those likely to encounter
overdose victims including friends and families of opioid
users and health-care practitioners carry the opioid over-
dose reversal agent naloxone.

BOX 21–1 n Opioid Policies

Source: (48)

t CASE STUDY
Drug-Free Workplace Policy
Development

You are an occupational health nurse working with a
midsized manufacturer in a state that legalized medical
and recreational cannabis use. As a member of the
health and safety committee, you are tasked to develop
a drug-free workplace policy.

Using the Substance Abuse and Mental Health Serv-
ices Administration (SAMHSA) Drug-Free Workplace
Toolkit (https://www.samhsa.gov/workplace/toolkit),
answer the following:

1. What key stakeholders should be included in the
drug-free workplace policy development taskforce?

2. What drug-free workplace laws and regulations
(federal, state, and local) would apply to this
company?

7711_Ch21_537-568 21/08/19 11:09 AM Page 544

C H A P T E R 2 1 n Health Planning, Public Health Policy, and Finance 545

A rise in opioid overdoses is detected. What now?

Naloxone

Coordinated,
informed efforts

can better prevent
opioid overdoses

and deaths

Community Members

Local Health Departments

Community-Based Organizations

Mental Health and Substance
Abuse Treatment Providers

Local Emergency Department

First Responders | Public Safety |
Law Enforcement Officers

Medication-assisted
treatment (MAT)

Figure 21-1 Rise in Opioid Overdoses is Detected: What Now? (Centers for Disease Control and Prevention.
(2018, March 6). Vital Signs: Opioid overdoses treated in emergency departments. Retrieved from https://www.cdc.gov/
vitalsigns/opioid-overdoses/index.html https://www.cdc.gov/vitalsigns/opioid-overdoses/infographic.html#infographic)

7711_Ch21_537-568 21/08/19 11:09 AM Page 545

Likewise, the decision to offer health insurance and/
or paid sick leave to employees beyond what might be
specified by national, state, or local law is an important
health-related policy decision of businesses. Some busi-
nesses require employees to participate in health risk
assessments and wellness programs to avoid paying a
higher insurance premium. This is particularly prevalent
among companies with self-funded insurance programs.
Nutrition information provided by restaurants is another
example of a health-related business decision policy. A
local amateur hockey league may require that all players
wear protective headgear while on the ice. Some schools
have implemented health policies that restrict vending
choices during school hours. Such initiatives at the or-
ganizational or business level can build on governmental
policies such as recent policies by school districts to
change to healthier foods in the school lunch programs.52

Various stores, including a number of national chains,
have established policies about not selling inhalants to
minors and/or have moved inhalants to a secure area to
prevent shoplifting.

Principles of Public Health Policy
Public health policy focuses on promoting and protecting
the health of populations. It should be based on evidence
and be both ethically sound and culturally appropriate.

Health Policy Assessment and Planning
Process
Effective public health policy is grounded in the health
assessment and planning process, a problem-focused
process (Chapters 4 and 5). The health planning process,
the policy process, and the nursing process use similar
terms.

Assessment of health status, social data, needs, and
resources is an essential first step in the policy process.

Goals and objectives for the policy are established with
input from stakeholders, those directly or indirectly
affected by the policy. Think of a school nurse who needs
to make an authoritative decision about which children
will be screened for vision problems. The school has lim-
ited resources and the state does not have a definitive
policy about which children or grade levels to screen.
Discussion with other school nurses shows that the ma-
jority of schools screen children in first and second
grades. The nurse will use the policy process to make a
decision about vision screening. What evidence-based
standards exist regarding vision screening of school-age
children? What evidence is there about the yield (new
cases discovered) of vision screening at various grades?
What else would be needed besides screening for an
effective vision health program? Where can the nurse
refer children who lack the means to pay for the services
of an optometrist and need glasses?

In the health policy assessment and planning process,
much attention is given to the development of the policy.
Specific policy alternatives are posited and analyzed re-
garding factors such as cost, likely effectiveness, social
and political feasibility, and equity. A school nurse mak-
ing policy about vision screening would specify policy al-
ternatives regarding vision screening. One policy might
be to require vision check-ups as a prerequisite to enter-
ing or transferring to the school.

Using Explicit Evaluation Criteria
for Policy Planning
Policy alternatives can be judged according to explicit
evaluation criteria. Three criteria most often used are ef-
fectiveness, efficiency, and equity (Table 21-1). Effec-
tiveness is the likelihood of achieving the goals and
objectives of the policy. Increasing physical activity in a
population might include requiring daily physical edu-
cation classes for all schoolchildren, which may be more
effective than open access to a community fitness center
for residents of a school district. Efficiency is achieve-
ment of policy goals relative to cost. The cost of pro-
viding daily physical education classes to school-age
children (hiring teachers, increased facility require-
ments, lengthening the school day to accommodate the
requirement, and lost opportunity costs of a required
class in physical education vs. math or music, etc.)
would be compared with the cost of providing access to
physical fitness facilities for all residents (facility capital
costs, additional staff, liability insurance, etc.). Equity is
fairness or justice in the distribution of a policy’s costs,
benefits, and risks. Using the prior example, the require-
ment of daily physical fitness courses provides a benefit

546 U N I T I I I n Public Health Planning

3. Draft a drug-free workplace policy for this company,
including:
a. Purpose Statement and Goals
b. Definitions and Prohibitions
c. Description of how employees will be

educated/informed about the new policy
4. What impact would the presence of collective bar-

gaining have on the policy development process?
5. What should the policy be regarding workers who

fail a routine drug screen test?
6. Should the policy be different for workers who have

a permit to use medical cannabis? Why or why not?

7711_Ch21_537-568 21/08/19 11:09 AM Page 546

exclusively for the school-age population, whereas open
access to fitness facilities potentially benefits all age groups.
Taxpayers would incur the costs for both policy choices.
Weighing these three key criteria helps policy makers
decide which policy approach to implement. Of course,
maintaining the status quo is always another policy
approach to take. In this case, the third unstated policy is
to continue “business as usual” with students having phys-
ical education classes twice a week and those with the
financial means and desire joining a fitness facility. Other
important criteria for evaluating policy include liberty/
freedom, political feasibility, social acceptability, admin-
istrative feasibility, and technical feasibility.7

A theory links the proposed policy with the actions,
behaviors, and/or decisions of others. Many public health
policies are based on psychological or economic theories.
A law imposing a penalty for being detected by police for
not wearing a seat belt raises the potential cost of that ac-
tion. This policy is based on at least two theories: rational
action choice theory and the theory of reasoned action.

Rational action choice theory assumes that individuals
will make choices that benefit them the most with the
least cost.52 In this scenario, the theory suggests that in-
dividuals will buckle up to avoid the financial penalty.
Ajzen and Fishbein’s (1975, 1980) theory of reasoned ac-
tion also explains and supports this policy.53 The theory
suggests that behavioral intentions depend on a person’s
attitude about the behavior and subjective norms. Be-
cause subjective norms, perceived expectations from oth-
ers, and intention to comply with those expectations
guide personal behavior, policies have the potential to
influence behavior by influencing how others behave
and, more specifically, by changing the social norm of
using seat belts.

Policies are formulated, interpreted, and imple-
mented. Implementing policy is a complex activity that
involves determining and enacting the various activities
that will put the policy into effect. For instance, laws are
interpreted by the executive branch of government and
implemented by numerous agencies and organizations,

C H A P T E R 2 1 n Health Planning, Public Health Policy, and Finance 547

TABLE 21–1 n Selected Criteria for Evaluating Public Policy Proposals

Criterion Definition Limits to Use

Effectiveness

Efficiency

Equity

Liberty/
Freedom

Political
feasibility

Social
acceptability

Administrative
feasibility

Technical
feasibility

Estimates involve uncertain projection of future
events.

Measuring all costs and benefits is not always
possible. Policy decision making reflects political
choices as much as efficiency.

Difficulty in finding techniques to measure equity;
disagreement over whether equity means a fair
process or equal outcomes.

Assessment of impacts on freedom is often
clouded by ideological beliefs about the role of
government.

Difficult to determine. Depends on perceptions of
the issues and changing economic and political
conditions.

Difficult to determine even when public support
can be measured. Depends on saliency of the
issues and level of public awareness.

Involves projection of available resources and
agency behavior that can be difficult to estimate.

Often difficult to anticipate technological change
that would alter feasibility.

Likelihood of achieving policy goals and
objectives or demonstrated
achievement of them.

The achievement of program goals or
benefits in relation to the costs. Least
cost for a given benefit or the largest
benefit for a given cost.

Fairness or justice in the distribution of the
policy’s costs, benefits, and risks across
population subgroups.

Extent to which public policy extends or
restricts privacy and individual rights and
choices.

The extent to which elected officials
accept and support a policy proposal.

The extent to which the public will accept
and support a policy proposal.

The likelihood that a department or
agency can implement the policy well.

The availability and reliability of technology
needed for policy implementation.

Source: Adapted with permission from Kraft, M., & Furlong, S.R. (2015). Public policy: Politics, analysis, and alternatives (ed 5). Washington,
DC: Sage/CQ Press.

7711_Ch21_537-568 21/08/19 11:09 AM Page 547

including employers, health-care providers, service
agencies, and public health departments. States may in-
terpret and enforce federal laws differently. Specifically,
implementation involves developing the details of the
process that will allow for the intended outcome to take
place. This could include such things as hiring person-
nel, establishing fines or penalties for those who do not
follow the policy, and disseminating information about
the policy.

Stakeholder Involvement
Like the nursing process, in which it is important to in-
volve the client as much as possible, stakeholder involve-
ment is important in the policy process. In assessment, or
identification of the policy issue, sometimes stakeholders
identify the need for a policy and sometimes they identify
a problem but are not sure what type of policy will best ad-
dress the problem. In Chapter 5, you read about the Elm-
wood Senior residence and concerns for isolation because
of violence in their neighborhood. Community members,
parents of young children, and the elders living in a senior
residence facility felt that community violence kept them
from physical activities such as walking outside and spend-
ing time in the park. The community health nurse ob-
tained information from religious organizations, school
representatives, seniors, and other community stakehold-
ers to plan a program to address the perceived barrier to
physical activity. At the organizational level, Elmwood res-
idential facility coordinated an escort service for the resi-
dents. At the community level, local law enforcement
increased their presence through periodic patrolling of this

neighborhood. The school recognized the need for in-
creased after-school activities for the youths. The nurse
worked with community organizers to obtain funds for
after-school activities for teens.

Focus on Health Determinants
Health status is a complex interaction of environmental,
socioeconomic, genetic, health service, and behavioral de-
terminants. Public health policy attempts to change
health status by influencing these determinants as precur-
sors to morbidity and mortality. Public health policy em-
phasizes intervention in environmental protection, health
promotion, and specific disease prevention. The concept
of influencing determinants of health prior to the devel-
opment of poor health or even physiological changes that
would lead to poor health is known as upstream thinking.
Lead poisoning and skin cancer are examples of public
health problems that can be diminished or avoided with
the implementation of upstream policies designed to pre-
vent those problems (Table 21-2). Note that some up-
stream policies directly change the physical environment,
whereas some policies require behavioral change.

Federal programs, such as Medicaid that provide
health services to poor families and laws such as the
Family Medical Leave Act (FMLA) that guarantee con-
tinuation of work for those experiencing a health event
in their family are examples of policies affecting socioe-
conomic determinants. The decision of an employer to
provide paid sick leave for workers is a type of socioeco-
nomic policy that, in most states and communities, is left
to the employer.

548 U N I T I I I n Public Health Planning

TABLE 21–2 n Examples of Upstream Policies Addressing Specific Public Health Problems or Issues

Public Health Problem/Issue Upstream Policies

Lead poisoning in children

Exposure to secondhand smoke

High rates of cardiovascular disease

Infant and maternal health

Poor nutrition among poor

Dental caries

Herd immunity or individual immunity

Unintentional injuries of children

Federal and state restrictions on use of leaded paint in residential use

Restaurant association’s endorsement of smoke-free facilities among its members

Health insurance policy to co-fund gym or weight-reduction club memberships
Local zoning laws requiring sidewalks and bike paths in area of new development
Drug store chains deciding not to sell tobacco products

Employer providing onsite lactation room in workplace

Supplemental Nutrition Assistance Program (SNAP), previously known as Food
Stamps, that provides assistance to low- and no-income individuals and families
living in the United States

Municipality adding fluoride to drinking water

School entry vaccination laws

Child safety seat laws

7711_Ch21_537-568 21/08/19 11:09 AM Page 548

Health-care providers’ expansion of primary care serv-
ices to weekend and evening hours improves access to care,
increases primary care utilization, and generally improves
health. When public health departments provide free vac-
cinations in schools, it increases immunization rates and
strengthens herd immunity. State laws mandating certain
vaccinations for school entry are also examples of policies
having an impact on health through health services.

A school district’s decision to implement a tooth-
brushing program for preschool and elementary students
is intended to influence oral hygiene behavior of children
and families and improve overall oral health. A construc-
tion company’s decision to implement random drug test-
ing for employees who operate heavy equipment may
reduce drug use and injuries among employees. Mandat-
ing certain vaccinations for health-care workers is an-
other example affecting worker behavior.

Evidence-Based Practice
Do the health policies previously described really affect
health? Although anecdotal evidence exists for many
health policies, some health policies are not supported by
a body of scientific evidence. For example, although there
is fairly good evidence that a sedentary lifestyle combined
with extreme obesity is related to increased morbidity and
mortality, the evidence that mandating sidewalks or in-
cluding nutrition information on restaurant menus re-
sults in positive changes in individual actions, behaviors,
and decisions is less clear. It is difficult if not impossible
to randomly assign individuals or even communities to
these interventions. Therefore, it is difficult to evaluate the
impact of these interventions on health.

Another example is the evidence that drinking fluor-
idated water reduces the number of dental caries. Al-
though theoretically it would be possible to randomly
assign communities supplied by separate water systems
to fluoridated or nonfluoridated water status, in the
United States a decision such as fluoridation of water is
under local control and is often a political decision. There
is often no authority to give permission for random as-
signment. In this case, the evidence of the success of the
program is based on population data over time. Based on
the evidence, there has been a decline in dental caries
overall in countries that fluoridate water and those that
do not.57 This is because other changes have been intro-
duced, including topical fluoride applications, fluori-
dated toothpastes, and salt and milk fluoridation. With
100 years of accumulated population-level evidence that
fluoride in many forms reduces dental carries, the World
Health Organization (WHO) recommends that public

C H A P T E R 2 1 n Health Planning, Public Health Policy, and Finance 549

n EVIDENCE-BASED PRACTICE
Cost Effectiveness of Bike Lanes/Trails

Practice Statement: Produce a built environment
strategy to increase physical activity through bicycle use.
Targeted Outcome: Increasing physical activity in
communities with pedestrian and bike paths.
Supporting Evidence: To address the growing rates
of obesity, many communities are investing in environ-
mental strategies designed to improve pedestrian or
bicycle transportations systems to increase physical ac-
tivity. In fact, the Community Preventive Services Task
Force noted that residents’ physical activity increased
in communities with new or improved projects or poli-
cies that combined transportation (e.g., pedestrian or
cycling paths) with environmental design (e.g., access to
public parks).54 Built Environment Approaches involve

interventions that enhance opportunities for active
transportation and leisure-time physical activity.
Recommended Approaches: The Community Pre-
ventive Services Task Force noted that, across several
longitudinal studies, physical activity outcomes were
favorable for studies involving enhanced walking/biking
recreational- and transportation-related studies. From
a cost-benefit perspective, Wang and colleagues (2005)
found that, for every $1 spent on trails for physical
activity, there was a $2.94 direct medical benefit.55 A
recent study of the cost-effectiveness of bike lanes in
New York City also found that, in addition to the fi-
nancial return on investment, increased bike/pedestrian
lanes reduced pollution and risk of injury as compared
to not having such lanes.56 Both studies demonstrated
that investments in bike lanes were a good value as
they address multiple public health problems.

Related policies that support biking include mandat-
ing sufficient bike racks, bicycle friendly parking
ordinances, zoning ordinances that discourage an
overabundance of surface parking lots and road
design standards that include protected bike lanes.

References:
1. Wang, G., Macera, C.A., Scudder-Soucie, B., Schmid, T.,

Pratt, M., & Buchner, D. (2005). A cost-benefit analysis
of physical activity using bike/pedestrian trails. Health
Promotion Practice, 6(2), 174-179. Doi: 10.1177/
1524839903260687.

2. Gu, J., Mohit, B., Muennig, P.A. (2017). The cost-effectiveness
of bike lanes in New York City. Injury Prevention, 23(4),
239-243. Doi: 10.1136/injuryprev-2016-042057.

7711_Ch21_537-568 21/08/19 11:09 AM Page 549

health policy support the use of fluoridated toothpastes
and, where economically, technically, and culturally fea-
sible, water fluoridation.58 In the United States, in addi-
tion to fluoridation of water supplies, fluoride varnish
programs have been implemented. This intervention in-
volves the application of a thin layer of fluoride to the
teeth of children.59 School districts concerned with dental
health may adopt other related policies such as limiting
sugar-laden vending choices. Evaluating the effectiveness
of one policy, such as a varnish policy, is difficult because
of the other interventions in current use.

There are a number of good sources of reviews for
evidence-based practice on which to base policy deci-
sions. The Agency for Healthcare Research and Quality
(AHRQ) U.S. Preventive Services Task Force publishes
a Guide to Clinical Preventive Services (Clinical Guide)
that recommends clinical preventive services based on
systemic review of clinical practices.60 This regularly up-
dated guide includes dozens of reviews in areas such as
alcohol and drug abuse, cancer screening, nutrition, and
exercise.

A second source, complementary to the AHRQ
guide, is the CDC Guide to Community Preventive Serv-
ices: The Community Guide: What Works to Promote
Health, referred to as the Community Guide.61 The Com-
munity Guide includes systematic reviews and recom-
mendations for interventions that promote population
health (Table 21-3). For instance, regarding skin cancer
prevention, the Community Guide recommends a wide
variety of interventions focused on promoting sun pro-
tection behaviors and environmental protections.62

A third good source is the Cochrane Reviews, a data-
base of systematic reviews of the effects of health-care
interventions (Table 21-4).63 The reviews are conducted
by a global collaboration of volunteers and a small staff
in London, United Kingdom. Although many of the
Cochrane Reviews are clinically focused, there are a
number that have a public health emphasis. For in-
stance, in the area of injury control, there are reviews
on interventions for promoting smoke alarm owner-
ship and use, and interventions for preventing injuries
in the construction industry.

550 U N I T I I I n Public Health Planning

TABLE 21–3 n Task Force on Community Preventive Services

Selected Systematic Reviews on Policy Interventions Conducted from the Guide to Community Preventive Services

Topic Policy Setting Intervention Title Recommendation

Preventing
Excessive

Alcohol Use

Preventing
Skin
Cancer

Motor Vehicle–
Related Injury
Prevention

Recommended
(Sufficient Evidence)

Insufficient Evidence

Recommended
(Strong Evidence)

Insufficient Evidence

Recommended
(Strong Evidence)

Enhanced enforcement of laws prohibiting sales to
minors

Regulation of outlet density

Responsible beverage service training

Educational and policy: childcare centers

Educational and policy: primary school settings

Educational and policy: secondary schools and colleges

Educational and policy: outdoor recreation settings

Educational and policy: outdoor occupation settings

Reducing alcohol-impaired driving: sobriety
checkpoints

Reducing alcohol-impaired driving: lower legal blood
alcohol concentrations for young and inexperienced
drivers

Community

Education

Community

Worksite

Community

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C H A P T E R 2 1 n Health Planning, Public Health Policy, and Finance 551

TABLE 21–3 n Task Force on Community Preventive Services—cont’d

Topic Policy Setting Intervention Title Recommendation

Oral Health

Promoting
Physical
Activity

Tobacco Use

Vaccine
Preventable
Diseases

Recommended
(Strong Evidence)

Recommended
(Sufficient Evidence)

Insufficient Evidence

Recommended
(Strong Evidence)

Recommended
(Sufficient Evidence)

Insufficient Evidence

Recommended
(Sufficient Evidence)

Reducing alcohol-impaired driving: 0.08% blood
alcohol concentration (BAC) laws

Reducing alcohol-impaired driving: minimum legal
drinking age

Use of child safety seats: laws mandating use

Use of safety belts: laws mandating use

Use of safety belts: primary (vs. secondary)
enforcement laws

Dental caries (cavities): community water fluoridation

Dental caries (cavities): school-based or -linked sealant
delivery

Built Environment Approaches combining
transportation system interventions with land use
and environmental design

Family-based Interventions

College-based Physical Education and Health
Education

Increasing tobacco use cessation: increasing the unit
price of tobacco products

Reducing tobacco use initiation: increasing the unit
price of tobacco products

Reducing exposure to environmental tobacco smoke:
smoking bans and restrictions

Restricting minors’ access to tobacco products:
community mobilization with additional
interventions

Restricting minors’ access to tobacco products: active
enforcement of sales laws directed at retailers

Restricting minors’ access to tobacco products: laws
directed at minors’ purchase, possession, or use of
tobacco products

School tobacco-free policies

Smoke-free policies to reduce tobacco use among
workers

Vaccination requirements for childcare, school, and
college attendance

Community

Education

Community

Community,
Home,
School

School

Community

Education

Worksite

Education

Continued

7711_Ch21_537-568 21/08/19 11:09 AM Page 551

Ethical and Cultural Implications of Policy
Public health policy ethics involve principles and values
that guide authoritative decisions made in government,
agencies, or organizations intended to influence popula-
tion health. A basic assumption of public health policy is
that society has the right, and even an obligation, to col-
lectively assure conditions for healthy people. An addi-
tional assumption is that the collective can sometimes
impose on individual rights for the sake of the common
good. There is debate about the balance between the
autonomy, privacy, and liberty interests of individuals
and the collective interests of a population. There is also
debate about the appropriate role of government in-
volvement in promoting population health.

An example is the Community Preventive Services
Task Force recommendation for universal helmet laws.
The recommendation was based on strong evidence of
the effectiveness of motorcycle helmet laws.64 Some argue
that requiring the use of helmets violates a person’s in-
dividual rights. Despite the strength of the evidence, as

of 2018, a few states did not have helmet laws, and some
states only required the use of helmets for individuals 17
and younger.65

Policies toward migrants from other countries are re-
flective of local culture and have cultural and ethical and
cultural implications. Reasons for migration include fam-
ily unification, economic opportunity, wars, violence,
and/or discrimination in their country of origin. It appears
that climate change will further exacerbate poverty, war,
and violence in some areas leading to increased migratory
pressure and even mass migrations.66 The U.S. grants a
limited number of authorizations to immigrate and, in
collaboration with the United Nations and the Interna-
tional Refugee Committee, offers asylum and resettlement
to refugees and migrants fleeing war and/or persecution.
The number of individuals granted refugee status and re-
settlement is limited and varies over time. Additionally,
some migrants, for instance those affected by a natural
catastrophe, may be granted temporary protected status
in the U.S. for a limited time.

552 U N I T I I I n Public Health Planning

TABLE 21–3 n Task Force on Community Preventive Services—cont’d

Topic Policy Setting Intervention Title Recommendation

Violence
Prevention

Worksite
Health
Promotion

Insufficient Evidence

Recommended Against
(Strong Evidence)

Recommended
(Sufficient Evidence)

Firearms laws
• Bans on specified firearms or ammunition
• Restrictions on firearm acquisition
• Waiting periods for firearm acquisition
• Firearm registration and licensing of firearm owners
• “Shall issue” concealed weapons carry laws
• Child access prevention laws
• Zero tolerance of firearms in schools
• Combinations of firearms laws

Transfer of juveniles into adult court system to reduce
violence

Smoke-free policies to reduce tobacco use among
workers

Community

Worksite

Source: Adapted from The Community Guide. (2014). Topics. Retrieved from http://www.thecommunityguide.org/.

TABLE 21–4 n Sources for Reviews of Evidence-Based Practice for Basing Public Health Policy

Community Guide

Clinical Guide

Cochrane Reviews

www.thecommunityguide.org

www.ahrq.gov/clinic/uspstfix.htm

www.cochranelibrary.com

Centers for Disease Control and Prevention, Task Force
on Community Preventive Services

Agency for Healthcare Research and Quality, U.S.
Preventive Services Task Force

Cochrane Library

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C H A P T E R 2 1 n Health Planning, Public Health Policy, and Finance 553

n CULTURAL CONTEXT
Undocumented Immigrants

Foreign nationals who illegally reside in a country are
known as undocumented immigrants, unauthorized
immigrants, or illegal aliens. These immigrants may illegally
cross the border, overstay visas, or participate in mar-
riages solely for immigration status. They usually have lim-
ited access to public services, such as individually focused
public health services and government vouchers for food,
and, because of fear of deportation, are often afraid to re-
port crimes. They may be subject to dangerous conditions
during border crossings,and, once in the U.S., exposed to
labor exploitation, sex trafficking, slavery, and housing
discrimination. Federal, state, and local governments have
interpreted laws and regulations regarding undocumented
immigrants differently over time, depending on world poli-
tics, economic conditions in the U.S., and the nationalities
or home regions of the immigrants.

Although undocumented children are entitled to public
education, many localities have policies, such as proof as
residency or guardianship, which hinder educational ac-
cess. Undocumented college students are not eligible for
federal loans and, in many states, need to pay out-of-state
tuition. Starting in 2012, certain undocumented immi-
grants who migrated to the U.S. as juveniles were given
protection from deportation along with the ability to
apply for a work permit. There have been political and
legal challenges to this policy, with some arguing that these
migrants did not choose to come to the U.S. and know no
other country as their home whereas others argue that
this kind of policy encourages illegal immigration.67

Culture, in its broadest sense, refers to learned knowl-
edge, attitudes, and behaviors of groups of people, which
often are accepted without question. We often think of
the culture of various ethnic and racial groups; however,
all groups, including communities and workplaces, have
a culture. Most people are members of multiple cultural
groups, and policy makers are influenced by their own
cultural groups as well as the culture of their constituents
and other stakeholders.

Public health policies can affect culture by changing
knowledge, attitudes, and behaviors of individuals and
groups (Fig. 21-2). For example, changes in the social ac-
ceptability of tobacco use allowed for smoking restriction
policies that would have been unacceptable in the 1960s.
Smoking restriction policies, in turn, affect knowledge,
attitudes, and behaviors regarding smoking.

Culturally acceptable health policies are those that
make sense to the people they affect. For example, many of

the HP objectives are aimed at reducing health dispar-
ities.13 It is critical to consider the unique cultural
makeup of the community in determining appropriate
programmatic and policy decisions. A policy prohibit-
ing individuals from serving foods prepared in their
home for general consumption at large social gather-
ings (e.g., funerals and weddings) may help reduce the
incidence of foodborne illness but would be met with
resistance by groups that traditionally prepare foods in
the home for such occasions. Conversely, a policy allow-
ing individuals and families to rent a small area of land
within a community garden in an urban area would be
well received by individuals from cultures with a tradition
for consuming homegrown produce. These examples
demonstrate the importance of obtaining stakeholder
input during the policy planning process.

Many public health policies target vulnerable groups.
Poverty and unemployment disproportionately affect
people of color, and many rely on public health insur-
ance for coverage. Policies specifically benefiting im-
poverished individuals have the potential to benefit
minority groups to a greater degree. For instance, CHIP
has the potential to improve the health of minority pop-
ulations by improving access to health services, leading,
it is hoped, to fewer illnesses and resulting in decreased
school absenteeism and increased high school gradua-
tion rates.

The Legislative Process and Public
Health Policy
Advocating for the best interest of patients is second
nature to nurses, but advocating for health-care policies is
often unfamiliar territory. To effect policy change for the
profession and for patient care, it is important that nurses
be familiar with the legislative process and with how to
make their opinions count regarding specific legislation.
Nurses should have a grasp of how a bill becomes law in
the U.S. Congress (Fig. 21-3). Similar processes take place
in state legislatures.

Culture

Health Policy

Figure 21-2 Relationship of culture and health policy.

7711_Ch21_537-568 21/08/19 11:09 AM Page 553

554 U N I T I I I n Public Health Planning

From Bills to Laws: The Course of Legislation in Congress

Agreement

Bills approved in identical form by the House and Senate are presented to the President.

President signs
measure

Measure
becomes law

If President does not sign measure into law within 10 days

If Congress is in session,
measure becomes law

If Congress is not in
session, measure does not
become law (”pocket veto”)

Measure does not become
law unless both chambers

override veto by 2/3 majority

President vetoes
measure

Committee
Action

Unanimous Consent Negotiations
or Other Scheduling Action

Senate Debate Vote on Passage

Each chamber appoints
members to a conference

committee, which reconciles
differences and writes a

conference report

House and Senate
exchange amendments to
bill and reach agreement

One chamber agrees to
the other chamber’s bill

House Debate Vote on Passage

House approves
conference report

Senate approves
conference report

Senate Debate Vote on Passage

Unanimous Consent Negotiations
or Other Scheduling Action

Reported by Full Committee

Referred to Senate Committee

Rules Committee or Other
Scheduling Action

House Debate Vote on Passage

Rules Committee or Other
Scheduling Action

Reported by Full Committee

Referred to House Committee

or or

United States
Senate

Bill Introduced

United States
House

Bill Introduced

Figure 21-3 How a bill becomes law. (Adapted from Congressional Research Service, A division of the Library of Congress.)

7711_Ch21_537-568 21/08/19 11:09 AM Page 554

The U.S. Constitution includes a series of checks and
balances to ensure adequate opportunity for considera-
tion and debate of an issue. Congress, made up of the
House of Representatives and the Senate, is the official
body through which all legislation is presented. The Sen-
ate is composed of 100 members, two from each of the
50 states, regardless of population or area, who serve for
6 years. The House of Representatives is composed of
435 members elected every 2 years from among the
50 states, apportioned by their population. The Consti-
tution limits the number of representatives to not more
than one for every 30,000 people. Each member of the
Senate or House of Representatives has one vote.

The chief function of Congress is making laws. Both
the Senate and House of Representatives have equal
legislative functions and powers with just a few excep-
tions. Ideas for legislation come from members of
Congress, from their constituent groups, and from
executive communication from the President, a mem-
ber of the President’s cabinet, or a head of an independ-
ent agency such as the Agency for Toxic Substances and
Disease Registry.68

Once an idea or concern is presented, the elected offi-
cial can introduce a bill to Congress. The representative
or senator becomes its sponsor and other legislators can
cosponsor the piece of legislation. The bill is given a num-
ber (preceded by H.R. if proposed in the House of Rep-
resentatives and S. if a bill is introduced by the Senate)
and referred to the appropriate committee or committees
(i.e., House Ways and Means or Senate Appropriations
Committee).

Perhaps the most crucial phase of the legislative
process is the action taken by committees. Once in com-
mittee, the bill undergoes extensive consideration and
debate. It is during this phase that government officials,
industry experts, and anyone with interest in the bill can
give testimony. The period when a bill is being consid-
ered in committee is an important time to contact leg-
islative staff and legislators who are on the committee
considering the bill. For example, in 2017, the American
Nurses Association advocated for a number of legislative
bills, including the Safe Staffing for Nurse and Patient
Safety Act (S. 2446, H.R. 5052).69 In a similar manner,
the ANA advocated for regulations to improve the pack-
aging, storage, and disposal of opioids to the Food and
Drug Administration (FDA-2017-N-5897).70

Individuals and organizations that testify before a
committee must file a written statement of their pro-
posed testimony before they appear. Once before the
committee, testimony is limited to a brief summary of
their arguments. A transcript of the testimony is printed

and distributed to committee members as well as made
available to the public.

After hearings are completed, the bill enters a “markup”
phase in which a vote is taken to determine the action of
the committee. The committee can approve the bill,
amend the bill, “table” (postpone indefinitely), or reject
the bill. If the committee approves the bill, it moves on in
the legislative process. Bills can be rejected through a vote
or simply by not acting on them; this is commonly referred
to as “dying in committee.”

Once a bill is approved, it is reported to the full House
or Senate, where it is written and published. This in-
cludes the impact on existing law, budgetary considera-
tions, any tax implications (increases or decreases)
required by the bill, and the opinions of the committee
either for or against the legislation. A reported bill is
then placed on the legislative calendar of the House or
Senate, where it is scheduled for floor action and de-
bated before the full membership. Once general debate
has ended, a second reading of the bill begins, during
which amendments may be offered. Once debate ends
and amendments are approved, the full membership
votes for or against the bill.

Depending on the congressional body in which the bill
originates, once a bill is approved, it is sent to the other
chamber where the same process is repeated. Once both
chambers of Congress have approved the bill in identical
form, it is sent to the President of the United States for ac-
tion. The President may sign the bill into law, take no action
on the bill, or veto the bill. If the bill sits unsigned on the
President’s desk for 10 days while Congress is in session,
the bill automatically becomes law. If no action is taken on
a bill and Congress adjourns, the bill dies. This is referred
to as a “pocket veto.”68 Congress may override a veto by
the President by a two-thirds vote in favor of the bill in both
houses of Congress. Once a presidential veto is overridden,
it is written as a binding statute and becomes law. All laws
of the United States are published in the U.S. Code, a listing
of the general and permanent laws organized according
to subject matter under 50 title headings.71

To illustrate the process by which a bill becomes law,
the history of a law regarding online sex trafficking is a
good example. Nurses may encounter individuals who are
victims of human trafficking (e.g., sex or labor trafficking
or child soldiers). It is estimated that 600,000 to 800,000
adults and children worldwide are trafficked across inter-
national borders each year.72 Unfortunately, many vic-
tims of trafficking go undetected by health-care providers.
Nurses need to stay informed, ask questions, and know
what is going on in their community. To address the
growing problem of human trafficking, particularly via

C H A P T E R 2 1 n Health Planning, Public Health Policy, and Finance 555

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the Internet, Representative Ann Wagner (R) of Missouri
introduced H.R. 1865: “Allow States and Victims to Fight
Online Sex Trafficking Act of 2017,” to the House of Rep-
resentatives on April 3, 2017.73 This new law allows the
government to prosecute the owners of websites (e.g.,
Facebook, YouTube, Twitter) that aid or promote sex
trafficking due to posts of that site’s users. It also allows
users to sue those websites. Senator Robert Portman
(R-OH) introduced a sister bill, S. 1693 Stop Enabling Sex
Traffickers Act of 2017, which was placed on the Senate
legislative calendar effective January 10, 2018.74 Box 21-2
describes this bill’s progress through the 115th session of
Congress.

Participation of Nurses in Health Policy
There is power in numbers. According to the Bureau of
Labor Statistics, there are more than 2.9 million RNs em-
ployed in the United States.75 Individual nurses, like all
citizens, have the right and some would argue the duty
to be politically active, yet results of studies demonstrate
that nurses do not participate politically as much as they
could. Reasons for a lack of political involvement range
from professional demands (e.g., increasing workloads,
understaffing), personal responsibilities (e.g., family
roles, childcare), and lack of education regarding political
action.76

The implications of lack of political involvement by
nurses are extensive. Those who engage the system
through voting and lobbying for their causes receive the
attention of policy makers. Policy makers hear from in-
dividual physicians, pharmacists, and health insurance

leaders. Policy makers also hear from lobbyists and or-
ganizations representing these professional groups such
as the American Medical Association, Pharmaceutical
Research and Manufacturers of America, and America’s
Health Insurance Plans. Because the 3 million nurses in
the United States (more than three times the number of
physicians) constitute the largest segment of the health
workforce, imagine the impact if every nurse participated
in advocating for health policy. Health policy, one of the
most debated issues among political candidates, is influ-
enced by the efforts of individuals but even more so by
the efforts of organized groups and professional lobby-
ists. Nurses can affect policy through their individual
efforts and utilizing their collective power.

Individual and Group Participation
When nurses engage the political system, politicians
will see them as a powerful voting group to whom they
must pay attention to be successful in seeking reelec-
tion to office. Advocacy activities can include active in-
volvement in policy such as providing testimony,
writing letters, and meeting with your state and federal
legislators.77 Nurses engage in advocacy on behalf of
their patients every day; however, advocating for health
policy has the potential to affect entire populations.
Nurses interested in influencing the policy process,
even those with limited time and resources, can be-
come advocates for health policy legislation.78-80 They
can advocate for particular policies (Box 21-3). It helps
to follow specific guidelines for communicating with
policy makers (Box 21-4).

556 U N I T I I I n Public Health Planning

House- H.R. 1865
4/03/17 Representative Ann Wager (R – MO) introduced

H.R. 1865 amending the Communications Act of 1934
and clarifying that the Act does not prohibit enforce-
ment against providers and users of interactive com-
puter services relating to sexual exploitation of children
or sex trafficking. H.R. 1865 received bipartisan support.

11/30/17 Heard in Communications and Technology
12/12/17 Communications and Technology committee

ordered the bill be considered by the full House of
Representatives

2/27/18 Passes the House 388–25
4/11/18 Signed by President

Senate- S. 1693
8/01/17 S. 1693: Stop Enabling Sex Traffickers Act of

2017 Introduced by Senator Robert Portman (R-OH)
with bipartisan support

9/19/17 Considered by Senate Committee on Commerce,
Science, and Transportation

11/08/17 Senate Committee on Commerce, Science,
and Transportation orders a report on the bill for
further consideration

1/10/18 Reported by the Senate Committee on
Commerce, Science, and Transportation

As of November 2018, pending vote in the Senate

BOX 21–2 n How a Bill Goes Through the Legislative Process: H.R. 1865: Allow States and Victims to Fight
Online Sex Trafficking Act of 2017/ S. 1693: Stop Enabling Sex Traffickers Act of 2017

Sources: Govtrack. (n.d.). H.R. 1865: Allow States and Victims to Fight Online Sex Trafficking Act of 2017. Retrieved from https://www.
govtrack.us/congress/bills/115/hr1865

Govtrack. (n.d.). S. 1693: Stop Enabling Sex Traffickers Act of 2017. Retrieved from https://www.govtrack.us/congress/bills/115/s1693

7711_Ch21_537-568 21/08/19 11:09 AM Page 556

Members of Congress are most responsive to people
from their own jurisdictions. They and their staffers need
and want to have input from well-informed nurses to be
aware of priority problems and the ramifications of
changes in policy. Many nursing organization websites
provide a link at which you can enter a ZIP code to find

contact information for legislators and sample letters.
Nurses can increase their expertise in policy analysis and
development through workshops, internships, and fel-
lowships (Box 21-5).

Collective Participation
Most changes in policy are the result of intentional activity
of many individuals and groups. Because the policy process
is influenced by the knowledge, attitudes, and actions of
elected officials, influencing policy necessitates influencing
the knowledge, attitudes, and actions of those elected offi-
cials. Strategies range from joining an organization that
uses its collective powers to influence policy such as the
American Association of Critical Care Nurses (AACN),
Oncology Nurses Society (ONS), a state or national nursing
organization like the American Nurses Association (ANA),
or a multidisciplinary organization like the American Pub-
lic Health Association, to writing a letter or making a call
about an issue, to getting elected to public office.

Nurses can affect policy through the collective efforts
of professional organizations. However, RNs in the
United States do not always become members of organ-
izations. This is a disheartening finding, considering that
nurses who are in professional organizations are more
likely to be politically active.76,79 Professional organiza-
tions not only employ professional lobbyists who influ-
ence legislators through sustained activity over months
and years, they also form political action committees
whose very function is to engage in political advocacy
and fund-raising. Although individual advocacy efforts
are important, invitations to testify to Congress are typ-
ically offered to larger, organized groups that may have
taken a position on an issue. The advocacy of the profes-
sional organization combined with individual advocacy
efforts cannot be underestimated.81

C H A P T E R 2 1 n Health Planning, Public Health Policy, and Finance 557

• Communicating with legislators through e-mail, social
media, face-to-face communications (personal visit),
and phone calls—providing your name and
address during these communications in case the
legislator wishes to seek additional information about
his/her viewpoint. Letters are no longer preferred due
to safety issues as they are sometimes quarantined for
a period of time before they are delivered, especially
for federal legislators.

• Participating in annual state legislative days (i.e., Day
at the Capital).

• Joining organizations that use collective power to influ-
ence policy such as the American Nurses Association
(ANA), state/local nursing association, or specialty
nursing associations.

• Seeking out policy workshops, internships, or
fellowships.

• Attending a town hall meeting.

BOX 21–3 n Advocacy for Particular Health Policies

• Keep it short.
Effective communication is brief and direct.

• Focus on one topic.
Limit your communication to one topic/subject. Clearly
state your topic/subject in the opening paragraph.

• Share experiences.
Although using form letters to provide a template to
work from is easier, they do not carry the same weight as
communication written in your own words. Providing per-
sonal experiences and views gives the issue a human face.

• Provide your name and contact information, including
address.
Legislators and policy makers pay most attention to
communication that comes from individuals who have
the potential to vote for them. Including your contact
information also enables them to contact you with
questions or for clarification.

• Persistence pays off.
Contact legislators and their staff frequently, particularly
if they have not taken a position on an issue.

BOX 21–4 n Tips for Communicating With Policy
Makers

Congressional Fellows Program
Congressional Fellowships on Women and Public Policy
Coro Fellowship in Public Affairs
Kellogg Fellows in Health Policy Research
Nursing Organization Alliance: Nurses in Washington

Internship (NIWI)
Presidential Management Fellows Program
Robert Wood Johnson Health Policy Fellows Program
Watson Fellowships
The Wellstone Fellowship for Social Justice
White House Fellows Program

BOX 21–5 n Examples of Public Policy Internships
of Interest to Registered Nurses

7711_Ch21_537-568 21/08/19 11:09 AM Page 557

Nursing has a legacy of political advocacy. Florence
Nightingale, Lillian Wald, and Mary Breckinridge were
all instrumental in shaping public health policy during
their time. Today, political involvement by nurses con-
tinues to shape public health policy and contribute to so-
lutions to improve population health. Nursing has the
potential to affect health policy in any country because
of its large numbers in the health workforce. Institution
of sound public health policy improves the health of the
patients whom nurses care for and the communities in
which their patients live.

Public Health Finance
To further understand the public health system, it is im-
portant to understand how public health services are
funded. Public health finance is a complex system in-
volving funding streams, economic factors, and policy
and political changes. This complexity along with the
lack of transparency and the wide variation in local pub-
lic health discretionary spending make it difficult to es-
tablish a consistent blueprint of public health agency
funding. In the 1955 issue of the American Journal of
Public Health, Burney and Yoho suggested that “the eco-
nomic status of local government has been the most im-
portant single deterrent to the expansion of community
health services”.82 They posited that, as local health de-
partments strive to meet the needs identified in commu-
nities, they must also convince people that the benefits
of the services required to meet those needs are worth
the cost. This necessitates a realistic evaluation of all pub-
lic health programs and a degree of fiscal scrutiny, which
promotes selection of those programs predicted to have
the most significant impact on the population relative to
the costs involved (see Chapter 13).82 Unfortunately,
there appears to be little progress made in connecting the
relationship between public health funding/expenditures
to the health of populations.

Finance Terms
There are basic terms associated with health-care fund-
ing. Broadly speaking, health economics is a field that
encompasses the process of understanding the supply
and demand for health-care services.83As stated by the
CDC, “Economics [is] the study of decisions—the incen-
tives that lead to them, and the consequences from
them—as they relate to production, distribution, and
consumption of goods and services when resources are
limited and have alternative uses.” The CDC then
applies economics to the process for conducting cost-
benefit analysis as it applies to preventive strategies.

They compare the costs and outcomes among alterna-
tive strategies aimed at preventing adverse injury and
disease.84 Public health finance is specific to population-
level health care and includes the acquisition, utilization,
and management of the resources needed to deliver
public health services provided by public health agen-
cies and departments. It also includes an examination
of how those resources affect both population health
and the public health system.85

Public health economics examines the financing of
public health from a governmental perspective with a
focus on the delivery and funding of public health goods
and services. Public health economists are concerned
with the cost analysis, economic evaluation, modeling,
and analysis of health-care regulation on the cost, bur-
den, health, effectiveness, and efficiency of health pro-
grams.85 Cost comparisons of health outcomes or health
events may inform public health leaders and policy
makers regarding the return on investment for public
health funds. One modeling approach is the use of cost-
effectiveness analyses focusing on one outcome to deter-
mine the most cost-effective intervention when several
options exist. For example, the cost of screening an entire
town for a specific disease may cost $150 per new case,
whereas the cost of screening high-risk groups may iden-
tify cases at a cost of $50 per new case.85

Public Health Funding
People in every community in the United States have
come to expect a basic level of public health services, in-
cluding food and water safety and control of communi-
cable disease outbreaks. These services come with a price
tag and require a well-trained, well-equipped, and well-
prepared public health system. Funding levels and
sources of public health and disease prevention programs
vary dramatically from neighborhood to neighborhood,
community to community, city to city, and state to state.
To adequately provide these services requires stable and
adequate funding.86

An example of how funding affects public health is the
Flint, Michigan, water crisis of 2014-2017. A coalescence
of severe fiscal distress and the decision to change the city
water supply to a cheaper but corrosive source without
concomitant use of corrosion inhibitors led to a high
level of lead contamination of city water supplies. Al-
though community members complained about the
taste and smell of the water, it appears that lack of polit-
ical power of the affected low-income majority African-
American population delayed identification of the
problem. Thousands of children were exposed to lead
contamination.87

558 U N I T I I I n Public Health Planning

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Federal Funding
Historically, the federal government funded programs to
ensure the health of specific groups of people. In 1798, the
federal government created the Marine Hospital Service,
under the direction of the Surgeon General, to provide
health care for sick and disabled sailors and to protect the
nation’s borders against the importation of disease through
seaports.88 Funds for these services came from a per-month
charge of 20 cents taken from the wages of American
sailors.88 In 1879, the federal government established the
National Board of Health, charged with overseeing the
health of the public. Due to disagreement about the author-
ity of the U.S. government and other concerns, it ceased to
exist in 1893.89 Currently the United States Public Health
Service (USPHS) is charged with protecting the health of
the nation. Within the USPHS, many laws were created to
protect the public from disease. The federal government,
in cooperation with the health department, established
quarantine rules along with a means to record vital infor-
mation (e.g., births, deaths, and specified diseases).89 Fund-
ing for state and local municipalities to support these efforts
still comes primarily from federal and state sources.

The CDC, established in 1946, is a significant source
of public health funding through grants and contracts to
state and local public health departments. In fiscal year
2017, they reported that they awarded approximately
85% of their budget of about $11.9 billion through their
grant programs and contracts. They awarded more than
23,000 separate grant and contract actions and provided
more than $11.9 billion for public health programs. 90

The CDC funds health-related and research organiza-
tions that contribute to the CDC’s mission through
health information dissemination, preparedness, preven-
tion, research, and surveillance.91

All federal funds are categorical in nature and address
specific programming. Many local health departments
receive federal dollars to fund programs. Examples of
federal funds that help fund programs include the Title
V Maternal Child Health program; Women, Infants, and
Children (WIC); and the Well Women HealthCheck
Program. Changes in federal funding levels affect the
local health department to provide categorical program-
ming. Examples of the changing federal revenue streams
include increased funding to combat the growing opioid
abuse epidemic and decreased funding for public health
emergency preparedness.

State Funding
State health departments are central to the public health
system. The U.S. Constitution identifies the states as pri-
marily responsible for the health of their citizens and

authorized to carry out these functions through a variety
of state agencies.85 The official state public health agency
is often a freestanding department reporting to the gov-
ernor of the state. In many cases, the state health depart-
ments rely on regional or district offices to carry out their
responsibilities as well as to support the local health
departments.85 State statutes and policies dictate the
programs and services offered and include regulatory,
program, and service mandates. Funding for state health
departments and programs varies widely in the United
States, primarily coming from a combination of federal
grants and contracts, program fees, and tax revenues. Ex-
amples of state public health programs include adminis-
tering the WIC program, collection of vital statistics,
tobacco use prevention, public health laboratories, food
safety, and health facility regulation.85

Local Funding
The local health department, where most direct public
health service delivery occurs, provides the majority of
community prevention and clinical preventive services.
In 2016, local health department expenditures ranged
from $250,000 to more than $25 million.92 Local sources
(30%) provided the greatest source of funding, followed
by state funds (21%), federal dollars passed through the
state department (17%), and federal dollars provided di-
rectly to the state (7%). Medicaid, Medicare, private
grants, and fees make up the majority of local health
department funding.85,92,93

Significant variation exists in local health department
per capita revenues and expenditures throughout the
United States. In 2016, the local health department me-
dian per capita expenditure was $39, whereas the median
per capita revenue was $41. In 10 states, the median per
capita expenditure was less than $30, whereas in four
states it was more than $70.92 Reasons for this variation
are multifaceted and include geographical size, popula-
tion size and characteristics, variation in tax base among
counties and municipalities, types of services offered, and
type of governance (i.e., city, county, regional, state, or
shared governance).

Health department structure and governance can af-
fect the amount and source of funding for programming
(Box 21-6). In 2016, 69% of local health departments in
the United States were county-based, with 20% based in
city or townships and governed by a local board of health
or county commission or executive.92 The remainder of
the health departments served a regional or multicounty
jurisdiction or a mixed jurisdiction serving both a county
and a city located outside the county boundaries.92 These
differences may affect the revenue sources and per-capita

C H A P T E R 2 1 n Health Planning, Public Health Policy, and Finance 559

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funding levels that fund a local health department. For
example, health departments using a state/regional
model may not receive local levy as a revenue source.

Another critical factor in local health department
funding is the size of the population served and the array
of programs and services provided. In 2016, the median
annual expenditures for health department funding was
$1.3 million, with a range of $480,000 for local health de-
partments serving fewer than 25,000 people to $56.4 mil-
lion for those serving 1 million or more residents.92 This
variation in funding may lead to differences in service
availability and delivery across geographical locations.
Also, greater funding from both public and private
sources is sometimes, but not always, available to depart-
ments that demonstrate increased community health
needs (i.e., high morbidity and mortality rates, poverty
levels) and positive program outcomes. The types of
services most often provided include immunizations for
children and adults, communicable disease surveillance,
tuberculosis screening, inspection/licensing of retail food

establishments, environmental health programming, and
tobacco use prevention.92

The complexity and political constraints of public
health policy and related finance can be illustrated by
the Zika virus epidemic of 2015-2016. Zika virus is
spread by the bite of an infected daytime-active
mosquito (Aedes aegypti or Aedes albopictus), by an
infected pregnant woman to the fetus during preg-
nancy or at the time of birth, or, rarely, by sexual con-
tact.94 The Zika virus is usually asymptomatic or mild
and of short duration. However, there does seem to be
a relationship between Zika infection and later devel-
opment of Guillan-Barre syndrome. In utero transmis-
sion is related to serious birth defects, specifically
microcephaly and other brain defects. There is no
vaccine or cure for Zika.

An epidemic of Zika virus spread from 10 countries
in January 2015 to 65 countries in July of 2016.95 Public
health agencies and organizations in the U.S. and world-
wide were on high alert. Initially the National Institutes
of Health and CDC diverted funds from other funded
programs such as immunization, Ebola, and cancer to
fight this epidemic. Additionally, philanthropic funds
were raised.96 During the first three quarters of 2016, sev-
eral federal bills were proposed and debated to fund
federal Zika control and research efforts. These were
stymied because of political considerations related to po-
tential requests for medical abortion after discovering an
infection or fetal birth defects and because of debate
about which other programs, including the ACA, that
should receive less funding in exchange for Zika control
funding. Finally, in September 2016, Congress approved
$1.1 billion to combat the Zika virus.97

CDC funds were awarded to public health partners, in-
cluding all state public health departments and selected
local public health departments, to combat the virus.98

Funds were allocated within the CDC and to external part-
ners to enhance epidemiologic surveillance and investiga-
tion; teach health-care providers to identify Zika; build
laboratory capacity for diagnostic testing; keep blood sup-
plies safe; develop and contribute data to the U.S. Zika reg-
istry; research the relationship between Zika virus
infection and birth defects; and educate the public about
the virus, especially in regard to travel to Zika-affected
areas, personal protection to prevent mosquito bites, and
mosquito control.

Grants
Grants are monetary awards given by an organization
or government agency to plan and implement a pro-
gram or project. Often grant dollars are distributed via

560 U N I T I I I n Public Health Planning

Trust for America’s Health recommends:

1. Core funding for public health—at the federal, state,
and local levels—should be increased.

2. First dollars of core (PH) funding should be used
to assure all Americans are protected by a set of
foundational PH capabilities and services no matter
where they live.

3. Funding should be considered strategically, so funds
are used efficiently to maximize effectiveness in
lowering disease rates and improving health.

4. The Prevention Fund, identified as part of the Afford-
able Care Act enacted on March 23, 2010, should be
implemented quickly and strategically to effectively
and efficiently reduce rates of disease.

5. Stable, sufficient, dedicated funding should be provided
to support public health emergencies and major disease
outbreaks—so the country is not caught unprepared for
threats ranging from Ebola to an act of bioterrorism—
and is better equipped to reduce ongoing threats such as
the flu, foodborne illnesses and the measles.

6. Accountability should be a cornerstone of public
health funding. Americans deserve to know how
effectively their tax dollars are used, and the govern-
ment’s use of funds should be transparent and clearly
communicated with the public.

BOX 21–6 n Public Health Funding
Recommendations

Source: Trust for America’s Health. (2016). Investing in America’s Health: A state by
state look at public health funding and key health facts. Retrieved from http://
healthyamericans.org/assets/files/TFAH-2016-InvestInAmericaRpt-FINAL

7711_Ch21_537-568 21/08/19 11:09 AM Page 560

a competitive process with many agencies vying for the
same dollars. Other grants may be noncompetitive but
prescriptive in nature. With reduced budgets, many
public health agencies have turned to grants to offset re-
duced funding from local tax levies. National and local
organizations such as the United Way help support local
programs designed to serve some of the most vulnerable
populations (e.g., health care for the homeless). Grant
funds are often time limited, requiring the grantee to
demonstrate sustainability and a plan to evaluate the
outcomes of the project after the grant period ends.99

The Local Health Department Budget Process
Through the community health assessment process, local
health department representatives along with commu-
nity stakeholders (e.g., representatives from a variety of
community organizations, police and fire departments,
local health system) identify public health issues and ac-
tion plans to address these. The resulting community
health improvement plan identifies possible solutions to
public health issues that influence programming and
budget allocations. As public health budgets shrink, this
process provides a critical justification for program
revenues and expenditures.

The process of health department funding involves the
complex interaction of government agencies, public/pri-
vate partners, county officials, local taxpayers, and public
health agency staff (see Chapter 13). Inherent in the
process is the knowledge that public health funding, given
these interdependent relationships, can vary significantly
from one fiscal year to the next. Because local taxpayers
support the bulk of public health funding, economic in-
stability can have a significant impact on the ability of
health departments to deliver services. Many local health
departments rely on local tax dollars or levies affected by
both political and economic forces. For example, many
municipalities collect taxes based on property values. This
approach to taxation is vulnerable to the ups and downs
of the economy. When the housing market is down, and
property values fall, tax revenue is also reduced. This re-
sults in budget shortfalls that might lead to a reduction of
or charges for services that were once free.

Health programs mandated by state statute must be
provided regardless of budget concerns. Examples of
mandatory programs may include inspections of estab-
lishments serving food to the public and communicable
disease follow-up to limit the spread of illness. Others,
however, such as programs addressing child abuse pre-
vention or suicide prevention, may be vulnerable to re-
ductions or elimination if there are no grant funds or
partnerships to sustain them.

The public health nurse and other local health depart-
ment staff play a critical role in the budget process. Local
health departments typically operate on an annual fiscal
year (January to December) budget cycle, with programs
often funded through a combination of federal, state, and
local tax dollars. Other sources of program funding such
as grants may operate on a different fiscal cycle with report-
ing timelines from July to June or October to September.

Public health nurses in charge of specific programs must
provide the required reports to the funding source to en-
sure continued program funding. Public health nurses,
with their intimate connection to the community, help give
voice to those served, supporting board members and other
decision makers with real-life examples to add relevance,
relationship, and emotion to statistics and dry reports.

Funding and Access to Care
Low-income families face a web of problems that com-
promise their ability to financially seek out health care.
These problems can include a lack of health insurance,
unemployment, old age, incarceration, chronically ill or
disabled family members, lack of child support, debt, and
low educational level. Low minimum wages and unreal-
istically low federal poverty guidelines often leave these
families with an inability to support themselves and with-
out the knowledge of their eligibility for services. This
section discusses some of the federal/state programs that
offer a safety net for both health insurance and income.

Government Health Insurance Programs
Medicare and Medicaid account for the greatest expen-
diture of federal governmental health-care spending.
Through these programs, the federal government pur-
chases services for population groups via health-care
organizations, including both private and public sector
providers such as physicians, hospitals, health mainte-
nance organizations (HMOs), community health cen-
ters, and health departments.

Medicaid
Medicaid is a federal and state partnership that covers
health costs for certain groups of people, including those
with lower incomes, disabilities, older people, and some
families and children. Medicaid eligibility rules vary in
each state and are complicated by whether the state has
opted into the Medicaid Expansion as part of the ACA.
State-specific Medicaid eligibility and coverage can be
obtained on the Medicaid.gov website. Medicaid benefits
and the contrasts with Medicare benefits are found in
Table 21-5.

C H A P T E R 2 1 n Health Planning, Public Health Policy, and Finance 561

7711_Ch21_537-568 21/08/19 11:09 AM Page 561

The Medicaid services that must be covered for chil-
dren and sometimes for adults include: physical, occu-
pational, or speech therapy; eye doctor visits, eyeglasses;
audiology, hearing aids; prosthetic devices; mental
health services; respite and other in-home, long-term
care; case management; personal care services; and hos-
pice services.100

Medicaid is an evolving program that was initially
created in 1965 with the Social Security Amendments.
It took 18 years for it to become available in every
state.100,101 Initially, Medicaid focused on children under
the age of 21, but in the 1970s it was extended
to those who were disabled. In the 1980s, there were
inclusions for pregnant women, illegal immigrants for
some emergency situations, and dental needs. In 1991,
the Medicaid Drug Rebate Program was put into place
to cover the cost of prescription drugs; in 2000, the Breast
and Cervical Cancer Treatment and Prevention Act
allowed any uninsured woman with breast or cervical
cancer to be treated.100,101 The latest evolution was the
states’ optional opt-in to expanded Medicaid eligibility

under the ACA beginning in January 2014. The mini-
mum eligibility level for Medicaid is 133% of the federal
poverty level ($33,383 for a household of four for 2018)
for almost all Americans under the age of 65.102

Children’s Health Insurance Program
Children’s Health Insurance Program (CHIP) is also a
federal and state partnership that provides coverage for
children who live in families that earn incomes too high
to qualify for Medicaid but too low to afford private
health insurance. Basic eligibility is focused on three
groups: children up to age 19, pregnant women, and
other citizens and legal immigrants. Families of four with
incomes up to $52,208 are considered eligible for CHIP
with no copay; in some cases, families with higher in-
comes may also qualify.103 Pregnant women may be eli-
gible, and CHIP will generally cover lab testing, labor and
delivery costs, and 60 days of care after delivery. Finally,
U.S. citizens and some legal immigrants are covered, but
states have the option of providing this coverage. As with
Medicaid, undocumented immigrants are not eligible for

562 U N I T I I I n Public Health Planning

TABLE 21–5 n Comparison of Medicaid and Medicare

Medicaid Medicare

What is it?

Who runs the program?

What does it cover?

What does it cost?

A federal health insurance program for:
• Individuals aged 65 and older
• Certain disabled individuals, under age 65
• Individuals with end-stage renal disease

Federal government

Part A: Inpatient hospital care and some care
in a skilled nursing facility

Part B: Doctor visits and care received as an
outpatient, some preventive services

Part D: Some pharmacy prescription coverage
• Does not cover long-term custodial care

Depends on which parts of Medicare the
individual selects. It can include copayments,
deductibles, and premiums.

A combined state and federal health insurance
program for people with limited resources
and income. Certain components of the
program such as CHIP help certain
populations.

State government

Coverage is dependent on the state program
but typically covers:

• Laboratory tests and x-rays
• Inpatient hospital care
• Health screening
• Dental and vision care
• Long-term care and support in a skilled facility
• Family planning and midwifery services
• Doctor visits, outpatient health care
• Prescription drugs
• Home health-care services for certain people
• Nursing home care even when custodial

Depends on the rules in the state and the
income and resources of the individual. Many
are exempt from any out-of-pocket costs.
Others have copayments, deductibles, and
premiums.

Source: United Health Care. (2017). Medicare versus Medicaid. Retrieved from http://www.medicaremadeclear.com/about/medicare-
vs-medicaid/

7711_Ch21_537-568 21/08/19 11:09 AM Page 562

CHIP.103 The services provided are similar or identical
to Medicaid and include routine checkups, immuniza-
tions, dental and vision care, inpatient and outpatient
hospital care, and lab and x-ray services.104

Medicare
Medicare is health insurance that covers three groups
of people: people aged 65 or older, people under 65
with certain disabilities, and people of all ages with
end-stage renal disease (permanent kidney failure re-
quiring dialysis or a kidney transplant). Medicare is
also part of the Social Security Amendment signed into
law on July 30, 1965, by President Johnson, providing
the first federally funded health insurance for those 65
and older. The other significant change occurred in
2003 when President George W. Bush signed into law
and added the outpatient prescription drug benefit to
Medicare recipients.105

There are three parts to Medicare. Part A is Hospital
Insurance that covers inpatient care in hospitals, hospice,
some home health, as well as skilled nursing facilities that
are not considered custodial or long-term care settings.
Most people do not pay a premium because they have al-
ready paid for the insurance as part of their taxes. Part B
is Medical Insurance that covers doctors’ services, out-
patient care, and some additional services of physical and
occupational therapists, home health, and some medical
supplies. For this portion, most people paid a monthly
premium (about $134/month in 2018).106 If someone has
Part A and Part B, that person can choose to enroll in
Medicare Part C (Medicare Advantage). Part C allows
people to receive all of their care through a selected pri-
vate provider organization (such as an HMO or preferred
provider organization) administered by Medicare. Part D
is the Medicare prescription drug coverage and is actu-
ally a separate policy that one must purchase from a pri-
vate insurer. Beneficiaries choose a drug plan and pay a
monthly premium to reduce prescription drug costs.106

Government Income Support Programs
Temporary Assistance for Needy Families
Temporary Assistance for Needy Families (TANF) is a
cash assistance program generally limited to 60 months
in an adult’s lifetime. The money for this program is a
block grant from the federal government that allows flex-
ibility to each state for developing its own program. The
purpose of TANF is to make the assistance temporary,
not permanent, by supporting economically needy fam-
ilies, helping parents complete their education, teaching
job skills, and encouraging two-parent families. There are

work requirements for the adult program participants,
and teen parents must live with their parents or a super-
vising adult and remain in school. Most recipients of
TANF also qualify for Medicaid.107

People With Disabilities
The federal government administers two income supple-
ment programs that serve individuals with disabilities.108

The first is Social Security Disability Insurance (SSDI),
a federal program that provides income benefits to indi-
viduals (or in some cases, family members) if the disabled
person has worked long enough in the past (40 quarters,
10 years) to pay Social Security tax, and is expected to be
unable to work for at least 1 year. It can be provided on
a temporary or permanent basis as defined by the dis-
ability. There is no income or resource restriction.108

The Supplemental Security Income (SSI) is also a
federal income supplement program, but general tax rev-
enues, not Social Security taxes, fund it. It covers adults
and children who have a significant physical or mental
disability that has lasted or is expected to last at least
12 months, have limited income level and resources, or
have not met the work requirement for SSDI, as well as
people 65 and over without disabilities who meet the
financial limits. The disabled individual must remain
below the income threshold to continue to receive SSI.
It provides cash to meet basic human needs such as food,
shelter, and clothing. Most people who receive SSI also
qualify for Medicaid.108

Supplemental Nutrition Assistance Program
(SNAP) is sometimes colloquially called the Food
Stamp program and is administered by the Food and
Nutrition Service of the U.S. Department of Agricul-
ture. This program provides financial assistance for the
purchase of food to help recipients maintain a healthy
diet; it is the largest program in the domestic hunger
safety net. People who are eligible for TANF and SSI are
automatically eligible for SNAP, and others are eligible
if they meet the financial requirements.109 Women, In-
fants, and Children (WIC), a federal grant program
(not an entitlement program), also provides nutritional
supplements to nutritionally at-risk, low-income preg-
nant women until 6 weeks postpartum, breastfeeding
mothers until an infant’s first birthday, and children up
to the age of 5. WIC pays for essential items such as
milk, eggs, and baby formula, and currently serves up
to 53% of all infants born in the United States. The pro-
gram also provides education and counseling at the
WIC clinics, and screening and referrals to other health
and social service agencies.110

C H A P T E R 2 1 n Health Planning, Public Health Policy, and Finance 563

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n Summary Points
• Public health policies are authoritative governmen-

tal decisions made in government, agencies, or or-
ganizations that are directed toward influencing
actions, behaviors, or decisions influencing popu-
lation health.

• Public health policy is intrinsically connected to our
health-care system, values, and underlying philoso-
phies about the place of government versus the
market system.

• Public health policies are enacted at national, state,
and local levels of government as well as by busi-
nesses and organizations.

• Public health policies are grounded in the health
planning process. A policy’s likely effectiveness,
efficiency, and effect on equity should be
considered.

• Public health policies focus on health determinants
and are based on evidence.

• Nurses can be involved in the public health policy-
making process through individual and collective
actions.

• Public health departments receive funding from a
variety of sources including federal, state, and local
tax dollars as well as grants.

• The majority of funding for local health depart-
ments comes from local sources, and per-capita
funding varies widely across the United States
based on type of government structure (city,
county, region), geography, population size
and characteristics, tax base, and types of services
offered.

• The greatest expenditure of federal health-care dol-
lars are Medicare and Medicaid.

• Government income support programs, including
Social Security Disability, Supplemental Security
Income, and Woman, Infants, and Children,
provide support to persons whose income or
health status leaves them vulnerable to poor
health.

• The Affordable Care Act of 2010 signed into law
by President Obama, along with associated regula-
tions, overhauled the U.S. health-care system and
focused on improving quality and reducing cost of
health insurance for individuals. Notable changes
in coverage include greater access to preventive
care and services and the creation of health
insurance exchanges to increase coverage and
affordability.

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564 U N I T I I I n Public Health Planning

t CASE STUDY
Addressing the Opioid Crisis
Through Health Policy

Learning Outcomes
At the end of this case study, the student will be able to:

• Gain understanding of the public health policy.
• Describe the role of policy in the promotion of the

public’s health.

As a public health nurse in a small rural community
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from the state can fund purchase and distribution
of the opioid overdose reversal agent, naloxone.
Currently, the police department and local hospital
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of the next 2 years.

Discussion Questions:
1. Should the health department participate in the

program? Why or why not?
2. Assuming the health department decides to

participate:
a. What individuals, businesses, organizations, or

agencies should receive or not receive naloxone
doses?

b. Should the health department charge a nominal
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c. What elements should be included in a
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72. Sabella, D. (2011). The role of the nurse in combating human
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76. Vandenhouten, C. L., Malakar, C. L., Kubsch, S., Block, D., &
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77. American Public Health Association. (2018). Advocacy and
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78. Association of Public Health Nurses. (2016). Public Health
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569

Chapter 22

Health Planning for Emergency Preparedness
and Disaster Management
Gordon Gillespie

LEARNING OUTCOMES

After reading the chapter, the student will be able to:

KEY TERMS

1. Describe the impact of natural and manmade disasters
on population health.

2. Appreciate the unique role of nurses during disasters and
public health emergencies.

3. Discuss the five areas of focus in emergency and disaster
planning: preparedness, mitigation, response, recovery,
and evaluation.

4. Apply the emergency preparedness theoretical
framework to a public health disaster scenario.

5. Describe the structure and organization of local and
national disaster mitigation efforts.

6. Describe the process of epidemiological surveillance
during community disaster mitigation and recovery.

7. Recognize the role of functional needs support services
to optimize the health outcomes of vulnerable
populations affected by a disaster event.

Bioterrorism
Blast events
Blast wind
Crown fire
Disaster
Disaster epidemiology
Disaster management
Disaster planning

Emergency information
systems (EISs)

Emergency preparedness
Emergency preparedness

and disaster
management (EPDM)

Evacuation
Extreme heat

Ground fire
Hazardous materials
Manmade disaster
Mass casualty event
Mitigation
Natural disaster
Preparedness
Point of dispensing

Quarantine
Recovery
Response
Response evaluation
Risk communication
Surface fire
Surge
Triage

n Introduction
The necessity of strategic emergency preparedness and dis-
aster management for manmade disasters was made all too
clear in 2001 during the attacks on the World Trade Center
and the Pentagon. Natural disasters such as Hurricane
Katrina in 2005, the Haitian earthquake of 2010, Hurricane
Maria, and the Palu, Indonesia earthquake and tsunami of
2018 continue to highlight the ongoing process of learning
how best to address these events (Fig. 22-1). The world
watched in dismay at the impact these disasters had on
the communities involved. Despite the horror of the
September 11 attack on New York, the city had learned
from the 1993 World Trade Center bombing, and had an
emergency preparedness and disaster management plan in
place. For Katrina and the Haiti earthquake, by contrast,

the lack of clear plans resulted in increased mortality and
exacerbated the effect of the disasters on the communities
affected in both the short and long terms. These and other
events resulted in an increase in concentrated training by
health-care providers and first responders. The benefits of
this relentless training resulted in minimal loss of life dur-
ing the 2013 Boston Marathon bombings, yet further work
is needed as disasters such as Hurricane Maria unfold,
demonstrating the challenges of responding rapidly and
effectively when a large population is affected.

Because weather-related events are ubiquitous and can
occur without warning, humans have had little recourse
but to prepare to respond to the wrath of the environment
in which they live. Environmental devastation caused by
natural hazards of terrestrial origin (earthquakes, tsunamis,
blizzards, tornadoes, hurricanes, floods, wildfires, and

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extreme heat) is inevitable. Events such as the tornado that
hit Joplin, Missouri (2011), the tsunami in Japan and the
subsequent Fukushima nuclear disaster (2011), Superstorm
Sandy in the eastern United States (2012), Hurricane Maria
in Puerto Rico (2017), Hawaii’s Kilauea volcanic eruption
(2018), and the earthquake and tsunami in Palu, Indonesia
(2018), reveal an increasing intensity in disaster impact and
destruction. The number of people affected, and the human
and economic losses associated with these events have
placed an imperative on disaster planning for emergency
preparedness. Global warming, climate shift, sea-level rise,
and societal factors may coalesce to create future calamities.
Addressing disasters will take more than refining our abil-
ity to respond; sustainable approaches must be built
in based on equitable resilience.1 The International Red
Cross and Crescent Federation called for “… humanitarian
action, one that strives to strengthen the resilience of
vulnerable and at-risk communities.”2

Concurrent to these events is the ever-present risk of
a manmade disaster such as an accidental or deliberate
release of a biological, chemical, or radiological agent, or
the use of an explosive device. Forced migration and peo-
ple forcibly displaced by war (complex human emergen-
cies),3 acts of aggression, political upheaval, populist
uprisings, and the increasing incidence of global terrorist
attacks are reminders of the potentially deadly conse-
quences of our inhumanity toward one another. The
enormous human costs of forced migration—destroyed
homes and livelihoods, increased vulnerability, disem-
powered communities, and collapsed social networks and
common bonds—demand urgent and decisive action by
disaster relief agencies.3,4

Natural disasters result not only in increased morbidity
and mortality but also in destruction of property and nat-
ural resources. They can result in a reduction in economic
productivity and harm to both the natural and manmade
environments. The mental health impact on a community
may be extensive, debilitating, and long-lasting. The neg-
ative impact of natural and manmade disasters can, at a
minimum, be mitigated or perhaps prevented entirely.
In expecting the unexpected,7,8 much can be done in
advance to anticipate and mitigate the devastating effects
of natural and manmade disasters. Ongoing research in
disaster science is paving the way to a world prepared to
prevent and manage disaster (Box 22-1).

Disaster Nursing
Adequate disaster preparedness and response is essential
for the delivery of lifesaving interventions and the opti-
mization of population health outcomes.7–9 Nursing is
the single largest profession in the health-care system,
so many of the first responders and most of the “first-
receivers” during a disaster event are nurses. In the wake
of any catastrophic event, communities will need nurses
who will respond quickly and are clinically competent to
provide safe, appropriate, individual, and population-
based care.8,12

570 U N I T I I I n Public Health Planning

Figure 22-1 Devastation from the Haiti earthquake.
(From the CDC, photograph by Lt. Cmdr. Gary Brunette, 2010.)

Disaster science, accompanied by major advances in
technology and meteorology, has provided a better
understanding of the hallmark characteristics of natural/
environmental hazards and the disasters they cause.

• Eric Noji noted in his sentinel disaster book that
“understanding the way that people are injured or
die as a result of a natural or manmade disaster is a
prerequisite to preventing or reducing deaths and
injuries during future disasters.”6

• Better scientific evidence enables nurses, health-care
planners, and public health officials to prepare for
these types of events and to develop advance-warning
systems to minimize injuries and the loss of life.
Advance preparation for a major disaster can later
result in significant reductions in mortality.7,8

• Postdisaster research has demonstrated access to care
and accurate surveillance are key factors in the effects
of natural disasters.9,10

• The use of mass casualty incident (MCI) triage can
reduce morbidity and mortality, yet further work is
needed to train first responders to utilize triage during
real world events.11

BOX 22–1 n Disaster Science Sources

7711_Ch22_569-606 22/08/19 11:13 AM Page 570

During a disaster, priorities change, and it might be-
come necessary to establish crisis standards of care.13

This involves a complex response on multiple levels in-
cluding individuals, families, health-care providers, crisis
communication, and government at the local, state, and
national level.14 When a disaster is in motion, as it was
with the tsunami and earthquake in Palu Indonesia in
2018, the objective for health-care providers responding
to the scene shifts from providing high-quality, individ-
ualized care to providing population-based care with the
goal of saving as many lives as possible. Valuable lessons
were learned from disasters such as the attacks on 9/11,
the Indian Ocean-Southeast Asian tsunami (2004),
Hurricane Katrina (2005), and the powerful 9.0-magni-
tude earthquake that hit Japan (2011). In 2011, the
Centers for Disease Control and Prevention (CDC) pub-
lished standards for public health departments building
preparedness capabilities15 with evidence that these stan-
dards have improved the public health response.16 Yet
challenges remain, and lives are still lost as they were in
Puerto Rico following Hurricane Maria.

Prior to such epic disasters, many nurses had only
imagined what such events would be like. A heightened
awareness now exists concerning what these disasters
will demand of both responders and hospital-based first
receivers. Nurses are needed across the disaster contin-
uum during all phases.8 Nurses, as victim advocates and
health educators, adopt a population focus during the
emergency preparedness and disaster-planning process
by engaging community participation in the process and
disseminating vital health and safety information
throughout a disaster event. Nurses help shape disaster
policy in their role as planners, evaluators, and leaders in
health care.8,12 Imagine that you wake up in the middle
of the night to find that an earthquake has occurred, dev-
astating your community. Your first response is likely to
think about your family, friends, and pets. Children, par-
ents, and other loved ones immediately enter your mind.
Where are they? Are they safe? Your next thought may
be to see who you can help, where you should go, and
what can you do. Your desire to help is compelling, and
you want to respond. But are you ready?

Disaster experts encourage taking time in advance of
an event to evaluate your personal and professional readi-
ness to respond (Fig. 22-2). All nurses should be able to
answer basic questions related to disaster preparedness
(Box 22-2). Much work remains to be done to ensure all
members of the nursing profession possess the knowledge
and skills necessary to respond appropriately to any type
of disaster. The responsibility lies within our profession to
engender a broad-based professional culture of excellence,

C H A P T E R 2 2 n Health Planning for Emergency Preparedness and Disaster Management 571

both in disaster nursing care and in our health systems’
management of catastrophic events.8,12

Emergency Preparedness and Disaster
Management
Emergency preparedness is the planning process fo-
cused on avoiding or ameliorating the risks and hazards
resulting from a disaster to optimize population health
and safety. By contrast, disaster management is the in-
tegration of emergency response plans throughout the
life cycle of a disaster event. Disaster management efforts
are stimulated by the population perception of risk
related to the hazards associated with the disaster.17

Disasters pose a unique threat to the health of the pop-
ulations affected and require strategic planning prior to
an event occurrence and efficient management during
the emergency.15–17 Public health emergency prepared-
ness and disaster management form a shared responsi-
bility that extends far beyond local and state health
departments and government organizations.15 Col-
laboration among private health organizations, social
organizations, community health providers, commu-
nity agencies, and the population at large is crucial for
success.

A disaster is an emergency of such severity and mag-
nitude that the resultant combination of death, injury,
illness, and property damage cannot be effectively man-
aged with routine resources or procedures.17 Disasters
can result from a variety of specific hazards, including
natural disasters such as communicable disease epi-
demics and severe weather, as well as manmade disasters
such as terrorism and chemical spills. Disasters have the
ability to cause catastrophic morbidity and mortality in
a population. The impact on public health may be imme-
diate or insidious, developing slowly in the days and
weeks following the event. Hurricane Maria in 2017 and
a major earthquake in Palu, Indonesia, in 2018 illustrate
the widespread morbidity and mortality associated with
a disaster. These disasters caused death, acute injury,
massive property damage, and loss of essential services
to the population. In addition, both disasters have led to
long-term health effects because of the total destruction
of the existing health-care system. The 2013 Boston
Marathon bombing resulted in injury and death in a
small area with no collateral damage to buildings, but
this terror event affected an entire city. Because of the
risk posed by the suspects while they were still at large, a
citywide order to shelter in place was enforced until
shortly before the suspects were apprehended. The 2018

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Hawaiian eruption of the Kilauea volcano led to an ash
plume 10,000 feet high and a lava flow that released toxic
hydrochloric acid and glass volcanic particles into the at-
mosphere once it struck the Pacific Ocean.

Emergency Preparedness Theoretical
Framework
Emergency preparedness and disaster management
(EPDM) is a continuous cycle lacking a true beginning
or end. The overarching concept of the emergency pre-
paredness framework is prevention as it relates to public
health. Public health practitioners are constantly learning

from the events of the past and present, and trying to fore-
see issues of the future. To effectively prepare for emer-
gencies and manage disasters when they occur, EPDM
plans are needed at the community, state, national, and
global levels. Disaster plans must be developed so that
timely interventions can be rapidly disseminated when a
threat surfaces or an emergency happens.

The four key concepts of the preparedness framework
include preparedness, mitigation, response, and recovery
(Fig. 22-3), and a fifth component, evaluation.18,19 Another
term for the life cycle of a disaster is the disaster contin-
uum. It is characterized by three major phases: preimpact

572 U N I T I I I n Public Health Planning

Figure 22-2 Readiness to respond: Disaster timeline.

Preparedness:
• Proactive.
• Structuring the disaster response
based on assessment of risk.

Mitigation:
• Long-term measures implemented
prior to an event to reduce harm.
• Establishment of immediate
changes to the response plan as
needed.

Response:
• Implementation may occur prior to
impact when event is predicted.

Warning

Evaluation informs updating preparedness plan

TIME FRAME

KEY COMPONENTS OF THE DISASTER CONTINUUM

Pre-impact/event Impact/event Post impact/event

Mitigation:
• Continuous evaluation of mitigation
plan to insure maximum effective-
ness.
• Establishment of immediate
changes to the response plan as
needed.

Response:
• Implement disaster plan and
provide
– Health care
– Human relief services (water,
food, shelter)

Recovery:
• Focus is on stabilizing and re-
turning community to normal.

Evaluation:
• What worked, what did not work,
and what changes are needed to
the disaster plan.

Prior to event occurring During the event After the event has occurred

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(before), impact (during), and postimpact (after). These
phases provide the foundation for the disaster timeline
(see Fig. 22-2). Specific actions taken during these three
phases, along with the nature and scope of the planning,
will affect the extent of the illness, injury, and death that
occur. There is a degree of overlap across phases, but each
phase has distinct activities associated with it. Each phase

incorporates vital components necessary for the overall
success of the response and occurs over the timeline.

Disaster Planning
The purpose of disaster planning is to prevent or reduce
the risk for adverse consequences posed by a natural or
manmade disaster. Different approaches to disaster man-
agement are used, with some plans taking an organiza-
tional management approach, and other plans taking a
more systemic view.18 Disaster planning is broad in scope
and should always address collaboration and mutual aid
agreements across agencies and organizations. It should
define all advance preparations as well as describe needs
assessments, event management, and recovery efforts.
The ability of a community and outside support systems
to rapidly respond and provide needed medical treat-
ment and supplies, shelter, food, and clean water are es-
sential in the prevention of morbidity and mortality
associated with the aftereffects of the disaster. This is
more likely to occur when there is a plan in place that
specifies the three critical “Cs” of disaster response: com-
munication, coordination, and collaboration. In addition
to immediate needs, a plan also must include a method
to address the long-term effects of the disaster that exist
in a population after the dust has settled. Thus, emer-
gency preparedness can avert or reduce both the short-
term and long-term effects of a disaster.

In addition, during the disaster, a well-developed in-
frastructure is needed to manage it. For example, in 2018,
a massive earthquake and tsunami struck Palu, Indone-
sia, causing catastrophic damage. There was no warning
as the tsunami warning system was not working. Thus,
the lack of emergency preparedness resulted in increased
morbidity and mortality.

C H A P T E R 2 2 n Health Planning for Emergency Preparedness and Disaster Management 573

Figure 22-3 Disaster continuum framework.

When working in a practice setting, it is important that
nurses review the organization’s emergency prepared-
ness and disaster management plan. Things to identify
prior to the occurrence of a disaster:

• Where is a copy of the plan located for the
organization?

• What is the plan for the specific unit or area of the
organization?

• Example of items to review in the plan:
• Location of the command center
• Plan for back up emergency power
• Exit routes
• Roles for each person in the unit/area
• Specific instructions for different types of disasters
• Communication and coordination plan
• Triage plan and report to work plan
• Emergency alarm systems

• What is the link between the organization and
community/governmental agencies?

• What are the priorities in relation to vulnerable
populations?

BOX 22–2 n Organizational Disaster Plan Review

Preparedness

MitigationEvaluation

ResponseRecovery

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Impending Storm
Public Health Science Topics Covered:

• Development of an EPDM plan
• Environmental assessment
• Advocacy

Susan Doe, RN, MPH, worked as the vice president
of community outreach at a regional hospital located
near Atlantic Ocean coastal areas. After Hurricane
Florence, a team was convened to revamp the EPDM
plan for the region to help avoid the problems en-
countered in North Carolina. The team began by eval-
uating the risk for severe weather events, identifying
the populations at greatest risk, examining the role of

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574 U N I T I I I n Public Health Planning

various responders, and evaluating potential problems
posed by a hurricane.

Of particular concern to the team was the recent
building of vacation homes by nonresidents of the state
and the building of sophisticated beach barricades by
owners of multimillion-dollar homes to protect those
properties, which might increase damage to the shore-
line following storms. Although the recent construction
had been beneficial to the economy and had taken
place because of a lack of updated ordinances, the
development resulted in changes to the coastline that
potentially reduced natural ecological defenses to hur-
ricane damage, which had protected the community in
the past. In addition, construction had increased the
number of residences and persons at risk for hurricane-
related damage should a hurricane hit while the sum-
mer people were in town. Another concern was that
the summer residents might not be as knowledgeable
about evacuation and emergency shelters that perma-
nent residents knew about through word of mouth.
To help develop an EPDM plan that addressed these
concerns, the team members realized they needed to
educate themselves on the concepts of preparedness,
response, mitigation, and recovery to organize an
emergency preparedness and disaster management
plan for their community.

The team began by looking at prevention. Preven-
tion during emergency preparedness and disaster plan-
ning includes efforts at multiple levels with the aim of
preventing not only injury and mortality directly related
to the disaster but also reducing damage to the infra-
structure of the community, thus preventing long-term
negative health consequences. Sue and her team real-
ized that, during a hurricane, injury and death directly
related to the storm surge are the most immediate
health concerns and often result in the greatest loss of
life. A storm surge is an abnormal rise of water gener-
ated by a storm, over and above predicted astronomi-
cal tides, which can cause extreme flooding in coastal
areas, particularly when it coincides with normal high
tide, resulting in storm tides reaching up to 20 feet or
more. However, after the event has passed, damage to
the infrastructure of the community could result in se-
rious health consequences because of lack of access to
the essentials of food, water, shelter, and medical care.
If the community is severely damaged, a large segment
of the population may be unable to return to their
homes, resulting in long-term adverse economic and
mental health issues. They concluded that their EPDM
plan needed to include mechanisms for the prevention

of both the direct and indirect negative consequences
potentially related to a disaster event.

Sue invited a consultant from the International
Federation of Red Cross and Red Crescent Societies
to help educate the team. The consultant suggested the
team begin with primary prevention. This part of the
planning process focuses on the development of strate-
gies that include both what to do when the event
occurs and what prevention efforts can be done to
decrease the threat to persons and infrastructure. The
consultant explained that the prevention efforts of an
EPDM plan related to a hurricane event would address
their concern about evacuation, because they would
now have a clear evacuation plan prior to the storm
reaching coastal lands. This would help prevent injury,
death, and exposure to communicable disease. The
team began to develop a plan that included how to
mobilize members of the community to follow the plan.
Based on the lessons learned from Katrina, the team
included instructions in the plan that would help direct
members of the community in gathering life-sustaining
items. They also began to work on the evacuation plan,
paying particular attention to communication with
those visiting the coastal area as tourists and renters as
well as the year-round population. They realized that
efficiently evacuating the community at risk prior to a
hurricane reaching land was more complex than origi-
nally thought. Based on the events during Superstorm
Sandy in 2012, they realized the area affected by a hur-
ricane could be quite large and required moving a large
population well inland. To effectively design their plan,
they brought in the state police and transit authorities.

The team began to see that prevention efforts must
also include building an infrastructure to prevent dam-
age. Thus, their hurricane EPDM plan was expanded to
include the development of hurricane-specific building
codes and the construction of seawalls. They began to
examine the impact of private barriers being built
around the wealthier beach communities. Based on the
success of communities in other states that had insti-
tuted these policies to reduce risk, the team began to
draw up recommendations to their community requir-
ing that construction of new buildings near the coastal
area be resistant to the effects of high winds, storm
surge, and floodwaters.

Sue’s team put their EPDM plan in place. The fol-
lowing fall, a hurricane hit their area. It was listed as a
Category 2 hurricane and did not require mandatory
evacuations. Luckily, the team had put in place an evac-
uation system that included a plan for both voluntary

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Preparedness
Preparedness occurs before impact and is a proactive
process for putting in place the structure needed for
disaster response (see Fig. 22-2). It begins with a risk
assessment to help determine the likelihood of a disas-
ter occurring and identifying vulnerabilities. A next
step is developing a monitoring process to forecast
future disasters, including location, timing, and
magnitude of a possible future event.18 Preparedness
begins with defining the precise role of public health
providers during the various disaster events. Multiple
agencies join forces during a disaster to form an organ-
ized web of responders. Each agency must be aware of
its role in the plan and the chain of command appro-
priate for the situation.15,18 For example, in preparing
for a major hurricane, the EPDM plan would include
a clear delineation of the role of the state and local of-
ficials in the chain of command, and agencies would
be identified to serve as support staff. National agen-
cies are included as appropriate, such as the Federal
Emergency Management Agency (FEMA), the U.S.
Coast Guard, the CDC, the Environmental Protection
Agency, the National Guard, and the Department of
Homeland Security (DHS). Nongovernmental stake-
holders are included in the plan as needed for a hurri-
cane event such as local hospitals, the American Red
Cross, and utility companies.

Once the final EPDM plan for the impending storm
is established, each state and local agency included in
the plan must develop an individualized response plan
and disseminate the information to the organizational
and public stakeholders. A key component to emer-
gency preparedness is each responding organization
independently and collectively demonstrating their
role during a disaster. Drills must be conducted that

C H A P T E R 2 2 n Health Planning for Emergency Preparedness and Disaster Management 575

and mandatory evacuations. The community was well
informed about evacuation routes, and a system was in
place to inform seasonal renters. The majority of the
population, especially the seasonal renters, chose to
evacuate. The evacuations began 24 hours prior to the
storm, and there was little difficulty in handling the
traffic headed out of the area. Because of the smooth
evacuation process, there was minimal need
to rescue people in harm’s way after the storm made
landfall.

The team also included secondary prevention
components in their plan. The components began with
a focus on preventing injury and disease by designating
safe places for residents to shelter. They realized
that not everyone would be able to evacuate, and this
population would include those most vulnerable,
especially the elderly or those with disabilities. Thus,
they designated shelters that included a mechanism for
providing for health needs during the storm. The goal
of this part of their plan was to prevent initial or
secondary injury. Residents unable to evacuate were
directed to these safe locations throughout the area.
These were shelters that could withstand the hurricane
storm forces.

The team also incorporated tertiary prevention
strategies into the plan, that is, strategies designed to
minimize the disease effects among those previously ill
in the community. They discussed the need to provide
short-term pharmaceutical supplies, such as insulin,
oxygen, and heart medications, to members of the
population with noncommunicable illnesses.

After the hurricane, Sue and her team reviewed the
event to see how the plan worked. They found that,
once people were safely in a temporary shelter, the
strategies used to prevent the spread of disease and to
maintain health among the victims of the storm seemed
to work. During the planning, Sue had informed her
team that, without careful planning, respiratory and gas-
trointestinal disease could spread quickly in an area of
mass population relocation.18 The plan had helped en-
sure that uncontaminated food and water, as well as
proper personal hygiene supplies, were available at each
of the designated shelters. In addition, vital medical sup-
plies were available, not only to treat injury, but also to
provide care. For example, shelters had adequate sup-
plies of medications, including antibiotics and insulin for
diabetic residents. Each shelter had designated nurses to
help care for the relocated population. These nurses
were a vital asset in the community’s effort to maintain
health during a hurricane and its aftermath.

Sue and her team concluded that their EDMP had
helped to reduce mortality and morbidity. However,
following the hurricane, an inspection of the beachfront
property hit hardest by the storm confirmed their
suspicion that private barriers erected by homeowners
may have protected those homes but resulted in fur-
ther beach erosion in other areas. The team concluded
that a Category 4 or 5 hurricane could result in higher
threats to morbidity and mortality due to the instability
of the beaches. Also, further action was needed for
primary prevention that would require possible legisla-
tion as well as an allocation of funds to further protect
the coastline.

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involve both the community and the organizations
identified in the plan prior to an event to help identify
and improve on the areas of weakness. Drills can also
improve the efficiency of the response across multiple
levels to a disaster event.20 Establishing interorganiza-
tional communication becomes a priority during a dis-
aster drill, as does communication with the members
of the community.15,16

Mitigation
Mitigation primarily occurs during the preimpact phase
(see Fig. 22-2) as a means to limit adverse effects of the
disaster and covers a wide spectrum of issues, including
health, infrastructure, and the impact on the economy.
These are long-term measures that aim to moderate the
impact of the event. Evaluation of the plan must con-
tinue throughout the response to ensure maximum
effectiveness. The established response plans guide the
endeavor. The first priority is to identify the affected
population and environment and adjust the plan as
needed to specifically target the community of interest.
Each disaster is a unique event that affects populations
with varying severity. Flexibility and creative problem-
solving techniques are vital for an effective public health
response. For example, relief shelters should be identi-
fied in coastal regions prior to a hurricane event. How-
ever, the storm forces could compromise the integrity
of a relief shelter. Mitigation includes making immediate
changes to the response plan and identifying a safe
structure to which to relocate the population.

Returning to the example of a hurricane event,
hurricane-related mitigation strategies could include
building flood levees, developing flood zones, establish-
ing clearly marked evacuation routes, and enforcing
building codes.

Response
When a disaster happens, the plan is put into action
(see Fig. 22-2). The response requires activation of the
various procedures planned prior to the event; it may
begin before the actual event, as with predicted weather
events such as hurricanes and blizzards. For example,
prior to a predicted severe weather event, orders are
made to mandate evacuations, shore up seawalls, and
close schools and businesses. In other cases, the event
is unforeseeable and plan is put into effect as the event
begins and continues throughout its duration. The
time frame of the response phase is specific to the event
itself. The purpose is to save lives, address health
threats, and maintain basic human needs such as food,

shelter, and water. Effective response to a disaster is
enhanced when there is an incident command center
and trial runs of the plan are conducted prior to the
disaster.12

Recovery
Recovery begins as the event ends (see Fig. 22-2), with
a focus on stabilizing the community through both re-
construction and rehabilitation.18 Recovery efforts en-
compass a wide range of activities, including restoring
infrastructure and buildings, and relocating those who
have lost their homes. The purpose of the response
plan is to minimize the long-term effects of the disas-
ter and address both the immediate and long-term
needs of the community. In the case of a major hurri-
cane, recovery begins when hurricane storm forces
end and floodwaters recede. The length of recovery
varies depending on the type and intensity of the dis-
aster. Short-term and long-term population impacts
are identified after the initial event has concluded.
Evidence-based science should be applied to ensure
continuous population protection. The structural
stability of buildings and homes becomes a concern,
as well as the availability of the resources necessary for
survival. Power outages can continue for an extensive
amount of time. Contamination from the floodwaters
and displaced sewage can pose long-term population
effects. Epidemiological surveillance is needed to
identify a possible increase in communicable diseases
in the region, especially waterborne and foodborne
illnesses.

Evaluation
Evaluation is an ongoing process that may begin during
the event to help inform ongoing response, although the
majority will occur after the event is over (see Fig. 22-2).
Thorough evaluation should follow every disaster re-
sponse to identify areas that need improvement. Al-
though some models, such as FEMA’s model, do not
include evaluation as part of disaster planning, evaluation
is essential to help inform ongoing EPDM planning18 and
public health policies. This quality assurance process
should involve all responding agencies and participants,
including volunteers. Revisions to the disaster plan then
become incorporated into future drills, exercises, and mit-
igation efforts. The quality assurance process does not
cease until all gaps have been addressed and alternative
planning is in place. Future disaster planning should
always be based on empirical evidence derived from
previous disasters.18-21

576 U N I T I I I n Public Health Planning

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Disaster Epidemiological Surveillance
During a disaster, principles of epidemiology help deter-
mine the immediate and long-term effects to public
health. The critical focus of disaster epidemiology is to
prevent or decrease morbidity and mortality associated
with acute or noncommunicable illnesses.18

A community rapid needs assessment identifies the
priority health issues in the population and assesses
the availability and accessibility of health services (see
Chapter 4). As previously noted, primary, secondary, and
tertiary methods of prevention play a critical role during
disaster mitigation. Other strategies include education of
the population to address possible hazards, such as con-
taminants that have the potential to cause illness, and
attempting to stabilize unstable structures.

Emergency Information Systems
The rapid collection and dissemination of disaster-
related data form a core component of epidemiological
surveillance. Emergency information systems (EISs)
are designed to collect population data during the im-
pact, mitigation, and recovery phases. Rapid data col-
lection and analysis during a disaster ensure a timely
flow of information to the appropriate responders.22

Ongoing population data collection and surveillance
allow public health providers to identify the needs of the
population and design interventions to decrease mor-
bidity and mortality. Disaster surveillance concentrates
on the incidence, prevalence, and severity of illness and
injury related to the event. An increase in endemic or
communicable disease can follow the disaster impact
due to population displacement, overcrowded shelters,
disruption of normal sanitation practices, and loss of
health services. Data focused on communicable disease
or exacerbation of noncommunicable illness help guide
population treatment.

All health-care facilities, including hospitals and clin-
ics, must participate in the collection of emergency in-
formation. Minimal data collection includes the surge
capacity of an organization that specifies the number of
available beds, staffing needs, and supply shortages.
Tracking the name and number of patients who have
been treated and are awaiting treatment assists public
health officials with overall population surveillance.
Community health-care providers and private laborato-
ries are important sources of patient-related disease and
injury data. Community providers can also educate in-
dividuals about communicable diseases and injury treat-
ment. An integrated EIS should be developed during the

planning phase and made accessible to all emergency re-
sponding agencies.

The National Notifiable Diseases Surveillance System
(NNDSS) is an example of an electronic reporting data-
base.23 The NNDSS facilitates electronically transferring
public health surveillance data from the health-care system
to public health departments. It is a conduit for sharing
information that supports NNDSS. Today, when states
and territories voluntarily submit notifiable disease sur-
veillance data electronically to the CDC, they use data
standards and electronic disease information systems and
resources supported in part by the NNDSS. This ensures
that state data shared with the CDC are submitted quickly,
securely, and in an understandable form. The NNDSS
helps connect the health-care system to public health de-
partments and those health departments to the CDC by
providing leadership and resources to state and local
health departments to adopt standards-based systems
needed to support national disease surveillance strategy.
This enables health agencies to use information technology
more effectively by developing patient-centered systems
that help health departments identify issues such as co-
morbidities (multiple diseases or conditions) that occur in
the same individual over time. The NNDSS also defines
and implements content standards (i.e., disease diagnosis,
risk factor information, lab confirmation results) for the
health-care industry to use.23

Postimpact Epidemiological Surveillance
Population disease and injury outcomes can be antici-
pated based on the specific type of disaster affecting the
population. For example, an increase in diarrheal dis-
ease is common after a flood because of the disruption
in sanitation practices and integrity of the public health
infrastructure. Respiratory illness increases after a wild-
fire as a result of the atmosphere contaminants released
into the air.24 Epidemiologists determine the association
between the exposure, the disaster event, and the out-
come. A standard case definition is established to iden-
tify and monitor affected persons. Detection thresholds
must be flexible to capture the changing levels of risks
and priorities related to population illness and injury.
For example, respiratory illnesses and long-term burn
treatment will be anticipated following a wildfire.
Postimpact surveillance monitors the increase in respi-
ratory disease from baseline, and tracks burn cases
caused by environmental exposures. Epidemiologists
anticipate a spike in respiratory illness and bodily
injury postimpact. Surveillance continues until levels
stabilize back to the regional baseline. Data collected and

C H A P T E R 2 2 n Health Planning for Emergency Preparedness and Disaster Management 577

7711_Ch22_569-606 22/08/19 11:13 AM Page 577

disseminated during a disaster assist in future planning
efforts by helping to predict possible health issues and
prioritize health education needs of a population af-
fected by a similar disaster.

Natural Disasters
In 2017, the world watched in awe as the forces of
Hurricane Maria assaulted the island of Puerto Rico and
devastated the lives of 3 million people on the island.
Hurricane winds destroyed buildings, power sources,
potable water supplies, and transportation systems. The
community suffered injuries from debris and unstable
structures. Contaminated water and food supplies left
the people without adequate nutritional support. With
utility and transportation infrastructure in ruins, the
populace was without access to health care and re-
sources from the mainland United States. The images
of an event such as this guide the efforts for future
preparedness efforts.

Natural disasters are events that occur from forces in
nature that are not the direct result of human activity.
These events lack controllability and may vary in their
predictability. Their onset can be acute and rapid or slow
and progressive. Natural disasters vary in the type and
degree of population impact. The probability of an event
occurring will vary depending on geographical region
and season. In understanding the various types of natural
disasters and determining the likelihood of these events
occurring in a specific region, nurses can be active par-
ticipants in the planning process, the management of a
disaster, and the evaluation of the plan.

Cyclones, Hurricanes, and Typhoons
Cyclones are large-scale storms characterized by low
pressure in the center surrounded by circular wind mo-
tion. The U.S. National Weather Service’s (NWS) tech-
nical definition of a tropical cyclone is “a non-frontal,
warm-core, low pressure system of synoptic scale, de-
veloping over tropical or subtropical waters and having
a definite organized circulation.”29

In practice, that circulation is a closed airflow at the
earth’s surface, turning counterclockwise in the Northern
Hemisphere and clockwise in the Southern Hemisphere.
Severe storms arising in the Atlantic waters are known
as hurricanes, whereas those developing in the Pacific
Ocean and the China seas are called typhoons. The
precise classification (e.g., tropical depression, tropical
storm, hurricane) depends on the wind force (measured
on the Beaufort scale, introduced in 1805), wind speed,
and manner of creation (Box 22-3).

A hurricane is a tropical storm with winds that have
reached a constant speed of 74 miles per hour or more.25

Hurricane winds blow in a large spiral around a relatively
calm center known as the eye. The eye is generally 20
to 30 miles wide, and the storm may extend outward
400 miles. As a hurricane approaches, the skies will begin
to darken, and winds will grow in strength. As a hurricane
nears land, it can bring torrential rains, high winds, and
storm surge. A single hurricane can last for more than
2 weeks over open waters and can run a path along the
entire length of the Eastern Seaboard. August and Sep-
tember are peak months during the hurricane season
which lasts from June 1 through November 30. Satellites
track hurricanes from the moment they begin to form,
so warnings can be issued many days ahead of the storm
strike. The greatest damage to life and property is usually
not from the wind but from tidal surges and flash flood-
ing. Hurricanes are typically rated on a scale of 1 to 5,
known as the Saffir-Simpson Hurricane Wind Scale. Cat-
egory 3, 4, and 5 hurricanes are considered to be major
storms.26 Because of their violent nature, potentially pro-
longed duration, and potential effects on an extensive
area, hurricanes or cyclones are potentially the most
devastating of all storms.

A distinctive characteristic of hurricanes is the
increase in sea level, often referred to as storm surge
(referred to earlier in The Case of the Impending Storm).
This increase in sea level is the result of the eye creating
suction, the storm winds piling up water, and the tremen-
dous speed of the storm. Rare storm surges have risen as
much as 14 meters above normal sea level. This phenom-
enon can be experienced as a large mass of seawater
pushed along by the storm with great force. When it

578 U N I T I I I n Public Health Planning

A tropical cyclone is a rotating, organized system of
clouds and thunderstorms that originates over tropical or
subtropical waters and has a closed low-level circulation.
Tropical cyclones rotate counterclockwise in the
Northern Hemisphere. They are classified as:

• Tropical Depression: A tropical cyclone with maximum
sustained winds of 38 mph (33 knots) or less.

• Tropical Storm: A tropical cyclone with maximum
sustained winds of 39 to 73 mph (34 to 63 knots).

• Hurricane: A tropical cyclone with maximum sustained
winds of 74 mph (64 knots) or higher; also called
typhoons in the western North Pacific or cyclones in
the Indian Ocean or and South Pacific Ocean.

BOX 22–3 n Cyclone Terminology

Source: (26)

7711_Ch22_569-606 22/08/19 11:13 AM Page 578

reaches land, the impact of the storm surge can be exac-
erbated by high tide, a low-lying coastal area with a
gently sloping seabed, or a semienclosed bay facing the
ocean.26

The severity of a storm’s impact on humans is exacer-
bated by deforestation, which often occurs as a result of
population pressure. When trees disappear along coast-
lines, winds and storm surges can overtake land with
greater force. Deforestation on the slopes of hills and
mountains increases the risk of violent flash floods and
landslides caused by the heavy rain associated with trop-
ical cyclones. At the same time, the main benefit of
the rainfall, replenishment of water resources, may be
negated because of the inability of a deforested ecosystem
to absorb and retain water.

In anticipation of a hurricane making landfall, disaster
planners and health-care providers should note that the
Saffir-Simpson Hurricane Wind Scale does not address
the potential for other hurricane-related impacts such as
storm surge, rainfall-induced floods, and tornadoes. It
also should be noted that these wind-caused damages are
to some degree dependent on the local building codes in
effect and how well and how long they have been en-
forced. For example, building codes enacted during the
2000s in Florida, North Carolina, and South Carolina are
likely to reduce the damage to newer structures. How-
ever, for a long time to come, the majority of the building
stock in existence on the coast will not have been built to
a higher code. Hurricane wind damage is also very de-
pendent on other factors, such as duration of high winds,
change of wind direction, and age of structures.26,27

Deaths and injuries from hurricanes occur because
victims fail to, or are unable to, evacuate the affected area
or take shelter, do not take precautions in securing their
property, and/or do not follow guidelines on food and
water safety or injury prevention during recovery. Nurses
need to be familiar with the commonly used definitions
for severe weather watches and storm warnings to assist
with timely evacuation or finding shelter for affected
populations. Morbidity during and after the storm itself
results from drowning, electrocution, lacerations, and
punctures from flying debris and blunt trauma or bone
fractures from falling trees or other objects. Myocardial
infarctions and stress-related disorders can arise during
the storm and its aftermath. Gastrointestinal, respiratory,
vector-borne disease, and skin disease as well as uninten-
tional pediatric poisoning can all occur during the period
immediately following a storm.24 Injuries from improper
use of chain saws or other power equipment, disrupted
wildlife (e.g., bites from mammals, snakes, or insects),
and fires are common. Fortunately, the ability to detect,

track, and warn communities about cyclones, hurricanes,
and tropical storms has helped reduce morbidity and
mortality in many countries.

The Anatomy of a Natural Disaster: Lessons
Learned From Hurricane Katrina
The National Hurricane Center in Miami, Florida, noted
the increasing force of a tropical storm over the Bahamas
on August 23, 2005, and issued the first advisory, stating
that the weather system would become Hurricane Katrina.
The storm continued to strengthen over the next 2 days
and came ashore late Thursday evening on the coast of
Miami. The hurricane caused significant damage to the
coast as well as two fatalities. During Thursday night into
early Friday morning, the storm weakened in intensity and
was reclassified as a tropical storm. Hurricane Katrina
emerged from the Florida peninsula around 5 a.m. Friday
morning and immediately intensified after encountering
the warm Gulf of Mexico waters. The strength of the
hurricane grew over the next 48 hours. By 5 a.m. on
Sunday, August 28, 2005, the storm had been declared a
Category 4 hurricane, and continuous public warnings
were being aired to the potentially affected population.

The National Hurricane Center stated that Hurricane
Katrina was a potentially catastrophic storm at this time.
Rough storm waters began placing stress on the levees of
New Orleans as the storm continued to increase in sever-
ity throughout Sunday. Fears were expressed that flood-
ing could occur around the levees and along the Gulf of
Mexico coastline. Hurricane Katrina entered the Gulf at
Category 5. Late Sunday night, thousands of people who
were unable or chose not to evacuate New Orleans took
shelter in the Louisiana Superdome. At approximately
5 a.m. Monday, August 29, 2005, hurricane force winds
moved to within 100 miles of the Louisiana shore, creat-
ing strong winds, waves greater than 40 feet in height,
and heavy rainfall. The storm came ashore again around
11 a.m. Monday at the Louisiana and Mississippi border,
causing devastation to the cities of Biloxi and Gulfport.
Around this same time, a major levee in New Orleans
failed, sending floodwaters into the city. Floodwater
continued to pour into New Orleans during the day on
Tuesday.

All remaining residents were ordered to evacuate the
city on Wednesday, August 31, 2005. However, floodwa-
ter and hurricane debris prevented trucks or buses from
traveling to the area. Cries for help poured in from New
Orleans throughout Wednesday and Thursday as resi-
dents were stranded without food, water, or other essen-
tial life-sustaining supplies. The three days following the
failure of the New Orleans levee presented unbearable

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challenges to those staying in the overcrowded Super-
dome and Convention Center. The U.S. National Guard
arrived in New Orleans on Friday, September 2, 2005,
with food, water, and medical supplies, and the U.S. Con-
gress approved a bill containing $10.5 billion in relief aid.

Thousands of residents evacuated New Orleans and
the Gulf Coast following the initial warnings from the
National Hurricane Center. Thousands more lacked re-
sources and modes of transportation to leave the affected
area. These residents were directed to the Louisiana
Superdome and warned of the treacherous conditions that
lay ahead in the coming weeks. People were left without
clean water, food, or medical supplies. In the days follow-
ing the levee break, responding agencies encountered
confusion and disorganization. Responders faced chal-
lenges associated with jurisdictional authority and lacked
a clear disaster management structure necessary to
provide prompt and effective disaster relief. Vulnerable
populations, including the poor, older adults, and the dis-
abled, faced the greatest impact following the hurricane.
Persons with challenges related to physical disabilities and
financial resources faced numerous barriers to evacuation,
including lack of transportation or inability to pay for
hotel accommodations.

Thousands of residents from the Gulf Coast were a
displaced following Hurricane Katrina. The Category 5
hurricane destroyed cities along the coast and displaced
residents to various areas around the country for long
periods of time, and in some cases permanently. Many
residents suffered extreme economic loss with the de-
struction of their homes and businesses. The process of
rebuilding the lost cities was a feat that continued for
years following the tragic event.

The lessons learned from Hurricane Katrina stimulated
a new emphasis on disaster management and emergency
preparedness efforts. States organized legislative actions
and implemented policies and procedures regarding evac-
uation following the declaration of severe weather events.
Emergency response efforts were organized into a standard
structure to distinguish the role and authority of each re-
sponding agency and organization. Evidence of the suc-
cessful reorganization and planning was made evident in
2008 during the Hurricane Gustav resident evacuation
along the Gulf Coast. The efficient emergency preparedness
structure put in place was directly responsible for reducing
injury and death as well as mitigating any long-term effects.

Earthquakes
An earthquake, generally considered to be the most de-
structive and frightening of all forces of nature, is a sud-
den, rapid shaking of the earth caused by the breaking

and shifting of rock beneath the earth’s surface. This
shaking can cause buildings and bridges to collapse;
disrupt gas, electric, and phone service; and sometimes
trigger landslides, avalanches, flash floods, fires, and
huge, destructive ocean waves (tsunamis). Aftershocks
of similar or lesser intensity can follow the main quake.
Buildings with foundations resting on unconsolidated
landfill, old waterways, or other unstable soil are most
at risk. Buildings or trailers and manufactured homes
not tied to a reinforced foundation anchored to the
ground are also at risk because they can be shaken off
their mountings during an earthquake.

Worldwide, earthquakes were among the top dead-
liest disasters in 2017.28 Earthquakes can occur at any
time of the year. Earthquakes, like other similar disasters,
tend to cause more financial losses in industrialized
countries, and more injuries and deaths in undeveloped
countries.

The Richter scale measures the magnitude and inten-
sity, or energy, released by the quake and is an indication
of the earthquake’s force. This value is calculated based
on data recordings from a single observation point for
events anywhere on earth, but it does not address the
possible damaging effects of the earthquake. According
to global observations, an average of two earthquakes of
a Richter magnitude 8 or slightly more occur every year.
A one-digit drop in magnitude equates with a 10-fold in-
crease in frequency. In other words, earthquakes of mag-
nitude 7 or more generally occur 20 times in a year,
whereas those with a magnitude of 6 or more occur ap-
proximately 200 times a year.

Earthquakes can result in a secondary disaster, a cata-
strophic tsunami, discussed in a following section of this
chapter. Geologists have identified regions where earth-
quakes are likely to occur. With the increasing population
worldwide and urban migration trends, higher death tolls
and greater property losses are more likely in many areas
prone to earthquakes. At least 70 million Americans face
significant risk of death or injury from earthquakes be-
cause they live in one of the 39 seismically active states.
In addition to the significant risks in California, the Pa-
cific Northwest, Utah, and Idaho, six major cities with
populations greater than 100,000 are located within the
seismic area of the New Madrid fault (Missouri).29 Cities
in low- and middle-income countries where large num-
bers of people live on earthquake-prone land in structures
unable to withstand damage include, but are not lim-
ited to, Lima, Peru, Santiago, Chile, Quito, Ecuador, and
Caracas, Venezuela.

Deaths and injuries from earthquakes vary according
to the type of housing available, time of day of occurrence,

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and population density. Common injuries include cuts,
broken bones, crush injuries, and dehydration from being
trapped in rubble. Stress reactions also are common.
Morbidity and mortality can occur during the actual
quake, the delayed collapse of unsound structures, or
cleanup activity. Disruption of the earth may release
pathogens that, when inhaled, can lead to increased re-
ports of communicable disease. Mitigation involves de-
veloping and implementing strategies for reducing losses
from earthquakes by incorporating principles of seismic
safety into public and private decisions regarding the set-
ting, design, and construction of structures (i.e., updating
building and zoning codes and ordinances to enhance
seismic safety), and regarding buildings’ nonstructural
elements, contents, and furnishings.

Extreme Heat
Extreme heat from a population perspective is a weather
phenomenon characterized by substantially elevated out-
door temperatures or humidity conditions.30 Extreme heat
can result in an elevated body temperature, which then
leads to hyperthermia, dehydration, heat exhaustion, or
heatstroke. These conditions can cause internal organ dam-
age when the body loses the ability to regulate temperature.
Humid or muggy conditions, which add to the discomfort
of high temperatures, occur when a dome of high atmos-
pheric pressure traps hazy, damp air near the ground.

Over time, populations can acclimate to hot weather.
However, mortality and morbidity rise when daytime
temperatures remain unusually high several days in a
row and nighttime temperatures do not drop signifi-
cantly. Because populations acclimate to summer tem-
peratures over the course of the summer, heat waves in
June and July have more of an impact than those in Au-
gust and September. There is often a delay between the
onset of a heat wave and adverse health effects. Deaths
occur more commonly during heat waves when there is
little cooling at night and taper off to baseline levels if a
heat wave is sustained.31

Heat is the number one weather-related killer in the
United States, resulting in hundreds of fatalities each year.
In fact, on average, excessive heat claims more lives each
year than floods, lightning, tornadoes, and hurricanes
combined. In the disastrous heat wave of 1980, more than
1,250 people died. In the heat wave of 1995, more than
700 deaths in the Chicago area were attributed to heat;
and in July 2018, a record heat wave in North America
left more than 30 people dead in Canada.36 Heat kills by
pushing the human body beyond its limits. On average,
about 175 Americans succumb to the taxing demands of
heat every year. When our blood is heated over 98.6°F

degrees, our bodies dissipate the heat by varying the rate
and depth of blood circulation, by losing water through
the skin and sweat glands, and, as a last resort, by panting.
Sweating cools the body through evaporation. However,
high relative humidity retards evaporation, robbing the
body of its ability to cool itself.36 When heat gain exceeds
the level the body can remove, body temperature begins
to rise, and heat-related illnesses and disorders may de-
velop. Most heat disorders occur because the victim has
been overexposed to heat or has overexercised for his or
her age and physical condition. Other conditions that can
induce heat-related illnesses include stagnant atmos-
pheric conditions and poor air quality.31

Heat waves result in adverse health effects in cities
more than in rural areas. During periods of sustained
environmental heat—particularly during the summer—
the numbers of deaths classified as heat-related (e.g.,
heatstroke) and attributed to other causes (e.g., cardio-
vascular, cerebrovascular, and respiratory diseases) in-
crease substantially. Those at an increased risk for
heat-related mortality are older adults, infants, persons
with noncommunicable conditions (including obesity),
patients taking medications that predispose them to
heatstroke (e.g., neuroleptics or anticholinergics), and
persons confined to a bed or who otherwise are unable
to care for themselves.

Adverse health outcomes associated with high envi-
ronmental temperatures include heatstroke, heat exhaus-
tion, heat syncope (fainting), and heat cramps. Heatstroke
(i.e., core body temperature greater than or equal to 105°F
(40.4°C) is the most serious of these conditions and is
characterized by rapid progression of lethargy, confusion,
and unconsciousness; it is often fatal despite medical care
directed at lowering body temperature. Heat exhaustion
is a milder syndrome that occurs following sustained ex-
posure to hot temperatures and results from dehydration
and electrolyte imbalance. Manifestations of heat exhaus-
tion include dizziness, weakness, or fatigue; treatment is
supportive. Heat syncope and heat cramps are usually
related to physical exertion during hot weather.

Basic behavioral and environmental measures are es-
sential for preventing heat-related illness and death. Per-
sonal prevention strategies should include increasing time
spent in air-conditioned environments, increasing the in-
take of nonalcoholic beverages, and incorporating cool
baths into a daily routine. When possible, activities
requiring physical exertion should be conducted during
cooler parts of the day. Sun exposure should be mini-
mized, and light, loose cotton clothing should be worn.
The risk for heat-induced illness is greatest before
persons become acclimated to warm environments.

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Athletes and workers in occupations requiring exposure to
either indoor or outdoor high temperatures should take
special precautions, including allowing 10 to 14 days to
acclimate to an environment of predictably high ambient
temperature.31 Nurses and other health-care providers
can assist in preventing heat-related illnesses and deaths
by disseminating community prevention messages to
persons at high risk (e.g., older adults and persons with
pre-existing medical conditions) using a variety of com-
munication techniques. They also may establish emer-
gency plans that include provision of access to artificially
cooled environments.

Floods and Mudslides
Prolonged rainfall over several days can cause a river or
stream to overflow and flood surrounding areas. A flash
flood from a broken dam or levee or after intense rainfall
of 1 inch (or more) per hour often catches people unpre-
pared. Global statistics show that floods are the most fre-
quently recorded destructive events. In 2017, worldwide
flooding incidents accounted for 5 of the top 10 deadliest
disasters.28 Floods are the most common type of disaster
in the United States. The frequency of floods is increasing
faster than any other type of disaster. Much of this rise in
incidence can be attributed to uncontrolled urbanization,
deforestation, and the effects of climate change. Moreover,
the risk of flooding is expected to increase.33 Floods also
may accompany other natural disasters, such as sea surges
during hurricanes and tsunamis following earthquakes.

Except for flash floods, flooding causes few deaths di-
rectly. Instead, widespread and long-lasting detrimental
effects include damage to homes and mass homelessness,
disruption of communications and health-care systems,
and substantial loss of business, livestock, crops, and
grain, particularly in densely populated, low-lying areas.
The frequent, cyclic nature of flooding can mean a con-
stant and ever-increasing drain on the economy of rural
populations. Flood-related morbidity and mortality vary
from country to country. Flash flooding, such as from
excessive rainfall or sudden release of water from a dam,
is the cause of most flood-related deaths. Many victims
become trapped in their cars and drown when attempt-
ing to drive through rising or swiftly moving water.
Wading, bicycling, or other recreational activities in
flooded areas have caused other deaths. The health im-
pacts of flooding include communicable disease morbid-
ity exacerbated by crowded living conditions and
compromised personal hygiene, contamination of water
sources, disruption of sewage service and solid waste col-
lection, and increased vector populations. Waterborne
diseases (e.g., enterotoxigenic Escherichia coli, Shigella,

hepatitis A, leptospirosis, and giardiasis) become a sig-
nificant hazard, as do other vector-borne diseases and
skin disorders. Injured and frightened animals, haz-
ardous waste contamination, molds and mildew, and
dislodging of graves pose additional risks in the pe-
riod following a flood.34 Food shortages due to water-
damaged stocks may occur because of flooding and sea
surges. The stress and exertion required for cleanup fol-
lowing a flood also cause significant morbidity (mental
and physical) and mortality (e.g., myocardial infarction).
Fires, explosions from gas leaks, downed live electrical
wires, and debris all can cause significant injury.

Mudslides are another weather-related disaster. They
usually occur after heavy rains. A mudslide involves the
rapid movement of rocks, earth, and other debris down
a slope. They can be associated with floods, earthquakes,
and volcanic eruptions. The risk of a mudslide is in-
creased when the natural vegetation on a slope has been
modified following a wildfire or human activities.35 Mud-
slides occur in all 50 states, with many mudslides occur-
ring in California as a result of drought and wildfires. In
2017, mudslides were responsible for deaths in the Dem-
ocratic Republic of Congo, Sri Lanka, Columbia, Sierra
Leone, Bangladesh, India, and Nepal. The deadliest mud-
slide occurred in 1999, killing 30,000 to 50,000 people in
Vargas, Venezuela.

Tornadoes
Tornadoes are rapidly whirling, funnel-shaped air spirals
that emerge from a violent thunderstorm and reach
the ground. Tornadoes can have a wind velocity of up to
200 miles per hour and generate sufficient force to de-
stroy even massive buildings. The average circumference
of a tornado is a few hundred meters, and it is usually
exhausted before it has traveled as far as 20 kilometers.
Knowing some facts about tornados is useful when put-
ting together an EPDM plan for communities living in a
tornado–prone area of the country (Box 22-4).36

Approximately 1,000 tornadoes occur annually in the
United States, and none of the lower 48 states is immune.
Certain geographical areas are at greater risk because of
recurrent weather patterns; tornadoes most frequently
occur in the midwestern and southeastern states. Al-
though tornadoes often develop in the late afternoon and
more often from March through May, they can arise at
any hour of the day and during any month of the year.
Injuries from tornadoes (e.g., head injury, soft tissue in-
jury, secondary wound infection) occur from flying de-
bris or people being thrown by the high winds.
Stress-related disorders are more common, as is disease
related to loss of utilities, potable water, or shelter.

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Because tornadoes can occur so quickly, communities
should develop redundant warning systems (e.g., media
alerts and automated telephone warnings), establish pro-
tective shelters to reduce tornado-related injuries, and
practice tornado shelter drills. In the event of a tornado,
residents should take shelter in a basement if possible,
stay away from windows, and protect their heads. Special
outreach should be made to people with special needs,
who should make a list of their limitations, capabilities,
and medications, and have ready an emergency box of
needed supplies. People with special needs should have
a buddy who has a copy of the list and who knows the
location of the emergency box.

Tsunamis
A tsunami is a single or multiple tidal wave(s) created
from an earthquake on the ocean floor.25 On December
26, 2004, a 9.0 magnitude earthquake struck at approx-
imately 7 a.m. about 100 miles from the coast of Suma-
tra, Indonesia. The quake caused a massive tsunami
that killed more than 225,000 people and displaced an-
other 1.2 million. This disaster quickly elevated to a cri-
sis situation, affecting 11 countries and requiring global
relief aid and disaster responders. Seven years later, on
March 11, 2011, 31,000 people lost their lives from a
tsunami that hit Japan. In 2018, another tsunami took
more than 1,200 lives when it struck in Palu, Indonesia,
as the community was preparing for a festival near the
beach.

Initial tsunami-related morbidity and mortality occur
from the force of the water, impact with moving debris,
or crush injuries from falling structures. Long-term
effects are similar to those of a severe flood event: there
is an increase in water- and foodborne communicable
disease, an increase in respiratory illnesses related to
large numbers of displaced individuals in crowded relief
shelters, and a lack of necessary medical and fiscal re-
sources. In the case of the 2011 Japanese tsunami, dam-
age to a nuclear reactor at a power plant added the
hazard of a release of radioactivity into the environment.
Unfortunately, the Japanese tsunami has had an unex-
pected global impact. We now know that the Fukushima
nuclear power plant has been leaking radioactive water into
the surrounding groundwater, which eventually makes its
way into the Pacific Ocean. Also, debris swept into the
ocean made its way to the Pacific shores of the United
States, creating a long-term environmental problem.37

Submarine landslides and volcanic eruptions beneath
the sea or on small islands also can be responsible for
tsunamis, but their effects are usually limited to smaller
areas. Tsunamis are often mistakenly referred to as tidal
waves because they can resemble a violent tide rushing
to shore. Tsunamis are powerful enough to move
through any obstacle; therefore, damage from them
results from both the destructive force of the initial wave
and the rapid flooding that occurs as the water recedes.
Depending on the strength of the initiating event, under-
water topology, and the distance from its epicenter to the
shore, the effects of a tsunami can vary greatly, ranging
from being barely noticeable to total destruction.

Tsunami waves can be described by their wavelength
(measured in feet or miles), period (minutes or hours it
takes one wavelength to pass a fixed point), speed (miles
per hour), and height. Tsunamis may travel long distances,
increasing in height abruptly when they reach shallow
water, causing great devastation far away from the source.
In deep water, a person on the surface may not realize that
a tsunami is forming while the wave increases to great
heights as it approaches the coastline. The Pacific Tsunami
Warning Center maintained by the National Oceanic and
Atmospheric Administration (NOAA) monitors the Pa-
cific Ocean for possible tsunamis and issues warnings.38

Although this type of warning system is not yet available
in other parts of the world, it is being developed to provide
alerts about impending tsunamis across the globe.
Tsunamis are not preventable, nor predictable, but there
are warning signs. A number of events or signs are indica-
tive of a possible tsunami (Box 22-5).

In the immediate aftermath of a tsunami, the first
health interventions are to rescue survivors and provide

C H A P T E R 2 2 n Health Planning for Emergency Preparedness and Disaster Management 583

• They may strike quickly, with little or no warning.
• They may appear nearly transparent until dust and

debris are picked up or a cloud forms in the funnel.
• The average tornado moves southwest to northeast,

but tornadoes have been known to move in any
direction.

• The average forward speed of a tornado is 30 mph,
but may vary from stationary to 70 mph.

• Tornadoes can accompany tropical storms and
hurricanes as they move on to land.

• Waterspouts are tornadoes that form over water.
• Tornadoes are most frequently reported east of the

Rocky Mountains during spring and summer months.
• Peak tornado season in the southern states is March

through May; in the northern states, it is late spring
through early summer.

• Tornadoes are most likely to occur between 3 p.m.
and 9 p.m. but can occur at any time.

BOX 22–4 n Tornado Facts

Source: (36)

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medical care for any injuries. For people caught in the
waves, the force of the water may push them into debris,
resulting in the broadest range of injuries, such as frac-
tured extremities and head injuries. Drowning is the
most common cause of death associated with a tsunami.
Tsunami waves and the receding water are very destruc-
tive to structures in the run-up zone. Other hazards in-
clude flooding and fires from ruptured gas lines or tanks.

The floods that accompany a tsunami result in potential
health risks from contaminated water and food supplies.
Loss of shelter leaves people vulnerable to exposure to
insects, heat, and other environmental hazards. Further,
the lack of medical care may result in exacerbation of
noncommunicable diseases. Tsunamis have long-lasting
effects, and recovery necessitates long-term surveillance
of communicable water- or insect-transmitted diseases, an
infusion of medical supplies and medical personnel, and
the provision of mental health and social support services.

Potential waterborne diseases that follow tsunamis
include cholera; diarrheal or fecal-oral diseases, such
as amebiasis, cryptosporidiosis, cyclosporiasis, giardiasis,
hepatitis A and E, leptospirosis, parasitic infections,
rotavirus, shigellosis, and typhoid fever; animal- or
mosquito-borne illness, such as plague, malaria, Japanese
encephalitis, and dengue fever (and the potentially fatal
complication dengue hemorrhagic shock syndrome);
and wound-associated infections and diseases, such as
tetanus. Mental health concerns are another serious
consequence of tsunami events.

Volcanic Eruptions
A volcano is a mountain that opens downward to a reser-
voir of molten rock below the surface of the earth. Unlike
most mountains, which are pushed up from below, vol-
canoes are built up by an accumulation of their own
eruptive products. When pressure from gases within the
molten rock becomes too great, an eruption occurs.

Extremely high temperatures and pressure cause mantle,
located deep inside the earth between the molten iron
core and the thin crust at the surface, to melt and become
liquid rock or magma. When a large amount of magma
is formed, it rises through the denser rock layers toward
the earth’s surface. Eruptions can be quiet or explosive.
There may be lava flows, flattened landscapes, poisonous
gases, and flying rock and ash.

Because of their intense heat, lava flows are significant
fire hazards. Lava flows destroy everything in their path,
but most move slowly enough that people can move out
of the way. Fresh volcanic ash, made of pulverized rock,
can be abrasive, acidic, gritty, gassy, and odorous. Al-
though not immediately dangerous to most adults, the
acidic gas and ash can cause lung damage to small
infants, older adults, and those suffering from severe
respiratory illnesses. Volcanic ash can affect people hun-
dreds of miles away from the cone of a volcano.39

Sideways-directed volcanic explosions, known as lat-
eral blasts, can shoot large pieces of rock at very high
speeds for several miles. These explosions can kill by
impact, burial, or heat. They have been known to knock
down entire forests. Volcanic eruptions can be accom-
panied by other natural hazards, including earthquakes,
mudflows and flash floods, rock falls and landslides, acid
rain, fire, and (under special conditions) tsunamis. Ac-
tive volcanoes in the United States are found mainly in
Hawaii, Alaska, and the Pacific Northwest. The danger
area around a volcano covers approximately a 20-mile
radius. Some danger may exist 100 miles or more from a
volcano.39

Volcanic eruptions can endanger the lives of people
and property located both near to and far from a vol-
cano. The range of adverse health effects on the popu-
lation resulting from volcanic activity is extensive.
Immediate, acute, and nonspecific irritant effects have
been reported in the eyes, nasal passages, and upper
airways of persons exposed to the ash.39 Victims can
experience exacerbations of their asthma and chronic
obstructive pulmonary disease, and can asphyxiate due
to inhalation of ash or gases. Eruptions can result in
blast injuries and lacerations from projectile rock frag-
ments. Volcanic flow can cause fires and the destruc-
tion of buildings, with victims experiencing trauma and
thermal burns.

Prior to an eruption, communities living near an ac-
tive volcano need to develop an EPDM plan. During an
eruption, the first step is to evacuate, avoiding river beds
and low-lying areas. Another concern is the potential for
mudslides and exposure to falling ash.39 Following the
Kilauea Volcano eruption, ash shot upward more than

584 U N I T I I I n Public Health Planning

• There has been a recent submarine earthquake.
• The sea appears to be boiling, as large quantities of gas

rise to the surface of the water.
• The water is hot, smells of rotten eggs, or stings

the skin.
• There is an audible thunder or booming sound

followed by a roaring or whistling sound.
• The water may recede a great distance from the coast.
• Red light might be visible near the horizon and, as the

wave approaches, the top of the wave may glow red.

BOX 22–5 n Signs of a Possible Tsunami

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20,000 feet into the air, and sulfur dioxide created a
thick fog near Hawaii Volcanoes National Park. After an
eruption, it is essential to have shelters for the popula-
tion, especially for those whose homes may not be safe
to return to.

Winter Weather
Winter weather brings ice, snow, cold temperatures, and
often dangerous driving conditions; a major winter
storm can be lethal. Even small amounts of snow and ice
can cause severe problems for southern states where such
storms are infrequent. Nurses need to be familiar with
winter storm warning messages, such as wind chill, win-
ter storm watch, winter storm warning, and blizzard
warning. The NOAA defines a blizzard as an event last-
ing greater than 3 hours with winds over 35 miles per
hour, heavy snowfall, and decreased visibility. An ava-
lanche results when a mass of snow, rock, or ice rapidly
slides down a mountain or incline; it is also referred to
as a snow slide.29 Other issues with winter weather in-
clude ice storms and extreme cold.

These extreme conditions can prevent people from
using established modes of transportation and from ob-
taining life-sustaining supplies and sources of power. The
severity of the event can prevent emergency personnel
from gaining access to the affected population. Blizzards,
ice storms, and avalanches can strand individuals in
places without heat or electricity, preventing the use of
medical devices, and exposing a population to the pre-
viously discussed conditions. Prolonged exposure to
cold weather conditions can result in injuries, such as
hypothermia and frostbite (Table 22-1).

Transportation accidents are the leading cause of
death during winter storms. Preparing vehicles for the

winter season and knowing how to react if stranded or
lost on the road are the keys to safe winter driving. Mor-
bidity and mortality associated with winter storms
include frostbite and hypothermia, carbon monoxide
poisoning, blunt trauma from falling objects, penetrating
trauma from the use of mechanical snow blowers, and
cardiovascular events usually associated with snow re-
moval. Frostbite is a severe reaction to cold exposure that
can permanently damage its victims. A loss of feeling and
a light or pale appearance in fingers, toes, nose, or ear-
lobes are symptoms of frostbite. Hypothermia is a con-
dition brought on when the body temperature drops to
less than 90°F. Symptoms of hypothermia include un-
controllable shivering, slow speech, memory lapses, fre-
quent stumbling, drowsiness, and exhaustion.

Communities should include preparation for cold
weather events in their disaster plans. Individuals can re-
duce the impact of winter weather by taking preventive
mitigation steps such as home winterization activities
(insulating pipes, installing storm windows). At the pop-
ulation level, communities must have plans to handle in-
terruption to transportation, loss of power, injury, and
access to needed medical care. Of particular concern are
vulnerable populations such as older adults or the home-
less. Again, shelters may be needed to provide care in the
event of a power outage. Many urban communities will
increase their capacity to provide shelter to the homeless
during extreme cold.

Wildfires
Wildfires are raging and rapidly spreading fires that can
sweep quickly across large areas of land. They lack
predictability and often require enormous resources to
contain and extinguish. The Thomas Wildfire of 2017

C H A P T E R 2 2 n Health Planning for Emergency Preparedness and Disaster Management 585

TABLE 22–1 n Centers for Disease Control and Prevention Recommendations for Cold Weather Injuries

Health Effect Symptoms Treatment

Frostbite

Hypothermia

• Submerse affected area in warm, not hot, water.
• Remain in a warm area.
• Do not walk on or use effected parts.
• Do not rub or massage.
• Do not use a heating pad.

• Remove wet clothing.
• Keep victim in a warm room.
• Make skin-to-skin contact under cover of blanket.
• Warm the center of body first (i.e., chest, head, and groin).
• Use electric blanket if available.
• Provide warm beverage to increase core body temperature.

• Numbness usually located on cheeks,
toes, nose, chin, ears, and fingers

• White or grayish-yellow discoloration
• Waxy or firm skin

• Decreased consciousness
• Altered mental status
• Shallow respirations
• Pallor of the skin
• Shivering
• Confusion or disorientation

Source: (92)

7711_Ch22_569-606 22/08/19 11:13 AM Page 585

starting near Santa Paula, California, is the largest in Cal-
ifornia history. It burned more than 280,000 acres, forced
thousands of people from their homes, and consumed a
great number of structures. In 2011, multiple wildfires
burned thousands of acres in Texas, resulting in the
deaths of two firefighters. Three deaths occurred in a
wildfire in Colorado in 2012. A wildfire in 2013 in Pigeon
Forge, Tennessee, burned 230 acres and required 20 fire
departments to respond before the fire was under con-
trol. More recently, a series of wildfires starting in the
Great Smokey Mountains rapidly led to 14 deaths as fire
spread during the night to the tourist town of Gatlinburg,
Tennessee. It required the emergent evacuation of resi-
dents and tourists (Fig. 22-4). As residential areas expand
into relatively untouched forests, wild lands, and re-
mote mountain sites, forest fires increasingly threaten
people living in these communities.40 Protecting struc-
tures from fire poses extraordinary problems, often
stretching firefighting resources to the limit.

Morbidity and mortality associated with wildfires in-
clude burns, inhalation injuries, respiratory complications,
and stress-related cardiovascular events (exhaustion and
myocardial infarction experienced while fighting or fleeing
the fire).41 Compromised respiratory conditions can result
from the air pollution caused by the vast amount of smoke
generated by the fires. Another concern is taking precau-
tions to protect those who respond to fires. Responders are
at increased risk for morbidity and mortality. Volunteer
firefighters are at greatest risk; for example, 19 volunteer
firefighters lost their lives combating a wildfire in Arizona
in June 2013. The CDC provides specific guides for

protecting firefighters during cleanup to reduce their risk
of adverse consequences following the fire (Box 22-6).42

FEMA identified three areas of concern for public
health preparedness—before a fire, during a fire, and
after a fire.40 Pre-fire population considerations focus on
community education regarding actions that will en-
hance personal and public safety. Families are encour-
aged to have an evacuation plan at the first warning of a
fire outbreak, especially for vulnerable members of the
family such as children, older adults, and persons with
disabilities. People are encouraged to wear protective
clothing, shut off gas at the source, and gather all essen-
tial valuables and place them in a safe place for easy ac-
cess. During the fire, homeowners are asked to leave all
lights on inside the home, place a ladder outside in a
highly visible area, leave all doors unlocked, and evacuate
immediately. These measures are vital for responders to
effectively manage structure fires and protect the popu-
lation. Families should remain together in a central area
of the home if they become trapped by the wildfire. Even
after the wildfire is controlled, active embers and sparks
can settle on roofs and in attics, creating the potential for
further structure fires. It is important for people to watch
for these sources that can cause a home to reignite and
safely alleviate the threat.

Wildfires often begin unnoticed and spread quickly
by igniting brush, trees, and homes. There are three
different classes of wildfires. A surface fire, the most
common type, burns along the floor of a forest, moving

586 U N I T I I I n Public Health Planning

Figure 22-4 Remains of burnt riverside chalets from
2016 wildfire impacting Gatlinburg, TN. (Photo credit:
Gordon Gillespie.)

Have available:

• First aid
• Protective equipment

Workers face hazards even after fires are extinguished.
In addition to a smoldering or new fire, dangers include:

• Carbon monoxide poisoning
• Musculoskeletal hazards
• Heavy equipment
• Extreme heat and cold
• Unstable structures
• Hazardous materials
• Fire
• Confined spaces
• Worker fatigue
• Respiratory hazards

BOX 22–6 n CDC Fact Sheet: Worker Safety
During Fire Cleanup

Source: (42)

7711_Ch22_569-606 22/08/19 11:13 AM Page 586

slowly and killing or damaging trees. A ground fire is
usually started by lightning and burns on or below the
forest floor in the humus layer down to the mineral
soil. Crown fires spread rapidly by wind and move
quickly by jumping along the tops of trees. Depending
on prevailing winds and the amount of water in the en-
vironment, wildfires can quickly spread out of control,
causing extensive damage to personal property and
human life. If heavy rains follow a fire, other natural
disasters can occur, including landslides, mudflows,
and floods. Once the ground cover has been burned
away, little is left to hold soil in place on steep slopes
and hillsides, increasing the risk for mudslides. A
major wildfire can leave a large amount of scorched
and barren land. These areas may not return to pre-
fire conditions for decades. Danger zones include all
wooded, brushy, and grassy areas,43 especially those in
Kansas, Mississippi, Louisiana, Georgia, Florida, the
Carolinas, Tennessee, California, Massachusetts, and
the national forests of the western United States.

Epidemics
An epidemic occurs when there is an increase in cases sig-
nificantly higher than the usual number of cases. A pan-
demic describes epidemics occurring across the globe (see
Chapter 8).43 In the case of communicable diseases, EPDM
plans are needed to handle the emergence of a communi-
cable disease at epidemic proportions that puts a popula-
tion or populations at risk. Quick response is essential
because epidemics develop rapidly, resulting in human
and economic losses and political difficulties. An epidemic
or threatened epidemic can become an emergency when
certain characteristics are present (Box 22-7). The catego-
rization of an emergency differs from country to country,
depending on two local factors: whether the disease is en-
demic and whether a means of transmitting the agent ex-
ists. Frequently, the introduction of a pathogen and the
start of an epidemic may occur through an animal vector;
thus, veterinarians may be the first to identify a disease
new to a community.

Manmade Disasters
The events of September 11, 2001, in the United States
stimulated the worldwide emergence of preparedness plan-
ning for terrorism.15 Manmade disasters differ from nat-
ural disasters based on the human element associated with
high levels of morbidity and mortality in a population.
These events can be unintentional exposures or intentional
terrorist events. An expansive consortium of responders is
vital for an effective reaction to a manmade event.

Blast Events
Explosions have the potential to affect a population by
causing immediate physical injuries and destruction of
property and well as long-term emotional distress, dis-
ability, and damage to the community’s perception
of safety. Blast events are the result of a device explo-
sion. Immediate considerations following an explosion
include identifying the causative agent, the affected
geographical area, and extent of injury and damage. Re-
sponders must be aware of the appropriate personal pro-
tective equipment necessary for the situation and be
proficient in the proper techniques in using the equip-
ment. Only trained personnel should be involved in ex-
plosion mitigation until the safety of the blast scene is
established. An explosion generates a blast wave that
moves outward from the point of origin. In confined
spaces, irregular, high-pressure blast waves will cause
unpredictable injury patterns.44,45

The four stages of blast injuries include primary, sec-
ondary, tertiary, and quaternary (Table 22-2). Primary
reflects injuries due to the blast wave, which is the over-
pressurization impulse created by the blast. The injuries
from a blast result from the changes to the body brought
about by the overpressurization force that impacts the
surface of the human body. Most common blast injuries
associated with the primary stage of impact include
rupture of the tympanic membrane, causing temporary

C H A P T E R 2 2 n Health Planning for Emergency Preparedness and Disaster Management 587

Note: Not every characteristic need be present, and each
must be assessed with regard to its relative importance
locally:

• There is a risk of the introduction to and spread of the
disease in the population.

• A large number of cases may reasonably be expected
to occur.

• The disease involved is of such severity that it may lead
to serious disability or death.

• There is a risk of social or economic disruption
resulting from the presence of the disease.

• There is an inability of authorities to cope adequately
with the situation because of insufficient technical or
professional personnel, organizational experience,
and necessary supplies or equipment (e.g., drugs,
vaccines, laboratory diagnostic materials, vector-
control materials).

• There is a risk of international transmission.

BOX 22–7 n Epidemic Disaster Planning:
Emergency Signs

7711_Ch22_569-606 22/08/19 11:13 AM Page 587

or permanent hearing loss, and injury to the air-filled
organs in the body.44

Secondary injuries are the result of flying debris from
the blast. In the Boston Marathon bombing, the majority
of the injuries that required care were secondary injuries
that resulted in damage to lower extremities, which, in
some cases, required amputation. Tertiary injuries occur
due to the displacement of air caused by the explosion.
This creates what is called a blast wind that throws vic-
tims against solid objects. The videos from the Boston
Marathon bombing show runners falling to the ground
shortly after the bomb went off. Quaternary injuries in-
clude exacerbations of existing noncommunicable dis-
eases as well as the threat of infection at the site of the
wounds inflicted by the flying debris.

The response to the Boston Marathon bombings in
the spring of 2013 is an excellent example of effective
EPDM planning on the part of a city to deal with a blast-
related disaster. The health-care providers and first re-
sponders followed the plan, hospitals were ready to
receive the influx of wounded, and emergency care was

provided that saved lives. When interviewed by the
media, the physicians and nurses stated that they did
what they had been trained to do.

Chemical Exposure
Chemicals are found everywhere, from industrial work-
places to home cleaning products. Releases can range
from a small-scale, contained spill to a large release that
causes widespread environmental contamination. Imme-
diate priorities associated with a chemical exposure are
to evacuate the contaminated area and identify the chem-
ical. For example, visualize a motor vehicle crash involv-
ing a tanker vehicle transporting gasoline. Damage to the
vehicle could result in a chemical spill on the roadway.
Urgent actions involve restoring safety to the scene of the
crash, the surrounding environment, and the exposed
population. Chemical explosions can cause widespread
destruction and contaminate the air, soil, and water. The
explosive, flammable, poisonous, radioactive, and com-
bustible properties of a substance must be identified im-
mediately following a potential or active release.44,46

588 U N I T I I I n Public Health Planning

TABLE 22–2 n Blast Injuries

Category Characteristics Body Part Affected Types of Injuries

Primary

Secondary

Tertiary

Quaternary

Blast lung (pulmonary barotrauma)
Tympanic membrane rupture and middle ear damage
Abdominal hemorrhage and perforation
Globe (eye) rupture
Concussion (traumatic brain injury without physical

signs of head injury)

Penetrating ballistic (fragmentation) or blunt injuries
Eye penetration (can be occult)

Fracture and traumatic amputation
Closed and open brain injury

Burns (flash, partial, and full thickness)
Crush injuries
Closed and open brain injury
Asthma, chronic obstructive pulmonary disease or

other breathing problems from dust, smoke, or
toxic fumes

Angina
Hyperglycemia, hypertension

Gas-filled structures are
most susceptible—
lungs, gastrointestinal
tract, and middle ear.

Any body part may be
affected.

Unique to high-order
explosives (HE),
results from the
impact of the over
pressurization
wave with body
surfaces

Results from flying
debris and bomb
fragments

Results from
individuals being
thrown by the blast
wind

All explosion-related
injuries, illnesses, or
diseases not due to
primary, secondary,
or tertiary
mechanisms.

Includes
exacerbation or
complications of
existing conditions

Source: (44)

7711_Ch22_569-606 22/08/19 11:13 AM Page 588

Hazardous materials are substances found in multi-
ple forms that have the potential to cause death, morbid
health effects, and property damage. These materials pose
dangers to population health during production, storage,
use, and disposal. A placard, card, or plaque containing
a numerical code that identifies the type of chemical or
hazardous material being transported by railway, vehicle,
or waterway is required by the U.S. Department of
Transportation and allows emergency responders to im-
mediately identify the substance in question.47 Prepared-
ness actions to ensure patient and employee safety from
potential chemical exposures in a health-care organiza-
tion also are important. It is essential to know the com-
monly used chemicals in a hospital or health-care setting
and educate those handling the substance on proper use
and how to respond to a spill or human exposure.48 Ma-
terial safety data sheets contain information pertinent to
planning, such as safe handling techniques, toxic effects
of the material, and first aid considerations following
human exposure.

Radiation Exposure
Ionizing radiation exposure has the potential to cause im-
mediate and long-term adverse health effects in a com-
munity. The explosion at the Chernobyl nuclear power
plant on April 26, 1986, is the largest nuclear disaster in
world history and continues to plague parts of Europe.
The incident created a release of nuclear material, neces-
sitating the evacuation of approximately 116,000 people
from the highly contaminated area surrounding the re-
actor. Severe contamination resulted in Ukraine, Belarus,
and the Russian Federation, all of which were part of the
former Soviet Union. Trace contamination spread by
wind and water throughout eastern and western Eu-
rope.49 More than 600,000 people have been involved
with the mitigation of this radiation exposure during the
subsequent 3 decades.

The health effects associated with various types of al-
ternative energy sources have become a priority public
health planning component during the 21st century.
Considering the Chernobyl case, the World Health Or-
ganization (WHO) conducted a longitudinal study fol-
lowing the nuclear disaster and found an increase in
thyroid disease, leukemia, solid cancers, and mental dis-
orders among the population in the three severely con-
taminated countries. The lessons learned following the
Chernobyl disaster have guided the development of reg-
ulations associated with general radiation use.48 A profi-
cient knowledge of the regional contamination potential
will focus emergency preparedness and disaster planning
priorities specific to the population of interest.

Bioterrorism
Bioterrorism is a deliberate release of a pathogen that is
either naturally occurring or manmade and can create a
public health emergency. The agent is bacterial or viral
in origin. An event would typically present with a single
definitively diagnosed case of an illness to be known as a
bioterrorism agent, a cluster of patients presenting with
a similar clinical syndrome lacking clear etiology or ex-
planation, or an unexplained increase of a common syn-
drome above seasonal expectations. The CDC prioritizes
infectious agents into three categories based on the im-
pact and speed of transmission arranged from highest
priority to emerging agents (Table 22-3).15 Disaster miti-
gation would mimic that of a communicable disease epi-
demic; however, the rapid spread of disease and origin
identification present unique challenges. Primary care
providers, urgent care clinics, and emergency departments
(EDs) will be the first to experience the influx of patients
following the use of a biological weapon; therefore, detec-
tion and diagnosis would be made at the local level.

Disaster Response Structure
and Organization
All disasters are local yet have the potential to affect
health on regional, national, and global levels. Local
health departments and government officials engage
disaster response plans specific to the event and call on
the resources necessary to effectively manage and mit-
igate the situation. Disaster events present challenges
associated with the increased need for emergency
personnel and resources.

Consider the possibility of a major crash of a pas-
senger jet airplane. The potential for a large number
of victims with life-threatening injuries increases the
importance of a solid response structure for this event.
Increased numbers of medical responders and sup-
plies are needed to manage the number of potential
victims. Responders from local governmental and vol-
unteer agencies will be required to increase the power
of the workforce. The initial priority of the emergency
medical personnel is to identify the extent of illness
and injury, communicate the gravity of the situation
to local stakeholders and medical facilities, and begin
victim medical treatment.

Disaster Triage and Patient Tracking
Emergency responders (usually paramedics and other
emergency medical team members) begin victim treat-
ment with field triage. Triage is derived from a French

C H A P T E R 2 2 n Health Planning for Emergency Preparedness and Disaster Management 589

7711_Ch22_569-606 22/08/19 11:13 AM Page 589

term meaning to sort.11 Disaster triage determines the
severity of illness or injury suffered by victims and assists
responders with systematically distributing patients
evenly among the local hospitals. The system is a color-
coded, four-level process ranging from minor injuries to
those who are dead at the scene. A large-scale disaster
can produce significant numbers of victims stretching
beyond the capabilities of the emergency medical system
in a community. These scenarios are known as mass ca-
sualty events (MCEs) and require special considerations
during the disaster planning process.49 A chain of med-
ical care is established between emergency responders
and medical facilities. Although the plan of response
varies between communities, most share standardized
procedures.

During a disaster, patient and population tracking is a
core function of state and local public health officials.
Tracking becomes complicated when people evacuate to

areas other than public shelters. Population tracking be-
comes an even greater challenge when considering home-
less persons, incarcerated victims, shelters that do not
register the injured individuals, and deceased persons. Es-
tablished communication networks among hospitals,
mass treatment facilities, and health departments help
identify the location of injured victims seeking treatment.

Federal Response and Organization
The United States DHS is authorized by law to activate fed-
eral resources and assistance under certain circumstances.
Federal agencies can act on their own authority when ap-
propriate. For example, the Federal Bureau of Investigation
(FBI) has established authority when an act of bioterrorism
is suspected, and the Federal Aviation Administration
(FAA) maintains authority following an airplane crash.
State and local officials also can request federal assistance
when the disaster expands beyond the resources and

590 U N I T I I I n Public Health Planning

TABLE 22–3 n Bioterrorism Agents/Diseases by Category

Category Definition Agents/Diseases

Category A

Category B

Category C

• Anthrax
• Botulism
• Plague
• Smallpox
• Tularemia
• Viral hemorrhagic fevers, including Ebola

• Brucellosis
• Epsilon toxin
• Glanders
• Melioidosis
• Psittacosis
• Q fever
• Ricin toxin
• Staphylococcal enterotoxin B
• Typhus fever
• Viral encephalitis
• Water safety threats
• Food safety threats

• Nipah virus
• Hantavirus

Highest priority agents
These include organisms that pose a risk to national

security because they
• can be easily disseminated or transmitted from person

to person;
• result in high mortality rates and have the potential

for major public health impact;
• might cause public panic and social disruption; and
• require special action for public health preparedness.

Second highest priority agents
These include those that
• are moderately easy to disseminate;
• result in moderate morbidity rates and low mortality

rates; and
• require specific enhancements of CDC’s diagnostic

capacity and enhanced disease surveillance.

Third highest priority agents
These include emerging pathogens that could be

engineered for mass dissemination in the future
because of

• availability;
• ease of production and dissemination; and
• potential for high morbidity and mortality rates and

major health impact.

Source: (15a)

7711_Ch22_569-606 22/08/19 11:13 AM Page 590

capabilities of local responders. Resource assistance in-
cludes financial support, personnel assistance, and physical
supplies. The U.S. President has the authority to direct the
secretary of the DHS to assume responsibility for managing
a disaster when the event merits such an action.

Federal Emergency Management Agency
FEMA is the lead agency for and assumes coordination
of disaster responses following a presidential declaration
of authority under the Stafford Act. FEMA has direct ac-
cess to federal resources and funding. Federal financial
resources can be allotted for various functions including
preparedness, response, and recovery efforts for large-scale
disasters. FEMA is one of more than 27 agencies, along
with the American Red Cross, that provide technical sup-
port and personnel of disaster planning and mitigation.

National Response Framework
The National Response Framework (NRF), enacted in Jan-
uary 2008, supersedes the previous National Response
Plan. It serves as a guide for the nation during natural and
manmade disasters and uses an all-hazards approach to
comprehensive incident response. Built on its predecessor,
it includes guiding principles that detail how federal, state,
local, tribal, and private-sector partners, including the
health-care sector, prepare for and provide a unified
domestic response using improved coordination and inte-
gration. The plan provides national direction for all respon-
ders during a domestic disaster.

National Incident Management System
The National Incident Management System (NIMS)
enhances the ability to oversee a national response to
an event through a single, comprehensive management
model. Several key elements are incorporated into the
NIMS system, which functions to increase the effec-
tiveness of a national disaster response. An established
Incident Command System organizes areas such as
command, operation, planning, logic, and finances dur-
ing event mitigation and recovery. A unified command
is established to assist with clearly defining objectives
and joint decision making. Preparedness is another key
element of the system and enhances the readiness of re-
sponders regarding the performance of vital disaster
functions. The NIMS also provides organizational de-
sign for an interoperable communication infrastructure
and information systems. The Joint Information System
ensures that all levels of government are releasing the
same information and coordinate to deliver a unified
message to the public.17 Each key element of the NIMS
involves an intricate process and directly affects the
overall effectiveness of the systems.

Strategic National Stockpile
A large-scale disaster response will require access to large
amounts of pharmaceutical and medical supplies. The
Strategic National Stockpile (SNS) is a national repository
of antibiotics, chemical antidotes, antitoxins, life-support
medications, and IV administration, airway maintenance,
and medical-surgical supplies. Federal agencies such as the
Department of Health and Human Services, primarily the
CDC, are responsible for maintenance and delivery of SNS
assets, but state and local authorities must plan to receive,
store, stage, distribute, and dispense them. During a disas-
ter, the SNS program is designed to deliver pharmaceuticals,
vaccines, medical supplies, and equipment to states and
local jurisdictions affected by the event. Each state is respon-
sible for the management of the stockpile under which it
resides. Relationships with public and private agencies are
established within each state to ensure the maintenance and
delivery of supplies. Upon request, push packs filled with
medical and pharmaceutical supplies can be delivered to
any area in the United States in less than 12 hours and read-
ied for distribution by local health departments.

For example, a communicable disease outbreak affect-
ing large numbers of people in a rapid time frame would
demand resources outweighing the capabilities of the
local health departments. Local public health officials
would request the deployment of supplies from the SNS.
Bulk push packs then would be delivered to the prede-
termined destination for distribution to the local care
sites and medical facilities. Local public health providers
then would be responsible for the maintenance and dis-
tribution of the allotted supplies. Mass care facilities are
ideal for the prompt treatment of large numbers of pa-
tients. An example of a mass care facility is a disaster
treatment center opened in a local venue large enough
to house high volumes of community members. These
care facilities provide disaster triage and basic medical
care. Patients with critical or life-threatening injuries are
stabilized at these facilities and transported to an appro-
priate health-care institution.

Point of Dispensing
A point of dispensing (POD) site is set up when the pop-
ulation requires rapid medical treatment, prophylaxis, or
vaccination. PODs are designed to provide treatment to the
population in a rapid and organized fashion. Multiple sta-
tions work in assembly-line fashion, providing services
from screening to treating.14 Patients begin with registra-
tion, at which a log is maintained of all persons receiving
care in the POD. Patients are then screened for eligibility
of treatment and epidemiological background related to
the event. Once screened, patients move to a triage area
staffed by licensed health-care providers, such as nurses or

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physicians; here patients are assessed to determine whether
dispensing treatment is appropriate or whether further
evaluation is needed from a health-care facility. The acutely
ill are transferred immediately to a hospital for evaluation.
Individuals receiving prophylaxis or medical treatment for
minor symptoms then move to the dispensing station. Staff
at these stations include licensed health-care providers (in-
cluding pharmacists), who provide medication and/or
treatment. Counseling services, POD security, and medical
record-keeping also are vital components of the services
provided. Patients can receive medical and psychological
treatment while at the distribution center.

Multiple-Agency Consortiums
One concept that becomes obvious during emergency
preparedness and disaster planning is the need for mul-
tiple agencies employing collective expertise to decrease
disaster-related morbidity and mortality. The collabora-
tion of public health personnel, law enforcement agen-
cies, emergency responders, fire officials, and trained
volunteers is essential for effective population medical
treatment and physical protection. Organizational mod-
els such as NRF and NIMS provide guidance for local
and state health departments to develop a consortium of
disaster responders. The Medical Reserve Corps (MRC)
is a federally sponsored program that provides an organ-
ized structure for community public health and medical
volunteers. The program supports adequate training and
exercises to ensure safety and competence of responding
personnel.50 The local MRC is activated during both
emergency situations and nonemergent events, such as
blood and immunization drives.

Health-Care Facility Disaster Response
Health-care facility preparedness is the cornerstone of ef-
fective mass casualty management.49,51 Disasters present
the unique challenge of patients seeking medical attention
in large numbers that exceed the typical capacity of the
facility. A sudden increase in patients is referred to as a
surge.51 Large volumes of patients are associated with dis-
aster-related surge events, creating a demand for health
services in which additional capacity and capabilities are
required.51 Routinely practiced disaster drills and exercises
in an organization are the most effective strategies to in-
crease the effectiveness of health-care facility disaster re-
sponse. Each member of the institution must have
proficient knowledge of her or his role in the mitigation
efforts as well as proper internal and external communi-
cation procedures. It is crucial that surge plans are devel-
oped, documented, communicated, and exercised prior to
a mass casualty event.

Health-Care Facility Surge Planning
Surge plans developed by a health-care facility should be
compatible with the previously discussed national norms.
Allocation of roles and responsibilities are established
through the developed chain of command and planning
structure. The health-care organization must have a com-
mand group or an emergency management group. These
individuals are the leaders in the chain of command and
will hold the ultimate authority of the event mitigation.
Protocols should be developed in the institution pertaining
to internal events and communication with state or local
coordination centers. The organizational response varies
depending on the size of the incident. The predetermined
command staff is responsible for initiating and deactivating
a facility surge plan. A plan to scale up or scale down the
surge response is determined during the disaster mitigation
to meet the medical needs of the affected population. An
emerging issue regarding health-care facility disaster re-
sponse is the need for a community-based network of local
health-care providers. This network ensures the continua-
tion of health-care operations if the infrastructure is dam-
aged during the disaster.

Specific key components are essential for the develop-
ment of a facility surge plan. Efforts begin with discharg-
ing less acutely ill persons. Those who can be managed as
outpatients are released to create space for disaster vic-
tims. Elective procedures are canceled until the surge plan
is deactivated. The events may call for additional beds
being placed in predetermined locations and conversion
of inpatients to hold multiple individuals. Supplemental
staff is essential to carry out mass casualty care. Each
facility should develop a plan to call back staff for addi-
tional shifts to meet the needs of the community. During
a surge, hospitals and clinics work with the same amount
of supplies as they would under normal daily function.
Equipment and pharmaceutical resource management re-
quires conserving and rationing until additional supplies
are delivered to the health-care organization from local,
state, or federal stockpiles.

The network of health-care providers must derive a
unified plan for greater levels of surge. The need to share
equipment and resources may arise during event mitiga-
tion. Documented agreements on the procedure used to
distribute medical resources need to be established at a
local level during the planning phase. Established proce-
dures to call up facility volunteers also should be arranged
during the planning phase and authority granted to a
member of the chain of command to activate the volun-
teers. The need to provide rapid care to large numbers
of patients often requires abbreviated documentation, an
increased staff-to-patient ratio, and reduced testing

592 U N I T I I I n Public Health Planning

7711_Ch22_569-606 22/08/19 11:13 AM Page 592

procedures. Documentation protocols would be devel-
oped and exercised during the planning phase by all staff
and volunteers. Documentation should coincide with
local, state, and national norms to increase the ease in
transfer of patient-related information.

Training and Exercises
Training exercises should be established with local and in-
ternal personnel. Each facility must plan to the capacity of
the organization, and then provide disaster continuing
education to all staff members and volunteers. Disaster
plans and training are most effective when internal per-
sonnel and organizational stakeholders participate in the
design process. The materials used for training must be
specific to the surge plan established by the organization
and easily accessible by all involved persons. A key factor
involved in training exercises is the development of a
structure that maintains organizational function and pre-
vents confusion or poor communication among the re-
sponders. Training exercises scheduled at regular intervals
provide continuing education for new and senior staff and
allow for staff evaluation of surge mitigation effectiveness
(Fig. 22-5). Problems that arise during a disaster drill must
be addressed and incorporated into a new plan appro-
priate for the institution.

C H A P T E R 2 2 n Health Planning for Emergency Preparedness and Disaster Management 593

Figure 22-5 Training on setting up medical field tent.
Minor procedures can safely take place during health-care
fieldwork in a tent like this. (From the CDC, Jesse Blount.)

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Chemical Ka Boom
Public Health Science Topics Covered:

• Health planning
• Instituting an EPDM plan
• Managing a surge

During the EPDM planning process for his commu-
nity, John, a nurse working at the ED at the larger
(urban) hospital in the community, volunteered to be
a member of the command staff at the hospital in the
event of a disaster affecting his community. While
working in the ED, John received a call that there
had just been an explosion at a local chemical plant
located 15 miles from his hospital. It was midday, and
all of the plant employees were in the building during
the time of the event. The buildings and surrounding
structures had suffered considerable damage. Un-
known chemicals had been released into the
atmosphere. Emergency responders were on the
scene to evacuate the uninjured and transport the
injured to local health-care facilities, taking the most
severely injured to John’s ED.

John’s hospital received a call that there were mass
casualties, with many of the injured in need of medical
care. The command team activated the surge plan. Ad-
ditional personnel and volunteers were activated to re-
spond to the institution. Each of the trained staff in the
ED responded by performing his or her specific role in
the process. These roles varied from triaging, deter-
mining which patients were safe to treat and discharge
and which needed immediate medical treatment, to the
actual delivery of care. John was assigned to organize
the mass treatment areas inside the facility.

In this case, John also established a decontamination
zone as a priority given the chemical nature of the
event. As patients arrived at the ED, triage personnel
directed the individuals through decontamination
(if needed) while also providing essential life support
interventions (if needed). A rapid registration and
triage process followed before moving patients to the
appropriate area for treatment. Internal and communi-
tywide communication flowed through the command
team. External coordinators of the disaster’s aftermath
determined the status of the various health-care facili-
ties and the extent of patient casualties still requiring
medical treatment. Of particular concern was the pos-
sibility that community members not directly affected
by the explosion may have been affected by the release
of chemicals into the air and would need treatment.
John prepared the staff for a possible influx of walk-in
patients and made sure the staff followed the same
process for these patients as those transported via
medical responders. John and his team continued to
work, following the plan, scaling up or down based on
the volume of influx, until all was clear for the surge to
be deactivated.

7711_Ch22_569-606 22/08/19 11:13 AM Page 593

Disaster Communication
Communication is central to disaster planning and mit-
igation. Natural and manmade events are frequently ac-
companied by power outages, damage to telephone
towers, and interference in cell phone communication,
which present challenges to responders and victims. It is
critical that multiple agencies have the ability to exchange
information rapidly during and after the impact regard-
less of the technological limitations. Furthermore, com-
munication with the affected population must clearly
emphasize the potential for disaster-related illness and
injury as an event approaches without creating panic.
Population communication educates individuals and
families as to the appropriate actions necessary to pre-
vent disaster-related morbidity and mortality.

Risk Communications
Risk communication is an interactive process involving
individuals, groups, and institutions. It is the exchange
of information regarding the nature, magnitude, signif-
icance, control, and management of an associated
public health risk.52-54 The use of risk communication
principles assists the communicator in identifying the
strengths and weaknesses of various communication
outlets and maximizing the outreach potential of each.
Disasters are associated with fear, confusion, anger, and
worry. These emotions prevent individuals from com-
prehending complex messages. Thus, the use of clear,
concise, and easy-to-understand messages is essential

in the communication of information to a population
confronted with a disaster.

The two main goals of risk communication are to de-
crease the mental noise associated with a disaster event
and to establish trust among the affected population.
When a person is deeply concerned, the ability to
process information is severely impaired. During a dis-
aster, individuals experience a wide range of emotions
ranging from fear to anger. The mental agitation gener-
ated from strong feelings and emotions is known as
mental noise and can interfere with the ability to engage
in rational communication. Further complicating an in-
dividual’s ability to comprehend information during a
disaster is the level of trust people in an affected com-
munity have in the person or persons communicating
the information. The establishment of trust is essential
in all risk communication strategies. It helps to decrease
the mental noise experienced by the affected population.
Only after trust has been established can other goals,
such as disaster event education and mitigation princi-
ples, be accomplished.

Four main factors must be engaged to develop and
maintain trust among the population. Risk communica-
tion must be caring and empathetic, portray dedication
and commitment to the population, demonstrate com-
petence and expertise, and be honest and open.52 Com-
munity leaders should identify individuals or groups that
have a high level of trust with the population prior to an
event and seek their expert opinion during a crisis situ-
ation. Such groups typically include citizen groups,
health-care providers, safety professionals, scientists, and
educators. For example, building on The Case of the Im-
pending Storm, one of the stakeholders included in the
team was the local fire chief. He was well respected by
the community. He was chosen as the spokesperson for
promoting the plan to the community and also as the
point person for all media communication during and
immediately following a disaster. It is essential that those
communicating the information all agree on the infor-
mation to be communicated. Trust decreases when there
is a disagreement among experts, and communication
can break down. For example, if there is a lack of organ-
ization coordination, then multiple messages are released
that can contain conflicting information. The best choice
for a spokesperson is someone with the ability to engage
in sensitive and active listening. In addition, leaders must
be willing to acknowledge the risks and disclose infor-
mation. During the severe acute respiratory syndrome
(SARS) outbreak, China withheld information related to
the severity of the outbreak, thus delaying global efforts
needed to prevent a pandemic.

594 U N I T I I I n Public Health Planning

Eventually, John noted that the surge of patients had
slowed, all victims were accounted for, and those who
needed medical treatment were receiving it. Decreas-
ing the surge response began as soon as John was noti-
fied that the rapid influx of patients had ceased. One
responsibility of being a team leader is to continuously
communicate the needs of the surge to staff and
patients. Also, ongoing communication to victim family
members is crucial during a disaster scenario.

Once the disaster was over, and the hospital had
returned to normal daily functions, John led a quality
improvement meeting. The purpose of the quality
improvement effort was to collaboratively decide the
functions that worked effectively and those in need of
enhancement. The effectiveness of population disaster
care for a health-care facility in an event such as this
would be directly related to the level of preparedness
and the amount of training received by the staff and
volunteers.

7711_Ch22_569-606 22/08/19 11:13 AM Page 594

Emotions and fear surge when communities are faced
with crisis situations and disaster events, and effective com-
munication can reduce panic responses that occur related
to fear and misinformation. Population risk communica-
tion is often viewed as the most important component of
disaster mitigation and receives the greatest attention dur-
ing the preparedness process. The seven rules of population
risk communication are used by public officials to guide
their communication strategies (Box 22-8).52 A well-
prepared leader has arranged what he or she will commu-
nicate and has practiced the communication techniques
before the occurrence of an event. A leader needs to antic-
ipate the information that will be pertinent to the popula-
tion. An excellent example is Mayor Rudy Giuliani during
the September 11 attack on the World Trade Center. After
the 1993 bombing of the World Trade Center, Mayor
Giuliani, who took office in 1994, sought training in risk
communication and prepared for the possibility of another
disaster event. His preparation paid off, providing the
citizens of New York with clear communications that
helped to reduce panic.

Social and Mass Media Systems
The technological advances of the 21st century that have
made the rapid exchange of information possible have
revolutionized disaster communications.52 Social and
mass media systems such as Nixle, the Internet, Twitter,
YouTube, Facebook, and other social networking sites
increase the communication outreach potential of public
health providers. Using both traditional (television and
radio) and newer social media sources is an important
component of disaster communication.

Disaster events occur in rapid progression, and pop-
ulation communication must follow quickly. Media
messages must be consistent across the various commu-
nication sources and answer the most frequently asked
questions. Media messages must include information re-
garding what has happened, what is being done to re-
solve the issues, when and why it happened, if it will
happen again, and actions that should be taken by the

community members. For example, the Japan tsunami
(March 2011) provides an example of the application of so-
cial and mass media systems to disaster communications.
Japan’s highly advanced early warning system proved
key in saving lives but greatly underestimated the likely
height of the tsunami, and people perished by failing to
evacuate to higher ground. Many failed to receive up-
dated warnings about the tsunami height when local re-
lays such as community wireless speakers were damaged
by the earthquake or disabled by power cuts. A major
social media and technical emergency response pro-
vided a vital information lifeline to survivors but was
blunted by the large-scale power blackouts, the disrup-
tion of mobile telecommunications networks, and the
demographics of the disaster that affected coastal areas
where 30% of the population is over 60 years old and
less accustomed to accessing information online.54

Emergency Alert System
The Emergency Alert System (EAS) is a national public
warning system in the United States managed by the
Federal Communication Commission in conjunction
with FEMA and the NWS. The EAS requires all radio and
television broadcasters to provide population-level com-
munication during an emergency. State and local author-
ities can activate emergency alerts for use during severe
weather conditions. The U.S. President has sole
discretion over the use of alerts at the national level.
An audible siren is accompanied by broadcasted instruc-
tions during an emergency. The NWS develops the
weather-related information and disseminates pertinent
instructions about dangerous conditions to the affected
community. System effectiveness is established and
maintained through routine drills and exercises con-
ducted on local, state, and national levels.

Population Communication With Limited
Technology
Interruption to landline telephones and electronic com-
munication devices such as cell phones is likely to occur
during a disaster. Planning for this disruption in commu-
nication is an essential concept for emergency responders.
Emergency telecommunication systems must be estab-
lished before the loss of function or a call volume over-
load. Cellular telephones are the telecommunication
network of choice during a disaster. These wireless sys-
tems also can experience an overload, limiting the capa-
bilities available for emergency responders. Organizations
must create an emergency backup communication system
designed for activation following technological failure. An
illustration of communication devices that support

C H A P T E R 2 2 n Health Planning for Emergency Preparedness and Disaster Management 595

1. Accept and involve the public as a legitimate partner.
2. Plan carefully and evaluate your efforts.
3. Listen to the public’s specific concerns.
4. Be honest, frank, and open.
5. Coordinate and collaborate with other credible sources.
6. Meet the needs of the media.
7. Speak clearly and with compassion.

BOX 22–8 n Seven Rules of Risk Communication

Source: (52)

7711_Ch22_569-606 22/08/19 11:13 AM Page 595

disaster mitigation includes handheld radios, wireless In-
ternet devices, satellite phones, and beeper paging systems.

Public Health Law
Public health laws grant the authority for federal organiza-
tions to provide resources and expertise to state, local, and
private institutions during planning, direction, and delivery
of health-care services. The Pandemic and All-Hazards
Preparedness Act, passed in 2006 and reauthorized in
March 2013, amended the Public Health Service Act to
require the Secretary of Health and Human Services (HHS)
to lead all federal public health and medical responses in
public health emergencies.55 Included in this legislation are
many requirements to improve the ability of the nation to
respond to a public health or medical disaster or emer-
gency, such as the creation of the office of the Assistant
Secretary for Preparedness and Response (ASPR) and the
requirement to establish a near real-time, electronic, na-
tionwide public health situational awareness capability to
enhance early detection of, rapid response to, and manage-
ment of potentially catastrophic communicable disease
outbreaks and other public health emergencies. This legis-
lation also tasked HHS/ASPR to disseminate novel and best
practices of outreach to, and care of, at-risk individuals
before, during, and following public health emergencies.55

Legal Considerations: Quarantine
and Evacuation
The process of disaster management can interfere with
the civil liberties of an individual. State and local legisla-
tion supports disaster planning and grants legal authority
to responding agencies and organizations to interfere
with normal social functions and force individuals to
take actions they may not want to do, such as mandatory
evacuations or quarantine. Legislation is specific to the
function of the responding agency. For example, disaster
laws define law enforcement procedures and actions dur-
ing a bioterrorism event and specific public health func-
tions when considering a quarantine order. Although
voluntary actions are encouraged during a disaster, such
as individual isolation or prophylactic medication ad-
ministration, there are times when individuals are re-
quired to take the action whether they wish to or not.
Thus, the principle of public health—that the public’s
good overrides individual rights—is very much in play
during a disaster. However, quarantine must be ad-
dressed legally to prepare for events that lack community
voluntary compliance. The need for mandated actions
arises during planning for disaster mitigation that re-
quires comprehensive legislative support. National public

health laws serve as a guide to state and local officials that
can be altered to meet the needs of the community.

Health-care providers have an ethical obligation to
prevent the spread of communicable disease within a
community. Isolation of infectious individuals is a vol-
untary process that offers the least restrictive form of
transmission prevention. Physicians and public health
officials have the authority to institute a legal quarantine
if individuals refuse voluntary isolation. Quarantine is a
compulsory act that mandates infected persons to remain
confined to a home or health-care institution. Legal is-
sues associated with involuntary confinement arise
during a mandated quarantine, which require judicial re-
view, typically within 48 hours of initiation. Quarantine
preparedness actions involve the development of legis-
lation at the local and state levels, granting the authority
to institute short-term quarantine when warranted.17,58

Health officials must consider the best interest of the
community, while respecting individual autonomy,
when considering isolation or quarantine.

Evacuation, as with quarantine, begins as a voluntary
action following a recommendation from public health
officials. Levels of evacuation can vary from single build-
ings to a large-scale population event. Buildings with
known contamination from communicable disease
warrant the need for a small-scale evacuation. However,
an infectious outbreak of a highly virulent agent could
require a large-scale population evacuation. Severe
weather warning systems provide evacuation recommen-
dations through the EAS, prompting individuals and
families to leave prior to impact. Mandatory evacuation
becomes a crucial action when community members
refuse voluntary evacuation.17 These situations require
strategic legal planning before a disaster event.

The case of anthrax used as a bioterrorism agent pro-
vides a clear illustration of the importance of public health
isolation and quarantine. One confirmed case of anthrax
exposure is considered an outbreak. Isolation can begin as
a voluntary action by the source patient. A physician or
public health official can mandate quarantine if the in-
fected individual refuses voluntary isolation. Community-
based isolation could be necessary if a greater percentage
of the population becomes infected. Voluntary evacuation
of a contaminated house or building is a primary preven-
tion action taken to protect uninfected community mem-
bers from contracting disease. As with quarantine, legally
mandated evacuation can be ordered if individuals refuse
to voluntarily evacuate a contaminated building or geo-
graphical location. Protecting a population from harm is
a core function of the public health service and must re-
main the central focus when considering quarantine or

596 U N I T I I I n Public Health Planning

7711_Ch22_569-606 22/08/19 11:13 AM Page 596

evacuation. Proactive disaster planning, with emphasis on
legal preparation, can decrease the overall burden created
when individual civil liberties are disrupted.

Following hurricanes Katrina and Rita (in 2005),
the Uniform Laws Commission proposed the Uni-
form Emergency Volunteer Health Practitioners Act
(UEVHPA).56 Its scope is more limited than MSEHPA.
Generally, the UEVHPA would provide some protection
from civil liability for volunteer emergency health-care
providers and allow volunteer emergency health-care
providers to work in states other than where they are li-
censed. In 2017, the Good Samaritan Health Profession-
als Act was introduced in the U.S. Congress to afford
uniform protection from civil liability to health-care
providers responding to a nationally designated disaster
as a volunteer.57

Vulnerable Populations and Disaster
Some groups in society are more prone than others to
damage, loss, and suffering in the context of differing
disaster events. Racial and ethnic minorities, immigrants
and nonnative English speakers, women, children, older
adults, and persons who are disabled or impoverished
have all been identified as those most vulnerable to ad-
verse impacts from a disaster.59 Although these groups
differ in many ways, they demonstrate similarities in
that they often lack access to vital economic and social
resources, have limited autonomy and power, and have
low levels of social capital. These groups of individuals
often live and work in the most hazardous regions and
in the lowest-quality buildings, thus further exposing
them to risks associated with natural hazards.60

Demographic characteristics not limited to socioeco-
nomic status, race, gender, age, and disability frequently
intersect in complex ways that may increase the vulner-
ability of any given member of a social group. During the
past decade, there has been some movement away from
simple taxonomies or checklists of vulnerable groups to
vulnerable situations. This approach adds a vital tempo-
ral and geographical dimension to examining vulnera-
bility and the social contexts and circumstances in which
people live.60 In 2003, Cutter and colleagues’ extensive
work on addressing vulnerability during disasters helped
in the understanding of how certain social and environ-
mental factors such as age, stage of development, and
economic status increased risk for morbidity and mor-
tality (Box 22-9).61

When trying to understand why disasters happen and
who is affected most, it is crucial to recognize that nat-
ural events are not the only cause. As discussed earlier,

disasters are the product of social, political, and eco-
nomic environments that structure the lives and life
chances of different groups of people. The capacity for
resiliency following a disaster varies based on the pop-
ulation and the environment.60 Certain populations are
more vulnerable to disease and injury, and less apt to re-
cover physically, socially, and economically from the im-
pact of a large-scale disaster.61 Persons who are already
poverty-stricken are at considerable risk for adversity,
including decreased health, homelessness, long-term
displacement, and death.61

Children
Children are at special risk for increased morbidity and
mortality from disaster events because of their size,
anatomy and physiology, and their developmental sta-
tus. Because children have an increased potential for
injury and disease, public and emergency health-care
providers need to be trained to communicate at an age-
appropriate level for the average child during injury as-
sessment and pediatric emergency care. Many hospitals
are ill-prepared to receive and care for severely injured
children, and their capacity to accommodate a sudden
demand for pediatric care may be limited.62,63 Pedi-
atric-specific equipment, supplies, and medications
should be available to provide emergent care during the
aftermath of a disaster.64 Children may be separated
from their parents as a result of the disaster itself or
during the intervention phase as rescuers attempt to ex-
pedite the evacuation, triage injured children, and pro-
vide appropriate treatment. Efforts should be made to
keep siblings together as well as ensure the children’s
security until an adult family member is able to assume
custody.

C H A P T E R 2 2 n Health Planning for Emergency Preparedness and Disaster Management 597

Factors at the county level associated with social vulnera-
bility to environmental hazards include the following:

• Age
• Racial and ethnic disparities
• Occupation
• Personal wealth
• Housing stock and tenancy
• Density of the built environment
• Single-sector economic dependence
• Infrastructure dependence
• Persons with disabilities

BOX 22–9 n Factors Associated With Social
Vulnerability

Source: (61)

7711_Ch22_569-606 22/08/19 11:13 AM Page 597

Pregnant and perinatal women and infants are at in-
creased risk during a disaster event.65 Disasters limit the
availability and access to prenatal care, birthing centers,
and neonatal care. Following Hurricane Katrina, there
were no organized services for pregnant women and
neonates. Hospitals with maternity patients and low-
birth-weight newborns were evacuated, and many births
took place during the disaster in the Louie B. Armstrong
New Orleans International Airport without benefit of
clean water or electricity.

Older Adults
Older adults are more likely to have one or more non-
communicable illnesses such as hypertension, cardiovas-
cular disease, arthritis, and diabetes as well as limitations
on mobility. Even with proper disaster planning, older
adults may experience complications. They are not as
easily able or willing to evacuate as their younger coun-
terparts and may struggle to adapt to a new environment.
Nursing home patients are also at increased risk for poor
health and safety outcomes. During a disaster, nursing
home staff often works in understaffed conditions, have
less access to needed resources, and usually have lost
power. During Hurricane Irma in Hollywood, Florida,
14 residents in a nursing home died due to lack of air
conditioning, resulting in legislation that nursing homes
in Florida are now required to have backup generators.66

Special Needs Populations
Persons with a mobility or sensory disability may require
special assistance during and after a disaster. Persons
with a sensory disability have a limitation in the ability
to hear (e.g., hard of hearing, deaf) or see (e.g., blind, tun-
nel vision).67,68 Persons with a mobility disability include
persons with little to no use of their arms and/or legs.69

Assistive devices such as walkers, wheelchairs, or scoot-
ers may be required for ambulation or movement by this
population.

The person with a mobility or sensory disability may
have difficulty evacuating a building structure determined
to be unsafe (e.g., fire, earthquake). If the person is deaf,
the person may need to be notified that a disaster situa-
tion has been declared and have instructions provided in
writing or sign language. If the disaster is communicated
by a strobe light, as with a building fire, or on the bottom
(“crawl”) of a television screen, as with a tornado warning,
the blind will not be aware of the disaster. Communica-
tions need to be oral or through the use of sirens or bells
along with the strobes and television screens.

Disaster plans should be developed with comprehensive
planning efforts to accommodate the needs of these popu-
lations. Representatives from vulnerable population groups
should be included on disaster planning committees to in-
form and gain the population’s input. Plans should address
how individuals can prepare for the coming disaster, evac-
uate to safety if necessary, and protect themselves on-site
during and immediately after the disaster until rescue help
arrives when evacuation is not a possibility.67–69 Disaster
drills conducted in advance can test and ensure the plan’s
feasibility. Plans and drills should consider both the use and
absence of service animals and assistive devices.

598 U N I T I I I n Public Health Planning

n EVIDENCE-BASED PRACTICE
Pediatric Triage Tool

Practice Statement: Children affected by a disaster
require a specialized triage approach.
Targeted Outcome: Optimize the triage of injured
children based on pediatric physiology during a multica-
sualty incident.
Evidence to Support: The JumpSTART tool was
designed to provide an objective framework for
identifying the severity of injury in children. The tool
acknowledges key differences that exist between pe-
diatric and adult injury victims. It was specifically de-
signed for multicasualty settings and not for ED triage.
It is recognized as the gold standard for pediatric
triage during disasters. It was designed to consider
the physiological differences between pediatric and
adult victims. The materials are available online and
include a clear algorithm that can be copied and
distributed.

Recommended Approaches and Resources:
1. Romig, L. (2013). The JumpSTART pediatric MCI triage tool.

Retrieved from http://www.jumpstarttriage.com/
2. Cicero, M.X., Riera, A., Northrup, V., Auerbach, M.,

Pearson, K., & Baum, C.R. (2013). Design, validity,
and reliability of a pediatric resident JumpSTART
disaster triage scoring instrument. Academic Pediatrics,
13(1), 48-54.

3. Jones, N., White, M.L., Tofil, N., Pickens, M., Youngblood,
A., Zinkan, L., & Baker, M.D. (2014). Randomized trial
comparing two mass casualty triage systems (JumpSTART
versus SALT) in a pediatric simulated mass casualty event.
Prehospital Emergency Care, 18(3), 417-423. doi:10.3109/
10903127.2014.882997

4. Donofrio, J.J., Kaji, A.H., Claudius, I.A., Chang, T.P.,
Santillanes, G., Cicero, M.X., … Gausche-Hill, M. (2016).
Development of a pediatric mass casualty triage
algorithm validation tool. Prehospital Emergency Care, 20(3),
343-353. doi:10.3109/10903127.2015.1111476Maternal-
Infant

7711_Ch22_569-606 22/08/19 11:13 AM Page 598

FEMA released Guidance on Planning for Integration of
Functional Needs Support Services [FNSS] in General Pop-
ulation Shelters in November 2010.69 This guidance is in-
tended to ensure that individuals who have access and
functional needs receive lawful and equal assistance before,
during, and after public health emergencies and disasters.
This guidance can be incorporated into existing shelter
plans. It does not establish a new tier of sheltering nor alter
existing legal obligations. For example, the Americans with
Disabilities Act’s fair housing and civil rights requirements
are not waived in disaster situations, and emergency man-
agers and shelter planners have the responsibility to ensure
that sheltering services and facilities are accessible.

FNSS are services that enable individuals with access
and functional needs to maintain their independence in
a general population shelter. Individuals requiring FNSS
may have physical, sensory, mental health, cognitive,
and/or intellectual disabilities affecting their ability to
function independently without assistance. Others who
may benefit from FNSS include women in the late stages
of pregnancy, older adults, and people whose body mass
requires special equipment.69

Advanced planning is essential to ensure equal access
and services. Making general population shelters acces-
sible to persons with access and functional needs may re-
quire additional items and services, including durable
medical equipment such as walkers and wheelchairs;
consumable medical supplies such as medications and
diapers; and personal assistance services.

Plans also must be made for how medical support will
be implemented in general population shelters and how
to assess when individuals are not appropriate for these
settings because of medical needs. It is important for
emergency planners and public health officials to know
and understand the community’s demographic profile to
ascertain what services and equipment will be needed in
an emergency. Meeting with community partners, stake-
holders, providers, constituents, and service recipients,
including individuals with access and functional needs,
will enhance emergency planners’ and public health offi-
cials’ abilities to develop plans that successfully integrate
individuals with access and functional needs into general
population shelters. In addition, these collaboration efforts
will help educate community members with access and
functional needs about the importance of personal pre-
paredness plans.

Incarcerated Populations
U.S. Marshals became a box office hit when it was re-
leased by Warner Brothers Entertainment in 1998. Near
the movie’s opening sequence, an airplane transporting

incarcerated prisoners crash-landed along a small coun-
try road, then came to a stop as it rolled upside down into
a river. The prisoners who survived the disaster were se-
cured along the river’s bank until emergency medical as-
sistance arrived. In a real disaster, such as the Hurricane
Katrina disaster, concern was raised about the incarcer-
ated population in New Orleans. Disaster plans need to
include both protection of the inmates from the disaster
and plans to address possible release of prisoners into the
general public. Disasters involving incarcerated prison
populations outside the prison pose unique issues for dis-
aster mitigation because the safety of the general public
must be considered as well as the safety of the prisoners.
Disasters within a prison facility require careful consid-
eration of the safety of first responders.

Mental Health and Disaster
Stress and anxiety normally occur in populations in the
aftermath of a disaster. How quickly the symptoms re-
solve depends on the ability of each individual and family
to cope with stressful situations. A small percentage of
the population will experience severe symptomatology
or have symptoms that persist for months or years fol-
lowing the disaster event.

Mental Health Disorders Following Disaster
Acute stress disorder (ASD) and post-traumatic stress
disorder (PTSD) are mental health disorders experienced
following a stressful event such a disaster.70,71 Criteria for
ASD and PTSD include exposure to a specific event that
causes a sense of fear, helplessness, or horror. Persons
experiencing these stress disorders also may have flash-
backs or recurrent images of the trauma, actively avoid
reminders of the trauma, or be in a hyperarousal state
that affects their startle response, sleep, and concentra-
tion. Because the symptomatology of stress disorders
may initially be a normal stress response, ASD cannot be
diagnosed until the symptoms have persisted for at least
2 days. After 1 month of persistent symptoms, affected
persons will be diagnosed with PTSD. Many victims of
complex human emergencies experience PTSD.3

Somatization occurs to persons experiencing psycho-
logical stress without a physical problem to explain their
symptoms.72 Survivors of disasters may develop a variety
of somatic symptoms affecting their neurological, diges-
tive, and immune systems. Symptoms may include ab-
dominal pain, back pain, chest pain, diarrhea, headaches,
impotence, and vomiting.72

The mental health consequences of stress and soma-
tization affect survivors of a disaster in varying degrees.

C H A P T E R 2 2 n Health Planning for Emergency Preparedness and Disaster Management 599

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Other groups affected by a disaster are the friends and
relatives of disaster victims, the first responders, health-
care providers who participate in disaster-related activi-
ties, and community members who either believe they
are at risk for a similar disaster or empathize with the dis-
aster victims.74,75 Other persons reported as being at
higher risk for the development of PTSD are those who
knew someone who worked, was injured, or died at the
site of a disaster. Factors that contribute to risk for PTSD
are seeing dead bodies or body bags and being disturbed
by the smells emanating from the disaster site. The neg-
ative mental health effects may last only a few days or
may persist for years.

The occurrence of adverse psychological reactions
varies across affected populations. Negative reactions
are most common for children and adolescents, persons
living in a developing country, those who experience a
violence-related disaster (e.g., terrorism), females who
experience gender-based violence, ethnic minorities,
people living in poverty or at a low socioeconomic sta-
tus, those who have a pre-existing mental disease or dis-
order, and those individuals lacking a support system.
Although these population groups have a greater risk,
anyone who directly or indirectly experiences a disaster
(e.g., family members of disaster victims) may be at psy-
chological risk.

Stress Among Health-Care Workers
Health-care workers, including community/public
health nurses (PHNs), are at risk for experiencing neg-
ative stress related to rendering postdisaster care.
Nurses may experience secondary traumatic stress as a
result of their caring, compassion, and empathy with
disaster victims. Secondary traumatic stress is a psycho-
logical stress disorder that mimics ASD and PTSD, ex-
cept the symptoms are a direct result of the caregiving
experience and not a result of being the disaster vic-
tim.75,76 Nurses identified as experiencing secondary
traumatic stress need to be referred to employee assis-
tance programs or other professional or community
services to receive interventions that can help the
nurses to protect their mental health.

Mental Health Interventions
Psychological and psychosocial interventions need to be
initiated with persons experiencing negative mental
health consequences of a disaster. Interventions have
been identified at the level of the individual, family,
neighborhood, community, and society that may protect
mental health.77 Individual-level interventions include
religious affiliation, maintenance of a natural routine,

traditional healing, clinical treatment, play therapy, and
cognitive behavioral therapy. Family-level interventions
include family self-help networks and family education.
Community-level interventions include capacity build-
ing, public education, service coordination, and religion-
related social interactions such as a mass gathering for
prayer or worship.78-79

Nurses can apply specific strategies for identifying
persons at risk for and exhibiting ASD/PTSD following
a disaster.80 Referrals should be made to primary care
providers, mental health specialists, and community
resources able to provide diagnostic testing and mental
health care for affected persons. There are a number of
community mental health resources that can be used to
assist with potential mental health issues following a dis-
aster. Debriefing and counseling are additional interven-
tions that can be offered to the survivors and responders
in individual or group sessions following a disaster as
soon as feasible.

Interventions for the mental health consequences as-
sociated with a disaster start as soon as the awareness of
an impending disaster is known. Even though advance
warnings may occur before some natural disasters such
as hurricanes and blizzards, the public may not be ade-
quately prepared for the devastation, lack of resources,
and isolation that occur during the immediate aftermath
of a natural, technological, or manmade disaster.

Disaster Management, Ethics, and Culture
During a disaster, ethics often comes to the forefront.
Decisions have to be made that may result in choosing
whom to rescue and how to prioritize the response. In
addition, there are a multitude of nongovernmental
organizations (NGOs) that respond to disasters, some
of which are well known, such as the International
Red Cross, Oxfam America, and Oxfam International.
Often during a disaster, it is assumed that anything
done under the umbrella of charitable work is accept-
able. However, the ethics decisions made by these re-
sponders must be examined from a broader ethical
perspective.

In 2010, a group of church members from the
United States were arrested for attempting to transport
children from Haiti into the Dominican Republic follow-
ing the Haiti earthquake. They initially stated that the
children were orphans, but it soon became apparent that
some of the children still had living parents. Had the
church workers attempted to kidnap the children? Had
they coerced the parents into giving up the children with
the promise of a better life for the children? The church

600 U N I T I I I n Public Health Planning

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members were eventually let out of prison and returned
to the United States. Their case demonstrates that per-
sons attempting to assist during a disaster can end up
making decisions without thinking through the ethics of
their actions or understanding the culture of the people
they are trying to help. In 1994, six of the world’s largest
nongovernmental relief agencies established a code of
ethics (Box 22-10). It is not a binding code but rather one
that is voluntary and helps guide charities providing
disaster relief. The code is made up of 10 principal com-
mitments, beginning with the commitment that “the
humanitarian imperative comes first.”81 The principles
include respect for culture and the commitment to build
on local capacities.

During a disaster, difficult choices are made when
resources are scarce. For example, in the 2017 Hurri-
cane Maria disaster in Puerto Rico, there was a scarcity
of water, electricity, and food. The failure to put to-
gether a coordinated effort related to relief resulted in
supplies being bottled up in the ports.82 A good EPDM
plan includes a process for priority setting. Who will
get medical assistance, those who are the most ill or
those who are healthier and apt to have a longer life
span? Answering these questions requires a systems
approach that includes organizations and policy mak-
ers, and should occur during the planning phase. Not
only is EPDM a key component to health care today,
but ethics also plays a significant role in the develop-
ment and execution of EPDM plans. Natural and man-
made disasters have taken untold lives throughout the
history of mankind. In our modern world, we have
increased our capacity to respond quickly to disasters,
and through prevention, preparedness, mitigation, and
recovery we can reduce the short- and long-term adverse
effects of disasters more effectively than ever before.
However, increasing our capacity also has increased
the ethical issues confronting responders.83 EPDM
requires a culturally grounded plan that addresses the

C H A P T E R 2 2 n Health Planning for Emergency Preparedness and Disaster Management 601

1. The humanitarian imperative comes first.
2. Aid is given regardless of the race, creed, or national-

ity of the recipients and without adverse distinction
of any kind. Aid priorities are calculated on the basis
of need alone.

3. Aid will not be used to further a particular political
or religious standpoint.

4. We shall endeavor not to act as instruments of
government foreign policy.

5. We shall respect culture and custom.
6. We shall attempt to build disaster response on local

capacities.
7. Ways shall be found to involve program beneficiaries

in the management of relief aid.
8. Relief aid must strive to reduce future vulnerabilities

to disaster as well as meeting basic needs.
9. We hold ourselves accountable to both those we seek

to assist and those from whom we accept resources.
10. In our information, publicity, and advertising activities,

we shall recognize disaster victims as dignified human
beings, not hopeless objects.

BOX 22–10 n Principles of Conduct for the
International Red Cross and Red
Crescent Movement and NGOs in
Disaster Response Programs

Source: (81)

n CULTURAL CONTEXT
AND DISASTER

When a disaster occurs, the immediacy of the situa-
tion can result in NGOs and outside government
agencies rushing to provide assistance without always
taking into account the culture of the people in dis-
tress. For example, in response to the earthquake and
subsequent tsunami in Palu, Indonesia, with the high
death toll, government officials decided to bury the
bodies in a mass grave. Families were unable to con-
duct traditional rituals related to death practiced by
many Muslims and Christians that focus on honoring
the graves of ancestors. Funerals provide an impor-
tant means of ensuring the proper passage of the
spirit to the afterworld. The absence of these rituals
has the potential to add to the stress of the survivors,
both short term and long term.

There is rarely time to do a cultural assessment
when responding to a disaster yet doing a review of
available cultural information must be done to be as
effective as possible. Specific areas to include in your
review include an understanding of several key cultural
issues including but not limited to: (1) linguistic affilia-
tion especially in countries where the population
speaks more than one language; (2) social stratification
and whether or not there is a formal and/or informal
class system; (3) gender roles; (4) marriage, kinship,
and family; (5) religious beliefs; and (6) etiquette. Hav-
ing a basic understanding of these underlying cultural
components of a community will assist first responders
when engaging with the population they have come to
help. In communities with diverse populations, it may
require understanding the cultural differences and
similarities across more than one cultural and/or
religious group.

7711_Ch22_569-606 22/08/19 11:13 AM Page 601

hard choices that have to be made in a way that pro-
vides the greatest help to the greatest number and in-
cludes all those affected.

Healthy People
Because of the increased awareness of the need for pre-
paredness in the event of a disaster, Healthy People 2020
added a new objective: Preparedness.84 It is built on the
National Health Security Strategy released in 2009. This
strategy was developed to help pull together the various
approaches to EPDM so that the nation as a whole can
prepare for and respond in the event of a disaster. The
goal is to reduce the impact on health. The inclusion of
preparedness reflects the commitment the nation has
made in the years since September 11, 2001, and Hurri-
cane Katrina in 2005 to improve our ability to prepare
for and respond to disasters both natural and manmade.

n Summary Points
• Preparedness and sound disaster planning can

provide a community with the ability to respond
effectively to both manmade and natural disasters.

• Disaster epidemiological surveillance provides early
recognition and identification of infectious disease
outbreaks.

• Nurses play a key role in the planning phase,
contribute to prevention efforts related to disasters,
and provide needed services that help mitigate the
effects of a disaster. They are essential to the response
and recovery phases of a disaster.

• Effective communication throughout the disaster
continuum will help to mitigate the adverse effects of
the disaster.

602 U N I T I I I n Public Health Planning

n HEALTHY PEOPLE
Targeted Topic: Preparedness
Goal: Improve the nation’s ability to prevent, prepare
for, respond to, and recover from a major health incident
Overview: Preparedness involves government agen-
cies, NGOs, the private sector, communities, and indi-
viduals working together to improve the nation’s ability
to prevent, prepare for, respond to, and recover from
a major health incident. The Healthy People 2020 objec-
tives for preparedness are based on a set of national
priorities articulated in the National Health Security
Strategy of the United States of America (NHSS). The
overarching goals of NHSS are to build community
resilience, and to strengthen and sustain health and
emergency response systems.
HP 2020 Midcourse Review: This was a new topic
for 2020 and of the 5 objectives, 2 were archived,
1 was developmental, and the 2 measurable objectives
were baseline only, so no progress on meeting
objectives could be assessed.
Source: (83, 84).

n CELLULAR TO GLOBAL
As previously described, disasters have an impact on
individuals, families, and communities. Injury, expo-
sure to pollutants and infectious agents, and other
direct effects of a disaster can result in serious health
issues for the individual. At the national level, the
CDC has taken an active role in both preparedness
and response to disasters.85,86 Even with these

systems in place, when emergencies occur back to
back such as Hurricanes Irma and Maria, national re-
sponse capacity can end up stretched with negative
consequences. Disruption of the provision of essential
resources, such as the lack of power following Hurri-
cane Maria in Puerto Rico, resulted in multiple hard-
ships for the entire island. Often the effects of natural
and manmade disasters can have negative conse-
quences on a global scale. The year 1816 was known
as The Year Without a Summer, a result of the 1815
eruption of Mount Tambora in the Dutch East Indies.
The subsequent release of ash into the atmosphere
caused a “fog” that reduced the amount of sunlight
and caused cooler temperatures. As a result, there
was a reduction in the ability to grow needed crops,
which led to a worldwide shortage of food. More
recently, the attack on the World Trade Center
resulted in the escalation of armed conflict in the
Middle East that continues today. In addition, a major
disaster, such as the earthquake and tsunami in Palu,
Indonesia, often requires a global response. In re-
sponse, the WHO developed a registration system to
help build a global roster of foreign medical response
teams who would be able to respond in the event of
an emergency. It is called The Global Foreign Medical
Teams Registry, and it “…sets minimum standards for in-
ternational health workers and allows teams to outline
their services and skills clearly. This facilitates a more
effective response and better coordination between
aid providers and recipients.”87 The challenge to
prepare for disasters and to respond effectively will
continue, and nurses will continue to play a key role.

7711_Ch22_569-606 22/08/19 11:13 AM Page 602

• Vulnerable populations require special consideration
in emergency preparedness and disaster manage-
ment planning.

• There are acute and long-term mental health issues
following a disaster.

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C H A P T E R 2 2 n Health Planning for Emergency Preparedness and Disaster Management 603

t CASE STUDY
Flooding and the Older Adult

Learning Outcomes
By the end of this case, the student will be able to:

• Describe the challenges encountered when planning
for a major natural disaster.

• Identify functional needs support services needed re-
lated to a specific subset of the population.

• Develop a disaster plan for a natural disaster.

A local 200-bed nursing home has been ordered to
evacuate because of its location in a flood plain. Many
of the residents require oxygen and have a mobility dis-
ability. More than half of the patients suffer from
Alzheimer’s disease. You are the nursing director in
the public health department and part of the communi-
tywide team responsible for the community’s EPDM
plan. The community is located along a major river. It
has never flooded before, but a 100-year flood has
been predicted. When you review the community’s
plan, you find that the nursing home was not included
in it. You call the team together and point out that they
must be ready to include the nursing home in their plan
before the water starts rising.

1. Design a disaster plan in the event that the nursing
home experiences a flood and needs to be evacu-
ated. Questions to address include:
a. What members are essential for the planning

committee?
b. How will residents be notified of the need for

evacuation?
c. Where will residents be relocated?
d. How will residents be relocated?
e. How will the relocation of residents be

tracked?
f. What items need to be relocated with the

residents?
2. How will you address the following issues?

a. A resident with a sensory disability
b. A resident with a mobility disability
c. A resident requiring continuous oxygen
d. A resident with no limitations or special needs

e. How the residents will be notified of the need
for evacuation

h. Who will be responsible for the tracking and re-
locating of residents

i. How to assure the residents’ that their items will
be relocated

Finally, identify how the plan will differ based
on the time from notification for facility evacuation
to the time that evacuation needs to be completed
(e.g., 1 day’s warning vs. 1 hour’s warning).

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65. Centers for Disease Control and Prevention. (2018). Repro-
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66. Allen, G. (2017, Dec 24). After deaths during Hurricane Irma,
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67. National Organization on Disabilities. (2018). Disaster readi-
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68. Centers for Disease Control and Prevention. (2017).
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69. U.S. Department of Health and Human Services. (2017).
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70. National Institute on Mental Health. (2016). Post-traumatic
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71. Bryant, R.A. (2016). Acute stress disorder: What it is and how
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72. U.S. National Library of Medicine. (2018). Somatic symptom
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606 U N I T I I I n Public Health Planning

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A
Abandonment, 495
ABCS protocol, 225b
Abstinence (substance use), 261
Abusive sexual contact, 495
Access to care and funding, 561–563, 562t
Acquaintance violence, 284, 285f
Acquired immune deficiency syndrome

(AIDS). See HIV/AIDS
Active immunity, 201
Active surveillance, 75
Activities of daily living (ADLs), 218
Acute care settings

cardiopulmonary resuscitation (CPR)
in, 352, 353f

catheter-associated urinary tract
infections (CAUTI) in, 365–366,
365b, 365f

catheter-related bloodstream infections
(CR-BSI) in, 361–362, 362b

central line-associated bloodstream
infections (CLABSI) in, 366

cerebrospinal and postoperative central
nervous system infections in, 364

cohort studies in delivery of, 352–358,
354–355b

cultural context and, 347
definition of, 343–344
epidemiology of populations treated

in, 347–348, 348t
health care-associated infections and

multiple drug-resistant organisms in,
367

health planning and, 358–359, 359f
hospital-associated pneumonia (HAP)

in, 365
infection control and, 363–367, 365b,

365f
inpatient populations and, 348–352,

351b, 351f
intensive care units, 351, 351b
noncommunicable diseases and,

358–359
performance improvement and,

359–362, 361b, 361f, 362b
population health and, 344–348, 345b,

346t, 348t
sepsis in, 363–364
surgical site infections (SSI) in, 364
ventilator-associated pneumonia (VAP)

in, 365
Acute coronary syndrome (ACS), 358
Acute myocardial ischemia, 359
Acute stress disorder (ASD), 599
Addiction, 259, 389–390
Adolescent idiopathic scoliosis, 467–468

Adolescents. See also School nursing
alcohol use by, 266
bullying and, 458–459
dating violence and, 459
drug use by, 275
lesbian, gay, bisexual, transgender, queer

(LGBTQ+), 243–244
mental disorder in, 240–241, 241f
obesity in, 460–461
screening for suicide risk among, 251
in the workplace, 521–522
youth violence and, 305

Adult learning, 38
Adult Protective Services (APS), 494–495,

496–497, 497b
Advanced Practice Registered Nurses

(APRNs), 372, 538
Advocacy, 15, 36b, 414

environmental health, 134–140, 136f,
137b, 138f

for migrant workers, 177
primary care, 376–377
by public health nurses in public health

policy, 556–558, 557b
in school nursing, 468–470

Affordable Care Act (ACA), 25, 116, 178,
252, 348, 376, 539

maternal-infant and early childhood
home visiting under, 440

national health policy under, 541–542
school nursing and, 472

African American population. See also
Race

cardiovascular disease screening in,
44–48, 45f, 46f, 48f

drowning risk and, 294
health disparities and, 162
maternal mortality and, 424–425

Aged dependency ratio, 483, 483f
Ageism, 500
Agency for Healthcare Research and

Quality (AHRQ), 33
Task Force on Community Preventive

Services, 550, 550–552t
Agency for Toxic Substances and Disease

Registry (ATSDR), 58, 133
Agent (infectious disease), 60, 197–199,

198f, 198t
attack rates and, 205–206
life cycle of, 200–201, 201f

Aggregate, 6–7, 6b, 79
Aggregate data, 89
Aging. See also Older adults

communicable disease and, 490–492, 492t
Community Aging in Place, Advancing

Better Living for Elders (CAPABLE)
Program, 415, 488–490

continuing care retirement communities
(CCRCs) and, 500

definition of, 484–485
determinants of health and, 484–487
key research on, 486–487
naturally occurring retirement

community (NORC) and, 499–500
in place, 415, 499–500
population, 480–481, 481f
program planning and health promotion

in, 487–490, 488b, 489t
rectangularization of, 482
ten keys to healthy, 488, 488b
theories of, 485–486
of the workforce, 483, 483b

Agricultural workers. See Migrant workers
Air quality, 149–151, 150b, 408

in the WSCC model, 454
Air Quality Index (AQI), 149, 150b
Alcohol-impaired driving, 289
Alcohol use, 230, 263–265, 264f, 265f.

See also Substance use
by age group, 263–264, 264f
binge drinking, 257, 261
consequences of, 266
cultural context of, 259
disorder of, 264–265
in older adults, 497–498, 498b
policy level interventions to reduce

harm related to, 268–269, 269b
potential adverse outcomes associated

with, 260–261
screening brief intervention and referral

for treatment, 266–268
standard drink, 261, 262f
in vulnerable populations, 266

Alcohol use disorder (AUD), 264–265
in older adults, 497–498, 498b
stigma and, 277

Allergies, food, 463
Alzheimer’s disease and related dementias

(ADRD), 500–502, 501b
Ambient air, 149–150
Ambient air standard, 149
American Academy of Audiology, 460,

461b
American Academy of Family Physicians

(AAFP), 373
American Academy of Pediatrics (AAP)

on drowning prevention, 294
American Association of Occupational

Health Nursing (AAOHN), 512,
512b

American Association of Poison Control
Centers, 297

American Association of Retired Persons,
499

Index

607

7711_Index_607-630 21/08/19 11:08 AM Page 607

American Cancer Society, 50
American Diabetes Association, 65, 221
American Heart Association (AHA), 352
American Lung Association, 408
American Nurses Association (ANA), 2

on environmental health, 130, 131b
Public Health Nursing: Scope and

Standards of Practice, 11, 13–15, 14b,
15b

American Psychiatric Association
(APA), 246

American Public Health Association
(APHA), 314

Americans With Disabilities Act (ADA),
465, 466t, 468, 523

Analytical epidemiology
case-control studies and odds ratio,

71, 71b
clinical trials and causality, 73
cohort studies and relative risk, 34,

71–73, 72b
cross-sectional studies, 70
definition of, 70

Andragogy, 38
Antigenicity, 199
Anxiety, screening for, 249
Any mental illness (AMI), 240
Asian Americans, 246–247, 247b
Assaults by patients/visitors against

health-care workers, 528–529
Assessment, 3

community (See Community health
assessment)

health policy planning and, 546–548,
547t

personal cultural, 9b
workplace, 519–520, 520b

Assessment Protocol for Excellence in
Public Health (APEXPH), 84

Asset mapping, 82–83
Association of Supervision and

Curriculum (ASCD), 451
Assurance, 3
Asthma, 141–144

indoor air pollution and, 150–151
school nursing and, 464

Asylees, 178–180, 179b, 179t
At-risk alcohol use, 265, 265f
At-risk substance use, 257, 261
Attack rates, 68, 205–206, 206b
Attention-deficit/hyperactivity disorder

(ADHD), 463–464
Attributable risk, 34
Audiometric screening, 460, 461b
Automated external defibrillator

(AED), 463

B
Baby boomers, 481–482
Baltimore Longitudinal Study of Aging

(BLSA), 486–487

608 Index

Baltimore Syphilis Elimination Project,
209–210

Bandura, Albert, 37
Barton, Clara, 56
B. burgdorferi, 200–201, 201f
Behavioral health, 239
Behavioral prevention, 33
Behavioral risk factors, 58, 58f

for noncommunicable diseases, 225–226
Behavioral Risk Factor Surveillance System

(BRFSS), 65, 91, 241, 261, 289, 321
Behaviorism, 37
Bike lanes/trails, 549
Binge drinking, 257, 261
Biological agents, 133

workplace exposures to, 517
Biological theories of aging, 485–486
Biostatistics

community assessment and, 94–101
definition of, 65
mean, median, and mode, 65–66, 66b
percent change, 66, 66b
rates, 66–70, 67t, 68b, 69f, 69t

Bioterrorism, 333, 589, 590t
Bioterrorism and Emergency Readiness

Competencies for All Public Health
Workers, 333

Bisexual persons. See Lesbian, gay,
bisexual, transgender, queer
(LGBTQ+) population

Blast events, 587–588, 588t
Blast wind, 588
Blood alcohol concentration (BAC),

261, 277
Blood lead level (BLL), 134–140, 136f,

137b, 138f
Blood pressure, 43–44
Blood transfusion, 350
Bloom, Benjamin, 40
Bloom’s Taxonomy, 40, 41b
Body mass index (BMI), 73, 539

for children and teens, 461, 461b
diabetes and, 224

BRCA1 and BRCA2 genes, 223, 230
Breast cancer, 223, 230

primary care screening for, 382
Breastfeeding

promotion program for, 442–443
and women in the workplace, 523

Breckinridge, Mary, 56
Brewster, Mary, 12
Brief Symptom Checklist-18, 249
Built environment, 132
Burden of disease, 75

attributable to the environment, 130,
130t

communicable diseases (CDs), 193–197
mental disorders, 241
noncommunicable chronic disease,

220–221, 220b, 221b
sexually transmitted diseases, 207–208

substance use and, 257–262, 258f, 258t,
260b, 260t, 262f

Burn-related injuries
definition of, 290
estimating rates of, 292b
prevention of, 290–291
risk factors for, 290

Business/organizational health policy,
544, 546

C
Calment, Jeanne, 487
Campbell, Jacquelyn, 287
Cancer, 223, 223f, 230

screening for, 382
Cannabis, 258t
Cardiopulmonary resuscitation (CPR),

352, 353f
Cardiovascular disease (CVD)

Framingham Heart Study of, 352, 354,
354–355b

health planning and, 358–359, 359f
Healthy People 2020 on, 358–359, 359f
as leading cause of death and disability,

222–223
Mississippi Delta Health Collaborative

(MDHC) and, 224–225
screening for, 44–48, 45f, 46f, 48f
tobacco use and, 229
women and, 355–358, 355b

Caregiving for older adults with
Alzheimer’s disease and related
dementias, 501–502

Carrier, 199
Case-control studies, 71, 71b
Case fatality rate (CFR), 196, 203–204, 206
Case finding, 36b
Case management, 36b, 383

in the workplace, 525, 527
Categorical funds, 337
Catheter-associated urinary tract infections

(CAUTI), 365–366, 365b, 365f
Catheter-related bloodstream infections

(CR-BSI), 361–362, 362b
Causality, 61

clinical trials and, 73
Cellular immunity, 201
Census block, 89
Census data, 64–65, 89, 98, 98t

on the aging population, 480–481,
481f, 482f

Census tract, 89
Centenarians, 480, 487
Center for Epidemiological Studies

Depression Scale (CES-D), 49, 249
Centers for Disease Control and Prevention

(CDC), 17–19, 18b, 27, 165
on aging in place, 499
on climate change and health, 148, 148f
on clinical prevention services for older

adults, 492b

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Index 609

community data, 65
on drowning prevention, 294
on elder maltreatment, 495, 496b
on emerging communicable diseases in

older adults, 491
federal funding of, 558
Flu View, 193
on genomics and public health, 230
on health literacy, 38, 39b
Healthy Brain Initiative, 501, 501b
on maternal deaths, 55
Morbidity and Mortality Weekly

Report, 89
National Center for Environmental

Health, 131
Partnerships to Improve Community

Health (PICH), 78
Preventing Intimate Partner Violence

Across the Lifespan: A Technical
Package of Programs, Policies, and
Practices, 304

Racial and Ethnic Approaches to
Community Health (REACH)
program, 165, 166f

rapid needs assessment, 82
on school nursing and immunizations,

456–457
on screening in primary care, 382
states and, 543
on substance use, 261–262
surveillance by, 74–75
surveillance of injury and violence,

285–286
on surveillance of mental health

disorders, 241
on tobacco use in the Midwest, 378
on top 10 causes of death, 33–34, 34b,

347–348, 348t
on youth violence, 305

Centers for Medicare and Medicaid
Services (CMS), 542–543

Centralized (state) system of public health
departments (PHDs), 315

Central line-associated bloodstream
infections (CLABSI), 366

Central nervous system infections, 364
Cerebrospinal and postoperative central

nervous system infections in,
364

Chain of infection, breaking the, 201–202
CHANGE (Community Health

Assessment and Group Evaluation)
tool, 79, 83, 84t

case study, 94–101
data analysis, 93
list of sectors, 88–89
postassessment phase, 93
PRECEDE-PROCEED model and, 110

Chemical agents, 133
workplace exposures to, 516–517

Chemical exposure, 588–589

Child Abuse Prevention and Treatment
Act (CAPTA), 471

Childbirth, cultural context for, 421–422
Child maltreatment, 300–302, 301t, 302t
Children. See also Adolescents; Maternal,

infant, and child health; School
nursing

burn-related injuries in, 290
disasters and, 597–598
environmental health and asthma in,

141–144
exposure to lead-based paint in,

134–140, 136f, 137b, 138f
falls in, 294–295, 295b
health disparities and doctorless,

162–163
immigrant, 459–460
maternal-infant and early childhood

home visiting for, 440–442, 441b
mortality rate in, 420, 423, 425–426, 426t
poisoning in, 295–296, 296f
refugee, 448
vaccination recommendations for, 214
as vulnerable population, 144–145

Children’s Health Insurance Program
(CHIP), 542, 562–563

Children’s Health Insurance Program
(CHIP), 471

Chlamydia trachomatis, 207
Cholera, 9–10, 56–58, 57f
Chronic care model, 219, 219f
Chronic carrier, 199
Chronic disease, 74, 218–221, 219f, 220b,

221b. See also Noncommunicable
disease (NCD)

self-management of, 234
Chronic disease self-management

(CDSM), 234
Chronic lower respiratory disease, 223
Chronic obstructive pulmonary disorder

(COPD), 223, 235
Cigarette use. See Tobacco use
Cincinnati Children’s Hospital Medical

Center (CCHMC), 288
Clean Air Act, 149
Clear communication, 40
Climate change and health, 147–148, 147b,

148f
Clinical prevention, 33
Clinical trials, 73
Clostridium difficile, 367
Coalition building, 36b

definition of, 411
weight, 435–438

Cognitive framework, 37
Cohort studies, 71–73

in delivery of acute care, 352–358,
354–355b

Collaboration, 15, 36b, 338–339
definition of, 399
food deserts and, 384–386

primary care and, 392
in school nursing, 468–470

Collective violence, 284, 285f, 305–306
Colonization, 201
Colonoscopy, 49
Common source of infection, 203
Communicability and communicable

diseases, 211–213
Communicable diseases (CDs)

aging and, 490–492, 492t
burden of disease and, 193–197
communicability and, 211–213
controlling, 213
definition of, 191
diarrheal, 195
emerging and re-emerging, 195–196,

332, 491
HIV/AIDS (See HIV/AIDS)
infectious agents and cycle of

transmission, 197–205
infectious respiratory disease, 193, 193b
as main reason for morbidity and

mortality, 191–192
malaria, 193–194
nursing practice and, 192–193
outbreak investigation, 202–205, 203b,

204f
outbreaks, 74
sexually transmitted infections (STIs),

206–211
substance use and, 276

Communication
clear, 40
disaster, 594–595, 595b
in primary care, 392
risk, 594–595, 595b

Communities in Action: Pathways to
Health Equity, 6

Community, 6–7, 6b
-academic partnerships, 415
definition of, 78
population nursing roles in the, 413–415
resilience and, 244–245

Community-academic partnerships, 415
Community Aging in Place, Advancing

Better Living for Elders (CAPABLE)
Program, 415, 488–490, 499

Community-based participatory research
(CBPR), 83, 412–413

Community capacity, 107
Community data, 65
Community diagnoses, 116, 117b, 126

homelessness, 172–173
loneliness in older adults, 116–120, 118f

Community environmental health
assessment, 152–153, 152b

Community health, 78–79
primary prevention efforts and public

health departments (PHDs), 327–328
sexually transmitted infections and,

209–210

7711_Index_607-630 21/08/19 11:08 AM Page 609

Community health assessment, 77–78
burn-related injuries, 291–293
community-based participatory research

(CBPR), 83
comprehensive, 79, 80t, 86–104
concepts of relevance to, 82–83
core competencies for public health

professionals, 78, 78b
definition of, 77
definitions of community and

community health and, 78–79
environmental health, 152–153, 152b
epidemiology and biostatistics in, 94–101
food deserts and, 384–386
health disparities and, 162–163
health impact, 81–82, 82b
homelessness, 172–173
infant mortality, 319–322
low birth weigth, 437–438
migrant workers, 177
models and frameworks of, 83–86,

84t, 85f
needs assessment versus asset mapping

in, 82–83
population-focused, 79–80
problem- or health-issue-based, 81
rapid needs, 82
setting-specific, 80–81
types of, 79–82
windshield survey, 86–89, 87–88t

Community health centers (CHCs), 391
Community involvement in the WSCC

model, 455
Community-level risk factors for mental

disorders, 244
Community mapping, 92–93
Community members and primary care,

393–394
Community organizing, 36b, 114, 400–401

definition of, 409–410
primary care and, 392–393, 393t
process of, 411
public health nursing and, 409–411
as tool for change, 410–411

Community or herd immunity, 206
Community partnerships, 6, 338–339

definition of, 398–399
homelessness, 172–173
importance of, 399–401
migrant workers and, 177
in rural communities, 416

Community violence, 284, 285f, 304–305
Competencies for Public Health

Informaticians, 335
Comprehensive community assessment,

79, 80t, 86
data analysis, 93
evaluating the assessment process in, 93
postassessment phase, 93
primary community health data

collection in, 90–93

610 Index

secondary community health data
collection in, 89–90

windshield survey, 86–89, 87–88t
Comprehensive school physical activity

program (CSPAP), 451–452, 453f
Confounders, 71
Constructivism, 37
Consultation, 36b

in school nursing, 468
Continuing care retirement communities

(CCRCs), 500
Continuous source, 204
Convalescent carrier, 199
Coordinated school health, 451
Coordinated school health model, 451
Core end-stage indicators, 503
Corticotrophin-releasing hormone (CRH),

436
Council on Linkages Between Academia

and Public Health Practice, 78
Council on Linkages: Core Competencies for

Public Health Professionals, 335
Counseling, 36b

in the WSCC model, 453–454
Criteria air pollutants, 149, 150b
Critical care, 349–352, 351b, 351f
Critically ill or injured patients, 349
Cross-linkage or connective tissue theory

of aging, 486
Cross-sectional studies, 70
Crown fires, 587
Cultural competency, 8–9
Cultural context, 7–10

acute care settings and, 347
alcohol use, 259
clear communication, 40
disasters and, 601
end-of-life decisions and, 503–504
environmental health, 134
epidemiology, 60–61
health program planning, 120–121
immigrants in the workforce, 524
intimate partner violence, 303
mental illness stigma and, 245–247,

246b, 247b
noncommunicable diseases, 234–235
pregnancy and childbirth in the U.S.,

421–422
primary care and, 394
public health departments (PHDs),

324–325
school nursing and, 460
sexually transmitted diseases (STDs),

210–211
suicide, 298
sustainable urban development, 407
undocumented immigrants, 553
vulnerability and, 168

Cultural humility, 9
Culturally acceptable health policies, 553
Cultural shift, 234

Culture, 7, 8
disaster management and, 600–602,

601b
primary care and, 394–395
public health policy and, 552–553, 553f

Cyberbullying, 458–459
Cyclones, 578–580, 578b

D
Dandy, Walter, 349
Data

aggregate, 89
census, 64–65, 89, 98, 98t, 480–482,

481f, 482f
community, 65
deidentified, 89
mean, median, and mode, 65–66, 66b
percent change, 66, 66b
population, 64–65
qualitative, 91–93
quantitative, 90–91
rates, 66–70, 67t, 68b, 69f, 69t

Data analysis, 93
on alcohol use, 267–268

Data collection, 55
population, 64–65
primary community, 90–93, 100
by public health departments

(PHDs), 324
secondary community health, 89–90,

99–100, 100t
Dating violence, 459
Death. See also Mortality

of children, 420
due to cancer, 223, 223f
due to chronic lower respiratory disease,

223
due to diabetes, 223–224
due to heart disease and stroke, 222–223
due to substance use, 259
due to tobacco use, 269
due to unintentional injury, 283–284,

284b
hospice and end-of-life care prior to,

502–504, 503b
of infants, 157, 159–160, 159f, 422–423,

423f
leading causes of disability and, 222–224
maternal, 420–421
National Violent Death Reporting

System and, 285–286
premature, 220–221
by suicide, 297
top 10 causes of, 33–34, 34b, 222b,

347–348, 348t
top 10 causes of, by income, 192t
in the workplace, 525, 527f

Decentralized (local) systems of public
health departments (PHDs), 315

Deidentified data, 89
Deinstitutionalization, 252

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Index 611

Delivery of public health prevention
strategies, 33–34

Demand Control Model, 517–518
Dementia, 500–502, 501b
Demographic transition model, 64, 64f
Demography, 64–65, 64f
Dental caries, 549–550
Department of Health and Human Services

(DHHS), 18
Dependency ratio, 483
Dependent rates, 69–70
Depressants, 258t
Depression screening, 248–249
Descriptive epidemiology, 70
Determinants of health, 7–10

ecological, 26
public health policy focus on, 548–549,

548t
social, 26, 115

Determinants of vulnerability, 168–169,
169b

Diabetes, 221–224, 222f
race and prevalence of, 223, 380t
school nursing and, 464
states with highest rates of, 231t

Diagnosis, 43–44
community, 116–120, 117b, 118f,

126
sensitivity and specificity in, 44

Diagnostic and Statistical Manual of
Mental Disorders (DSM), 251, 259

Diarrheal disease, 195
Disability

leading causes of, 222–224
in the school setting, 464–465, 465b
in workers, 523–524

Disability-adjusted life years (DALY), 75,
220, 221, 221b

Disaster communication, 594–595, 595b
Emergency Alert System (EAS), 595
with limited technology, 595
risk, 594–595, 595b
social and mass media systems, 595

Disaster epidemiology, 577–578
Disaster management, 333. See also

Emergency preparedness
communication in, 594–595, 595b
definition of, 571
disaster nursing and, 570–571
ethics, culture, and, 600–602, 601b
federal response and organization,

590–592
health-care facility response, 592–593
organizational plan review, 571, 573b
public health law and, 596–597
triage and patient tracking, 589–590, 598
in the workplace, 530–531

Disaster nursing, 570–571
Disaster planning, 573–576
Disaster response structure and

organization, 589–594

Disasters
definition of, 571
disaster science and, 570, 570b
federal response and organization,

590–592
manmade, 587–589, 588t
mental health and, 599–600
natural, 578–587, 578b, 583b, 584b, 585t,

586b, 586f, 587b
timeline, 571, 572f
types of, 569–570, 570f
vulnerable populations and, 597–599,

597b
Disaster science, 570, 570b
Disaster triage and patient tracking,

589–590
Discharge rate, 345, 345b
Discharge status, 348
Discrimination, 169, 169b
Disease control and public health

departments (PHDs), 328–333, 329b,
332b

Disease(s). See also Communicable
diseases (CDs); Infectious disease;
Noncommunicable diseases
(NCD)

emerging and re-emerging, 195–196,
332, 491

investigations, 328–330, 329b
natural history of, 28–30, 28f, 29f
notifiable, 392, 393t
and other health event investigation, 36b

Disparities, health. See Health disparities
Disparity. See also Health disparities

definition of, 157
at the national and global level, 159–160,

159f
Dissociative anesthetics, 258t
Distracted driving, 289
Diversity, 7, 8. See also Ethnicity; Race

of children, 459–460
of older adults, 484
worker population, 514, 524–525

Dix, Dorothea, 56
Doctorless children, 162–163
Door-to-balloon time, 356
Downstream approach, 26–27
Dracunculiasis, 195
Drowning, 293–294, 293b, 294b
Drug Abuse Screening Test (DAST-10),

275–276
Drug-free workplace policy development,

544, 546
Drug use, 272–273, 389–390. See also

Opioids/opioid pain relievers (OPR)
abuse; Substance use

consequences of, 275
medication-assisted treatment (MAT)

for, 273–274
policy level interventions to reduce

harm related to, 276

public health departments (PHDs) and
deaths due to, 331–332, 332b

screening and treatment for, 275–276
stigma and, 277
in vulnerable populations, 275

Dry-cleaning workplace assessment,
532–533

Dual Capacity-Building Framework
for Family and School Partnerships,
455

Duration of substance use, 257

E
Early onset at-risk substance use, 497
Earthquakes, 580–581
Ebola virus, 74, 75
E. coli, 203–205, 203b, 206, 211–212, 213,

363–364
Ecological determinants of health, 26
Ecological fallacy, 73
Ecological model, 63
Economics, 558
Education, theories of, 37–38
Education for All Handicapped Children

(EAHCA), 464–465, 466t
Effectiveness, policy, 546, 547t
Efficiency, policy, 546, 547t
Effort-Reward-Imbalance Model, 518
Elderly, 480. See also Older adults
Elder maltreatment, 494–497, 496b, 497b
Electronic medical record (EMR), 357
Emergency Alert System (EAS), 595
Emergency information systems (EISs),

577
Emergency preparedness, 333. See also

Disaster management
definition of, 571
disaster communication in, 594–595,

595b
disaster epidemiological surveillance

and, 577–578
disaster nursing and, 570–571
disaster planning in, 573–576
disaster response structure and

organization, 589–594
Healthy People 2020 on, 602
necessity of, 569
theoretical framework for, 572–573,

573f
types of disasters and, 569–570, 570f
in the workplace, 530–531

Emergency preparedness and disaster
management (EPDM), 572–573, 573f,
601

environmental assessment and advocacy
for, 573–575

evaluation, 576
mitigation in, 576
preparedness in, 575–576
recovery, 576
response, 576

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Emergency Volunteer Health Practitioners
Act (UEVHPA), 597

Emerging or re-emerging infections,
195–196, 332

in older adults, 491
Emotional abuse, 300
Emotional health, 239–240
Emotional neglect, 300
Employee wellness in the WSCC model,

454–455
Endemic, 192
Endemic curve, 204, 204f
End-of-life care, 502–504, 503b
Enforcement, policy, 36b, 470–472
Engineering controls, 513
Environment (infectious disease), 60,

199–201, 199b, 200t, 201f
Environmental exposures, 133
Environmental health, 128–129

air quality, 149–151, 150b
approaches to, 130–132, 131f
built environment and, 132
climate change and, 147–148, 147b, 148f
community assessment, 152–153, 152b
definition of, 128
environmental justice and, 140–144,

141b, 143b
evidence-based practice in, 132
gene-environment interaction and, 147
global burden of disease and, 130, 130t
hazardous substances, 132–134
Healthy People 2020 on, 129, 129f
history, 134, 521
potable water and, 151–152, 152b
role of nursing in, 130–132, 131b, 131f
screening, case finding, advocacy and

policy case study, 134–140, 136f, 137b,
138f

vulnerable populations and, 144–147
Environmental health services, 323, 323b
Environmental justice, 140–144, 141b,

143b
Environmental monitoring, 513
Environmental prevention, 33
Environmental Protection Agency (EPA),

58, 89–90, 131
WSCC model for physical environment

and, 454
Environmental risk factors, 58–59

for noncommunicable diseases, 226
Environmental sustainability, 148
Environmental tobacco smoke (ETS), 269
Environment and resource availability,

9–10, 10b
Epidemics, 192, 587, 587b

measles, 215
Epidemic threshold, 209
Epidemiological frameworks, 59–61, 59f, 60f

causality in, 61
constants of person, place, and time in,

60, 60f

612 Index

ecological model in, 63
epidemiological triangle in, 59–60, 59f
web of causation in, 63, 63f

Epidemiological triangle, 59–60, 59f
workplace and, 510

Epidemiology, 55–56
analytical, 70–73, 71b
biostatistics in, 65–70, 66b, 67t, 68b,

69f, 69t
burn-related injuries, 290–293, 291b, 291f
causality in, 61
collective violence, 305–306
communicable diseases, 211–213
community assessment and, 94–101
community violence, 304–305
constants of person, place, and time in,

60, 60f
definition of, 56
demography in, 64–65, 64f
descriptive, 70
disaster, 577–578
drowning, 293–294, 293b, 294b
ecological model in, 63
epidemiological triangle in, 59–60, 59f
falls in children, 294–295, 295b
frameworks, 59–61, 59f, 60f
health promotion and applied, 61–63
historical beginnings of, 56–58, 57f
human genome, 230
investigating motor vehicle accidents

using, 75
of mental disorders, 241–242, 242f, 250
of motor vehicle crashes, 288–290
outbreak investigations, 73–75
poisonings, 295–297, 296f
of populations treated in acute care

settings in the U.S., 347–348, 348t
public health departments (PHDs) and,

328–333, 329b, 332b
risk factors in, 58–59, 58f
self-directed violence, 297–300, 298b,

298f, 299t
sexually transmitted infections, 411–412
substance use disorders, 272–273
tools of, 64–70
violence against children and women,

300–304, 301t, 302t, 303b
web of causation in, 63, 63f

Episodic care in the school setting,
463–464

Equality, 157–158, 158f
Equity, 157–158, 158f, 547t
Equity, policy, 546
Ergonomics, 518–519
Essentials of Doctoral Education for

Advanced Nursing Practice, 344
Estelle v. Gamble, 180
Ethics

in acute care setting, 356–357
of community-based participatory

research (CBPR), 413, 413b

disaster management and, 600–602,
601b

and disparity related to chronic diseases,
232, 232b

in occupational and environmental
health nursing, 512, 512b

public health, 318, 318b
public health nursing, 15
public health policy implications for,

552–553, 553f
of screening in primary care, 382
screening program, 50
vulnerability and, 169–170

Ethnicity. See also Race
definition of, 8
health disparities and, 539
prevalence of mental disorders and,

242, 242f
Evacuation, 596–597
Evaluation

emergency preparedness and disaster
management (EPDM), 576

formative, 124
health education, 42
health program, 123–125, 125b
process, 124
summative, 124

Evidence-based practice
assaults by patients/visitors against

health-care workers, 528–529
central line-associated bloodstream

infections (CLABSI), 366
culture and nutrition during pregnancy,

433–434
environmental health, 132
fall prevention for older adults, 494
for incarcerated persons, 181–182
maternal mortality prevention, 424
medication-assisted treatment (MAT),

273–274
multipronged home-based care

intervention for aging in place, 415
noncommunicable diseases, 233
nurse-family partnership model, 322
patient-centered medical home, 392
pediatric triage tool for disasters, 598
program planning, 121–122
public health policy and, 549–550,

550–552t
school nursing, 467–468
screening for suicide risk among

adolescents in primary care, 251
use of window guards, 295
vaccination recommendations during

childhood, 214
Exercise. See Physical activity
Exposures. See also Toxicity

chemical, 588–589
radiation, 589
risk assessment, 133
to toxins, 74, 132–133

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Index 613

types of, 133–134
in the workplace, 515–518, 531–533

Extreme heat, 581–582

F
Fair Labor Standards Act (FLSA), 521
Fair-Trade Act, 271
Faith community nursing, 413
Falls

in children, 294–295, 295b
health planning to prevent, 367–368
in older adults, 494

Family and Medical Leave Act (FMLA),
548

Family caregivers, 501
Family Educational Rights and Privacy Act

(FERPA), 471
Family engagement in the WSCC model,

455
Family planning programs, 326
Family violence, 284, 285f

child maltreatment, 300–302, 301t, 302t
definition of, 300
intimate partner violence (IPV),

302–304, 303b
Fatality Analysis Reporting System

(FARS), 289
Federal Communications Commission

(FCC), 271
Federal Emergency Management Agency

(FEMA), 82, 576, 590–591, 599
Federal funding, 558
Federally qualified health centers (FQHC),

400–401, 411–412
Federal Office of Rural Health Policy, 401
Femicide, 303b
Fetal alcohol spectrum disorders (FASD),

258, 266
Fetal alcohol syndrome (FAS), 262
Finance, public health, 558–561, 560b
Financial abuse or exploitation, 495
Financing of public health departments

(PHDs), 336–337
504 plans, 466t, 468
Flesh-eating bug, 211–213
Flint, Michigan, water crisis, 151–152,

152b, 558
Floods, 582, 603
Fluoridated toothpastes, 549–550
Focus groups, 91
Food allergies, 463
Food deserts, 384–386
Food for persons experiencing homelessness,

174
Food security, 174
Formal caregivers, 501
Formative evaluation, 124
Framingham Heart Study, 352, 354,

354–355b
Free-radical theory of aging, 485–486
Frequency of substance use, 257

Future of the Public’s Health in the
Twenty-First Century, The, 3, 5, 79,
324–325

G
Gay persons. See Lesbian, gay, bisexual,

transgender, queer (LGBTQ+)
population

Gender
alcohol use and, 261
cardiovascular disease and, 355–358,

355b
intimate partner violence (IPV) and,

302–304, 303b
prevalence of mental disorders and, 242,

242f
as social determinant of health, 231b
tobacco use and, 269
in the workforce, 523

Gender Bread Person, 183f
Gender identity, 182, 182b
Gene-environment interaction, 147
Generation time, 206
Genetic mutations in aging, 485
Genetic risk factors/genomics, 59

breast cancer, 223
noncommunicable disease, 230

Geographic information system (GIS), 93
public health departments (PHDs)

and, 336
Geriatric assessment instrument (GAI),

495
Geriatrics, 488
Gerontology, 488
Glass, Nancy, 287
Global health, 16f

defined, 15–16
dementia and, 502
low birth weight and, 436
primary care in, 373–374, 374f
public health organizations and

management of local to, 16–19
refugees and asylees and, 178–180, 179b,

179t
safe water and, 152
tobacco-use interventions and, 271–272,

272t
Universal Declaration of Human Rights

and, 164–165, 164b
Globalization, 4–5

primary care and, 373
Gonorrhea, 207
Government health insurance programs,

471, 539, 540, 541, 561–563, 562t
Government income support programs,

563
Grants, 560–561
Greater Than the Sum: Systems Thinking in

Tobacco Control, 319
“Green” jobs, 531
Ground fire, 587

Guide to Clinical Preventive Services, 550
Guide to Community Preventive Services:

The Community Guide: What Works
to Promote Health, 550

H
H1N1 virus, 29–30, 193, 332

public health departments (PHDs)
funding and, 337

rates, 68–69
H7N9 virus, 332
Haddon Matrix, 286, 287f, 289
Hallucinogens, 258t
Harm reduction model, 263, 264b
Hazardous materials, 589
Hazard Communication Standard, 516
Hazardous substances, 132–134
Health

climate change and, 147–148, 147b,
148f

definition of, 6
determinants of, 7–10, 484–487,

548–549, 548t
impact of homelessness on, 171–172
of incarcerated persons, 180–181
of LGBTQ+ persons, 184
of migrant agricultural workers, 177
of refugees and asylees, 179–180

Health-adjusted life expectancy (HALE),
220, 220b

Health Alert Network (HAN), 543
Health and Medicine Division (HMD),

National Academies of Sciences,
Engineering, and Medicine, 3, 5, 10

on performance improvement in acute
care settings, 360

on substance use disorders, 262–263
Health care-associated infections, 363
Health-care facility disaster response,

592–593
Health care for persons experiencing

homelessness, 174
Health-care system, U.S.

business/organizational health policy,
544, 546

health disparities in, 159–160, 159f,
539–540

health insurance in, 357, 539, 546
local health policy, 538, 543–544
market economy and, 538–539
national health policy, 540–542
state health policy, 542–543

Health Consequences of Smoking—50 Years
of Progress: A Report of the Surgeon
General, The, 269

Health disparities, 157–159, 158f
in access to care and immunizations,

539–540
benchmark areas to demonstrate

improvement to reduce childhood,
441b

7711_Index_607-630 21/08/19 11:08 AM Page 613

community assessment, health planning
and, 162–163

definition of, 158
low birth weight, 436
noncommunicable disease and,

230–232, 231b, 231t, 232b
race and, 539
school nursing and, 472
social determinants of health, social

capital, and social justice, 26, 115,
160–163, 160f, 161f

in the U.S., 159–160, 159f, 539–540
Health economics, 558
Health education, 15, 36–37

adult learning and, 38
definition of, 37
developing a teaching plan for, 39–41,

40b
evaluation in, 42
health literacy, 38–39, 39b, 39f
methods of instruction, 41–42
theories of education and, 37–38
in the WSCC, 451

Health gradient, 159
Health impact assessment (HIA), 81–82,

82b
Health inequity, 158
Health insurance, 357, 539

business/organizational health policy on,
546

government programs, 471, 539, 540,
541, 561–563, 562t

Health Insurance Portability and
Accountability Act (HIPAA), 357

Health literacy, 38–39, 39b, 39f
Health prevention, 27

delivery of strategies, 33–34
levels of, 30–32
universal, selected, and indicated

prevention models, 32–33, 32f, 34b
Health program planning

acute care and, 358–359, 359f
breastfeeding promotion, 442–443
burn-related injuries, 291–293
community diagnoses in, 116–120, 117b,

118f, 126
definition of, 107
evidence-based practice in, 121–122
food deserts and, 384–386
health disparities and, 162–163
and health promotion in aging, 487–490,

488b, 489t
Healthy People 2020 and, 108–109,

109b, 110b
key components of, 114–116, 115b, 115f
logic model, 111–114, 112f, 113t
for loneliness in older adults, 116–120,

118f
low birth weight, 437–438, 438–440
mental health, 250
national perspective on, 108

614 Index

noncommunicable diseases and,
226–229, 228f

overview of, 109–120
physical activity in older adults, 504–505
PRECEDE-PROCEED model, 110–111
to prevent falls, 367–368
program evaluation, 123–125, 125b
program implementation, 122–123
in rural communities, 401–405, 402t,

403f, 404f
in school nursing, 468–470
sexually transmitted infections and,

209–210
steps in, 107–108, 111t
substance use disorders, 272–273
in urban communities, 405–409, 406t,

407b, 408f
Health promotion, 15

in aging, 487–490, 488b, 489t
applied epidemiology and, 61–63
definition of, 26
mental health, 247–251, 249b, 249f
in primary care, 378, 380–381, 380t
upstream and downstream approaches

to, 26–27
in the workplace, 528–530

Health protection, 27
in primary care, 380–381

Health-related quality of life (HRQoL), 90
mental health and, 247–248
noncommunicable diseases and, 233

Health Resources and Services Administra-
tion (HRSA), 13, 441

Health risk appraisal (HRA), 529
Health services in the WSCC model, 453,

453b
Health status surveys, 100–104

sample report on findings from,
101–102b

Health teaching, 36b
Healthy Brain Initiative, 501, 501b
Healthy Cities movement, 414
Healthy Days core questions (CDC

HRQoL– 4), 91
Healthy Hunger-Free Kids Act, 452–453,

471–472
Healthy People 2020, 4, 4b, 18

access to primary care, 373
access to primary care and, 374f
on alcohol use, 265
on diabetes, 221–222, 222f
on disasters, 602
on disparities, 160
environmental health and, 129, 129f
examples of impact of social and

physical determinants of health,
165b

health care-associated infections and,
363

health program planning and, 108–109,
109b, 110b

on heart disease and stroke, 359, 359f
history of, 541
on HIV/AIDS, 194–195, 195f
on immunization and communicable

diseases, 202, 202f, 381
on injuries, 290
on LGBT health, 183–184
on maternal, infant, and child health,

422, 423f, 426
on mental health, 239, 240–241
on noncommunicable chronic disease,

219, 222
on obesity, 227
objectives to reduce low birth weight,

436
on occupational safety and health, 511
on older adults, 480, 483–484, 484f, 492
public health departments (PHDs) and,

333–334, 334f
school nursing and, 449–451, 449f,

470
on sexually transmitted diseases, 207,

207f
on social determinants of health, 161
on substance use, 263, 264f
on suicide, 300
on tobacco use, 270, 270f
on violence, 284–285, 285f, 290

Healthy People 2030, 18, 19b, 23–24, 160,
165, 319, 413

Healthy People policy agenda, 540–541
Healthy Schools Campaign, 454
Healthy Start program, 92–93, 325–326
Heart disease and stroke

as leading cause of death and
disability, 222–223

Mississippi Delta Health Collaborative
(MDHC) and, 224–225

screening for, 44–48, 45f, 46f, 48f
Heat, extreme, 581–582
Heavy drinking, 261
Heavy metals, 516–517
Henry Street Settlement, 421
Hierarchy of controls, 518, 519
High-income countries (HICs), 16
History, environmental health, 134, 521
HIV/AIDS, 210

at-risk LGBTQ+ and, 184–185
as communicable disease, 191, 194, 194b
Healthy People 2020 on, 194–195, 195f
natural history of disease and, 28–29
in older adults, 491
prevalence, 68
prevalence pot, 69
racial disparities in, 162
substance use and, 276
tuberculosis and, 196–197

HMD. See Health and Medicine Division
(HMD), National Academies of
Sciences, Engineering, and
Medicine

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Index 615

Homelessness
community assessment of, 172–173
definition of, 170
impact on health, 171–172
interventions and services for persons

experiencing, 173–174
persons experiencing, 170–171, 171t
primary, 170
secondary, 170
tertiary, 170

Home Visiting Evidence of Effectiveness
(HomVEE), 441b

Hospice care, 502–504, 503b
Hospital-associated pneumonia (HAP),

365
Hospital discharge rate, 345, 345b
Hospital recidivism, 347
Host (infectious disease), 60, 201
Hull House, 314
Human genome epidemiology, 230
Human genomics, 59, 230
Human immunodeficiency virus (HIV).

See HIV/AIDS
Humanism, 37
Human trafficking, 175, 175b, 555–556,

556b
Humoral immunity, 201
Hurricane Katrina, 579–580, 597
Hurricane Rita, 597
Hurricanes, 578–580
Hypertension, screening, diagnosing, and

monitoring, 43–44

I
Illegal aliens, 175
Immigrants, 175

occupational health and safety of, 524
school nursing outreach to, 459–460
undocumented, 553

Immunity, 201
Immunizations. See Vaccine(s)
Improving the Quality of Health Care for

Mental and Substance-Use
Conditions: Quality Chasm Series,
248

Inapparent carrier, 199
Incarcerated and correctional populations,

180–182
Incidence, 68–69, 69f, 69t
Incubating carrier, 199
Independent rates, 69–70
Index case, 197
Indicated prevention, 32f, 33

mental disorders, 248
substance use disorders, 263

Individual and community health and
public health departments (PHDs),
324–328

role of nurses in providing care, 327
Individualized education program (IEP),

465

Individualized family service plan, 465
Individualized Healthcare Plan, 466–467
Individual-level risk factors for mental

disorders, 243–244
Individuals with Disabilities Education Act

(IDEA), 464, 465b
Indoor air pollution, 150–151
Infant mortality rate (IMR), 157, 422–423,

423f
applying public health science to

reducing, 438–440
maternal mortality rate and, 423–424
preterm birth and, 423
in the U.S., 159–160, 159f
in vulnerable populations, 423

Infants. See Maternal, infant, and
child health

Infection control in acute care settings
catheter-associated urinary tract

infections (CAUTI), 365–366,
365b, 365f

central line-associated bloodstream
infections (CLABSI) in, 366

cerebrospinal and postoperative central
nervous system infections in, 364

hospital-associated pneumonia (HAP),
365

multiple drug-resistant organisms, 367
sepsis, 363–364
surgical site infections (SSI), 364
ventilator-associated pneumonia (VAP),

365
Infectious disease

agents, 60, 197–199, 198f, 198t
agents and attack rates, 205–206
breaking the chain of infection with,

201–202
emerging or re-emerging, 195–196, 332
environmental characteristics in, 60,

199–201, 199b, 200t, 201f
hosts, 60, 201
phase of epidemiology, 57–58
respiratory disease, 193, 193b
sexually transmitted infections (STIs),

206–211
water sanitation and, 9–10, 56–58, 57f

Infectivity, 73, 199
Influenza

calculating rates of, 67, 67t, 68b
as communicable diseases (CDs), 193
natural history of disease and, 29–30
outbreak investigations, 73–74
peak months of, 194f

Informants, key, 91–92
Information technology and public health

departments (PHDs), 335–336
Inhalants, 258t
Inherent resistance, 201
Injury. See also Violence

burn-related, 290–293, 291b, 291f
definition of, 284

determining risk for, 286
drowning, 293–294, 293b, 294b
falls in children, 294–295, 295b
intentional, 284
motor vehicle crashes, 34, 75, 288–290
in older adults, 493–497, 494b, 496b,

497b
overview of, 283–284
poisoning, 295–297, 296f
policy aimed at prevention of, 288
prevention of, 286–288
surveillance of, 285–286
types of, 284
unintentional, 284, 284b
in the workplace, 525, 527f

Inpatient populations, 348–352, 351b, 351f
Inspection activities, 333
Institute for Healthcare Improvement

(IHI), 360–361, 361b
Institute of Medicine (IOM), 3, 77, 79, 360.

See also Health and Medicine
Division (HMD), National
Academies of Sciences, Engineering,
and Medicine

on health program planning, 108
Instruction methods, 41–42
Intensive care units (ICUs), 351, 351b
Intentional injuries, 284

in older adults, 494–497, 496b, 497b
Intermittent source, 204
International Classification of Diseases,

10th Revision (ICD 10), 345–346,
346t

International Program on Chemical Safety
(IPCS), 297

International Red Cross and Red Crescent
Movement, 601, 601b

Interpersonal violence, 284, 285f
Intersectoral strategies, 248
Interventions, public health, 36–37b

health literacy, 39f
Intervention Wheel, 35–36, 35f, 108, 455
Intimate partner violence (IPV), 302–304,

303b
Inventory of resources, 90
Involuntary or passive smoking, 269
Iron lung, 351, 351f

J
Job stress, 517–518
Joint Committee on Health Education and

Promotion Terminology, 37
JumpSTART tool, 598

K
Keeping Children and Families Safe Act,

300
KEEPRA (Kinship/Economics/

Education/Political/ Religious/
Associations), 88

7711_Index_607-630 21/08/19 11:08 AM Page 615

Key informants, 91–92
Knowles, Malcolm, 38

L
Latency periods, 133
Late onset at-risk substance use, 497
Laws related to school nursing, 470–472
Lead poisoning, 134–140, 136f, 137b, 138f,

516–517
Least restrictive environment, 465
Legislative process and public health

policy, 553–558, 554f, 556b, 557b
Lesbian, gay, bisexual, transgender, queer

(LGBTQ+) population, 165
at-risk groups, 184–185
health of, 184
interventions and policy for, 185
maternal mortality among, 425
risk factors for mental disorders in,

243–244
suicide among, 297
as vulnerable population, 182–185

LGBTQ+ persons. See Lesbian, gay,
bisexual, transgender, queer
(LGBTQ+) population

Licensing, 333
Life closure, 504
Life cycle of infectious agents, 200–201,

201f
Life expectancy, 5, 64

chronic disease and, 220
disparities in, 158–159
increasing, 479

Life span, 480
Life-threatening emergencies in the school

setting, 462–467
Literacy, health, 38–39, 39b, 39f
Local funding, 558–559
Local health policy, 538, 543–544
Local public health departments, 19, 122,

543
activities of, 322–333, 323b, 323t, 329b,

332b
budget process for, 561

Logic model in health program planning,
111–114, 112f, 113t

Loneliness in older adults, 116–120, 118f
Low birth weight (LBW), 423, 430f,

435–438, 435f
community assessment and health

planning, 437–438
global and national initiatives to reduce,

436
March of Dimes Prematurity Campaign,

436–437
vulnerable populations and, 436

Lower middle income countries
(LMIC), 16

burn-related injuries in, 290
motor vehicle crashes in, 289

Low-income countries (LICs), 16

616 Index

climate change and, 147
environmental health in, 129

Low-risk use (substance use), 261
Lung cancer, 7
Lyme disease, 200–201, 201f, 333

M
Mainstream-smoke, 431
Major depressive disorder (MDD), 242
Major diagnostic category (MDC),

345–346, 346t
Malaria, 193–194
Mallon, Mary, 199b
Mammography, 50
Manmade disasters, 587–589, 588t, 590t
MAPP (Mobilizing for Actions Through

Planning and Partnerships), 79,
83–86, 84t, 85f, 322

Mapping, community, 92–93
March of Dimes Prematurity Campaign,

436–437
Marginalization, 169
Market economy, 538–539
Mass casualty events (MCEs), 590
Material safety data sheet (MSDS), 516
Maternal, infant, and child health, 79

applying public health science to acute,
438–440

breastfeeding promotion program for,
442–443

cultural contexts for pregnancy and
childbirth in the U.S. and, 421–422

infant mortality rate (IMR), 157,
159–160, 159f, 423–426, 423f

maternal-infant and early childhood
home visiting, 440–442, 441b

maternal mortality and, 420–421
mortality rate for children under 5,

425–426, 426t
population focus in, 426–435, 427b,

429b, 430f
prematurity and low birth weight, 423,

430f, 435–438, 435f
public health departments (PHDs) and,

325–326
review of assessment and planning in,

427–428
teenage pregnancy and, 428–433, 429b
trends in, 422–423, 423f
upstream approach to, 427
WHO maternal-child health indicators,

80, 80b
Maternal death rate, 55
Maternal health, 421
Maternal-infant and early childhood home

visiting, 440–442, 441b
Maternal mortality, 420–421, 423–424, 424f

vulnerable populations and, 424–425
Maternal mortality rate (MMR), 420–421
Matthew Shepard and James Byrd, Jr., Hate

Crimes Prevention Act, 185

Maxwell, James, 74
Mean (statistical), 65–66, 66b
Measles, 215
Measurement, substance use, 261–262
Median (statistical), 65–66, 66b
Medicaid, 471, 539, 540, 541, 561–562, 562t

states and, 542–543
Medical Reserve Corps (MRC), 592
Medicare, 539, 540, 541, 542–543, 562t,

563
Medication-assisted treatment (MAT),

273–274
Medication electronic monitoring system,

330
Medication interactions in older adults,

498
Meningitis, 364
Mental disorders

cultural context and stigma associated
with, 245–247, 246b, 247b

definition of, 240
epidemiology of, 241–242, 242f
prevalence of, 241–242, 242f
prevention of, 247–251, 249b, 249f
protective factors against, 244–245, 244b
screening for, 248–249
surveillance of, 241
treatment for, 251–252

Mental health, 239–240
behavioral, biological, environmental,

and socioeconomic risk factors in,
243–244, 243b

cultural context of, 245–247, 246b, 247b
disasters and, 599–600
epidemiology, surveillance, and program

planning for, 250
Healthy People 2020 on, 239, 240–241
policy related to treatment, 251–252
primary care setting integration of care

for, 249b
promotion of, 247–251, 249b, 249f
resilience and, 244–245, 244b
school nursing and, 465–467

Mental Health Parity Act, 252
Mental illness, 240
Mercury poisoning, 386–388, 387f, 388t
Methamphetamines, 274–275
Methicillin-resistance Staphylococcus

aureus, 201, 367
Metropolitan statistical areas (MSA), 403,

403f, 406–407
Miasma theory, 57
Middle East Respiratory Syndrome

(MERS), 332
Migrant workers, 175–177, 175b, 176f, 515

community assessment, partnership
building, and advocacy for, 177

intervention and services for, 177–178
occupational health and safety of, 524
policy on, 178
public health policy toward, 552–553

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Index 617

Mississippi Delta Health Collaborative
(MDHC), 224–225

Mitigation, disaster, 576
Mixed exposures, 134
Mobile sources, air contaminant, 149
Mode (statistical), 65–66, 66b
Mode of transmission, 199–200, 199b
Moderate use (substance use), 261
Modern slavery, 175, 175b
Monitoring, 43–44

sensitivity and specificity in, 44
Monogenetic diseases, 230
Morbidity, 68, 191–192
Morbidity and Mortality Weekly Report, 89
Mortality, 67–68, 191–192. See also Death

childhood, 420, 425–426, 426t
infant, 157, 159–160, 159f, 422–426, 423f
maternal, 420–421, 423–425, 424f

Mothers Against Drunk Driving
movement, 277

Motor vehicle crashes (MVCs), 34
epidemiology of, 288–290
investigated using epidemiology, 75
prevention of, 289–290
risk factors for, 288–289
in winter weather, 585, 585t

Mudslides, 582
Multidrug-resistant tuberculosis

(MDRTB), 196
Multiple-agency consortiums for disaster

management, 592
Multiple drug-resistant organisms, 367
Mycobacterium tuberculosis (TB), 56, 196
My Mood Monitor, 249

N
Narcotics, 258t
National Academy of Medicine, 3, 5, 10,

248
National Academy of Sciences, Engineering,

and Medicine, 3
National Aging in Place Council, 499
National Ambient Air Quality Standards,

149
National Ambulatory Medical Care Survey,

241
National Association of County and City

Health Officials (NACCHO), 122,
152, 315, 322, 325, 330, 337

National Association of Free Clinics,
383–384

National Association of School Nurses
(NASN), 447, 455

National Association of State School Nurse
Consultants (NASSNC), 468

National Cancer Center, 89–90
National Cancer Institute, 319
National Center for Environmental Health,

CDC, 131
National Center for Health Statistics

(NCHS), 70, 89

National Center on Elder Abuse (NCEA),
495, 497

National Child Abuse and Neglect Data
System, 300

National Epidemiologic Survey on Alcohol
and Related Conditions (NESARC),
261

National Health and Nutrition Examination
Survey (NHANES), 89, 241, 460

National Health Interview Survey (NHIS),
89, 241

National health organizations, 17
National health policy, 540–542
National Heart, Lung, and Blood Institute

(NHLBI), 354
National Hospital Ambulatory Medical

Care Survey, 241
National Hospital Discharge Survey, 241
National Incident Management System

(NIMS), 591
National Institute for Occupational Safety

and Health (NIOSH), 74, 89, 511,
513

National Institute on Alcohol Abuse and
Alcoholism (NIAAA), 266

National Institute on Drug Abuse (NIDA),
271, 275–276

National Institute on Environmental
Health Sciences, 147

National Institutes of Health (NIH), 40
National Notifiable Diseases Surveillance

System (NNDSS), 577
National Nursing Home Survey, 241
National Occupational Research Agenda

(NORA), 511
National Oceanic and Atmospheric

Administration (NOAA), 583
National Poison Data System, 295
National Prevention Strategy, 25, 25f, 27
National Public Health Performance

Standards Program (NPHPSP), 3b
National Quality Forum (NQF), 49
National Response Framework (NRF), 591
National Rural Health Association, 401
National School Lunch Program, 27
National Survey on Drug Use and Health

(NSDUH), 261
National Violent Death Reporting System,

285–286
National Vital Statistics System (NVSS),

289
Native Americans, suicide prevention

and, 298
Natural disasters

cyclones, hurricanes, and typhoons,
578–580, 578b

definition of, 578
earthquakes, 580–581
epidemics, 587, 587b
extreme heat, 581–582
floods and mudslides, 582

tornadoes, 582–583, 583b
tsunamis, 583–584, 584b
volcanic eruptions, 584–585
wildfires, 585–587, 586b, 586f
winter weather, 585, 585t

Natural history of disease, 28–30, 28f, 29f
Naturally occurring retirement community

(NORC), 499–500
Neglect, 300, 495
New England Centenarian Study, 487
Nightingale, Florence, 12, 56, 64, 349
Noncommunicable diseases (NCD), 28,

50–51
acute care and, 358–359
burden of disease, 220–221, 220b, 221b
chronic, 74, 218–221, 219f, 220b, 221b,

234
cultural context of, 234–235
disparity and, 230–232, 231b, 231t, 232b
evidence-based practice and, 233
in older adults, 492–493, 492b, 492t
outbreaks, 74
prevention strategies for, 232–234
primary care and prevention/

management of, 382–383
program planning and, 226–229, 228f
risk factors for, 224–230, 225b
in the U.S., 221–224, 222b, 222f, 223f

Normative Aging Study, 487
Notes on Hospitals, 349
Notifiable diseases, 392, 393t
Nurse-family partnership model, 322
Nurse-managed health centers (NMHCs),

414
Nurses’ Health Study, 65, 72, 358
Nursing practice research, 344–347, 345b,

346t
Nutrition

and culture during pregnancy, 433–434
exercise, obesity, and, 225–226
food deserts and, 384–386
in the WSCC model, 452–453

O
Obesity

built environment and, 132
nutrition, exercise, and, 225–226
in older adults, 492, 492t
pregnancy and, 431
program planning and community

assessment for, 226–229, 228f
screening for, 460–461

Occupational and environmental health
history, 134, 521

Occupational and environmental health
nurses (OEHN), 510–512, 510b,
512b

ethics and, 529–530
landmark events in evolution of, 510,

511b
roles of, 525–526t, 525–530, 527f

7711_Index_607-630 21/08/19 11:08 AM Page 617

Occupational disease surveillance, 525,
525–526t

Occupational health and safety, 509–510
adolescent workers and, 514, 521–522
assaults by patients/visitors against

health-care workers and, 528–529
controlling hazards and injuries in the

workplace and, 518–519
emergency preparedness and disaster

management and, 530–531
emerging issues in, 530–532
ergonomics and, 518–519
exposures in the workplace and,

515–518
focus of, 510
formal programs for, 513–515
Healthy People 2020 on, 511
Hierarchy of controls and, 518, 519
immigrant or foreign-born persons and,

524
key agencies in, 512–513
occupational and environmental health

history in, 521
older workers and, 483, 483b, 522–523
role of the nurse in, 525–526t, 525–530,

527f
routes of exposure in, 518
teams, 510b
unions and, 514–515
vulnerable workers and, 521–525
women in the workforce and, 523
worker populations and, 514
workers with disabilities and, 523–524
workplace assessment in, 519–520, 520b

Occupational Safety and Health (OSH)
Act, 512

Occupational Safety and Health Adminis-
tration (OSHA), 510, 512–513,
531–532, 542

O’Connor v. Donaldson, 252
Odds ratio, 71, 71b
Office of Minority Health (OMH), U.S.,

165
Office of National Drug Control Policy

(ONDCP), 276
Older adults. See also Aging

ageism against, 500
alcohol use by, 266
changing diversity of, 484
communicable diseases (CDs) in,

490–492, 492t
Community Aging in Place, Advancing

Better Living for Elders (CAPABLE)
Program, 415, 488–490

definition of, 480
dementia and Alzheimer’s disease in,

500–502, 501b
determinants of aging and health in,

484–487
disasters and, 598, 603
elder maltreatment in, 494–497, 496b, 497b

618 Index

evidence-based practice on engagement
of, 121–122, 122f

fall prevention for, 494
growing population of, 479–480
health of, 480–487
Healthy People 2020 on, 480, 483–484,

484f
home-based care for aging in place of,

415
hospice and end-of-life care for,

502–504, 503b
injury and violence in, 493–497, 494b,

496b, 497b
LGBTQ+, 185
loneliness in, 116–120, 118f
noncommunicable diseases (NCD) in,

492–493, 492b, 492t
physical activity in, 504–505
program planning and health promotion

for, 487–490, 488b, 489t
promoting mental health among,

252–253
substance use in, 497–499, 498b
as vulnerable population, 145–147
in the workforce, 483, 483b, 522–523

Old-old, 480
Ongoing education and practice

evaluation, 15
Online Sex Trafficking Act of 2017,

555–556, 556b
On War and Public Health, 305
Opioids/opioid pain relievers (OPR) abuse,

256, 272–273, 389–390
hotspot report on, 273b
public health policy and, 544, 544b, 564
rise in detection of, 545f

Organic solvents, 517
Outbreak investigation, 73–75, 202–205,

203b, 204f
Outreach, 36b

P
Paint, lead, 134–140, 136f, 137b, 138f
Palliative care, 503, 503b
Pandemic, 192
Parish nursing, 413
Partnerships to Improve Community

Health (PICH), CDC, 78
Passive immunity, 201
Passive surveillance, 75
Pathogen, 197
Pathogenic bacteria, 203
Pathogenicity, 199
Patient-centered medical home (PCMH),

391–392, 391b
Patient Health Questionnaire 2, 249
Patient population, 344

critically ill or injured, 349
Patient Protection and Affordable Care

Act. See Affordable Care Act (ACA)
Patient tracking, disaster, 589–590

Pattern of substance use, 257
PDSA cycle, 361–362
Pedagogy, 38
Percent change, 66, 66b
Performance improvement and acute care

settings, 359–362, 361b, 361f, 362b
Period prevalence, 68
Person, place, and time epidemiological

constants, 60, 60f
Personal cultural assessment, 9b
Personal protective device (PPD), 517
Personal protective equipment (PPE), 513
Pertussis, 73–74, 395
Pesticides, 517
PhotoVoice, 92
Physical abuse, 300, 495
Physical activity

bike lanes/trails for, 549
in children, 451–452, 453f
nutrition, obesity, and, 225–226
in older adults, 504–505

Physical agents, 133
Physical education, 451–452, 453f
Physical environment in the WSCC model,

454
Physical exposures in the workplace,

515–517
Physical neglect, 300
Physical violence, 302
Physiological dependence, 260
Place, poverty, and race, 162
Pneumonia, 365
Point in time estimate of homelessness,

170–171
Point of dispensing (POD), 591–592
Point source

air contaminant, 149
infection, 204

Poisoning
definition of, 295
lead, 134–140, 136f, 137b, 138f, 516–517
mercury, 386–388, 387f, 388t
public health departments (PHDs) and

unintended, 331–332, 332b
Polio, 195, 350–351, 351f
Pollution

air, 149–151, 150b, 408
water, 9–10, 56–58, 57f, 151–152, 152b

Polygenetic diseases, 230
Popcorn lung, 530
Population aging, 480–481, 481f
Population attributable risk (PAR), 34
Population data, 64–65
Population-focused assessment, 79–80

in older adults, 493
Population-focused care, 6–7

across settings and nursing specialties, 11
school nursing practice, 455–468

Population health, 6, 23–25
acute care setting and, 344–348, 345b,

346t, 348t

7711_Index_607-630 21/08/19 11:08 AM Page 618

Index 619

promotion, risk reduction, and health
protection, 25–27

Population nursing roles, 413–415
Population(s), 6, 6b

inpatient, 348–352, 351b, 351f
patient, 344
vulnerable, 144–147
worker, 514

Postassessment phase, 93
Postimpact epidemiological surveillance,

577–578
Post-traumatic stress disorder (PTSD)

community violence and, 305
disasters and, 599–600
in refugees and asylees, 179–180
risk factors for, 243
war and, 306

Potable water, 151–152, 152b
Poverty, 162

as social determinant of health, 231b
top 10 leading causes of death by income

and, 192t
vulnerability and, 167, 167t

Poverty guidelines, 167, 167t
Poverty threshold, 167
PRECEDE-PROCEED model, 110–111
PREEMIE Act, 436
Pregnancy. See also Maternal, infant, and

child health
cultural context for, 421–422
evidence-based practice on culture and

nutrition during, 433–434
obesity and, 431
teenage, 428–433, 429b
tobacco use and, 431–433

Pregnancy Risk Assessment Monitoring
System (PRAMS), 241

Premature death, 220–221
Preparedness, 575–576
Preterm birth, 423, 430f, 435–438, 435f
Preterm labor, 437
Prevalence, 28, 68–69, 69f, 69t

alcohol use, 263–264
homelessness, 171
mental disorders, 241–242, 242f
tobacco use, 269

Prevalence pot, 28–29, 29f, 69, 69f
Prevented fraction, 34
Preventing Intimate Partner Violence

Across the Lifespan: A Technical
Package of Programs, Policies, and
Practices, 304

Prevention, 27
Alzheimer’s disease and related

dementias, 500–501
burn-related injuries, 290–291
child maltreatment, 302, 302t
communicable diseases in older adults,

491–492, 492t
and control of communicable diseases,

213

delivery of strategies, 33–34
drowning, 294, 294b
elder maltreatment, 495–496
and epidemiology in primary care,

376–383
falls in children, 295
falls in older adults, 494
homelessness, 174
injury and violence, 286–288
intimate partner violence, 304
levels of, 30–32
motor vehicle crashes, 289–290
noncommunicable diseases, 232–234
occupational safety and health, 513–514
primary (See Primary prevention)
within the primary care setting,

377–381, 378–380t
public health departments (PHDs) and

community health primary,
327–328

school nursing, 455–468
secondary (See Secondary prevention)
substance use disorders, 262–263
suicide, 298, 299, 299t
tertiary (See Tertiary prevention)
tuberculosis, 328–330, 329b
unintentional poisonings, 296–297
universal, selected, and indicated models

of, 32–33, 32f, 34b
upstream approach to maternal-child

health continuum and, 427
violence, 458–459

Primary care
advocacy and, 376–377
community members and, 393–394
community organizations and, 392–393,

393t
continuum of, 372, 373f
culture and, 394–395
definition of, 372
emerging public health issues in,

389–390
epidemiology and targeted prevention

levels in, 376–383, 378–380t
evolution of, 373–376, 374f, 375b
food deserts and, 384–386
health promotion in, 378, 380–381, 380t
immunization and health protection in,

380–381
mercury poisoning and, 386–388, 387f,

388t
ongoing use of public health science in,

390–394, 391b, 393t
primary prevention in, 377–381,

378–380t
private, 386–388, 387f, 388t
public, 383–386
secondary prevention in, 379–380t,

381–382
tertiary prevention in, 380t, 382–383
in the U.S., 373

Primary community health data collection,
90–93, 100

Primary health care, 374
Primary homelessness, 170
Primary prevention, 30–31

elder maltreatment, 495–496
health education, 36–42
noncommunicable diseases, 232
occupational safety and health, 513–514
in primary care, 377–381, 378–380t
public health departments (PHDs) and,

327–328
in school nursing, 455–460

Private primary care, 386–388, 387f, 388t
Problem- or health-issue-based

assessment, 81
Process evaluation, 124
Professional relationships and

collaboration, 15
Program evaluation, 123–125, 125b

nine steps of, 124–125, 125b
Program implementation, 122–123
Prospective studies, 72
Protective factors, 244–245, 244b
Protocol for Assessing Community

Excellence in Environmental Health
(PACE EH), 152–153, 152b

Psychoactive substances, 257, 258t
Psychological/emotional violence, 303
Psychological exposures in the workplace,

517–518
Psychological or emotional abuse, 495
Psychological services in the WSCC model,

453–454
Psychosocial factors, 133
Psychosocial theories of aging, 486
Public health

access to care and funding for, 561–563,
562t

challenges and trends for frameworks of,
4–6

as component of nursing practice across
settings and specialties, 10–11

core competencies, 335, 335b
definitions and functions of, 2
essential services of, 3b
ethical questions in, 5
funding and access to care, 561–563,

562t
funding of, 558–561, 560b
globalization of, 4–5
global to local, 16–19
interventions in, 36–37b
life expectancy and, 5
notifiable diseases and, 392, 393t
nursing practice and, 10–11
primary care and emerging issues in,

389–390
top 10 achievements in, 18b

Public Health Accreditation Board, 336
Public health departments (PHDs)

7711_Index_607-630 21/08/19 11:08 AM Page 619

activities of local, 322–333, 323b, 323t,
329b, 332b

additional challenges for, 337–338
assessment by, 3
assurance by, 3
basic mandate of, 313–314
core functions of, 3, 316–318, 318b
data collection and analysis by, 324
disaster preparedness and, 333
disease control, epidemiology, and

surveillance by, 328–333, 329b, 332b
emerging or re-emerging infections

and, 332
environmental health services, 323, 323b
essential services of, 3b, 318, 319f
financing of, 336–337
future challenges for, 333–334, 334f
geographic jurisdiction of, 315, 316f
history of, 314–315
immunization and health protection

programs, 326–327
individual and community health

activities by, 324–328
information technology and, 335–336
interventions by, 318–319, 320f
maternal and child health and, 325–326
mission of, 314
policy development by, 3
quality improvement and accreditation

of, 336
regulation, licensing, and inspection by,

333
role of public health nurses in, 316–322,

318b, 319f, 320f
school health and, 326
sexually transmitted infections and, 330
structure of, 314–315, 315f
tuberculosis management, 328–330,

329b
workforce in, 315, 317f, 334–335, 335b
zoonotic diseases and, 332–333

Public health economics, 558
Public health finance, 558–561, 560b
Public health frameworks, 4–6

emerging, 5–6, 5f
Public Health Functions Steering

Committee, 3
Public health informatics, 335
Public health infrastructure, 1
Public health interventions, 36–37b
Public health law

disaster management and, 596–597
legislative process and, 553–558, 554f,

556b, 557b
Public health nurses, 12

participation in health policy, 556–558,
557b

stress in, 600
Public health nursing (PHN)

in the 20th century, 12–13, 12f
in the 21st century, 13, 13f

620 Index

beginnings in the United States, 12
communicable diseases (CDs) and,

192–193
community-academic partnerships

and, 415
community organizing and, 409–411
core competencies, 13, 15b
as core component of nursing history,

11–13, 12f
definition of, 11
in disaster preparedness, 333
in environmental health, 130–132, 131b,

131f
ethics, 15
in federally qualified health centers,

400–401
framework for, 35–36, 35f, 36b
future of, 10–11
health program planning and, 108
in the Healthy Cities movement, 414
in nurse-managed health centers

(NMHCs), 414
parish nursing/faith community

nursing, 413
in prevention of injury and violence,

286–288
principles of, 11b
in providing individual care, 327
in public health departments (PHDs),

316–322, 318b, 319f, 320f
research projects in, 344–347, 345b, 346t
roles and responsibilities in, 13, 15
in rural and urban environments,

408–409, 416
scope and standards of practice, 13–15,

14b, 15b
as specialty, 11–15
standards of professional performance,

13, 14b
in war, 306

Public health nursing framework, 35–36,
35f, 36b

Public Health Nursing: Scope and
Standards of Practice, 13–15, 14b, 15b,
335, 360

Public health organizations
state and local, 165
United States, 165
Universal Declaration of Human Rights,

164–165, 164b
Public health policy, 36b

activities of nurses and, 537–538
aimed at prevention of injury and

violence, 288
assessment and planning process,

546–548, 547t
definition of, 537
development of, 3
effectiveness, efficiency, and equity,

546–548, 547t
elder maltreatment, 496–497, 497b

enforcement of, 36b, 470–472
environmental health and, 134–140,

136f, 137b, 138f
environmental justice and, 140–144,

141b, 143b
ethical and cultural implications of,

552–553, 553f
evidence-based practice and, 549–550,

550–552t
focus on health determinants, 548–549,

548t
for incarcerated persons, 180
interventions to reduce alcohol-related

harm, 268–269, 269b
interventions to reduce drug-related

harm, 276
interventions to reduce tobacco-related

harm, 271–272, 272t
legislative process and, 553–558, 554f,

556b, 557b
for LGBTQ+ persons, 185
local and county, 538, 543–544
in market economy, 538–539
mental health, 248, 251–252
for migrant workers, 178
national, 540–542
for persons experiencing homelessness,

174
primary care and, 391–392, 391b
principles of, 546–553, 547t, 548t,

550–552t, 553f
public health finance and, 558–561
school nursing and, 470–472
stakeholder involvement in, 548
state level, 542–543
students with disabilities and, 464–467,

465b, 466t
and the U.S. health-care system,

538–546, 545f
U.S. health-care system and, 538–546,

544b, 545f
Public Health Preparedness and Response

Core Competencies, 333, 335
Public health prevention frameworks,

27–28
delivery of strategies, 33–34
levels of prevention, 30–32
natural history of disease, 28–30, 28f, 29f
universal, selected, and indicated

prevention models, 32–33, 32f, 34b
Public health science, 2–4
Public health services (PHS)

10 essential, 115f
ten essential, 3b

Public health systems, 307
and services research, 336

Public primary care, 383–386

Q
Qualitative data, 91–93
Quality improvement

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Index 621

accreditation of public health
departments (PHDs) and, 336

acute care settings, 359–362, 361b, 361f,
362b

Quality of substance use, 257
Quantitative data, 90–91
Quantity of substance use, 257
Quarantine, 596–597
Queer+ persons. See Lesbian, gay, bisexual,

transgender, queer (LGBTQ+)
population

R
Race. See also African American

population
child maltreatment and, 300
comparing dependent and independent,

69–70
definition of, 8
diabetes and, 223, 380t
health disparities and, 539
homelessness and, 171, 171t
immigrant or foreign-born workers and,

524
infant morality rate and, 423
intersection of poverty, place, and, 162
myth of, 8
obesity and, 461
of older adults, 484
poisoning and, 295, 296f
prevalence of mental disorders and, 242,

242f
public health department workforce

and, 315
socioeconomic risk for noncommunicable

disease and, 231
tobacco use and, 269
in the workforce, 524–525

Racial and Ethnic Approaches to Commu-
nity Health (REACH) program, CDC,
165, 166f

Racism, 169
Radiation exposure, 589
Rapid needs assessment, 82
Rates, 66–70

prevalence, incidence, 68–69, 69f, 69t
types of, 67–68

Rathbone, William, 11–12
Reach Effectiveness Adoption Implementa-

tion Maintenance (RE-AIM)
framework, 502

Recovery, disaster, 576
Rectangularization of aging, 482
Referral and follow-up, 37b
Refugees, 178–180, 179b, 179t, 448
Registered nurses (RNs), 538
Regulatory activities, 15, 333

school nursing and, 470–472
Rehabilitation Act, Section 504, 466t, 468
Relative risk (RR), 34, 71–73, 72b
Reliability, 44

Reservoir, 199
Resilience, 244–245, 244b
Resistance to disease, 201
Resources for Organizing and Social

Change, 410
Respiratory disease, 193, 193b
Response, emergency preparedness and

disaster management (EPDM), 576
Retrospective studies, 71, 72
Right censoring, 73
Risk communication, 594–595, 595b
Risk factors

behavioral, 58, 58f, 243–244, 243b
biological, 243–244, 243b
burn-related injuries, 290
child maltreatment, 300–302, 301t
community violence, 305
definition of, 58
drowning, 293, 293b
elder maltreatment, 495
environmental, 58–59, 243–244, 243b
falls in children, 294–295
genetic, 59
injury or violence, 286
intimate partner violence, 303–304
mental disorders, 243–244, 243b
motor vehicle crashes, 288–289
noncommunicable diseases, 224–230,

225b
phase of epidemiology, 58
sexually transmitted diseases (STDs),

208, 208f
socioeconomic, 243–244, 243b
substance use, 257–259, 261–262
suicide, 297–299, 298f
unintentional poisonings, 296

Risk reduction, 27, 34
Road traffic injury (RTI), 288
Robertson, Bruce, 350
Role of Public Health Nurses in Emergency

and Disaster Preparedness,
Response, and Recovery, 333

Root, Francis, 12
Rosner, David, 407
Routes of entry, 133
Routes of exposure in the workplace, 518
Rural communities, 401–405, 402t, 403f,

404f, 407b, 416
maternal mortality in, 425

Rural Healthy People 2020, 402, 402t

S
Safar, Peter J., 352
Safe Kids Coalition, 288
Safe to Sleep Campaign, 426, 427b
Sampling, 90–91
Sandy Hook school shooting, 454, 462
Sanitary phase of epidemiology, 57
Sanitation, 9–10, 56–58, 57f
Saunders, Cicely, 502
School Breakfast Program, 452

School nursing, 326. See also Adolescents;
Children

advocacy in, 468–470
asthma and, 464
bullying and, 458–459
consultation in, 468
definition of, 447
diabetes and, 464
episodic care in, 463–464
evidence-based practice on, 467–468
future challenges for, 472–473
Healthy People 2020 and, 449–451, 449f
historical foundations of, 448–449
laws related to, 470–472
life-threatening emergencies in the

school setting and, 462–467
mental health disorders and, 465–467
outreach to immigrant populations in,

459–460
policy development and enforcement in,

470–472
population-based, 455–468
primary prevention in, 455–460, 456f,

457f
referral and follow-up in, 462
responsibilities in, 447–448
secondary prevention in, 460–462, 461b
sexuality and sex education in, 458
student disabilities and, 464–465, 465b
tertiary prevention in, 462–468, 465b,

466t
violence prevention in, 458–459
whole school, whole community, whole

child (WSCC) model and, 451–455,
452f, 453b, 453f, 473

Schorr, Lisbeth, 122
Scope and standards of practice, public

health nursing, 11, 13–15, 14b, 15b
Screening, 37b, 42–43

adolescent idiopathic scoliosis, 467–468
at-risk alcohol use, 266, 267–268
cardiovascular disease in African

American men, 44–48, 45f, 46f, 48f
of children and adolescents in school

nursing, 460–461, 461b
criteria for programs in, 48–50
definition of, 42
diagnosis, monitoring, and, 43–44
drug use, 275–276
environmental health, 134–140, 136f,

137b, 138f
ethical considerations with, 50
mental disorders, 248–249
in primary care, 382
sensitivity and specificity in, 44
suicide risk among adolescents in

primary care, 251
tobacco use, 270–271

Screening, brief intervention, and referral
for treatment (SBIRT) approach,
248–249, 267–268

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Secondary attack rate, 68, 206
Secondary cases, 197
Secondary community health data

collection, 89–90, 99–100, 100t
Secondary homelessness, 170
Secondary prevention, 30, 31–32

elder maltreatment, 495–496
noncommunicable diseases, 232
occupational safety and health, 513–514
in primary care, 379–380t, 381–382
in school nursing, 460–462, 461b
screening and early identification,

42–50, 45f, 46f, 48f
screening for mental disorders, 248–249

Secondhand smoke exposure, 269
Selective prevention, 32f, 33

mental disorders, 248
substance use disorders, 262–263

Self-directed violence (SDV), 284, 285f,
307

prevention of, 299, 299t
risk factors for, 297–299, 298b, 298f

Self-management, chronic disease, 234
Self-neglect by older adults, 494–495
Sensitivity, 44
Sepsis, 363–364
September 11, 2001, terrorist attacks,

587
Serious mental illness (SMI), 240

prevalence of, 242, 242f
Setting-specific assessment, 80–81
Severe acute respiratory syndrome (SARS),

196, 332
Severe maternal mortality (SMM), 425
Sex trafficking, 555–556, 556b
Sexual abuse, 300, 495
Sexuality and sex education in school

nursing, 458
Sexually transmitted diseases (STDs),

205–206, 411–412
burden of disease and, 207–208
cultural context and, 210–211
emerging, 210
in older adults, 491
public health departments (PHDs) and,

330
risk factors, 208, 208f
school nursing and, 458

Sexual violence, 302–303
Shared or mixed systems of public health

departments (PHDs), 315
Shelter for persons experiencing

homelessness, 173–174
Shelton v. Tucker, 252
Side stream smoke, 431
Silica, 531–532
Slavery, modern, 175, 175b
Smallpox, 196
Smoking. See Tobacco use
Snellen eye chart, 460
Snow, John, 9–10, 56–57, 57f, 64

622 Index

Social and emotional climate in the WSCC
model, 454

Social and mass media systems, 595
Social capital, 160–161

vulnerability and, 168
Social determinants of health, 26, 115,

160–163, 160f, 161f
noncommunicable disease and, 231b
school nursing and, 462

Social-ecological model, 5, 5f
Social gradient, 159
Social justice, 114–116, 161–162
Social learning theory, 37
Social marketing, 37b
Social Security, 540

Disability Insurance (SSDI), 563
Social services in the WSCC model,

453–454
Society of Trauma Nurses (STN), 287–288
Socioeconomic risk for noncommunicable

disease, 231–232, 231b, 231t, 232b
Socioeconomic status (SES), 167, 167t
Special needs population and disasters,

598–599
Special populations. See also Vulnerable

populations
national policy and, 542
public health policy and, 537–538

Specificity, 44
Speed and motor vehicle crashes, 289
Stage of Change (Transtheoretical) Model,

488, 489t
Stakeholder involvement in health policy,

548
Stalking, 303
State funding, 558
State healthy policy, 542–543
State of the Air 2018, 408
State public health departments, 19
State school nurse consultant (SSNC), 468,

469b
ST-elevation myocardial infarction

(STEMI), 356–358
Stigma, 169

mental disorders and, 245–247, 246b,
247b

substance use and, 276–277
Stimulants, 258t
Stop, Drop, and Roll campaign, 291, 291f
Stop Enabling Sex Traffickers Act of 2017,

555–556, 556b
Stranger violence, 284, 285f
Strategic National Stockpile (SNS), 591
Stress

among health-care workers, 600
job, 517–518

Struthers, Lina Rogers, 449
Substance Abuse and Mental Health

Service Administration (SAMHSA),
248

Drug-Free Workplace Toolkit, 544, 546

on screening, brief intervention, and
referral to treatment (SBIRT), 267

Substance use, 389–390. See also Alcohol
use; Drug use; Opioids/opioid pain
relievers (OPR) abuse; Tobacco use

adverse consequences related to, 257,
260t

at-risk, 257
binge drinking, 257
classes of psychoactive substances in,

257, 258t
communicable diseases and, 276
disorder of, 259–261, 260b
global burden of disease and, 257–262,

258f, 258t, 260b, 260t, 262f
as leading cause of death, 256–257
models for prevention and treatment of

disorders of, 262–263
in older adults, 497–499, 498b
and risk across the continuum of use

and life span, 257–259, 258f
statistics on, 256
stigma and, 276–277

Substance use disorders (SUD), 259–261,
260b

Sudden Infant Death Syndrome (SIDS),
426–427, 427b

Sudden unexpected infant death (SUID),
426

Suicide. See Self-directed violence (SDV)
Summative evaluation, 124
Super centenarians, 480
Supplemental Nutrition Assistance

Program (SNAP), 563
Supplemental Security Income (SSI), 563
Surface fires, 586–587
Surge (disaster response), 592
Surgical site infections (SSI), 364
Surveillance, 37b, 74–75

communicable diseases, 211–213
disaster epidemiological, 577–578
of injury and violence, 285–286
of mental health disorders, 241, 250
public health departments (PHDs) and,

328–333, 329b, 332b
state level, 543
substance use, 261–262, 272–273
tuberculosis management, 328–330,

329b
Surveys, 90–91, 100–104

sample report on findings from,
101–102b

Survival rate, 350
Susceptibility, 201
Sustainability, 173, 407
Syphilis, 208, 209–210

T
Task Force on Community Preventive

Services, AHRQ, 550, 550–552t
Teaching plans, 39–41, 40b

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Teenage pregnancy, 428–433, 429b
Telehealth, 405
Temporary Assistance for Needy Families

(TANF), 563
Terrorism, 587, 588

bioterrorism, 333, 589, 590t
Tertiary homelessness, 170
Tertiary prevention, 30, 32

elder maltreatment, 495–496
noncommunicable disease and, 50–51
noncommunicable diseases, 232–233
occupational safety and health, 513–514
in primary care, 380t, 382–383
in school nursing, 462–468, 465b, 466t
treatment for mental disorders, 251

Theories of aging, 485–486
Theories of education, 37–38
Thompson, Warren, 64
Threat of physical or sexual violence, 303
Ticks, 200–201, 201f
Tobacco use, 61–63, 319. See also

Substance use
calculating rates of, 66–67
cancer and, 223
comparing independent and dependent

rates of, 69–70
consequences of, 270
deaths due to, 269
methods of, 269
policy level interventions to reduce

harm related to, 271–272, 272t
pregnancy and, 431–433
prevalence of, 269
as risk factor for noncommunicable

diseases, 229–230
screening and treatment for, 270–271
stigma and, 276
in vulnerable populations, 270

Tolerance, 260
Toothpastes, 549–550
Tornadoes, 582–583, 583b
Total Worker Health, 511
Toxicity, 132. See also Exposures

popcorn lung, 530
workplace exposures and, 516–517

Toxicology, 525
Toxigenicity, 199
Toxins, exposure to, 74, 132–133
Training and exercises for disaster

response, 593
Transgender persons. See Lesbian, gay,

bisexual, transgender, queer
(LGBTQ+) population

Transinstitutionalization, 252
Triage, disaster, 589–590, 598
Tsunamis, 583–584, 584b
Tuberculosis (TB), 56, 196, 206

in HIV patients, 196–197
management of, public health

departments (PHDs) and, 328–330,
329b

Typhoid, 10b, 199b
Typhoons, 578–580

U
UNAIDS 909090, 195
Undocumented immigrants, 553
UNICEF, 375–376, 375b
Unintentional injuries, 284, 284b

burn-related, 290–293, 291b, 291f
drowning, 293–294, 293b, 294b
falls in children, 294–295, 295b
motor vehicle crashes, 34, 75, 288–290
in older adults, 494
poisoning, 295–297, 296f, 331–332, 332b

Unions, 514–515
United Mine Workers of America

(UMWA), 514
United Nations’ Sustainable Development

Goals (SDGs), 17b, 24, 24b, 148, 425
United Steel Workers of America, 514
United Way, 561
Universal Declaration of Human Rights,

164–165, 164b
Universal health literacy precautions,

39, 39b
Universal prevention, 32–33, 32f

mental disorders, 248
substance use disorders, 262

Upper middle-income countries
(UMICs), 16

Upstream approach, 26–27, 427
Urban agglomerations, 406, 406t
Urban communities, 405–409, 406t, 407b,

408f
U.S. Administration on Aging National

Center on Elder Abuse (NCEA),
495

U.S. Code, 555
U.S. Constitution, 555
U.S. Consumer Product Safety

Commission, 295
U.S. Department of Agriculture (USDA),

90, 404
U.S. Office of Minority Health (OMH), 165
U.S. Preventive Services Task Force, 33
U.S. Public Health Service (USPHS), 82

V
Vaccine(s)

controlling communicable diseases
through, 213

global health and, 16f
influenza and pertussis, 73–74
in primary care, 380–381, 395
public health departments (PHDs)

programs for, 326–327
recommendations for children, 214
school nursing and, 455–457

Validity, 44
Vancomycin-resistant enterococci, 367

Ventilator-associated pneumonia (VAP),
365

Very low birth weight (VLBW), 435
Veterans, suicide among, 298
Violence. See also Injury

assaults by patients/visitors against
health-care workers, 528–529

against children and women, 284, 285f,
300–304, 301t, 302t, 303b

collective, 284, 285f, 305–306
community, 284, 285f, 304–305
cyberbullying, 458–459
dating, 459
definition of, 284
determining risk for, 286
in older adults, 493–497, 494b, 496b,

497b
policy aimed at prevention of, 288
prevention of, 286–288
school nursing and prevention of, 458–459
surveillance of, 285–286
types of, 284–285, 285f

Violence Against Women Act, 287
Virginia Tech shooting, 246–247
Virulence, 199
Vision screening, 460
Vital statistics, 324
Volcanic eruptions, 584–585
Vulnerability, 158
Vulnerable populations, 165–170

alcohol use in, 266
children, 144–145
cultural context and, 168
definition of, 158
disaster and, 597–599, 597b
drug use in, 275
ethical issues and, 169–170
homelessness in, 170–174, 171t
immigrants, 175
incarcerated and correctional

populations, 180–182
infant mortality rate among, 423
lesbian, gay, bisexual, transgender,

queer+ persons, 182–185
low birth weight disparity and, 436
maternal mortality rate among, 424–425
migrant workers, 175–178, 175b, 176f
multiple determinants of, 168–169, 169b
older adults, 145–147
poverty in, 167, 167t
refugees and asylees, 178–180, 179b, 179t
screening of, in school nursing, 462
social capital and, 168
suicide in, 297–298, 307
tobacco use in, 270
in the workplace, 521–525

W
Wald, Lillian, 12, 56, 314, 421, 440, 448
War, 284, 285f, 305–306, 405–406

critical care and, 349–350

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Water quality, 151–152, 152b
Water sanitation, 9–10, 56–58, 57f
Web of causation, 63, 63f
Well Women HealthCheck Program, 558
Wernicke-Korsakoff syndrome, 498
Westburg, Granger, 413
West Nile virus, 196
What Works in Schools: Healthy Eating,

Physical Activity, and Healthy Weight,
470

Whole school, whole community, whole
child (WSCC) model, 451, 452f, 473

community involvement in, 455
components of, 451–455
counseling, psychological, and social

services in, 453–454
employee wellness in, 454–455
family engagement in, 455
framework for 21st century school

nursing practice, 455, 456f, 457f
health education in, 451
health services in, 453, 453b
nutrition environment and services in,

452–453
physical education and physical activity

in, 451–452, 453f
physical environment in, 454
social and emotional climate in, 454

Wildfires, 585–587, 586b, 586f
Williams, Serena, 425
Window guards, 295, 295b
Windshield survey, 86–89, 87–88t
Winslow, C.E.A., 3, 5
Winter weather, 585, 585t
Withdrawal, 260
Women. See also Gender

cardiovascular disease in, 355–358, 355b
Fair Labor Standards Act (FLSA) and

nursing, 523
Nurses’ Health Study and, 65, 72, 358
violence against, 302–304, 303b
in the workforce, 523

624 Index

Women, Infants, and Children (WIC)
services, 325, 558, 563

Workers
adolescent, 514, 521–522
assaults by patients/visitors against

health-care, 528–529
with disabilities, 523–524
diversity of, 514, 524–525
female, 523
immigrant or foreign-born, 524
migrant (See Migrant workers)
minority group, 514, 524–525
older, 483, 483b, 522–523
public health departments (PHDs), 315,

317f, 334–335, 335b
stress among health-care, 600
vulnerable, 521–525

Workers’ compensation, 527–528
Work-family interface, 523
Workplace, the

adolescents in, 521–522
assessment of, 519–520, 520b
epidemiological triangle and, 510
exposures in, 515–518, 531–533
health promotion in, 528–530

Workplace walkthrough, 519–520, 520b
World Health Day, 372, 374
World Health Organization (WHO), 3,

16–17, 24, 28
on alcohol use, 265, 265f
on burden of disease, 75
on burn-related injuries, 290–291, 291b
on childhood deaths, 420
on climate change, 147–148, 147b
on defining older adults, 480
definition of environmental health, 128
definition of femicide, 303b
definition of global health, 15–16
definition of health, 6
definition of health education, 37
on diarrheal disease, 195

on fluoridated toothpastes, 549–550
global strategy to reduce harmful alcohol

use, 268–269, 269b
health-adjusted life expectancy (HALE),

220, 220b
Healthy Cities movement, 414
on infant mortality rate (IMR) in Africa,

157
International Program on Chemical

Safety (IPCS), 297
maternal-child health indicators, 80, 80b
on meningitis, 364
on mental health, 240, 248, 249f
on noncommunicable chronic

disease, 51
on palliative care, 503, 503b
on primary care, 372, 374–375
on radiation exposure, 589
rapid needs assessment, 82
on school nursing, 472–473
on social gradient, 159
on suicide, 297–299, 298b
surveillance by, 75
on surveillance of mental health

disorders, 241
tobacco-use interventions, 271–272,

272t
Universal Declaration of Human Rights

and, 164–165, 164b
on violence, 284–285, 285f

Y
Years of potential life lost (YPLL), 221
Youth violence, 305

Z
Zero Suicide (ZS) model, 299
Zika virus, 196, 201, 560
Zoonotic diseases, 200–201, 201f, 332–333

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Title Page

Dedication

Preface

Contributors

Reviewers

Acknowledgments

Table of Contents

UNIT I Basis for Public Health Nursing Knowledge and Skills

Chapter 1 Public Health and Nursing Practice

Chapter 2 Optimizing Population Health

Chapter 3 Epidemiology and Nursing Practice

Chapter 4
Introduction to Community Assessment

Chapter 5 Health Program Planning

Chapter 6 Environmental Health

UNIT II Community Health Across Populations: Public Health Issues

Chapter 7 Health Disparities and Vulnerable Populations

Chapter 8
Communicable Diseases

Chapter 9 Noncommunicable Diseases

Chapter 10 Mental Health

Chapter 11 Substance Use and the Health of Communities

Chapter 12 Injury and Violence

UNIT III Public Health Planning

Chapter 13 Health Planning for Local Public Health Departments

Chapter 14 Health Planning for Acute Care Settings

Chapter 15 Health Planning for Primary Care Settings

Chapter 16 Health Planning with Rural and Urban Communities

Chapter 17 Health Planning for Maternal-Infant and Child Health Settings

Chapter 18 Health Planning for School Settings

Chapter 19 Health Planning for Older Adults

Chapter 20 Health Planning for Occupational and Environmental Health

Chapter 21 Health Planning, Public Health Policy, and Finance

Chapter 22 Health Planning for Emergency Preparedness and Disaster Management

Index

Cornerstones of Public Health Nursing

Revised 2007 1 Minnesota Department of Health
Adpated from Original by Center for Public Health Nursing, 2004

Public Health Nursing Practice:

Focuses on the health of entire populations

Reflects community priorities and needs

Establishes caring relationships with communities, systems,
individuals and families

Grounded in social justice, compassion, sensitivity to diversity,

and respect for the worth of all people, especially the vulnerable

Encompasses mental, physical, emotional, social, spiritual, and
environmental aspects of health

Promotes health through strategies driven by epidemiological

evidence

Collaborates with community resources to achieve those
strategies, but can and will work alone if necessary

Derives its authority for independent action from the Nurse

Practice Act

Cornerstones from Public Health Cornerstones from Nursing
Population based Relationship based
Grounded in social justice Grounded in an ethic of caring
Focus on greater good Sensitivity to diversity
Focus on health promotion and prevention Holistic focus
Does what others cannot or will not Respect for the worth of all
Driven by the science of epidemiology Independent action
Organizes community resources
Long-term commitment to the community

Definitions

Public Health

Public health is what we, as a society, do collectively to assure the conditions in which
people can be healthy.1

“Public Health is the Science and Art of preventing disease, prolonging life, and
promoting health and efficiency through organized community effort for the sanitation
of the environment, the control of communicable disease, and the development of the
social machinery to insure 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.”2

Nursing

“[Nursing is defined to have] charge of the personal health of somebody… and what
nursing has to do… is to put the patient in the best condition for nature to act upon
him.”3

“The unique function of the nurse is to assist the individual, sick or well, in the
performance of those activities contributing to his health or recovery (or to peaceful
death) that he would perform unaided if he had the necessary strength, will, or
knowledge. And to do this in such a way as to help him gain independence as rapidly as
possible… [The nurse] is temporarily the consciousness of the unconscious, the love of
life for the suicidal, the leg of the amputee, the eyes of the newly blind, a means of
locomotion for the infant, knowledge and confidence for the young mother, the [voice]
for those too weak or withdrawn to speak.”4

Public Health Nursing

Public health nursing is the synthesis of the art and science of public health and
nursing.5

One good community nurse will save a dozen policemen.
Herbert Hoover

Revised 2007 2 Minnesota Department of Health
Adapted from Original by Center for Public Health Nursing, 2004

1 Adapted from The Future of Public Health. National Academy Press, 1988.
2 C.E.A. Winslow. The Untilled Field of Public Health, Modern Medicine, Vol. 2. pp. 183-191, 1920.
3 Nightingale, Florence. Notes on Nursing: What It Is and What It Is Not. London: Harrison and Sons, 1859, preface
and p.75 (Commemorative Edition, Lippincott, 1992).
4 Henderson, VA. Basic principles of nursing care. London: International Council of Nurses, 1961.
5 Cornerstones of Public Health Nursing. Minnesota Department of Health, 1999.

Revised 2007 3 Minnesota Department of Health
Adapted from Original by Center for Public Health Nursing, 2004

Applying the Cornerstones to
Public Health Nursing Practice

FOCUSES ON THE HEALTH OF ENTIRE POPULATIONS

Population
• A population is a collection of individuals who have one or more personal or

environmental characteristics in common.
• Population-based interventions are not limited to only those who seek service or who

are poor or otherwise vulnerable.

A population-of-interest is a population that is essentially healthy but who could
improve factors which promote or protect health.

A population-at-risk is a population with a common identified risk factor or risk-
exposure that poses a threat to health

Examples of populations include:
• All families of newborn infants
• All older adults at risk for falls
• Everyone who drinks well water
• All children at risk for vaccine-preventable disease
• All adolescents at risk for depression

REFLECTS COMMUNITY PRIORITIES AND NEEDS

Population-based practice reflects the priorities of the community. Community
priorities are determined through an assessment of the population’s health status and a
prioritization process.

Community assessment is defined as:
The regular and systematic collection, analysis, and dissemination of information on the
health of the community; including statistics on health status, awareness of community
health needs, and epidemiologic and other studies of health problems.

A community assessment process:
• Assesses the health status of all populations and for all health-related areas in the

community, regardless of whether the public health agency has responsibility or
programmatic efforts in those areas

• Produces results that serve as the foundation for planning how public health and the
community will address public health problems

ESTABLISHES CARING RELATIONSHIPS WITH
COMMUNITIES, SYSTEMS, INDIVIDUALS AND FAMILIES

Caring is often considered the “art of nursing, that part of nursing which creates the
circumstances under which the “curative” parts can happen.

More than just words, intents, beliefs, or values; it encompasses stance, touch,
orientation thoughts and feelings fused with physical presence and action.1

Relationships
The foundation of any therapeutic or healing activity is the interactions among people,
which may be described as relationship-centered care. All public health nursing
interventions are provided in the context of a relationship. The relationships that public
health nurses establish with the communities, families, individuals and systems they
serve are grounded in personal integrity, honesty, consistency, and trustworthiness.

“Nobody cares how much you know
until they know how much you care.”

GROUNDED IN SOCIAL JUSTICE, COMPASSION, SENSITIVITY TO
DIVERSITY, AND RESPECT FOR THE WORTH OF ALL PEOPLE,

ESPECIALLY THE VULNERABLE

Social Justice
Public health nurses’ commitment to the communities, families, and individuals they
serve emanate from a combination of the passion underlying their social justice beliefs
that all persons regardless of circumstances are entitled equally to a basic quality of life.

“Social justice is the foundation of public health… that invincible human spirit that led
so many of us to enter the field of public health in the first place: a spirit of that has a
compelling desire to make the world a better place, free of misery, inequity, and
preventable suffering, a world in which we all can live, love, work, play, ail, and die with
our dignity intact and our humanity cherished.”2

Compassion
“The nurse is temporarily the consciousness of the unconscious, the love of life for the
suicidal, the leg of the amputee, the eyes of the newly blind, a means of locomotion for
the infant, knowledge and confidence for the young mother, the (voice) for those too
weak or withdrawn to speak.”3

Revised 2007 4 Minnesota Department of Health
Adapted from Original by Center for Public Health Nursing, 2004

1 Patricia Benner, Christine Tanner, Catherine Chesla. Adapted from Expertise in Nursing Practice: Caring, Clinical
Judgment, and Ethics. New York: Springer, 1996: p.233.
2 Krieger and Birn, Editorial, AJPH, November 1997
3 Henderson, VA. Basic principles of nursing care. London: International Council of Nurses, 1961.

Revised 2007 5 Minnesota Department of Health
Adapted from Original by Center for Public Health Nursing, 2004

Sensitivity to Diversity
• Values cultural diversity in communities
• Possesses capacity for cultural self-assessment and competence in adapting to

diversity.

Respect for the worth of all people, especially the vulnerable
Vulnerable populations are populations at risk of poor physical, psychological, or social
health.

ENCOMPASSES MENTAL, PHYSICAL, EMOTIONAL, SOCIAL,
SPIRITUAL, AND ENVIRONMENTAL ASPECTS OF HEALTH

Definition of holistic nursing:
“All nursing practice that has healing the whole person as its goal.”1

Historical precedents:
“The work we are speaking of has to do with maintaining health by removing things
which disturb it… dirt, drink, diet, damp, and drains.”2

“Appalled at the conditions she found among the wives of the soldiers she tended, i.e.,
respectable women, living in 3-4 rooms of the damp basement of a hospital, where a
fever broke out. In this place the sick were attended and 22 babies born.”
Ms. Nightingale:
• Procured a house
• Had it cleaned and furnished
• Organized a plan to give employment to soldiers’ wives
• Started a school for the children
• Got a chaplain to visit the families and help them
• Advocated in her writings that the wives and children not be forgotten when

planning for the soldiers3

Lillian Wald envisioned the Henry Street Settlement as an opportunity to “unite people
through their human and spiritual interests.” As a result, the Settlement continually
expanded to meet the needs of its community by supplementing the nursing activities
with social programs that included:
• Dramatic activities
• Vocational training for boys and girls
• Three kindergartens
• Classes in carpentry, sewing, art, diction, music, and dance
• Clubs for boys, girls, men, young women, and mothers
• A drama club with its own theater
• Summer camps for children at a Settlement-owned farm

1 American Holistic Nurses Association.
2 Florence Nightingale.
3 Whall. The Family as the Unit of Care. Public Health Nursing. Volume 3. December, 1986.

Revised 2007 6 Minnesota Department of Health
Adapted from Original by Center for Public Health Nursing, 2004

• Two large scholarship funds
• Study rooms staffed with people to help children with their homework
• Playgrounds for children
• A neighborhood library1

PROMOTES HEALTH THROUGH STRATEGIES DRIVEN
BY EPIDEMIOLOGICAL EVIDENCE

Levels of prevention
• Primary – promotes health and prevents problems before they occur
• Secondary – detects and treats problems early
• Tertiary – limits further negative effects from a problem

Epidemiology
• Describes the health status of populations
• Explains the causes of diseases
• Predicts the occurrence of disease
• Controls the distribution of disease

COLLABORATES WITH COMMUNITY RESOURCES TO ACHIEVE THOSE

STRATEGIES, BUT CAN AND WILL WORK ALONE IF NECESSARY

Can and will work alone if others are unable or choose not to work on an
issue
• Protecting the health of the public is a fundamental responsibility of government
• Core government functions of public health: Assessment, Policy Development &

Assurance

DERIVES ITS AUTHORITY FOR INDEPENDENT ACTION
FROM THE NURSE PRACTICE ACT

• Legally established scope of practice
• Broad authority for action
• Professionally guided standards and expectations

Cornerstones
• Endure across time and place
• Underlying meaning of our work
• Provides guidance and direction for our practice

1 www.jwa.org/Jwa-1999/exhibit98/wald

Revised 2007 7 Minnesota Department of Health
Adapted from Original by Center for Public Health Nursing, 2004

For additional information:

Sue Strohschein, MS, BSN, APRN, BC
Office of Public Health Practice
Minnesota Department of Health

PO Box 64975
St. Paul, MN 55164-0975

Phone: 320-223-7344
Sue.strohschein@state.mn.us

THE 10 ESSENTIAL
PUBLIC HEALTH
SERVICES
To protect and promote the health of all people in
all communities

The 10 Essential Public Health Services provide a
framework for public health to protect and promote
the health of all people in all communities. To achieve
equity, the Essential Public Health Services actively promote
policies, systems, and overall community conditions that
enable optimal health for all and seek to remove systemic
and structural barriers that have resulted in health inequities.

Such barriers include poverty, racism, gender discrimination,
ableism, and other forms of oppression. Everyone should
have a fair and just opportunity to achieve optimal health
and well-being.

ESSENTIAL PUBLIC HEALTH SERVICE #1
Assess and monitor population
health status, factors that influence
health, and community needs and
assets

ESSENTIAL PUBLIC HEALTH SERVICE #3
Communicate effectively to inform
and educate people about health,
factors that influence it, and how to
improve it

ESSENTIAL PUBLIC HEALTH SERVICE #6
Utilize legal and regulatory actions
designed to improve and protect the
public’s health

ESSENTIAL PUBLIC HEALTH SERVICE #7
Assure an effective system that
enables equitable access to the
individual services and care needed
to be healthy

ESSENTIAL PUBLIC HEALTH SERVICE #9
Improve and innovate public health
functions through ongoing evaluation,
research, and continuous quality
improvement

ESSENTIAL PUBLIC HEALTH SERVICE #10
Build and maintain a strong
organizational infrastructure for
public health

ESSENTIAL PUBLIC HEALTH SERVICE #8
Build and support a diverse and
skilled public health workforce

ESSENTIAL PUBLIC HEALTH SERVICE #5
Create, champion, and implement
policies, plans, and laws that impact
health

ESSENTIAL PUBLIC HEALTH SERVICE #4

Strengthen, support, and mobilize
communities and partnerships to
improve health

ESSENTIAL PUBLIC HEALTH SERVICE #2
Investigate, diagnose, and address
health problems and hazards
affecting the population

Created 2020

2Created 2020

ESSENTIAL PUBLIC
HEALTH SERVICE #1

Assess and monitor population health status,
factors that influence health, and community
needs and assets

• Maintaining an ongoing understanding
of health in the jurisdiction by collecting,
monitoring, and analyzing data on health
and factors that influence health to
identify threats, patterns, and emerging
issues, with a particular emphasis on
disproportionately affected populations

• Using data and information to
determine the root causes of health
disparities and inequities

• Working with the community to
understand health status, needs, assets,
key influences, and narrative

• Collaborating and facilitating data
sharing with partners, including multi-
sector partners

• Using innovative technologies, data
collection methods, and data sets

• Utilizing various methods and
technology to interpret and communicate
data to diverse audiences

• Analyzing and using disaggregated
data (e.g., by race) to track issues and
inform equitable action

• Engaging community members as
experts and key partners

THIS SERVICE INCLUDES:

3Created 2020

ESSENTIAL PUBLIC
HEALTH SERVICE #2

Investigate, diagnose, and address health
problems and hazards affecting the
population

• Anticipating, preventing, and mitigating
emerging health threats through
epidemiologic identification

• Monitoring real-time health status
and identifying patterns to develop
strategies to address chronic diseases
and injuries

• Using real-time data to identify
and respond to acute outbreaks,
emergencies, and other health hazards

• Using public health laboratory
capabilities and modern technology to
conduct rapid screening and high-volume
testing

• Analyzing and utilizing inputs from
multiple sectors and sources to consider
social, economic, and environmental root
causes of health status

• Identifying, analyzing, and distributing
information from new, big, and real-time
data sources

THIS SERVICE INCLUDES:

4Created 2020

ESSENTIAL PUBLIC
HEALTH SERVICE #3

Communicate effectively to inform and
educate people about health, factors that
influence it, and how to improve it

• Developing and disseminating
accessible health information and
resources, including through collaboration
with multi-sector partners

• Communicating with accuracy and
necessary speed

• Using appropriate communications
channels (e.g., social media, peer-
to-peer networks, mass media, and
other channels) to effectively reach the
intended populations

• Developing and deploying culturally
and linguistically appropriate and
relevant communications and
educational resources, which includes
working with stakeholders and influencers
in the community to create effective and
culturally resonant materials

• Employing the principles of risk
communication, health literacy, and
health education to inform the public,
when appropriate

• Actively engaging in two-way
communication to build trust with
populations served and ensure accuracy
and effectiveness of prevention and
health promotion strategies

• Ensuring public health communications
and education efforts are asset-
based when appropriate and do not
reinforce narratives that are damaging to
disproportionately affected populations

THIS SERVICE INCLUDES:

5Created 2020

ESSENTIAL PUBLIC
HEALTH SERVICE #4

Strengthen, support, and mobilize
communities and partnerships to
improve health

• Convening and facilitating multi-
sector partnerships and coalitions that
include sectors that influence health
(e.g., planning, transportation, housing,
education, etc.)

• Fostering and building genuine,
strengths-based relationships with a
diverse group of partners that reflect the
community and the population

• Authentically engaging with community
members and organizations to develop
public health solutions

• Learning from, and supporting,
existing community partnerships and
contributing public health expertise

THIS SERVICE INCLUDES:

6Created 2020

ESSENTIAL PUBLIC
HEALTH SERVICE #5

Create, champion, and implement policies,
plans, and laws that impact health

• Developing and championing policies,
plans, and laws that guide the practice of
public health

• Examining and improving existing
policies, plans, and laws to correct
historical injustices

• Ensuring that policies, plans, and laws
provide a fair and just opportunity for
all to achieve optimal health

• Providing input into policies, plans,
and laws to ensure that health impact is
considered

• Continuously monitoring and
developing policies, plans, and laws that
improve public health and preparedness
and strengthen community resilience

• Collaborating with all partners,
including multi-sector partners, to develop
and support policies, plans, and laws

• Working across partners and with
the community to systematically and
continuously develop and implement
health improvement strategies and plans,
and evaluate and improve those plans

THIS SERVICE INCLUDES:

7Created 2020

ESSENTIAL PUBLIC
HEALTH SERVICE #6

Utilize legal and regulatory actions designed
to improve and protect the public’s health

• Ensuring that applicable laws are
equitably applied to protect the public’s
health

• Conducting enforcement activities
that may include, but are not limited to
sanitary codes, especially in the food
industry; full protection of drinking water
supplies; and timely follow-up on hazards,
preventable injuries, and exposure-
related diseases identified in occupational
and community settings

• Licensing and monitoring the quality
of healthcare services (e.g., laboratory,
nursing homes, and home healthcare)

• Reviewing new drug, biologic, and
medical device applications

• Licensing and credentialing the
healthcare workforce

• Including health considerations in laws
from other sectors (e.g., zoning)

THIS SERVICE INCLUDES:

8Created 2020

ESSENTIAL PUBLIC
HEALTH SERVICE #7

Assure an effective system that enables
equitable access to the individual services
and care needed to be healthy

• Connecting the population to needed
health and social services that support
the whole person, including preventive
services

• Ensuring access to high-quality and
cost-effective healthcare and social
services, including behavioral and mental
health services, that are culturally and
linguistically appropriate

• Engaging health delivery systems to
assess and address gaps and barriers
in accessing needed health services,
including behavioral and mental health

• Addressing and removing barriers to
care

• Building relationships with payers
and healthcare providers, including the
sharing of data across partners to foster
health and well-being

• Contributing to the development of a
competent healthcare workforce

THIS SERVICE INCLUDES:

9Created 2020

ESSENTIAL PUBLIC
HEALTH SERVICE #8

Build and support a diverse and skilled public
health workforce

• Providing education and training that
encompasses a spectrum of public
health competencies, including technical,
strategic, and leadership skills

• Ensuring that the public health
workforce is the appropriate size to
meet the public’s needs

• Building a culturally competent public
health workforce and leadership that
reflects the community and practices
cultural humility

• Incorporating public health principles in
non-public health curricula

• Cultivating and building active
partnerships with academia and other
professional training programs and
schools to assure community-relevant
learning experiences for all learners

• Promoting a culture of lifelong learning
in public health

• Building a pipeline of future public
health practitioners

• Fostering leadership skills at all levels

THIS SERVICE INCLUDES:

10Created 2020

ESSENTIAL PUBLIC
HEALTH SERVICE #9

Improve and innovate public health functions
through ongoing evaluation, research, and
continuous quality improvement

• Building and fostering a culture of
quality in public health organizations and
activities

• Linking public health research with
public health practice

• Using research, evidence, practice-
based insights, and other forms of
information to inform decision-making

• Contributing to the evidence base of
effective public health practice

• Evaluating services, policies, plans, and
laws continuously to ensure they are
contributing to health and not creating
undue harm

• Establishing and using engagement
and decision-making structures to
work with the community in all stages of
research

• Valuing and using qualitative,
quantitative, and lived experience as
data and information to inform decision-
making

THIS SERVICE INCLUDES:

11Created 2020

ESSENTIAL PUBLIC
HEALTH SERVICE #10

Build and maintain a strong organizational
infrastructure for public health

• Developing an understanding of the
broader organizational infrastructures
and roles that support the entire public
health system in a jurisdiction (e.g.,
government agencies, elected officials,
and non-governmental organizations)

• Ensuring that appropriate, needed
resources are allocated equitably for the
public’s health

• Exhibiting effective and ethical
leadership, decision-making, and
governance

• Managing financial and human
resources effectively

• Employing communications and
strategic planning capacities and skills

• Having robust information technology
services that are current and meet
privacy and security standards

• Being accountable, transparent, and
inclusive with all partners and the
community in all aspects of practice

THIS SERVICE INCLUDES:

Created 2020

The 10 Essential Public Health Services

Glossary

Community is a group of people who have common characteristics; communities can be defined by

location, race, ethnicity, age, occupation, interest in particular problems or outcomes, or other similar

common bonds. Ideally, there would be available assets and resources, as well as collective discussion,

decision-making and action. (Turnock, BJ. Public Health: What It Is and How It Works. Jones and Bartlett,

2009)

Equity is defined as a fair and just opportunity for all to achieve good health and well-being. This requires

removing obstacles to health such as poverty and discrimination and their consequences, including

powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe

environments, and healthcare. It also requires attention to health inequities, which are differences in

population health status and mortality rates that are systemic, patterned, unjust, and actionable, as

opposed to random or caused by those who become ill.

Health is a state of complete physical, mental and social well-being and not merely the absence of disease

or infirmity. The bibliographic citation for this definition is: Preamble to the Constitution of WHO as adopted

by the International Health Conference, New York, 19 June – 22 July 1946; signed on 22 July 1946 by the

representatives of 61 States (Official Records of WHO, no. 2, p. 100) and entered into force on 7 April

1948. The definition has not been amended since 1948.

Healthcare sector is defined as entities that provide clinical services, mental health services, oral health

services, provide or pay for services for individuals, or facilitate the provision of services to individuals.

Entities in this sector may include hospitals, health systems, health plans, health centers, behavioral health

providers, oral health providers, etc.Law(s) refer to the aggregate of statutes, ordinances, regulations,

rules, judicial decisions, and accepted legal principles that the courts of a particular jurisdiction apply in

deciding controversies brought before them. The law consists of all legal rights, duties, and obligations that

can be enforced by the government (or one of its agencies) and the means and procedures for enforcing

them. (Garner, B.A. editor. Black’s

Law Dictionary. 8th ed. West Group; 2004)

Law(s) refer to the aggregate of statutes, ordinances, regulations, rules, judicial decisions, and accepted

legal principles that the courts of a particular jurisdiction apply in deciding controversies brought before

them. The law consists of all legal rights, duties, and obligations that can be enforced by the government

(or one of its agencies) and the means and procedures for enforcing them. (Garner, B.A. editor. Black’s

Law Dictionary. 8th ed. West Group; 2004)

Population health is the health outcomes of a group of individuals, including the distribution of such

outcomes within the group. The field of population health includes health outcomes, patterns of health

determinants, and policies and interventions that link these two. Population health approaches are

community or policy non-clinical approaches that aim to improve health and wellbeing of a group of

individuals. This differs from population health management which refers to improving clinical health

outcomes of individuals through improved care coordination and patient engagement supported by

appropriate financial and care models. (Adapted from Kindig and Stoddart).

Created 2020

The 10 Essential Public Health Services

Glossary

Public health is defined as the science of protecting the safety and improving the health of communities

through education, policy making and research for disease and injury prevention. (CDC Foundation).

Research is a systematic investigation, including research development, testing, and evaluation, designed

to develop or contribute to generalized knowledge. (United States Department of Health and Human

Services. Healthy People 2020. Washington, DC)

– Community-based Participatory Research (CBPR) is a collaborative approach to research that

equitably involves all partners in the research process and recognizes the unique strengths that

each brings. CBPR begins with a research topic of importance to the community, has the aim of

combining knowledge with action and achieving social change to improve health outcomes and

eliminate health disparities. (W. K. Kellogg Foundation, Community Health Scholars Program, 2001

quotes from Minkler M, and Wallerstein N, editors. Community-Based Participatory Research for

Health. San Francisco, CA: Jossey-Bass Inc.; 2003)

To view the complete 10 Essential Public Health Services, visit https://phnci.org/uploads/resource-

files/EPHS-English .

https://phnci.org/uploads/resource-files/EPHS-English

Public health interventions:
Applications for public health

nursing practice
SECOND EDITION

2019

Public health interventions: Applications for public health nursing practice
Second edition
Marjorie Schaffer, PhD, RN, PHN
Susan Strohschein, DNP, RN, PHN (retired)

Suggested citation: Minnesota Department of Health. (2019). Public health interventions: Applications for
public health nursing practice (2nd ed.).

Minnesota Department of Health
Community Health Division
PO Box 64975
St. Paul, MN 55164-0975
651-201-3880
health.ophp@state.mn.us
www.health.state.mn.us

To obtain this information in a different format, call: 651-201-3880.

mailto:health.ophp@state.mn.us

http://www.health.state.mn.us/

Contents
Acknowledgements ……………………………………………………………………………………………………………………………. 5

Foreword …………………………………………………………………………………………………………………………………………… 7

Introduction ………………………………………………………………………………………………………………………………………. 8

Overview of evidence-based practice and related topics …………………………………………………………………… 17

Red wedge ………………………………………………………………………………………………………………………………………. 25

Surveillance …………………………………………………………………………………………………………………………………. 25

Disease and health event investigation …………………………………………………………………………………………… 40

Outreach ……………………………………………………………………………………………………………………………………… 53

Screening …………………………………………………………………………………………………………………………………….. 65

Case-finding …………………………………………………………………………………………………………………………………. 78

In review ……………………………………………………………………………………………………………………………………… 87

Green wedge ……………………………………………………………………………………………………………………………………. 91

Referral and follow-up ………………………………………………………………………………………………………………….. 91

Case management ………………………………………………………………………………………………………………………. 104

Delegated functions ……………………………………………………………………………………………………………………. 115

In review ……………………………………………………………………………………………………………………………………. 128

Blue wedge ……………………………………………………………………………………………………………………………………. 131

Health teaching ………………………………………………………………………………………………………………………….. 131

Counseling …………………………………………………………………………………………………………………………………. 142

Consultation ………………………………………………………………………………………………………………………………. 155

In review ……………………………………………………………………………………………………………………………………. 165

Orange wedge ………………………………………………………………………………………………………………………………… 167

Collaboration ……………………………………………………………………………………………………………………………… 167

Coalition-building ……………………………………………………………………………………………………………………….. 181

Community organizing ………………………………………………………………………………………………………………… 193

In review ……………………………………………………………………………………………………………………………………. 204

Yellow wedge …………………………………………………………………………………………………………………………………. 207

Advocacy …………………………………………………………………………………………………………………………………… 207

Social marketing …………………………………………………………………………………………………………………………. 220

Policy development and enforcement …………………………………………………………………………………………… 237

In review ……………………………………………………………………………………………………………………………………. 248

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I N T R O D U C T I O N

P U B L I C H E A L T H I N T E R V E N T I O N S | 5

Acknowledgements
The 2019 evidence update of Public health interventions: Applications for public
health nursing practice builds on the foundational work of Linda Olson Keller, DNP,
RN, PHN, FAAN; Susan Strohschein, DNP, MS, RN, PHNA (retired); and Laurel Briske,
MA, RN, CPNP (retired). Their visionary leadership brought together public health lit-
erature and the expert practice of public health nurses to make the Intervention
Wheel a reality for everyday public health nursing practice. The contributions of Dr.
Keller and Dr. Strohschein in the dissemination of the Intervention Wheel create a
legacy and responsibility for all public health nurses in intervening to improve popu-
lation health.

Reviewers
We are also grateful to our reviewers who read and critiqued drafts of individual in-
tervention wedges. The reviewers asked good questions and made insightful com-
ments, essential for revising this document for readability, clarity, accuracy, and ap-
plicability to public health nursing practice.

With thanks, to the following reviewers:

Linda J.W. Anderson, DNP, MPH, RN, PHN
Bethel University

Linda Bauck-Todd, MS, RN, PHN
Minnesota Department of Health

Kathleen Bell, EdD, RN, PHN
St. Catherine University

Angela Bosshart, BSN, RN, PHN
Hennepin County

Bonnie Brueshoff, DNP, RN, PHN
Dakota County

Bethany Divakaran, DNP, MPH, RN, PHN
Concordia University

Kari Glavin, PhD, MSc, RN, PHN
VID Specialized University

Karen S. Goedken, MSN, PHN
Hennepin County

Pamela L. Guthman, DNP, RN-BC
University of Wisconsin-Eau Claire

Sheryl Jacobson, MS, RN
Viterbo University

Maren Jensen, RN, PHN
Hennepin County

Wendy Kvale, MS, MPH, PHN
Minnesota Department of Health

Janelle Lambert, BSN, PHN
Minnesota Department of Health

Karen Jorgensen-Royce, MSN, RN, PHN
Wright County

Karen Loewenson, MA, RN, PHN, CNE
St. Catherine University

Stacie O’Leary, MA, RN, PHN, LSN
Independent School District 197

Mary Orban, MA, PHN
Minnesota Department of Health

Patricia M. Schoon, DNP, MPH, RN, PHN
Metropolitan State University

I N T R O D U C T I O N

6 | P U B L I C H E A L T H I N T E R V E N T I O N S

Jernell Walker, BSN RN, PHN
Hennepin County

Carol Wentworth, BSN, RN, PHN
Carver County

Maureen Wosepka, MSN, RN, PHN, LSN
St. Catherine University

Susan Zahner, DrPH, RN, FAAN
University of Wisconsin-Madison

Linda Reveling Smith, MPH, RN, PHN
Winona State University

Stephanie Rivery, DNP, RN, PHN
Dakota County

Amalia Roberts, DNP, RN, PHN
Dakota County

Anna Terry, MSN, RN, PHN
Dakota County

Project staff
Julia Ashley, MA, PHN
Minnesota Department of Health

Kristin Erickson, MSN, RN, APHN-BC
Minnesota Department of Health

Allison Hawley March, MPH
Minnesota Department of Health

Reviewer notes
I found the formatting and updated evidence cited in the chapters much more clear
and applicable to current practice. I believe the evidence tips’ formatting makes the
full chapters for each intervention on the wheel a great deal more “readable” and
easier for everyone to grasp.

***

Overall, this is a very straightforward way for students and public health nursing pro-
fessionals alike to refer to and know exactly what an intervention encompasses, as
well as ideas for implementing the intervention, and how to stay in the public health
nursing swim lane when working with other health care entities in the health care
system and in communities.

***

I was very impressed with the comprehensiveness of the intervention definitions, ap-
plications, and evidence tips.

***

I appreciated using stories and application questions as appropriate triggers for dis-
cussion in my teaching practice.

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Foreword
Public Health Interventions: Applications for Public Health Nursing Practice, first
published in 2001 and commonly known as the Public Health Intervention Wheel,
guides the actions of public health nurses and their colleagues nationally and inter-
nationally across cultures and countries. During the past 18 years, practitioners have
used the Intervention Wheel framework to plan and evaluate practice, as well as re-
spond to emergency preparedness, develop control measures for emerging conta-
gious disease outbreaks, and promote lifestyle changes related to population health
improvement.

Significant growth of the evidence base of the 2001 manual and the corresponding
development of evidence-based public health practice led to the need to publish a
second edition that reflects new evidence. Although the literature search is not ex-
haustive, we have used a systematic process to identify new evidence and revisit pre-
vious evidence. We hope this evidence update broadens the support for implemen-
tation of the 17 public health interventions. We realize that many expert public health
practitioners hold a wealth of practice-based evidence that may not be reflected in
this update. We encourage you to share that evidence through presentations and
publication.

We do not expect that every public health professional will be proficient in all inter-
ventions at all practice levels. Your role and your agency determines the range, fre-
quency, and practice level of respective interventions. In a larger agency, practition-
ers may focus on one or two interventions across one practice level. In a smaller
agency, practitioners may use multiple interventions across multiple practice levels.
Wherever you practice, you may find that your actions encompass a variety of inter-
ventions based on a range of evidence levels.

We hope this evidence update inspires you to grow your public health practice and
support environments in which people can be healthy. In so doing each one of us
contributes to the vision of Lillian Wald, founder of American community nursing:

The call to nurse is not only for the bedside care of the sick, but to help in
seeking out the deep-lying basic cause of illness and misery, that in the
future there may be less sickness to nurse and to cure. (Wald, 1915, p. 65)

–Marjorie Schaffer, PhD, RN, PHN and Susan Strohschein, DNP, RN, PHN (retired)

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Introduction
Public health interventions: Applications for public health nursing practice, 2nd edition

Background
Under the leadership of public health nurses, the Minnesota Department of Health
(MDH) developed a manual, Public health interventions: Applications for public
health nursing practice, to guide public health nursing practice. MDH distributed this
manual, commonly known as the Public Health Intervention Wheel, to public health
departments and public health nurses in 2001. Informed by literature and expert
practice, the Public Health Nursing Intervention Wheel framework provides a com-
mon language that names the work of public health nurses.

Two articles published in 2004 provide details about the development and dissemi-
nation of the manual:

 Keller, L. O., Strohschein, S., Lia-Hoagberg, B., & Schaffer, M. A. (2004).
Population-based public health interventions: Practice-based and evidence-
supported (Part I). Public Health Nursing, 21(5), 453-468.

 Keller, L. O., Strohschein, S., Schaffer, M. A., & Lia-Hoagberg, B., (2004).
Population-based public health interventions: Innovations in practice, teaching,
and management (Part II). Public Health Nursing, 21(5), 469-487.

Public health nurses in Minnesota, across the United States, and in other countries,
including Australia, Ireland, and Norway, embrace and use the Public Health Inter-
vention Wheel (Anderson et al., 2018; Baisch, 2012; Bigbee, 2012; Depke, 2011;
Leahy-Warren, 2018; McDonald et al., 2015; Reilly, Collier, & Edelstein, 2011;
Schaffer, Anderson, & Rising, 2016; Schaffer, Kalfoss, & Glavin, 2017).

How has public health nursing practice changed?
Since the 2001 dissemination of the Public Health Intervention Wheel, changes in the
socioeconomic and political landscape triggered changes in public health nursing
practice. Health care reform policy began to address social determinants of health,
prevention, and population health in community settings (Swider, Berkowitz,
Valentine-Maher, Zenk, & Bekemeier, 2017; Bekemeier, Zahner, Kulbok, Merrill, &
Kub, 2016) driving public health practice to respond in like manner. In response to
the September 11, 2001 terrorist attacks and bioterrorism incidents, the U.S. federal
government provided substantial funding to state and local governments for emer-
gency preparedness activities (Katz, Attal-Juncqua, & Fischer, 2017). This funding led
to including emergency preparedness activities and opportunities in public health
nursing practice.

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At the same time, challenges to the public health infrastructure affected the availa-
bility of resources and support for public health nursing practice. These challenges
include insufficient funding, resulting in budget cuts and loss of prevention and health
promotion services; a declining public health workforce, including public health
nurses (PHNs); and workforce issues, such as non-competitive salaries, retirements,
technology changes, lack of diversity, and lack of formal public health training
(Bekemeier et al., 2016).

In response to these events and challenges, public health nurses require increased
skills in system- and community-level interventions. Strengthening the public health
system and improving population health depends upon expertise in community en-
gagement and partnership development (National Institutes of Health, 2011; Robert
Wood Johnson Foundation, 2017). Decreasing resources for public health work de-
mand that public health nurses work efficiently and effectively. Using best evidence
to support interventions when collaborating with systems and communities improves
population health and reduces health care dollars spent on acute and crisis health
care. This manual updates the best evidence for public health nursing interventions
and provides PHNs with the knowledge and tools to design and implement effective
interventions in their practice.

How has the Public Health Intervention Wheel
changed?
All of the interventions and the five Intervention Wheel wedges remain the same.
The authors simplified the manual content, and updated and aligned intervention
definitions with new evidence found in the literature. Each intervention includes the
following sections:

 Definition
 Practice-level examples (individual/family, community, or systems)
 Relationships to other interventions
 Basic steps for the intervention with application example
 Key points from evidence (summarizes relevant evidence with evidence levels)
 Wheel notes (concerns, thoughts, challenges relevant to the intervention)
 Reference list

A few things to keep in mind when using the manual:

 Practice-level examples related to each intervention facilitate distinguishing be-
tween practice levels.

 Real examples from the literature and/or public health nursing experience form
the basis of application examples related to the intervention basic steps.

 Key points from evidence include research and non-research (evidence that re-
flects expert practice in the public health field that has not come through a rig-
orous research process) evidence.

 A story with application questions at the end of each intervention wedge en-
courages consideration of the intervention and facilitates application of the in-
tervention’s basic steps.

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Method
The authors searched CINAHL (Cumulative Index to Nursing and Allied Health Litera-
ture) as the primary database for evidence updates on public health interventions from
2000 to 2018. The name of the intervention combined with other terms, such as public
health, public health nursing, intervention, community, and nursing narrowed the
search. For some interventions, alternative terms yielded additional articles, such as
the use of health education for health teaching. Journals yielding a high number of ar-
ticles addressing public health interventions included Public Health Nursing, the Journal
of Community Health Nursing, the Journal of School Nursing, the American Journal of
Public Health, and the Journal of Public Health Management and Practice.

Searching government health-related websites and textbooks provided other sources
of evidence. Government websites included the Centers for Disease Control and Pre-
vention (CDC), the National Association of County and City Health Officials (NACCHO),
the World Health Organization (WHO), the U.S. Department of Health and Human
Services, and state health departments. Classic textbooks on some of the interven-
tions provided evidence for each intervention’s basic steps.

The authors used the Johns Hopkins Nursing Evidence-Based Practice Model (Dang &
Dearholt, 2018) to categorize evidence levels (for further explanation of evidence-
based practice, see Overview of evidence-based practice and related topics, on p. 16).
Although all five levels of evidence support basic steps and key evidence points for
interventions, lower levels of evidence predominate. Non-experimental studies pro-
vide the primary basis for research evidence for interventions.

Public health nursing interventions
Public health nurses work in or out of schools, homes, clinics, jails, shelters, mobile
vans, and dog sleds. They work with communities, the individuals and families that
compose communities, and the systems that affect the health of those communities.
Regardless of where or with whom they work, all PHNs use a core set of interventions
to accomplish their goals.

Interventions are actions that public health nurses take on behalf of individu-
als/families, communities, and systems, to improve or protect health status (Minne-
sota Department of Health, 2001, p. 1).

This framework, known as the Intervention Wheel, defines the scope of public health
nursing practice by type of intervention and level of practice (individual/family, com-
munity, or systems), rather than by the site of service such as home, school, occupa-
tional health, clinic, and others. The Intervention Wheel describes the scope of prac-
tice by what is similar across settings and describes the practice of public health nurs-
ing at the individual/family, community, or systems level. The Intervention Wheel an-
swers the question, “What do public health nurses do?” and delineates public health
nursing as a specialty practice of nursing. These interventions are not exclusive to
public health nursing, as they are also used by other public health disciplines, except
for delegated functions.

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The Intervention Wheel:
The “how” of public health nursing practice
The Intervention Wheel integrates three distinct and equally important components:

1. The population-basis of public health interventions

2. Three levels of public health practice:
 Individual/family
 Community
 Systems

3. Seventeen public health interventions:
 Surveillance
 Disease and health event

investigation
 Outreach
 Screening
 Case-finding
 Referral and follow-up
 Case management
 Delegated functions
 Health teaching

 Counseling
 Consultation
 Collaboration
 Coalition-building
 Community organizing
 Advocacy
 Social marketing
 Policy development and

enforcement

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The Intervention Wheel consists of a colorful outside ring, three inner rings, and 17
“wedges” or “slices.” All public health interventions are population-based. A popula-
tion is a collection of individuals who have one or more personal or environmental
characteristics in common. A population of interest is a population that is essentially
healthy, but who could improve factors that promote or protect health. A population
at risk is a population with a common identified risk factor or risk exposure that poses
a threat to health.

Intervention wedges
The interventions are grouped with related interventions; these “wedges” are color
coordinated to make them more recognizable.

Red wedge: Surveillance, disease and health event investigation, outreach, screen-
ing, case-finding. Surveillance is often paired with disease and health event investi-
gation, even though either can be implemented independently. Screening frequently
follows either surveillance or disease and health event investigation and is often pre-
ceded by outreach activities in order to maximize the number of those at risk who
actually get screened. Most often, screening leads to case-finding, but this interven-
tion can also be carried out independently or related directly to surveillance and dis-
ease and health event investigation.

Green wedge: Referral and follow-up, case management, and delegated functions
are often implemented together.

Blue wedge: Health teaching, counseling, and consultation are more similar than
they are different. Often health teaching and counseling are paired.

Orange wedge: Collaboration, coalition-building, and community organizing are
grouped together because they are all types of collective action and are often carried
out at the community or systems level of practice.

Yellow wedge: Advocacy, social marketing, and policy development and enforce-
ment are often interrelated when implemented. In fact, advocacy is often viewed as
a precursor to policy development; and social marketing is seen by some as a method
of carrying out advocacy.

Population-based interventions
The Intervention Wheel is grounded in population-based practice. Interventions are
population-based if they address all of the following:

1. An entire population
2. An assessment of community health
3. Broad determinants of health
4. All levels of prevention
5. All levels of practice

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1. Public health interventions are population-based if they focus
on entire populations possessing similar health concerns or
characteristics
Population-based interventions are not limited to only those who seek service or who
are poor or otherwise vulnerable. Population-based planning always begins by iden-
tifying everyone in the population of interest or the population at risk. For example,
it is a core public health function to assure that all children are immunized against
vaccine-preventable disease. Even though limited resources compel public health de-
partments to target programs toward those children known to be at particular risk
for being under- or unimmunized, the public health system remains accountable for
the immunization status of the total population of children.

2. Public health interventions are population-based if they are
guided by an assessment of population health status determined
through a community health assessment process
A population-based model of practice begins with a community health assessment
process. Public health analyzes health status (risk factors, problems, protective fac-
tors, assets) within populations; establishes priorities; and plans, implements, and
evaluates public health programs and strategies. Public health agencies assess the
health status of populations on an ongoing basis, so that public health programs re-
spond appropriately to new and emerging problems, concerns, and opportunities.
Since the 2010 passage of the Affordable Care Act (sometimes known as the ACA, the
Patient Protection and Affordable Care Act, or Obamacare), nonprofit hospitals and
hospital systems must also conduct community health needs assessments to main-
tain their federal tax-exempt status. This incentivizes local public health departments,
hospital systems, and other community partners to collaborate on the community
health assessment process.

3. Public health interventions are population-based if they
consider the broad determinants of health
A population-based approach examines all factors that promote or prevent health. It
focuses on the entire range of factors that determine health, rather than just personal
health risks or disease. Examples of broad determinants of health include income and
social status, race and ethnicity, housing, nutrition, employment and working condi-
tions, social support networks, education, neighborhood safety and violence issues,
physical environment, personal health practices and coping skills, cultural customs
and values, and community capacity to support family and economic growth.

4. Public health interventions are population-based if they
consider all levels of prevention, with a preference for primary
prevention
Prevention is anticipatory action taken to prevent the occurrence of an event (pri-
mary prevention) or to minimize its effect after it has occurred (secondary preven-
tion). A population approach is different from the medical model in which persons
seek treatment when they are ill or injured. Not every event is preventable, but every

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event does have a preventable component. A population-based approach presumes
that prevention may occur at any point.

 Primary prevention promotes health and protects against health threats. It is
implemented before a problem develops; it targets essentially well populations.
Primary prevention promotes resiliency and protective factors or reduces sus-
ceptibility and exposure to risk factors. Examples of primary prevention include
building assets in youth and immunizing for vaccine-preventable diseases. In re-
cent literature, this approach is often labeled an “upstream” approach, in which
the focus of care modifies the social determinants of health with the goal of
preventing disease and disability (Schoon, Porta, & Schaffer, 2019).

 Secondary prevention detects and treats problems in their early stages. It is im-
plemented after a problem has begun, but before signs and symptoms appear.
Secondary prevention keeps problems from causing serious or long-term effects
or from affecting other people. It identifies risks or hazards and modifies, re-
moves, or treats them before a problem becomes more serious. It targets pop-
ulations that have risk factors in common. An example is screening for home
safety and correcting hazards before an injury occurs.

 Tertiary prevention limits further negative effects from a problem. It is imple-
mented after a disease or injury has occurred. Tertiary prevention alleviates the
effects of disease and injury and restores individuals to their optimal level of
functioning. It targets populations who have experienced disease or injury. Ter-
tiary prevention keeps existing problems from getting worse—for instance, col-
laborating with health care providers to ensure periodic examinations, to pre-
vent complications of diabetes such as blindness, renal disease failure, and limb
amputation.

Whenever possible, public health programs emphasize primary prevention.

5. Public health interventions are population-based if they
consider all levels of practice
This concept is represented by the inner three rings of the Intervention Wheel; the
inner rings of the wheel are labeled individual/family-focused, community-focused,
and systems-focused

A population-based approach considers intervening at all possible levels of practice.
Interventions may be directed at the entire population within a community, the sys-
tems that affect the health of those populations, and/or the individuals and families
within those populations known to be at risk.

 Population-based systems-focused practice changes organizations, policies,
laws, and power structures. The focus is not directly on individuals and commu-
nities but on the systems that impact health. Changing systems is often a more
effective and long-lasting way to impact population health than requiring
change from community norms or from every single individual in a community.

 Population-based community-focused practice changes community norms, at-
titudes, awareness, practices, and behaviors. It is directed toward entire popu-
lations within the community or occasionally toward specific groups within
those populations. Community-focused practice is measured in terms of what
proportion of the population actually changes.

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 Population-based individual-focused practice changes knowledge, attitudes,
beliefs, practices, and behaviors of individuals or families. This practice level is
directed at individuals, alone, or as members in a family or group. Individuals
receive services upon identification with a population at risk.

Interventions at each of these levels of practice contribute to the goal of improving
population health status. Public health professionals determine the most appropriate
level(s) of practice based on community need and the availability of effective strate-
gies and resources. No one level of practice is more important than another; in fact,
population health issues are addressed at all three levels, often simultaneously.

For example, when considering smoking rates among adolescents, public health
nurses intervene at all practice levels. At the individual practice level, public health
nurses teach middle school chemical health classes to increase knowledge about the
risks of smoking, change attitudes toward tobacco use, and improve refusal skills
among youth 12 to 14 years old. At the community level of practice, public health
nurses coordinate youth-led and adult-supported social marketing campaigns to
change the community norms regarding adolescents’ tobacco use. At the systems
level of practice, public health nurses facilitate community coalitions that advocate
for city councils to adopt stronger ordinances restricting over-the-counter youth ac-
cess to tobacco.

Cornerstones of public health nursing
Population-based practice drives the Intervention Wheel but does not address why
PHNs practice public health nursing. The Cornerstones of Public Health Nursing syn-
thesize the values and beliefs of public health and nursing to explain the values and
beliefs that are the foundation for the practice of public health nursing (Keller,
Strohschein, & Schaffer, 2011). Values and beliefs from public health entwine with
the values and belief of nursing to produce public health nursing. Public health values
include social justice, a population focus, reliance on epidemiology, health promotion
and prevention, the greater good, and long-term commitment to community. Nurs-
ing contributes additional values and beliefs: caring and compassion, holistic and re-
lationship-centered practice, sensitivity to vulnerable populations, and independent
practice (pp. 251-252).

The Intervention Wheel and the core public
health functions, essential services
Implementing interventions to address public health problems and opportunities
identified through a community assessment result in PHNs fulfilling the core func-
tions of public health and the 10 essential public health services. The specific set of
interventions selected and implemented vary from community to community, from
population to population, from problem to problem, and from department to depart-
ment. Public health nurses often address the essential services as part of a team with
members from other public health disciplines and other community partners. Schoon
et al. (2019) provide a detailed description of core functions and the 10 essential pub-
lic health services, with application to public health nursing practice (pp. 151-153).

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Using the public health intervention framework
In general, the intervention framework provides a reasoned, systematic approach to
practice:

 Use an intervention’s basic steps to most effectively use time.
 Use interventions for problem solving when stuck or strategies are not going as

expected.
 Apply best practices for planning and evaluating public health nursing interven-

tions.

Specifically, one can use the Intervention Wheel to:

 Assure that all three levels of intervention are considered during program plan-
ning (that is, have interventions at the individual/family, community, and sys-
tems levels been considered?)

 Examine the scope of an agency’s practice (Do the programs delivered cover the
entire scope of practice? Are there certain interventions or levels that could be
added?)

 Describe public health nursing’s contributions to collaboration or coalition-
building

 Explain public health nursing to other disciplines and community members
 Orient new staff
 Build and enhance staff intervention skills
 Determine what changes to evaluate (health status or intermediate changes at

the individual/family, community, and systems levels) as a result of the inter-
vention

 Teach nursing students about public health nursing
 Select evidence to support effective public health nursing practice

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Overview of evidence-
based practice and related
topics
What is evidence-based practice?
Evidence-based practice is a problem-solving approach used by health professionals
to make clinical decisions (Dang & Dearholt, 2018). Evidence-based practice involves
reviewing the best available research evidence (randomized controlled trials, quasi-
experimental studies, and non-experimental studies) and non-research evidence
(clinical practice guidelines, position statements, literature reviews, quality improve-
ment and evaluation data, case reports, and expert opinion) in order to determine
the most effective interventions for improving client outcomes.

Why is evidence-based practice important to
public health nurses?
Evidence-based practice is important to PHNs because it is more likely to contribute to:

 Improved population health
 Intended outcomes
 Effective guidelines and protocols

When do public health nurses use evidence-
based practice?
Public health nurses use evidence to inform selection of recommended interventions
as they collaborate with individuals/families, communities, systems, and other
professionals.

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What are the levels of evidence that inform
evidence-based practice?
Based on the Johns Hopkins Nursing Evidence-Based Practice Model, evidence is cat-
egorized into five levels based on rigor (Table 1). Level 1 represents the highest level
of evidence and level 5 represents the lowest level of evidence. Level 1 is more rigor-
ous than level 5.

Level 1 Experimental studies (randomized controlled trials); systematic re-
views of randomized controlled trials

Level 2 Studies with quasi-experimental designs; systematic reviews of mixed
randomized controlled trials and quasi-experimental studies or only
quasi-experimental studies; includes pretest-posttest evaluations

Level 3 Studies with non-experimental designs; includes qualitative studies
and surveys; systematic reviews of non-experimental studies that
may also include randomized controlled trials and quasi-
experimental studies

Level 4 Clinical practice guidelines; consensus panels; position statements

Level 5 Literature reviews; quality improvement evaluation; program eval-
uation; case reports; expert opinion

Table 1: Evidence levels, key features, and public health nursing
practice examples

Evidence level Key features Example

Level 1
(most rigorous)

Experimental study,
randomized
controlled trial

Systematic review
of randomized
controlled trials

Intervention
present

One variable
manipulated

Participants
randomized into
experimental and
control groups

Older adults who received home
visits had decreased difficulty and
dependence for meal preparation,
telephone use, shopping, and ordi-
nary housework (instrumental activ-
ities of daily living) when compared
with older adults who had usual
care (Li, Liebel, & Friedman, 2013).

Level 2

Quasi-experimental
study

Systematic review
of both randomized
controlled trials and
quasi-experimental
studies or only
quasi-experimental

Intervention
present

Lacks either
randomization of
participants or a
control group

School nurses collaborated with a
hospital and a school of nursing to
develop and implement an injury
prevention curriculum for helmet
safety in elementary schools. Stu-
dents from the intervention group
reported increased helmet use after
the intervention when compared
with the control group (Adams,
Drake, Dang, & Le-Hinds, 2014).

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Evidence level Key features Example

Level 3

Non-experimental

Systematic review
of studies in first
three levels

Qualitative study

Surveys

May contain
intervention

Lacks both
randomization of
participants and a
control group

In response to an online survey in
29 states, PHNs reported conduct-
ing ongoing surveillance for tuber-
culosis, vaccine preventable dis-
eases, sexually transmitted dis-
eases, pediculosis (lice), food borne
diseases, and elevated blood lead
levels in their communities
(Schaffer, Keller, & Reckinger,
2015).

Level 4

Clinical practice
guidelines

Expert panels

Position statements

Opinion of
respected
authorities or
national-level
expert panels based
on scientific
evidence

CDC offers guidelines for the han-
dling and storage of breast milk
(Centers for Disease Control and
Prevention, 2017).

Level 5
(least rigorous)

Literature or
integrative reviews

Quality
improvement

Program
evaluation*

Case reports

Expert opinion

Experiential
evidence of experts

Program evaluation of the Pregnant
and Parenting Team Program meas-
ured program effectiveness with
data on birth outcomes, active en-
rollment in school, delay of repeat
pregnancy, maternal-infant bonding
and attachment, use of community
resources, and infant growth and
development. Outcome data
showed progress toward goals in-
cluding improvements in birth out-
comes and school enrollment
(Schaffer, Goodhue, Stennes, &
Lanigan, 2012).

Source: Dang & Dearholt, 2018; Schoon, Porta, & Schaffer, 2019.

* A program evaluation could be level 2 or 3 if study design is consistent with criteria for
those levels.

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What are some terms and definitions related to
evidence level?
 Literature review: Summarizes published literature without systematic ap-

praisal of quality or strength (Dearholt & Dang, 2018, p. 149)
 Meta-analysis: Uses statistical methods to analyze the results of a group of in-

dividual quantitative research studies
 Meta-synthesis: Combines the results of a group of individual qualitative re-

search studies
 Qualitative studies: Collect data using words vs. statistical analysis. These stud-

ies have no randomization, no manipulation, and little control
 Quantitative studies: Collect data using numerical measures and statistical anal-

ysis; includes experimental, quasi-experimental, and non-experimental research
 Systematic review: Critical appraisal of research evidence

Where is evidence found?
Quality evidence resides in the following locations:

 Nursing and public health literature databases, such as CINAHL and PubMed
 Google Scholar (avoid general search engines like Google)
 Government organizations (e.g., Centers for Disease Control and Prevention)

Two online resources feature evidence-based findings and recommendations for
public health interventions:

 U.S. Department of Health and Human Services: The Community Guide
 McMaster University: Health Evidence

How is the quality of evidence determined?
Although determining the level of evidence is one way of measuring its rigor, PHNs
also need to consider the quality of the evidence for both research and non-research
evidence. For each evidence level, Johns Hopkins Nursing Evidence-Based Practice:
Model and Guidelines (3rd ed.) by Dang and Dearholt (2018) specifies criteria for
determining whether the evidence is high quality, good quality, or low quality with
major flaws.

What process does a public health nurse use to
evaluate evidence?
Dang and Dearholt (2018) describe the PET process, which involves three steps for
evaluation of evidence (Table 2). Although individual public health nurses can review
evidence for practice, a team approach is often used to review evidence and deter-
mine best practices.

https://www.thecommunityguide.org/

https://www.healthevidence.org/

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Table 2: PET process

Phase Actions Example

Practice
question

Examine the practice
concern

Develop the evidence-
based practice
question

Involve stakeholders,
leadership, and the
team in refining the
question

Public health nurses who provide health
teaching, counseling, and consultation at
a local senior center have noted the
absence of several regular attendees due
to reduced mobility from falls. The PHNs
on the team providing senior services
decide to assess the fall risk of seniors
who attend the clinic. Their practice
question is: What fall risk assessment
tool for older adults in the community is
accurate and convenient to use?

Evidence

Conduct a search for
the evidence

Appraise the evidence

Summarize individual
evidence

Synthesize strength
and quality of
available evidence

Develop
recommendations for
practice change

The team consults with the state health
department and the local community
hospital to determine if guidelines for fall
risk assessment exist. They collaborate
with a local school of nursing to conduct
a search for evidence-based fall risk
assessments and appraise evidence for
level and quality.

Translation

Determine if
suggested practice
changes are feasible,
appropriate, and a
good fit

Create action plan

Implement and
evaluate the change

Disseminate findings

The team meets to determine which fall
risk assessment tool would best meet
their needs for assessing older adults in
the community based on the available
evidence. They create a plan for
implementing the fall risk assessment at
the senior center. After implementing
the plan, the team evaluates changes
that clients made in their home
environments and mobility practices
following participating in fall risk
assessment and education. The PHNs
present their findings at a local public
health nursing conference.

Note: Refer to Dang and Dearholt (2018) for a more complete explanation of each of
the three evidence-based practice (EBP) phases, tools useful for guiding EBP, how to
create an EBP-friendly organizational environment, and EBP examples.

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References
Foreword
Wald, L. (1915). The house on Henry Street. New York, NY: Henry Holt.

Introduction
Anderson, L. J. W., Schaffer, M. A., Hiltz, C., O’Leary, S. A., Luehr, R. E., & Yoney, E. L. (2017). Public

health interventions: School nurse practice stories. The Journal of School Nursing, 34(3),
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Baisch, M. J. (2012). A systematic method to document population-level nursing interventions in
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Bekemeier, B., Zahner, S. J., Kulbok, P., Merrill, J., & Kub, J. (2016). Assuring a strong foundation
for our nation’s public health systems. Nursing Outlook, 64, 557-565.
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Bigbee, J.L & Issel, L. M. (2012). Conceptual models for population-focused public health nursing
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Dang, D. & Dearholt, S. L. (2018). Johns Hopkins nursing evidence-based practice: Model and
guidelines, 3rd ed. Indianapolis, IN: Sigma Theta Tau International.

Depke, J. L. & Onitilo, A. A. (2011). Coalition building and the Intervention Wheel to address breast
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Katz, R., Attal-Juncqua, A., & Fischer, J. E. (2017). Funding public health emergency preparedness
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Keller, L. O., Strohschein, S., & Schaffer, M. A. (2011). Cornerstones of public health nursing. Public
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Leahy-Warren, P., Day, M. R., Philpott, L., Glavin, K., Gjevjon, E. R., Myhren, A. K., et al. (2018). A
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McDonald, A., Frazer, K., Duignan, C., Healy, M., Irving, A., Marteinsson, P., et al. (2011). Validating
the ‘Intervention Wheel’ in the context of Irish public health nursing. British Journal of
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Minnesota Department of Health. (2001). Public health interventions: Applications for public
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Reilly, J. R., Collier, J., & Edelstein, J. (2011). Collaborative design and use of an agency feedback
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Schaffer, M. A., Anderson, L. J. W., & Rising, S. (2016). Public health interventions for school
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Schaffer, M. A., Kalfoss, M., &Glavin, K. (2017). Public health nursing interventions to promote
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Schoon, P. M., Porta, C. M., & Schaffer, M. A. (2019). Population-based public health clinical
manual: The Henry Street model for nurses, 3nd ed. Indianapolis, IN: Sigma Theta Tau
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Overview of evidence-based practice and related topics
Adams, C., Drake, D., Dang, M., & Le-Hinds, N. (2014). Optimization of injury prevention outreach

for helmet safety. Journal of Trauma Nursing, 21, 133-138.
doi:10.1097/JTN.0000000000000047

Centers for Disease Control and Prevention (CDC). (2017). Proper handling and storage of human
milk. Retrieved from
https://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm

Dang, D. & Dearholt, S. L. (2018). Johns Hopkins nursing evidence-based practice: Model and
guidelines, 3rd ed. Indianapolis, IN: Sigma Theta Tau International.

Li, Y., Liebel, D. V., & Friedman, B. (2013). An investigation into which individual instrumental
activities of daily living are affected by home visiting nurse intervention. Age and
Ageing, 42, 27-33. doi: 10.1093/ageing/afs151.

McMaster University. (n.d.). Health evidence. Retrieved from https://www.healthevidence.org/

Schaffer, M. A., Goodhue, A., Stennes, K., & Lanigan, C. (2012). Evaluation of a public health nurse
visiting program for pregnant and parenting teens. Public Health Nursing, 29(3), 318-231.

Schaffer, M. A., Keller, L. O., & Reckinger, D. (2015). Public health activities: Visible or invisible?
Public Health Nursing, 32(6), 711-720. doi: 10.1111/phn.12191

Schoon, P. M., Porta, C. M., & Schaffer, M. A. (2019). Population-based public health clinical
manual: The Henry Street model for nurses, 3rd ed. Indianapolis, IN: Sigma Theta Tau
International Society of Nursing.

U.S. Department of Health and Human Services. (n.d.). The Guide to Community Preventive
Services (The Community Guide). Retrieved from https://www.thecommunityguide.org/

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Surveillance
Surveillance is “an ongoing, systematic collection, analysis and interpretation of
health-related data essential to the planning, implementation, and evaluation of pub-
lic health practice” (World Health Organization, 2018).

Historically, nurses collected data and used statistics to improve health outcomes.
Florence Nightingale collected and analyzed data on preventable deaths in the mili-
tary in the 19th century to inform professional standards of care. In the early 20th cen-
tury, Lillian Wald partnered with the Metropolitan Life Insurance Company to involve
nurses in data collection for a study on mortality from tuberculosis (Earl, 2009).

Practice-level examples
Population of interest: Entire population with special attention to pregnant women,
elderly, immunocompromised, those with chronic illnesses, and infants less than six
months of age.

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Problem: Seasonal influenza, which can be fatal. The incidence of influenza was ele-
vated across the United States during the 2017-18 season. The Centers for Disease
Control and Prevention (2018) surveillance data for one week in February 2018 indi-
cated the proportion of outpatient visits for influenza-like illness was 6.4 percent
(compared with a national rate of 2.2 percent during the same week in 2017), and 13
pediatric deaths occurred.

Systems level
Local and state public health departments routinely collect data from outpatient and
hospital laboratories to detect the influenza virus. Facilities with people in close prox-
imity to one another, such as long-term care facilities and schools, report when their
residents or students report flu-like symptoms above a certain rate. Public health
nurses (PHNs) assigned to communicable disease control programs in local and state
health departments monitor this information for evidence of outbreaks, which would
indicate a need for increased dissemination of information on prevention to the public.

Community level
Nurses in Ontario staffed a telephone health helpline to recruit and monitor partici-
pants with influenza-like symptoms. Participants obtained a nasal specimen through
self-swabbing and submitted it for testing and laboratory confirmation. An evaluation
study demonstrated that self-swabbing was a practical strategy for collecting surveil-
lance data on the influenza virus and results were similar to other surveillance sys-
tems in practice (McGolrick et al., 2016).

Individual/family level (case-finding)
Public health nurses routinely inquire about flu-like symptoms with the individuals,
families, and groups, and colleagues with whom they work. During staff meetings,
PHNs report and monitor flu activity in the area.

Relationship with other interventions
Surveillance focuses on significant health threats like contagious diseases, as well as
health events such as chronic diseases, injury, and violence. Similar to disease and
health event investigation, surveillance collects and analyzes health data. Unlike in-
vestigating diseases and other health events, however, surveillance is an ongoing pro-
cess, which detects trends and seeks to identify changes in the incidence (that is, the
occurrence of new cases over a set period of time) and prevalence (that is, the com-
bined number of old and new cases at any one point in time). Many texts treat sur-
veillance and disease and health event investigation as a single intervention.

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Surveillance is often confused with monitoring and/or screening. It is important to
differentiate:

 Surveillance assesses population health status before and after health events,
looks at whole populations, measures the population health status, and may
serve as the method to track cases

 Monitoring implies a constant adjustment of practice and looks at specific
groups or individuals

 Screening detects previously unknown cases in a population and may serve as
the method to find cases

Purposes of surveillance include:

 Serves as an early warning system to identify public health emergencies
 Guides public health policies and strategies
 Documents impact of intervention in meeting public health goals
 Helps to understand the epidemiology of a health problem in order to set prior-

ities (World Health Organization, 2018)

Basic steps
The following steps are adapted and synthesized from a number of sources (Hopkins,
2005; Klingler et al., 2017; Lee, Montgomery, Marx, Olmsted, & Scheckler, 2007; Lee,
Teutsch, Thacker, & St. Louis, 2010; Merrill, 2017):

1. Consider whether surveillance is appropriate
Since surveillance uses personnel, time, and financial resources, identify the problem
and the need for surveillance data.

 What threat does the problem pose for population health?
 To what extent is information known about the problem, its causal factors, pat-

terns of occurrence, and populations at risk?
 Is baseline data established, which is needed for comparison? Is the available

data adequate?
 Is the problem preventable?
 What are the resources required to successfully facilitate planning?

2. Acquire necessary knowledge of the problem
Acquiring knowledge about factors that contribute to a health problem and the con-
sequences of that health problem helps determine the priority for developing a sur-
veillance system.

Understanding a problem’s “natural course of history,” the course that the condition
would predictably take if nothing were done to intercede, will provide information
about the severity of the problem and guide selection of strategies to address the
problem. For example, progressive pulmonary tuberculosis kills 50 percent of those

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infected within five years if left untreated. Dental caries continue to decay without
treatment. Children with amblyopia, without treatment, eventually lose vision in the
affected eye.

3. Establish criteria for what constitutes a “case”
Establish clear criteria to increase the accuracy of identifying a case:

 Criteria include person, place, and time (that is, who is at risk, where the event
occurs, and when it occurs).

 Consider available clinical and laboratory diagnostic information.

4. Collect data from multiple sources
Aim to collect sufficient and reliable data. The use of existing data sets reduces the
expenditure of resources needed for surveillance.

 Consider readily available data such as vital records, hospital discharge and
emergency room visit data, medical management information and billing sys-
tems, local public health data, police records, and school records.

 Check existing registries and surveys for data regarding the population of interest.
 Consult community partners for insights on relationships of health determinants.
 Add insights from available qualitative data.

5. Maintain ethical standards
Assure confidentiality and protection of privacy. Remove personal information from
data.

Ethical infringements in the surveillance process may contribute to harm and reduce
the meaning and value of the data.

Ethical issues identified in a systematic qualitative review of ethical issues in public
health surveillance include:

 Background conditions related to a lack of or inappropriate guiding frameworks
for making judgments on surveillance systems

 Design and implementation issues regarding conflicts about priority setting for
choice of surveillance system or poorly designed systems that do not consider
contextual factors that influence surveillance

 Data collection and analysis privacy breaches, and consideration of informed
consent

 Concerns about use of data, including privacy protection when data is shared
outside the surveillance system, and the possibility of harm through stigmatiza-
tion or discrimination in the dissemination of sensitive data

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6. Analyze data
Use appropriate scientific and epidemiological principles. The level of analysis re-
quired varies from condition to condition.

Analyze data systematically to provide meaningful information for making decisions.

In general, analyses include such elements as:

 An assessment of the crude number of cases (that is, the number of actual cases)
and rates (the number of cases per a given denominator, such as 100 persons,
or 10,000 or 100,000)

 A description of the population in which the condition occurs (e.g., age, gender,
race, and ethnicity)

 Where the condition occurs
 Time period over which the condition occurs

7. Effectively interpret and disseminate data
Interpret and disseminate data so decision-makers at all levels readily identify and
understand the implications.

Target users and communicate in a timely way:

 Develop dissemination plans that fit intended data users.
 The communication of “data” can take many forms to reach intended users.

Data is often disseminated in the form of specific numbers. Graphs, tables, and
visuals enhance understanding of the data. Communicate data through stories
of clients’ experiences, using a qualitative approach.

 Disseminate the information on a regular basis, not just during times of crisis.

8. Evaluate impact of the surveillance system
Evaluating the surveillance system helps refine and improve the system for future use.

 Was the data collected sufficient to support accurate analysis?
 Did it generate answers to problems?
 Was the information timely?
 Have decisions been made to take action in response to information from the

surveillance?
 Was it useful to those interested?
 How was the information used?
 How can it be made more useful?
 Will the information be used in the future?

Example
Nurses in Ontario, Canada staffed a telephone health helpline to recruit and monitor
participants with influenza-like symptoms (McGolrick et al., 2016).

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1. Consider whether surveillance is appropriate
A telephone health helpline combined with nasal self-swabbing is a surveillance strat-
egy for early detection of influenza viruses. Clients do not have to go to a clinic for
data collection; they receive a self-swabbing package and return it by mail.

2. Acquire necessary knowledge of the problem
“Influenza viruses circulate worldwide and affect people of all ages causing significant
morbidity and mortality annually” (McGolrick et al., 2016, p. 2). Influenza is transmit-
ted through respiratory droplets released into the air from coughing, sneezing, or
talking, which are then inhaled or ingested. Influenza viruses can also spread indi-
rectly through contaminated hands or surfaces. Symptoms include sudden onset of
high fever, runny nose, cough, headache, exhaustion, malaise, and inflammation of
the upper respiratory tract. Many people who are infected experience mild symp-
toms, but severe infection can lead to death.

3. Establish criteria for what constitutes a “case”
Callers to the telephone health helpline are recruited to receive a self-swabbing
packet if: 1) they meet the categories of referral or self-care, and 2) they are at least
2 years old and experiencing one or more symptoms (fever, cough, runny nose, or
sore throat). Cases of influenza are confirmed by laboratory testing.

4. Collect data from multiple sources
Over one year, 87 specimens out of 664 test positive for influenza. The telephone
health helpline measures a 13.1 percent positivity rate, compared to 13.7 percent
from FluWatch, Canada’s national surveillance system that monitors the spread of flu
and flu-like illnesses in the same area and time period.

5. Maintain ethical standards
Although effective as a surveillance strategy, a delay in receiving a test result could
lead to a delay in treatment. Providing education about self-care and when to seek
medical help can reduce potential harm.

“A laboratory diagnosis promotes the rational use of antiviral agents and discourages
the inappropriate prescription of antibiotics, which could in turn potentially reduce
inappropriate treatment of influenza-like illness in up to 50 percent of cases”
(McGolrick et al., 2016, p. 8).

Self-swabbing through the telephone health helpline provides a potential benefit by
reducing visits to clinics and emergency departments, which may reduce viral trans-
mission in the community.

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6. Analyze data
Two datasets [are] used for the self-swabbing study, one with the raw
number of cases by week and another with an adjusted number of cases
by week accounting for the increase in the number of nurses . . .
recruiting participants at that time. (McGolrick et al., 2016, p. 4)

7. Effectively interpret and disseminate data
The implementation of a self-swabbing surveillance system provides an
opportunity for public health authorities to generate diagnostic information
that can be relayed to physicians. Further, this diagnostic information will
aid in the practice of antimicrobial stewardship, which is an ongoing issue
especially as it pertains to the inappropriate prescription of antimicrobials
for the treatment of viral infections. (McGolrick et al., 2016, p. 8)

8. Evaluate the impact of the surveillance system
Based on comparisons with other influenza virus surveillance systems, telephone
health helpline self-swabbing surveillance “has significant potential as an adjunct tool
for the surveillance of influenza viruses in Ontario” (McGolrick et al., 2016, p. 1).

Key points from evidence
For a description of evidence levels, visit: Introduction: Overview of evidence-based
practice and related topics.

 1. Surveillance as a nursing intervention
Surveillance is an intervention in nursing classification systems and nursing literature:

 Nursing Interventions
Classification (NIC)

 Nursing Minimum Data Set
(NMDS)

 Omaha System

 Public Health Intervention Wheel
 Public health surge events and

bioterrorism preparedness
 Infection control practices in

disaster management

Level 3 sources:

 Akins, Williams, Silenas, & Edwards, 2005
 Monsen et al., 2013
 Polivka et al., 2008

Level 5 sources:

 Schoneman, 2002
 Vane, Winthrop, & Martinez, 2010

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 2. Types of surveillance
Surveillance systems are passive, active, sentinel, or special.

 Passive: Health care providers send case reports to the local health department.
 Active: The PHN or other health department employee searches for cases by

contacting local health care providers and agencies.
 Sentinel: Trends in commonly occurring diseases and health problems are

monitored.
 Special: A system to collect specific information is established; for example, de-

termining links between disease agents and terrorist attacks.

Level 5 source:

 Stanhope & Lancaster, 2016

 3. Criteria for surveillance
Criteria for identifying high-priority health events for surveillance include:

 Frequency of event: Incidence, prevalence, mortality
 Severity of event: Case fatality ratio, hospitalization rate, disability rate, years of

potential life years lost
 Cost
 Preventability
 Communicability
 Public interest

Level 5 source:

 Lee et al., 2010

 4. Characteristics of surveillance
Characteristics of effective surveillance:

 Acceptability
 Flexibility
 Positive predictive value

(proportion of true cases)
 Quality
 Representativeness

 Sensitivity
 Simplicity
 Stability
 Timeliness
 Validity (measuring what is

supposed to be measured)

Level 5 source:

 Centers for Disease Control and Prevention, 2012

 5. Surveillance in conjunction with other systems
Surveillance is most effective when done in conjunction with other systems in the
community. Advantages:

 Access to other data sets
 The potential to design coordinated data collection systems among the partners

from the start of a process

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 The potential for shared technological capacity
 The opportunity for discussion with collaborators about measures or indicators

to collect

Level 5 sources:

 Baisch, 2012
 Friedman & Parrish, 2010
 Oliver, 2010

 6. Surveillance examples from the literature
There are many examples of public health surveillance systems in the literature and
their use to identify public health interventions:

 The District of Columbia Department of Health Environmental Public Health
Tracking Network used climate change and health data to assess vulnerabilities
and disease burden associated with heat, air quality, and hospitalizations for
asthma and acute myocardial infarction.

 The Omaha System, which collects clinical data, identified unmet needs in six
problem areas for the children with special needs population, demonstrating
feasibility for use in program evaluation, case management, and surveillance.

 Local health departments used telephone-based surveillance to identify cases of
disease.

 An analysis of electronic health records contributed to estimating childhood
obesity rates and highlighting the need for early intervention for at-risk children.

 A web-based surveillance system for hepatitis C increased the timeliness of
reporting.

 Immunization registries, confidential population-based information systems that
contain information about immunizations of a population in a geographic area,
can be used to support clinical decision-making and improve the quality of care.

 The effect of alcohol sales restrictions in convenience stores on intentional in-
jury-related ambulance pickups for 15- to 24-year-olds was analyzed through
geographic information system (GIS) spatial analysis of data from the U.S. Cen-
sus Bureau and community emergency medical services.

 The rate of participating schools increased in a statewide school-based asthma
surveillance program (using student health records) over a five-year period,
providing a clear picture of pediatric asthma across the state.

Level 2 sources:

 Heisey-Grove, Church, Haney, & DeMaria, Jr., 2011
 Masho, Bishop, Edmonds, & Farrell, 2014

Level 3 sources:

 Anderko, Davies-Cole, & Strunk, 2014
 Dausey et al., 2008
 Flood et al., 2015
 Medaglia, Knorr, Condon, & Charleston, 2013
 Monsen et al., 2013

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Level 5 sources:

 Baisch, 2012
 Hinman & Ross, 2010

 7. Web-based surveillance advantages and disadvantages
Emerging web-based surveillance systems have advantages and disadvantages:

 They are intuitive, adaptable, low-cost, and operate in real time.
 There is the possibility of inaccurate interpretation and prediction of health sta-

tus, stemming from an individual’s internet activity.
 There may be privacy issues.

Level 3 sources:

 Choi, Cho, Shim, & Woo, 2016
 Klingler, 2017

 8. Using surveillance for influenza
Influenza surveillance using telephone triage and electronic syndromic surveillance
(near real-time data collection) in the Department of Veterans Affairs correlated
strongly with Centers for Disease Control and Prevention data for weekly influenza
hospitalizations, influenza tests performed, and positive influenza tests. Nurses used
protocols and clinical software to systematically assess clients’ chief complaints,
symptoms, and medical history.

Level 3 source:

 Lucero-Obusan, Winston, Schirmer, Oda, & Holodniy, 2017

 9. Developments in surveillance
Developments in population health surveillance initiatives include:

 Mental health measures are now included in national level surveillance surveys.
Collecting data on resilience, coping skills, protective factors, cultural factors, and
positive mental health aspects provides information for disease prevention and
mental health promotion strategies. Challenges to surveillance of mental health
include variable and non-specific measures, differences in time periods, variability
in including substance abuse, and different methods of data collection.

 The population health record documents health status and influences on health
for a defined population. In addition to monitoring population health status and
outcomes, other uses include conducting community health assessments, iden-
tifying population health disparities, and designing public health interventions,
programs, and policies.

 Social media was used to conduct participatory surveillance of diabetes device
safety. Surveys collected information on participants’ experience with blood glu-
cose monitors, continuous glucose monitors, and insulin delivery devices.

 Population health rankings based on current health outcome data (e.g., prema-
ture death, self-reported health, birth outcomes, clinical care, and health behav-
iors) are used for community assessment, setting agendas to improve health

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outcomes, and establishing a broader responsibility for population health
through multi-sectoral collaboration.

 A narrative review found 23 articles on the use of electronic health records for
population health surveillance. Challenges included incomplete population cov-
erage, inability to link data systems, and variations in data quality.

Level 3 sources:

 Mandl et al., 2014
 Rohan, Booske, & Remington, 2009

Level 5 sources:

 Freeman et al., 2010
 Friedman & Parrish, 2010
 Oliver, 2010
 Paul et al., 2015

 10. Increasing data accuracy and usefulness with surveys
Strategies for increasing the accuracy and usefulness of data on health behaviors ob-
tained from surveys:

 Conduct pilot surveys before full implementation.
 Put systems in place for quality assurance and control.
 For nonresponse, consider incentives and pre-notification.
 For better coverage of a population, consider multimode collection.
 For better coverage of younger age groups, consider use of cellular telephones.
 For language barriers, employ bilingual interviewers.
 With limited space for questions, consider rotating surveys.
 For reducing cost, consider multimode data collection, e.g., internet-based sur-

veys with a smaller number of household surveys.

Level 5 source:

 Mokdad & Remington, 2010

Wheel notes

Epidemiology
Public health nurses use the science of epidemiology to conduct surveillance.

Epidemiology is:

[The] study of the occurrence and distribution of health-related states or
events in specified populations, including the study of the determinants
influencing such states, and the application of this knowledge to control
the health problems (Porta, 2008, p. 120).

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Public health nurses use epidemiological theory to find answers and solutions. Epide-
miology as a systematic process guides the search for contributing factors, data col-
lection, and monitoring of health and illness events (Frayham & Anderko, 2009;
Schoon, Porta, & Schaffer, 2018).

Innovations
Geographic information systems (GIS) increase the capacity for data collection in sur-
veillance. GIS refers to computer-based tools that store, visualize, analyze, and inter-
pret geographic data. Using GIS helps answer data-related questions (Centers for Dis-
ease Control and Prevention, 2016). For example, using GIS to examine preterm birth
rates in specific census tracks in Philadelphia, PHNs analyzed the data to better un-
derstand the environments of mothers and families and identify interventions for ge-
ographical areas with the highest risk for preterm birth (Block, 2011). The Centers for
Disease Control and Prevention (CDC) offers data sets and training modules for using
and interpreting GIS generated data: GIS and Public Health at CDC (Centers for Dis-
ease Control and Prevention, 2016).

PHNs increasingly use electronic health records for surveillance. Electronic health rec-
ords needs to be compatible with other systems (across health departments and
other health systems) in order to aggregate data. The Public Health Data Standards
Consortium (2019) established recommendations for collecting data through elec-
tronic health records.

Resources
The Centers for Disease Control and Prevention established the Surveillance Resource
Center, which provides access to information and tools for conducting surveillance:
interactive database systems; methods; legal, ethical, and policy issues; and tools and
templates. A few examples:

 Asthma: Data, statistics, and surveillance: Asthma surveillance data
 Behavioral Risk Factor Surveillance System
 Foodborne Diseases Active Surveillance Network (FoodNet)
 National Environmental Public Health Tracking Network
 Breastfeeding: Maternity care practices: CDC mPINC (Maternity Practices in In-

fant Nutrition and Care) Survey
 Adolescent and school health: SHPPS (the School Health Policies and Practices

Study)
 Tuberculosis: Data and statistics

https://www.cdc.gov/gis/

https://www.cdc.gov/surveillancepractice/

https://www.cdc.gov/asthma/asthmadata.htm

https://www.cdc.gov/BRFSS/

https://www.cdc.gov/foodnet/index.html

https://ephtracking.cdc.gov/

https://www.cdc.gov/breastfeeding/data/mpinc/

https://www.cdc.gov/healthyyouth/data/shpps/

https://www.cdc.gov/tb/statistics/

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Disease and health event
investigation
Disease and health event investigation systematically gathers and analyzes data re-
garding threats to the health of populations, ascertains the source of the threat, iden-
tifies cases and others at risk, and determines control measures.

Examples of “threats to health” include actual or potential acts of bioterrorism and
chemical or other hazardous waste spills. Natural disasters such as tornadoes, floods,
hurricanes, earthquakes, and extreme heat or cold inherently create opportunities for
disease and health event investigation. While investigation traditionally focuses on con-
tagious diseases, it also focuses on chronic diseases, injury, and other health events.

The investigative process consists of identifying and verifying the source of the threat;
identifying cases, their contacts, and others at risk; determining control measures;
and communicating with the public as needed. Not all health events are preventable.
Natural disasters cannot be prevented, but planned public health responses can re-
duce the severity of their impact via preventive measures that mitigate or reduce the
severity of effects.

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Practice-level examples
Population of interest: Women of childbearing age and their partners living or trav-
eling in tropical climates.

Problem: The Zika virus is transmitted to people through a bite from an infected mos-
quito (Aedes genus) in tropic and sub-tropic geographical areas. The virus can be
transmitted person to person via sexual intercourse, perinatal transfer, and blood
transfusion. Congenital Zika is associated with brain abnormalities, including micro-
cephaly (Karwowski et al., 2016).

Systems level
The National Association of County and City Health Officials (2018a) conducted a sur-
vey on maternal child health capacity to respond to the Zika virus. Local health de-
partments in ten priority states (Alabama, Arizona, California, Florida, Georgia, Ha-
waii, Louisiana, Mississippi, New York, and Texas) participated in the survey. Local
health departments provided the following prevention and response actions: infor-
mation to travelers (94 percent), outreach and communication to clinicians (90 per-
cent), lab testing (83 percent), maternal child health surveillance (72 percent), and
rapid detection and follow-up of birth defects (47 percent). The lab results provided
a picture of the burden of disease (total effect of a disease on a community) useful
for planning an adequate response.

Community level
A local health department aimed to communicate the risk of transmission of the dis-
ease from mosquitoes and recommended mosquito control strategies. The local
health department gathered information from the Centers for Disease Control and
Prevention (CDC, 2018) and communicated information with other providers in the
community to create public awareness about transmission of disease from mosqui-
toes. The local health department shared information concerning mosquito surveil-
lance; removing areas of stagnant water where mosquitoes lay eggs; control of lar-
vae, pupae and adult mosquitoes; and many resources that provide instructions on
mosquito control strategies.

Individual/family level (case-finding)
When providing services to women of childbearing age, public health nurses (PHNs)
inquire about symptoms of infection in women and their partners and history of
travel or residence in environments with infected mosquitoes present. Recommend-
ing testing for Zika infection contributes to identifying and reporting possible out-
breaks, which can lead to implementing control measures.

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Relationship with other interventions
Disease and health event investigation is frequently paired with surveillance; these two
interventions are often discussed as a single process. However, investigation stands
alone when broadly applied as data gathering or “fact-finding” methodology. Surveil-
lance looks ahead for expected events; investigation responds to an unexpected event.
Investigation frequently leads to case-finding and referral and follow-up.

Basic steps
The following steps are adapted from several sources (Bisen & Raghuvanshi, 2013;
Centers for Disease Control and Prevention, 2015; Stanhope, 2016):

1. Identify investigation team and resources
All information and activities related to the investigation need to go through the in-
vestigation team to reduce any confusion about responsibilities.

 Investigating teams should be sent as early as possible to the area where the
disease or health threat is reported. Several factors determine the size and com-
position of the investigating team, including the size of the affected area, terrain
and accessibility, and population density.

 Local health departments and state health departments may have staff who
have expertise in investigation of specific outbreaks of disease or other health
events (e.g., communicable disease, chronic disease, injuries). Public health
nurses may serve on the team if the investigation goal is consistent with their
role and responsibilities.

 Public health nurses also may be on the front lines in their interactions with in-
dividuals and communities where early signs of a disease or other health event
occurs.

2. Confirm the existence of the disease or threat
Before expending resources on investigating the disease or health threat, verify the
initial report.

Information about the disease or health threat can be obtained from active, passive,
sentinel, and special surveillance reports (see: Surveillance: Key points from evi-
dence: 2. Types of surveillance); reports from health facilities; media reports; and re-
ports originating from the community. Information should be collected from all pos-
sible sources and verified.

3. Verify the diagnosis/define a case
Defining what constitutes a case makes it possible to obtain numerical data about the
extent of the disease or health threat.

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“A case is a person in a population who has been identified as having a particular
disease, disorder, injury, or condition” (Merrill, 2017, p. 7). A case may be categorized
as suspect, probable, or confirmed. A case may need to be confirmed by laboratory
testing of blood or other body fluid.

A case definition identifies:

 Illness features or condition characteristics
 Agent if known
 Typical symptoms for illness or condition
 Time range of illness or condition
 Geographic range
 Other criteria specific to agent, e.g., DNA fingerprint of pathogen

4. Estimate the number of cases
Estimate of the number of cases in a population to inform response plan.

Cases are generally reported as a percentage or proportion of the population. The
following terms are used to describe the occurrence of disease or health problems in
a population and are reported as rates (e.g., number of cases per 10,000 people).

 Incidence: Number of new cases in a population in a given period of time
 Prevalence: “Proportion of a population who have a specific characteristic in a

given time period” (National Institutes of Mental Health, 2017)
 Mortality: Number of deaths in a population
 Morbidity: Number of people ill in a population

5. Collect data including persons, place, time, lab
results, and relevant records or reports
Collecting specific data determines the “who, what, when, and where” of the disease
or health threat.

Using a specific data collection form organizes data from laboratory reports, medical
records, client charts, and information provided by health providers, agencies, and
others in the community. Possible relevant variables for data collection are age, sex,
underlying disease, geographical location, and possible exposure sites. Additional
data collection strategies may include direct observation, interviewing cases, per-
forming physical assessment, and collecting specimens.

Questions to ask include:

Person

 Who and how many are affected?
 Who else might be affected?
 Is there a connection between the people affected and their age, sex, race, and

socioeconomic status?

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Place

 Does it matter where people live or work?
 Are the cases limited to a certain area or widely dispersed?
 Does the area naturally harbor certain disease agents?

Time

 Does the time of day or association with a specific event, such as weather con-
ditions, appear to make a difference?

6. Develop and evaluate a hypothesis
A hypothesis explains the why and how disease or heath events occur and guides the
investigation.

 Formulate a working hypothesis based on signs and symptoms of the disease or
health event. The hypothesis may be modified as the investigation reveals fur-
ther details about transmission or development of the disease or health event.

 Test the working hypothesis through data analysis, using statistics. Two exam-
ples of data analysis are spot maps and the epidemic curve. A spot map identifies
the geographic locations of people who have the disease, health problem, or
characteristic. An epidemic curve illustrates in graph form how cases are distrib-
uted by time of onset, revealing any time clusters in the epidemic.

 When a large proportion of a population or community is affected at the same
time by the same disease or health event, it is called an epidemic. For example,
an increase in mortality from opioid use in the late 2010s (referred to as an opi-
oid crisis) is considered an epidemic.

 Consider the accuracy of the conclusion resulting from the data. Strategies to
improve data accuracy:
▪ Comparing reports from previous similar investigation
▪ Collaboration with others involved in the investigation
▪ Sharing and comparing data
▪ Collecting secondary data (reviewing data collected by others) to confirm

suspicion/conclusion

7. Institute control measures and communicate
findings
Control measures reduce incidence and negative effects of disease and health events.
Disseminate evidence of effective strategies to prevent and/or reduce development
of disease and negative health events.

 Assure that identified cases receive needed treatment, implement measures for
prophylaxis if effective, and provide education to identified cases and persons
with known exposure.

 Systems may institute control measures (health care agencies; city, state, and
federal government; public health departments). Epidemiological evidence on
the origin, spread, and development of the disease or health event determines
the use of control measures.

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 Instituting control measures often involves collaborating across organizations and
systems, including industry and business. For example, during a foodborne disease
outbreak, control measures may include recalls and facility improvements.

 Consider all levels of prevention needed to reduce the incidence and prevalence
of the disease or health threat: primary prevention (before the problem occurs),
secondary prevention (treatment very early in the problem), and tertiary pre-
vention (treatment and rehabilitation for consequences of disease or health
event). Provide referral and follow-up for anyone in need of treatment.

 Communicating findings occurs through many modalities (e.g., official reports,
media, internet, public service announcements). When crafting communication,
create messages that motivate behavior change for reducing risk transmis-
sion/development of the disease or health event but avoid language leading to
fear or panic.

8. Maintain surveillance
Capture the continuing trajectory of the disease or health event to inform continued
decision making about strategies and policies.

 The epidemic curve indicates the decline of the disease or health event. When
an outbreak appears to be over, public health officials continue surveillance for
a period to make sure additional cases do not occur.

 For many health events (e.g., injuries, gun violence, teen pregnancy, cardiovas-
cular disease, cancer, diabetes, and others), surveillance remains ongoing to de-
termine trends and whether control strategies have been effective.

 Evaluating effectiveness of the investigation includes determining the elimina-
tion or prevention of the problem or risk, resources required, areas for improv-
ing efficiency, and lessons learned for future investigations.

Example
A public health nursing supervisor of the maternal child health program in a local
health department joins a team assigned to follow up reports from a local hospital on
several cases that test positive for the Zika virus.

1. Identify investigation team and resources
The hospital asks the PHN to join the team because of her expertise with a public
health program that served pregnant women in the community. Others on the team
include an epidemiologist, a communications specialist, and a clerical staff member.

2. Confirm the existence of the disease or threat
The team first needs to identify whether other cases had occurred in nearby commu-
nities. The team consults with CDC on the most recent information available on the
spread of the Zika viruses.

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3. Verify the diagnosis/define a case
A positive lab test identifies a Zika case.

4. Estimate the number of cases
Estimates depend on location and presence of infected mosquitoes. The team must
also consider travel from areas known to have Zika virus infections.

5. Collect data including persons, place, time, lab
results, and relevant records or reports
The team uses a data collection form to record specific information needed for dis-
ease investigation. It reviews medical records, and records lab results, age, sex,
symptoms, geographic location (work and home), travel history, and sex partners.

6. Develop and evaluate a hypothesis
The team uses its expertise to create a spot map to identify the geographic locations
of people identified as cases and possible transmission patterns.

7. Institute control measures and communicate
findings
The team communicates findings to relevant government entities to initiate mos-
quito control measures, and communicates to the public ways to reduce risk of expo-
sure to the Zika virus. The team also educates cases about potential for sexual trans-
mission of virus, and initiates follow-up of pregnant women diagnosed with the Zika
virus or who have partners infected with the Zika virus to monitor pregnancy for pos-
sible birth defects.

8. Maintain surveillance
The team continues to evaluate incidence of Zika infections and whether Zika infec-
tion rates are diminishing, and monitors the environment for reduction of places
where mosquitoes lay eggs.

The National Association of County and City Health Officials (NACCHO) created a free
modifiable document, Zika Resources for Local Health Departments (2018b), with tem-
plates, toolkits, and resources provided by CDC, local health departments and other
partners for local health department adaptation in response to Zika virus infections.

http://eweb.naccho.org/eweb/DynamicPage.aspx?WebCode=proddetailadd&ivd_qty=1&ivd_prc_prd_key=786e6aab-8831-4169-8edd-a45832b85ce0&Action=Add&site=naccho&ObjectKeyFrom=1A83491A-9853-4C87-86A4-F7D95601C2E2&DoNotSave=yes&ParentObject=CentralizedOrderEntry&ParentDataObject=Invoice%20Detail

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Key points from evidence
For a description of evidence levels, visit: Introduction: Overview of evidence-based
practice and related topics.

 1. Considering subgroup characteristics
When conducting disease and health event investigation, it is important to consider
characteristics of different subgroups in order to determine the most effective treat-
ment and response. Examples of subgroups include race/ethnicity, age, gender, and
place (urban, suburban, or rural).

Level 3 sources:

 Aponte, 2009
 Gangeness, 2009

 2. Risk assessment tools
Risk assessment tools guide decision-making and actions across jurisdictions and lev-
els of government during the investigation process. Examples include the CDC Influ-
enza Risk Assessment Tool and the CDC Pandemic Severity Assessment Framework.

Level 4 source:

 Holloway, Rasmussen, Zaza, Cox, & Jernigan, 2014

 3. Recommendations for effective investigation
Focus groups with 28 expert enteric (foodborne disease) investigators resulted in rec-
ommendations for effective investigation:

Preparation

 Understand the pathogen’s epidemiology, transmission, and control measures.
 Review relevant demographic information (gender, age, residence).

Contacting cases

 Use voicemail and text messaging for specific demographic groups that do not
answer the phone.

Building rapport

 Promote comfort and relief of anxiety during the interview.
 Explain the purpose of the interview and assure confidentiality.
 Allow cases to tell their story.
 Be empathetic and respectful of differences (culture, religion, language).

Identifying the source

 Educate each case about pathogen and transmission.
 Use a calendar to help the case remember dates, activities, and events close to

onset of symptoms.
 Use questionnaires with common risk factors and questions to help with recall.

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Education

 Provide education about identified source to prevent further illness.
 Be sensitive, neutral, and non-judgmental when educating about high-risk be-

haviors, sexual behavior, and cultural practices.

Excluding from specific work environments

 If exclusion is required from working in food-related, health care, or childcare
settings, communicate the need for exclusion from work close to the end of the
interview to avoid loss of rapport.

Linking cases

 Communicate with enteric disease investigators, public health inspectors, epi-
demiologists, data entry staff, and with staff in other jurisdictions to link cases.

 Use spreadsheets and other software tools, a point person in the coordinator
role, and meetings of case investigators to link cases to a common source or
food venue.

Level 3 source:

 Ing, Lee, Middleton, Moore, & Sider, 2014

 4. Recommendations following an outbreak investigation
Following an investigation of an influenza outbreak (H1N1) in a First Nations commu-
nity in Manitoba, Canada researchers offered these recommendations for future out-
break prevention: daily surveillance for disease detection and monitoring; an effec-
tive communication strategy; and addressing health determinants (e.g., housing con-
ditions, potable water, and sanitation).

Level 3 source:

 Pollock, Sagan, Oakley, Fontaine, & Poffenroth, 2012

 5. Measures to control outbreaks
Measures to control an outbreak of E. coli infections resulting from exposure to con-
taminated pork products in Canada included “product recalls, destruction of pork
products, temporary food facility closures, targeted interventions to mitigate im-
proper pork handling practices, and prosecution of a food facility operator” (p. 1480).

Level 5 source:

 Honish et al., 2014

 6. Novel strategies for investigation
Novel strategies for investigation include:

 Review of restaurant reviews on Yelp by foodborne epidemiologists identified
three previously unreported food outbreaks.

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 Cluster survey methodology can be used for rapid assessment in humanitarian
emergencies. The area under assessment is divided into 30 clusters of a mini-
mum of 30 households. Then one household is randomly selected for interview
for each of the 30 clusters.

 Disease intervention specialists used smartphone technology to enhance tradi-
tional contact investigation of sexually transmitted diseases, increasing success-
ful partner notification and case-finding.

 DotMapper is an open source tool that quickly produces maps showing case lo-
cations and epidemiological characteristics. This tool can be used without
needed training in geographic information systems.

Level 3 sources:

 Harrison et al., 2014
 Pennise, Inscho, & Herpin, 2015

Level 5 sources:

 Morris & Nguyen, 2008
 Smith & Hayward, 2016

 7. Skills for outbreak investigation
Public health nurses have the skills needed for outbreak investigation: identifying an
outbreak, following the investigative process, and collaborating with the community
on a response.

Level 5 source:

 Sistrom & Hale, 2006

 8. School nurses and student immunizations
A quality improvement project was conducted in Vermont schools to provisionally
admit students without immunization documentation, aimed to reduce the number
of provisionally admitted students. Strategies used by school nurses included main-
taining an immunization tracking system for all students and using the Vermont Im-
munization Registry to locate missing immunization information for students. School
nurses in participating schools reported a decline in the number of provisionally ad-
mitted students over the course of the project.

Level 5 source:

 Davis, Varni, Barry, Frankowski, & Harder, 2016

 9. Efficacy of simulation
Simulation is an effective experiential strategy in teaching public health nursing stu-
dents to practice outbreak investigation skills.

Level 3 source:

 Alexander, Canclini, Fripp, & Fripp, 2017

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Wheel notes

Public health nurses identify health concerns
that need disease and health event investigation
Public health nurses may notice an increase in disease and other health events as
they interact with clients in communities. Public health nurses may alert the state or
county epidemiologist about the need for investigation and, in some agencies, PHNs
may also have a role on the investigative team. Public health nurses possess skills that
contribute to disease and health investigation initiatives, including their ability to
build rapport with clients, view clients holistically, and gain client trust for obtaining
relevant information.

Some examples of disease and health event investigation that PHNs may encounter
in their practice:

 Cancer
 Communicable diseases, e.g.,

tuberculosis, meningitis, giardia
 Exposure to hazards and toxins in

the environment
 Foodborne and waterborne

outbreaks
 Garbage houses
 Lead
 Lice and scabies

 Maltreatment of vulnerable
individuals

 Natural disasters, e.g., flooding,
hurricanes, tornadoes

 Rabies
 Sexually transmitted infection, e.g.,

gonorrhea, chlamydia, syphilis
 Suicide
 Vaccine-preventable disease, e.g.,

measles, pertussis

Non-infectious diseases and other health events
Although much of the literature that addresses disease and health event investigation
focuses on outbreaks of infectious disease, public health experts are also called on to
investigate increases in incidence of other threats to health. One example is investi-
gation of cancer clusters. A cancer cluster occurs when more cancer cases than ex-
pected occur in a group of people in a geographic area over a specific time. CDC offers
guidelines for investigating clusters of health events (Abrams, Anderson, &
Blackmore, 2013). The increasing incidence of gun violence is another example of a
health threat (Kennedy, 2016). A public health approach seeks to identify individuals
and communities at risk for gun violence, determine contributing factors, and design
strategies that reverse the normalization of gun violence (Butts, Roman, Bostwick, &
Porter, 2015).

Using disease and health event investigation to
resolve local health concerns
Implementing an investigation does not require a large and complex system if the
problem is not large and complex. For instance, in investigating why certain clients

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consistently missed clinic appointments, a PHN discovered that most of the clients
had addresses in the same neighborhood. With a little more investigation, the PHN
connected their missed appointments with the lack of availability of public transpor-
tation. This connection led to a different conclusion than “willful noncompliance,”
and a different resolution to the problem.

References
Abrams, B., Anderson, H., & Blackmore, C. (2013). Investigating suspected cancer clusters and

responding to community Concerns: Guidelines from CDC and the Council of State and
Territorial Epidemiologists. Morbidity and Mortality Weekly Report, 62(8), 1-26.

Alexander, G. K., Canclini, S. B., Fripp, J., & Fripp, W. (2017). Waterborne Disease Case
Investigation: Public Health Nursing Simulation. Journal of Nursing Education, 56(1), 39-
42. doi: 10.3928/01484834-20161219-08

Aponte, J. (2009). Diabetes-related risk factors across Hispanic subgroups in the Hispanic health
and nutritional examination survey (1982–1984). Public Health Nursing, 26(1), 23-38.
doi: 10.1111/j.1525-1446.2008.00741.x

Butts, J. A., Roman, C. G., Bostwick, L., & Porter, J. R. (2015). Cure violence: A public health model
to reduce gun violence. Annual Review of Public Health, 36, 39-53. doi:
10.1146/annurev-publhealth-031914-122509

Bisen, P. S. & Raghuvanshi, R. (2013). Emerging epidemics: Management and control. New Jersey:
John Wiley & Sons, Inc.

Centers for Disease Control and Prevention (2015). Multistate and Nationwide Foodborne
Outbreak Investigations: A step-by-step guide. Retrieved from
https://www.cdc.gov/foodsafety/outbreaks/investigating-
outbreaks/investigations/index.html

Centers for Disease Control and Prevention (2018). Integrated mosquito management. Retrieved
from https://www.cdc.gov/zika/vector/integrated_mosquito_management.html

Davis, W. S., Varni, S. E., Barry, S. E., Frankowski, B. L., & Harder, V. S. (2016). Increasing
immunization compliance by reducing provisional admittance. The Journal of School
Nursing, 32(4), 246-257. doi: 10.1177/1059840515622528

Gangeness, J. E. (2009). Rural women’s perceptions of availability, development, and maintenance
of rural built environments. Online Journal of Rural Nursing and Health Care, 9(2), 52-66.

Harrison, C., Jorder, M., Stern, H., Stavinsky, F., Reddy, V., Hanson, H., et al. (2014). Using online
reviews by restaurant patrons to identify unreported cases of foodborne illness—New
Yoark City, 2012-2013. Morbidity and Mortality Weekly Report, 63(20), 441-445.

Holloway, R., Rasmussen, S. A., Zaza, S., Cox, N. J., & Jernigan, D. B. (2014). Updated preparedness
and response framework for influenza pandemics. Morbidity and Mortality Weekly
Report, 63(RR06), 1-9.

Honish, L., Pumnja, N., Nunn, S., Nelson, D., Hislop, N., Gosselin, G., et al. (2014). Escherichia coli
O157:H7 infections associated with contaminated pork products – Alberta, Canada, July-
October 2014. (2017). Morbidity and Mortality Weekly Report, 65(52), 1477-1481.

Ing, S., Lee, C., Middleton, D., Moore, S., & Sider, D. (2014). A focus group study of enteric disease
case investigation: successful techniques utilized and barriers experienced from the
perspective of expert disease investigators. BMC Public Health, 14, doi: 10.1186/1471-
2458-14-1302

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Karwowski, M. P., Nelson, J. M., Staples, J. E., Fischer, M., Fleming-Dutra, K. M., Villanueva, J. E., et
al. (2016). Zika Virus Disease: A CDC Update for Pediatric Health Care Providers.
Pediatrics, 137(5).

Kennedy, M. S. (2016). Gun violence as a public health problem: When will our outrage lead to
action? American Journal of Nursing, 116(2), 7.

Merrill, R. M. (2017). Introduction to epidemiology. Burlington, MA: Jones & Bartlett Learning.

Morris, S. K. & Nguyen, C. K. (2008). A review of the cluster survey sampling method in
humanitarian emergencies. Public Health nursing, 25(4), 370-374. doi: 10.111/j.1525-
1146.2008.00719.x

National Association of County and City Health Officials (NACCHO). (2018a). Maternal child health
capacity for Zika response. Retrieved from
https://www.naccho.org/uploads/downloadable-resources/FINAL-MCH-Zika-Report

National Association of County and City Health Officials (NACCHO). (2018b). Zika resources for
local health departments. Retrieved from
http://eweb.naccho.org/eweb/DynamicPage.aspx?Site=naccho&WebKey=504423cd-
4faf-4204-82f7-c9eb659af65c

National Institutes of Mental Health. (2017). What is prevalence? Retrieved from
https://www.nimh.nih.gov/health/statistics/what-is-prevalence.shtml

Pennise, M., Inscho, R., & Herpin, M. (2015). Using smartphone apps in STD interviews to find
sexual partners. Public Health Reports, 30, 245-252.

Pollock, S. L., Sagan, M., Oakley, L., Fontaine, J., & Poffenroth, L. (2012). Investigation of a
pandemic H1N1 influenza outbreak in a remote First Nations community in Northern
Manitoba, 2009. Canadian Journal of Public Health, 103(2), 90-93.

Sistrom, M. G. & Hale, P. J. (2006). Outbreak investigations: Community participation and role of
community and public health nurses. Public Health Nursing, 23(3), 256-263.

Smith, C. M. & Hayward, A. C. (2016). DotMapper: An open source tool for creating interactive
disease point maps. BMC Infectious Diseases, 16, 1-6. doi: 10.1186/s12879-016-1475-5

Stanhope, M. & Lancaster, J. (2016). Public health nursing: Population-centered care in the
community. St. Louis, MO: Elsevier.

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Outreach
Outreach locates populations of interest or populations at risk and provides infor-
mation about the nature of the concern, what can be done about it, and how to ob-
tain services.

Outreach activities may be directed at whole communities, targeted populations
within those communities, and/or systems that affect the community’s health. Out-
reach includes risk communication; outreach success occurs when those considered
at risk receive the information and act on it.

Practice-level examples
Population of interest: 15- to 24-year-olds.

Problem: Individuals age 15 to 24 years old account for half the burden of Chlamydia
trachomatis (CT) and Neisseria gonorrhea (NG) infections among reported sexually
transmitted infections (STIs), although they represent 27 percent of the sexually ac-
tive population. CT and NG can be asymptomatic, and untreated infections can lead

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to serious long-term health consequences (pelvic inflammatory disease, infertility,
blood and joint infections, transmission of HIV infection). In a focus group study in
Omaha, barriers to screening included confidentiality to seeking testing, fear of being
judged, and not knowing testing site locations (Delair et al., 2016).

Systems level
A public health nurse (PHN) at the Minnesota Department of Health (MDH) collabo-
rated with professionals around the state to create the Minnesota Chlamydia Part-
nership (Minnesota Department of Health, 2018). The Partnership works to develop
public and professional awareness about the rising incidence of chlamydia. One out-
come of the work is information for health professionals posted on the MDH website.

Community level
The Douglas County Health Department in Omaha offers a hard-to-reach population
(youth ages 15 to 24 years old) a community-based screening program for CT and NG
in public libraries. A trained county health department STI specialist is posted at li-
brary branches at specific times to obtain urine samples from interested library pa-
trons. “The library STI screening program effectively reaches a younger, asympto-
matic, and predominantly Black population compared to a traditional health depart-
ment clinic site” (Delair et al., 2016, p. 289).

Individual/family level (case-finding)
A rural “street nurse” in British Columbia provided outreach to a marginalized popu-
lation. Services offered include testing for STIs, chlamydia treatment, pregnancy test-
ing, emergency contraception, and help completing forms for financial support. Set-
tings included schools, a drop-in center, a mall, a youth center, and “the street.” The
street nurse collaborated with other PHNs, health care providers, mental health
workers, and social workers in making and receiving referrals (Self & Peters, 2005).

Relationship with other interventions
At the community practice level, outreach often operates simultaneously with social
marketing. Use of social marketing principles results in an effective outreach mes-
sage. A broadly focused social marketing intervention to raise a community’s aware-
ness about HIV/AIDS, for instance, can be paired with an outreach intervention de-
signed specifically for those at high-risk, such as IV-drug users or men engaging in sex
with men. More commonly, however, outreach is used in conjunction with health
teaching to inform those at risk about that risk and encourage them to seek attention.
Outreach is also often implemented as a precursor to other interventions in the In-
tervention Wheel’s red wedge, particularly screening.

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Basic steps
Berthold (2009) described steps for planning and implementing outreach in Founda-
tions for Community Health Workers (pp. 437-451):

1. Define the community served by the outreach
Knowing the community helps to determine the most effective outreach strategies.

a. Identify key opinion leaders that have earned respect and confidence of the
community.

b. Identify potential outreach sites where the people in the community spend time.
c. Visit local agencies to find out about the services they provide.

2. Identify the health issue and the health
outcomes you hope to promote
Identifying health outcomes will give you a clear sense of what you want to accomplish.

3. Conduct research on the health issues,
including previous programs and outreach
campaigns
Seek to fully understand causes of the health issue, consequences, and available
treatments, methods for prevention, and previous programs and campaigns. By re-
searching the health issue and the community, you can develop outreach strategies
more likely to promote the desired outcomes.

Answer the following questions:

a. What did programs do?
b. What was the outcome?
c. How did the community perceive the program?
d. What were the successes and mistakes?

4. Organize outreach team
Preparation helps the outreach event go smoothly and provides a welcoming, com-
fortable environment for participants.

Consider the following:

 Number of people needed
 Materials to bring to site (written materials, business cards, health supplies, hy-

giene products, list of resources)
 Funding and donations to support costs of outreach
 Referral information

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 Forms needed to document contacts with people and the services provided
 How to dress for the outreach event or activity

5. Build trusting relationships in the community
The community observes what you do. Give the community time to get to know and
accept you.

a. Contact people you already know; tell them about your role and agency you
work for, services you plan to provide, and how you think they will benefit the
community. Ask for their assistance and advice.

b. Identify key opinion leaders in the community; continue dialogue and nurture
relationships.

c. Network with community at local events.
d. Identify community agencies that share common goals.
e. Work with key opinion leaders to organize a community forum to introduce

yourself and your program. Ask them what they know about the health problem
and who they think you should be talking with.

f. Be patient, keep your promises, and remain true to your word.

6. Prepare and implement plan for approaching
potential clients in outreach setting
The strategies used to approach potential clients influence client engagement in the
outreach intervention.

a. Be ready to start the conversation.
b. Be respectful of time and interests.
c. Keep message simple and brief.
d. Distribute outreach materials if appropriate.
e. Use humor, games, and interactive exercises.

7. Evaluate results of the outreach intervention
Evaluate outreach effectiveness. Use lessons learned to inform future outreach inter-
ventions.

Consider the following:

 Did the target population hear the message?
 Who acted on the message?
 Who received the message but did not act on it?
 Who did not receive the message?
 What barriers prevented people from receiving and/or acting on the message?
 What factors contributed to outreach success?

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Example
A screening program for Chlamydia trachomatis (CT) and Neisseria gonorrhea (NG),
offered in public libraries, was developed to provide outreach to a high-risk popula-
tion that would likely not seek care at traditional STI clinics (Delair et al., 2016).

1. Define the community to be served by the
outreach
Staff identify where STI testing currently occurs and consider other possible testing
sites in Douglas County, Nebraska, which has high STI rates.

2. Identify the health issue and the health
outcomes you hope to promote
The health issue is CT and NG infections among individuals, ages 15 to 24 years old.
The desired health outcome is increasing screening rates to identify STIs and follow
up with treatment.

3. Conduct research on the health issues,
including previous programs and outreach
campaigns
CT and NG infection rates in Douglas County are consistently above state and national
averages (in 2016). Less than half of people who should be screened for these infec-
tions are tested. Barriers to obtaining screening include being asymptomatic, lack of
health insurance, unable to pay subsidized fees, lack of transportation, concerns
about confidentiality, not knowing location of testing, and traditional testing sites de-
signed for adults. A systematic review of outreach STI programs concludes that out-
reach programs in neighborhood venues (community centers, shelters, sports clubs,
and schools) are more effective than outreach on the streets or in open public areas.

4. Organize outreach team
The Douglas County Health Department develops the community-based CT and NG
outreach program to be offered in library branches across Omaha. A STI specialist is
placed in public libraries for 20 hours per week to offer screening. They obtain urine
samples from people interested in participating. Other team members that could
contribute to outreach planning and implementation include a health department
program planner and clerical staff and library administration and staff.

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5. Build trusting relationships in the community
The health department can collaborate with existing STI screening sites in the county
to gain input on the screening process and best practices for communicating infor-
mation. Key leaders in public health in the county should be kept up to date on out-
reach plans. Information about available screening and schedule at the public librar-
ies can be publicized at community events. Staff can also seek input from high school
and college students about what information will encourage people in their age group
to participate in the screening program.

6. Prepare and implement plan for approaching
potential clients in outreach setting
Public libraries are open to community members, access is free, and they are often
located near the center of town, schools, and universities. They offer many kinds of
education information and resources. An STI screening program in a library may ap-
peal to different groups in comparison to other settings such as a hospital, clinic, or
community STI testing site. Staff can tailor the information provided to 15- to 24-year-
olds to motivate participation. Applying the Health Belief Model is useful in tailoring
interventions that address perceptions of risk, benefits, severity, cues to action, and
self-efficacy for this population group (Sohl & Moyer, 2007).

7. Evaluate results of the outreach intervention
The health department collaborates with the University of Nebraska Medical Center
to evaluate the effectiveness of the outreach intervention. Positive screens are 9.9
percent of 997 library records for CT infections and 2.7 percent for NG infections.
Positive screens in libraries are lower compared to traditional clinics (11.2 percent for
CT infections and 5.3 percent for NG infections). The library outreach program is ef-
fective in reaching clients who are younger, asymptomatic, and black.

Key points from evidence
For a description of evidence levels, visit: Introduction: Overview of evidence-based
practice and related topics.

 1. Focusing outreach on populations most in need of screening
Outreach interventions should focus on populations that have used screening oppor-
tunities less frequently in the past.

Level 1 source:

 Allen, Stoddard, & Sorenson, 2008

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 2. Considering social network characteristics
Considering social network characteristics (family, friends, barriers to screening, cul-
tural preferences) when planning outreach interventions increases screening follow-
through.

Level 1 source:

 Allen et al., 2008

Level 3 sources:

 Alexandrake, Mooradian, 2010
 Erwin et al., 2007

 3. Utilizing workers within communities’ social networks
Training lay health workers, community health representatives, or peer leaders with
similar socio-cultural characteristics to the population and who are part of the social
networks of the population, increases effectiveness of reaching those who are most
underserved and positively affects health outcomes in the population.

Level 1 source:

 Nguyen et al., 2009

Level 2 source:

 Sudarson, Jandorf, & Erwin, 2011

Level 3 sources:

 King et al., 2017
 Reinschmidt et al., 2006

 4. Best practices for community-focused outreach activities
In a qualitative study on PHNs’ use of the outreach intervention, participants identi-
fied involvement in community-focused outreach activities, including community fo-
rums, county fairs, immunization clinics, presentations at local groups and meetings,
and senior forums. Outreach best practices included: identifying the target audience,
developing an outreach plan with community input, discussing potential barriers, and
evaluating the quality and success of the program. The PHNs identified the following
lessons about outreach:

 Figure out what people want and how to get the information to them; involve
the target audience in the plan.

 Create clear messages with accurate and up-to-date resources.
 Identify providers and agencies for offering needed services.
 It takes work to raise awareness and make a change in community norms

(Tembreull & Schaffer, 2005, pp. 350-351).

Level 3 source:

 Tembreull & Schaffer, 2005

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 5. Improving client health behavior and access
Examples of effective outreach activities that improved client health behavior or ac-
cess to health services:

 A neighborhood-based approach to reaching low-income populations used new-
born registries, proactive nursing outreach, and collaboration with a home visit-
ing agency to improve access to health-promotion services.

 An intervention designed to increase physical activity in local parks included ob-
taining input from park users and community residents, five training sessions on
outreach and marketing for park directors and park advisory board members,
and funding for each intervention park.

 An informational brochure on colorectal cancer and colonoscopy was mailed to
a primary care population 50 years and older who were referred by a primary
care physician for a screening colonoscopy.

 Postcards and telephone calls were provided to a primary care population of
women, ages 65 to 79, to promote bone density screening.

 The Arkansas Community Connector program used trained community health
workers to provide outreach to locate people living in the community who are
at risk for entering nursing homes.

 The Healthy Living and Learning Center, located in a public library in Petersburg,
Virginia, assists patrons in accessing health information and resources.

 A mental health outreach program located older adults in the community, who
were identified by professionals and community gatekeepers as at-risk, isolated,
abused, and delusional.

Level 1 sources:

 Cohen et al., 2013
 Denberg et al., 2006

Level 2 sources:

 Brown, Perkins, Blust, & Kahn, 2015
 Felix, Mays, Stewart, Cottoms, & Olson, 2011

Level 3 sources:

 Denberg et al., 2009
 Ports et al., 2015
 Yang, Garis, & McClure, 2006

 6. Maximizing online reach
Based on an analysis of social media conversations on bullying, researchers made the
following recommendations to maximize the reach of StopBullying.gov and exposure
to the content of the website:

 When creating public health campaigns, analyze language used by target audi-
ence to ensure messages resonate with the audience.

 Connect with online influencers’ authority in social media conversations by fol-
lowing or liking their organizations on social media.

 Retweet, share, and comment on influencers’ activity that is consistent with
federal messages.

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 Share StopBullying.gov content directly with influencers, using similar terms.
 Live tweet at conferences and events.

Level 3 source:

 Edgerton et al., 2016

 7. Supplement health promotion with art
In a health promotion project in Canada called “The Novella Approach to Inform
Women Living on Low Income about Early Breast Cancer Detection,” peer educators
created “novellas” involving art (painting, sculpture, written narratives) to express
their life experiences as breast cancer survivors.

The peer educators used the novella approach to reach out with their message about
the importance of early detection to over 900 women. Based on program evaluation,
authors made the following recommendations for effective outreach:

 Be present where the women live, work, or gather, such as food banks, day
cares, churches, mosques, cultural centers, and workplaces.

 Be sensitive to religious and cultural beliefs and values.
 Allow time to develop and nurture working relationships in the community.
 Engage community representatives to work within the community rather than

using an expert model that works outside of the community.
 Graphic artwork and pointed health promotion messages work best for out-

reach in health fairs and community events rather than at hospitals or events
where persons with a recent cancer diagnosis may be present.

Level 5 source:

 Herbison & Lokanc-Diluzio, 2008

 8. Tailoring interventions to populations
A systematic review on tailored interventions for outreach to populations to promote
mammography screening found that tailoring interventions to the health belief
model and including a physician recommendation had the strongest influence on ob-
taining mammography screening. Tailoring interventions to the Health Belief Model
addresses perceptions of risk, benefits, severity, cues to action, and self-efficacy to
motivate decision-making.

Level 2 source:

 Sohl & Moyer, 2007

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Wheel notes

Joining forces in outreach
Working with other community partners is essential for effective outreach. When
providing services to individuals (home visiting, school nursing), PHNs may note a
health problem or illness that appears to occur more often than usual. In this situa-
tion, they may use case-finding to reach out to the population to identify additional
individuals who are experiencing the health problem or illness. PHNs are likely to in-
volve other staff and organizations to locate individuals who are at-risk or ill.

With community-level outreach, PHNs collaborate with other professionals, health
care and other relevant organizations, businesses, and people who represent the
population in order to develop effective outreach strategies.

Level of evidence
A number of studies identified in key points from evidence have a high evidence level
(experimental and quasi-experimental studies). When outreach intervention pro-
grams are compared with usual care in level 1 and level 2 studies, PHNs can confi-
dently use the recommendations in designing outreach interventions.

Outreach by community health workers
Evidence supports the effectiveness of outreach conducted by community health
workers. The role of the community health worker has emerged in response to eco-
nomic pressures and health care reform measures (Kauer, 2016). To be effective, the
community health worker role must be clearly defined. Community health workers
require training, supervision, and ongoing support. PHNs may work with community
health workers on an outreach team and need to be knowledgeable about guidelines
for community health worker responsibilities and accountability.

References
Alexandrake, I. & Mooradian, A. D. (2010). Barriers related to mammography use for breast

cancer screening among minority women. Journal of the National Medical Association,
102(3), 206-218.

Allen, J. D., Stoddard, A. M., & Sorenson, G. (2008). Do social network characteristics predict
mammography screening practices? Health Education & Behavior, 35(6), 763-776. doi:
10.1177/1090198107303251

Berthold, T. (2009). Health outreach. In Foundations for community health workers (pp. 437-451).
Hoboken, NJ: Jossey-Bass.

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Brown, C. M., Perkins, J., Blust, A., & Kahn, R. S. (2015). A neighborhood-based approach to
population health in the pediatric medical home. Journal of Community Health, 40, 1-11.
doi: 10.1007/s10900-014-9885-z

Cohen, D. A., Han, B., Derose, K. P., Williamson, S., Marsh, T., & McKenzie, T. L. (2013). Physical
activity in the park: A randomized controlled trail using community engagement.
American Journal of Preventive Medicine, 45(5), 590-597.
doi.org/10.1016/j.amepre.2013.06.015

Delair, S. F., Lyden, E. R., O’Keefe, Simonsen, K. A., Nared, S. R., Berthold, E. A., et al. (2016). A
novel library-based sexually transmitted infection screening program for younger high-
risk groups in Omaha, Nebraska, USA. Journal of Community Health, 41, 289-295. doi:
10.1007/s10900-015-0095-0

Denberg, T. D., Coombes, J. M., Byers, T. E., Marcus, A. C., Feinberg, L. E., Steiner, J. F., et al.
(2006). Effect of a mailed brochure on appointment-keeping for screening colonoscopy:
A randomized trial. Annals of Internal Medicine, 145(12), 895-900.

Denberg, T. D., Meyers, B. A., Lin, C., Libby, A. M., Min, S., McDermott, M. T., et al. (2009). An
outreach intervention increases bone densitometry testing in older women. Journal of
the American Geriatrics Society, 57(2), 341-347. doi: 10.1111/j.1532-5415.2008.02111.x.

Edgerton, E., Reiney, E., Mueller, S., Reicherter, B., Curtis, K., Waties, S., & Limber, S. P. (2016).
Identifying new strategies to assess and promote online health communication and
social media outreach: An application in bullying prevention. Health Promotion Practice,
17(3), 448-456. doi: 10.1177/1524839915620392

Erwin, D. O., Johnson, V. A., Trevino, M., Duke, K., Feliciano, L., & Jandorf, L. (2007). A comparison
of African American and Latina social networks as indicators for culturally tailoring a
breast and cervical cancer education intervention. Cancer, Supplement 109(2), 368-377.
doi: 10.1002/cncr.22356

Felix, H. C., Mays, G. P., Stewart, M. K., Cottoms, N., & Olson, M. (2011). Medicaid savings resulted
when community health workers matches those with needs to home and community
care. Health Affairs, 30(7), 1366-1374.

Herbison, S. & Lokanc-Diluzio, W. (2008). The novella approach to inform women living on low
income about early breast cancer detection. Health Promotion Practice, 9(3), 294-304.
doi: 10.1177/1524839906289166

Kauer, M. (2016). Community health workers-birth of a new profession. Journal of the American
Society on Aging, 40(1), 56-63.

King, C., Goldman, A., Gampa, V., Smith, C., Musket, O., Brown, C., et al. (2017). Strengthening the
role of community health representatives in the Navajo nation. BMC Public Health, 17,
1-10. doi: 10.1186/s12889-017-4263-2

Minnesota Department of Health. (2018). The Minnesota Chlamydia Partnership (MCP). Retrieved
from https://www.health.state.mn.us/diseases/chlamydia/mcp.html

Nguyen, T. T., Le, G., Nguyen, T., Lai, K., Gildengoren, G., Tsoh, G., et al. (2009). Breast cancer
screening among Vietnamese Americans: A randomized controlled trial of lay health
worker outreach. American Journal of Preventive Medicine, 37(4), 306-313.

Ports, K. A., Ayers, A., Crocker, W., Hart, A., Mosavel, M., & Rafie, C. (2015). Community
perceptions and utilization of consumer health care center. Journal of the Medical
Library Association, 103(1), 35-39. doi.org/10.3163/1536-5050.103.1.007

Reinschmidt, K. M., Hunter, J., B., Fernandez, M. L., Lacy-Martinez, C. R., de Zapien, J. G., &
Meister, J. (2006). Journal of Health Care for the Poor and Underserved, 17(2), 256-264.

Self, B. & Peters, H. (2005). Street outreach with no streets. Canadian Nurse, 101(1), 20-24.

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Sohl, S. J. & Moyer, A. (2007). Tailored interventions to promote mammography screening: A
meta-analytic review. Preventive Medicine, 45, 252-261. doi:
10.1016/j.ypmed.2007.06.009

Sudarson, N. R., Jandorf, L., & Erwin, D. O. (2011). Multi-site implementation of health education
programs for Latinas. Journal of Community Health, 36(2), 193-203. doi:
10.1007/s10900-010-9297-7

Tembreull, C. L. & Schaffer, M. A. (2005). The intervention of outreach: Best practices. Public
Health Nursing, 22(4), 347-353.

Yang, J. A., Garis, J., & McClure, R. (2006). Clinical mental health outreach to older adults: Serving
the hard-to-serve. Clinical Gerontologist, 29(2), 71-79. doi: 10.1300/J018v29n02_08

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Screening
Screening identifies individuals with unrecognized health risk factors or asympto-
matic disease conditions in populations.

Screening aims to: 1) detect health risks and disease to reduce adverse consequences,
transmission of disease, and suffering, and 2) improve prevention and treatment out-
comes (World Health Organization, 2013).

Three types of screening exist:

 Mass: Screening the general population for a single risk or multiple health risks
at community events or locations, such as health fairs at work sites or health
appraisal surveys at county fairs (community level).

 Targeted: Screening a discrete subgroup within the population, such as those at
risk for HIV infection (individual/family level).

 Periodic: Screening a discrete population subgroup on a regular basis, over time,
for predictable risks or problems. Examples include breast and cervical cancer
screening among age-appropriate women, well child screening, and the follow-
along associated with early childhood development programs (individual/family
level).

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Practice-level examples
Population of interest: Children at risk for lead poisoning.

Problem: Children exposed to environmental lead exhibit neurotoxic effects, including
learning and behavior problems, lower intelligence, slowed growth and development,
hearing and speech problems, and anemia. In Flint, Michigan, elevated blood levels
increased from 2.4 percent to 4.9 percent among children younger than five years after
the city switched the water source to the Flint River. Because the water treatment did
not include a chemical corrosion-inhibiting compound, lead leached into the water
supply from plumbing. Higher rates of elevated blood levels occurred in socially
disadvantaged neighborhoods with older homes (Hanna-Attisha, LaChance, Sadler, &
Schnepp, 2016; Hanna-Attisha, 2017; Maqsood, Stanbury, & Miller, 2017).

Systems level
State law in Michigan mandates screening children under 5 years old insured by Med-
icaid, and children enrolled in WIC, for blood lead levels (Michigan Department of
Community Health, 2009). Michigan State University and the Hurley Medical Center
in Flint launched the Pediatric Public Health Initiative to mitigate the effects of the
Flint water crisis. Through this initiative, PHNs received a wealth of resources for ad-
ditional child development screening in at-risk populations including maternal-infant
support programs, universal home-based early intervention, early childhood educa-
tion, and parenting support programs (Hanna-Attisha, 2017).

Community level
The Michigan Department of Health and Human Services offers a Lead Safe Home
Program that provides lead testing and hazard control services to qualifying families
through grants. The Michigan Department of Community Health created a “Finding a
Healthy Home” checklist, which assists families in screening a potential new home for
safety. The checklist includes resources for promoting lead-safe homes. Public health
nurses offer these resources when they screen families with young children for lead
toxicity.

Individual/family level (case-finding)
For families with young children, PHNs use a lead screening questionnaire to deter-
mine risk status and need for referral: Lead testing/lead screening plan for Flint,
Michigan (Michigan Department of Health and Human Services, 2016).

Relationship with other interventions
Social marketing and outreach interventions frequently occur prior to the screening
intervention, especially with regard to the mass screening intervention. Health

https://www.michigan.gov/documents/mdch/testing-screening071009_287511_7

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teaching and counseling interventions usually occur simultaneously with screening
or as a feature of the interview conducted post-screening. Referral and follow-up
interventions often occur for those requiring further assessment of risk or symptoms.

Basic steps
The following steps are adapted from the World Health Organization (2013):

1. Assess the situation
Before initiating screening, determine the health risk or disease threat to population
health and whether interventions exist to follow up on screening results.

a. Determine previous screening activities and results in the population, including
cost-effectiveness and outcomes.

b. Review the epidemiology.
c. Identify existing health services and access to care for the population.
d. Identify existing screening guidelines.
e. Identify relevant groups for partnership (organizations providing health services,

supportive community leaders, and providers and health workers who conduct
the screening and follow-up treatment services).

2. Develop the program
Development of the screening program should include:

a. Scope (who and how many in the population and the geographic area)
b. Program design (e.g., clinic, home visits, mobile clinic, laboratory, health fair)
c. Identification of the screening algorithm (step-by-step screening process)
d. Referral of individuals with positive results to treatment, monitoring, and

support

3. Prioritize risk groups
Screening population groups with the highest risk effectively identifies individuals
most likely to benefit:

a. Prioritize risk groups in each setting:
 Assess potential benefits and harms, acceptability of screening approach,

number needed to screen, and cost-effectiveness.
 Determine prevalence of the risk or disease in the population group, the risk

for poor treatment outcomes if diagnosis is delayed, the epidemiological sit-
uation, capacity of the health system, and the availability of resources.

b. Avoid indiscriminate mass screening.

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Figure 1: Pediatric developmental screening flowchart

Adapted from CDC (2017b).

4. Use evidence-based algorithm and approach
a. Screening algorithms identify the steps in the process and communicates the

process (for an example of developmental screening, see Figure 1).
b. Screening algorithms vary for different groups (for example, children or adults).
c. Algorithm selection depends on the risk group, health risk or disease prevalence,

resource availability, and plan feasibility.
d. Evidence to consider when selecting a screening tool (Adam & Hilfinger, 2016):

 Reliability: What is the consistency of the screening tool in obtaining accu-
rate results?

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 Validity: Does the screening tool measure what it is intended to measure?
 Sensitivity: Does the screening tool accurately identify the occurrence of

the health risk or signs of disease?
 Specificity: Does the screening tool accurately identify individuals who do

not have the health risk or signs of disease?
e. When selecting a screening approach, identify strategies to ensure:

 Consent
 Mitigation of potential stigma or negative social consequences
 Communication of relevance
 Incentives

5. Plan, budget, and implement
Ensure adequate resources, including funding and personnel for implementation.

The screening plan includes the following components:

a. Selection or creation of protocols and tools
b. Criteria for evaluating screening strategies (Dans, Asuncion, & Silvestre, 2011, p.

231):
 High burden of illness
 Accurate tests
 Early treatment more effective than late treatment
 Safe diagnostic tests and early treatment
 Cost commensurate with potential benefit

c. Identification of available resources for implementation, including funding, hu-
man resources, and feasible interventions and treatment

d. Hiring and training staff for identified roles
 Outreach and/or contact investigations
 Data entry, management, monitoring, and analysis
 Program management, coordination, and problem solving

e. Pilot testing
f. Initial evaluation

6. Monitor and evaluate
Evaluate the effectiveness of the screening approach and determine changes needed
for future screening activities.

a. Monitor:
 Collection of key information and performance
 Consistency with screening program’s goals
 Use of data collection tools

b. Evaluate analysis and the reporting system.
c. Conduct an outcomes analysis; use mathematical modelling to estimate the im-

pact on the incidence and prevalence of the health risk or disease in the targeted
community.

d. Seek screening program feedback from the population screened.

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Example
The Michigan Department of Health and Human Services offers a Lead Safe Home
Program that provides lead testing and hazard control services to qualifying families
through grants (Hanna-Attisha et al., 2016; Maqsood et al., 2017).

1. Assess the situation
In April 2014, the city of Flint, Michigan changes its water supply to the Flint River
while waiting for a new pipeline from Lake Huron. After the switch, city residents
report concerns about water color, taste, and odor, and negative effects on health,
such as skin rashes. Due to lack of a corrosion inhibitor and the high percentage of
lead pipes and plumbing in the water distribution system, the chemical makeup of
the Flint River water contribute to lead leaching into the drinking water. Although
researchers from Virginia Tech University report increases in water lead levels, the
impact on blood lead levels remains unknown.

2. Develop the program
Staff analyze “differences in pediatric elevated blood lead level incidence before and
after Flint.” (Hanna-Attisha et al., 2016, p. 283).

3. Prioritize risk groups
The highest risk group included children under 5 years of age living within the city of
Flint receiving water from the city. Children living outside the city with an unchanged
water source provided a comparison group.

4. Use evidence-based algorithm and approach
A computer algorithm links multiple tests of the same child to Medicaid data files and
the state immunization registry: “A blood lead level equal to or greater than 5 mi-
crograms per deciliter of blood (≥5 μg/dL) is considered elevated by CDC” (Maqsood
et al., 2017, p. 6). The laboratory tests for blood lead level uses a venous or capillary
blood sample. Capillary blood tests may produce false positive results; confirmation
of elevated capillary blood tests occurs with a venous blood test.

5. Plan, budget, and implement
Screeners communicate the lead testing status of children to Medicaid managed care
plans, who use the data to contact providers not compliant with Medicaid lead
screening requirements. Local health departments conduct follow-up with Medicaid
fee-for-service providers not in compliance with the Medicaid screening require-
ments. Local health departments receive a weekly update of blood tests, indicating
venous or capillary. The local health departments (LHDs) follow up with the families

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of children completing capillary lead screening and encourage them to see their pro-
vider for a confirmatory venous test.

LHDs use the weekly data reports to identify and follow up on children with
EBLLs (elevated blood lead levels). Depending on resources, LHDs provide
case management services to children with EBLLs and their families. Case
management may include a home visit to make a visual assessment of lead
hazards, an assessment of the child’s growth and development, [which are
screening activities] education of the caregivers on nutrition and cleaning,
and referrals to other agencies for interventions. A nurse consultant
supports case management activities at the LHDs through training and
technical consultations. LHDs use a web-based application to track case
management activities (Maqsood et al., 2017, p. 7).

6. Monitor and evaluate
Key recommendations to improve the lead poisoning screening strategy:

 Improve “the completeness, accuracy, and timeliness of the surveillance system
by implementing a modernized data management system and automating the
process of receiving and compiling reports from laboratories.”

 “Partner with other agencies to increase the proportion of children with EBLLs
based on capillary tests receiving a confirmatory venous test.”

 “Launch a new program to increase reimbursement to local health departments
for the provision of in-home nursing case management for Medicaid children
with EBLLs, supported by training and technical assistance.”

 “Collaborate with the Michigan Department of Health and Human Services Lead
Safe Home Program to expand environmental inspection services and financial
support for home lead abatement” (Maqsood et al., 2017, p. 3).

Key points from evidence
For a description of evidence levels, visit: Introduction: Overview of evidence-based
practice and related topics.

 1. Principles and guidelines for effective health screening
In 1968, the World Health Organization published of principles/guidelines for effec-
tive health screening:

 The condition should be an important health problem that carries with it notable
morbidity and mortality.

 There should be an accepted treatment for patients with recognized disease.
 Facilities for diagnosis and treatment should be available.
 There should be a recognizable latent or early symptomatic stage.
 There should be a suitable test or examination.
 The test should be acceptable to the population.

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 The natural history of the condition, including development from latent to de-
clared disease, should be adequately understood.

 There should be an agreed policy on whom to treat as patients.
 The cost of finding, diagnosing, and treating patients should be economically

balanced in relation to the anticipated overall expenditure on medical care.
 Case-finding should be a continuing process and not a “once and for all” project.

Level 5 sources:

 Stifler & Dever, 2015
 Wilson & Jungner, 1968

 2. Successful screening programs
A successful screening program is:

 Valid (accurate)
 Reliable (precise)
 Capable of large-group administration
 Minimally invasive
 Worth the effort and expense
 Ethical and effective (meets public health goal, benefits outweigh possible harms)
 Simple, rapid, inexpensive, safe, and acceptable

Level 5 sources:

 Adams & Hilfinger, 2016
 Friss & Sellers, 2014

 3. Asking the right questions
Questions to ask when planning a screening program:

 Is the health problem important to the individual and community?
 Is diagnostic and follow-up intervention available to all?
 Is there high public acceptance of the screening program and tools/tests?
 Is there an adequate scientific knowledge base about the epidemiology of the

health risk or disease, efficacy of prevention, and/or treatment?
 Is there evidence that the results of the screening program can improve the nat-

ural history of the health risk or disease for a significant proportion of those
screened?

Level 5 source:

 Friss & Sellers, 2014

 4. Considering ethical issues
Ethical issues to consider when conducting screening:

 Preventing harm: Does the risk of screening offset the benefits?
 Self-determination: Individuals who are offered screening should decide if the

screening is acceptable to them
 Confidentiality: Individual screening results are protected health information

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 Equity: Ensure that everyone who may be at risk for the health problem or dis-
ease has access to recommended screening strategies

Level 5 source:

 Asuncion, Silvestre, Dans, & Dans, 2011

 5. Using standardized screening instruments
A systematic review on developmental screening in children under 5 years old admin-
istered primarily by nurses, found that training nurses to use standardized instru-
ments contributed to an acceptable level of reliability and improved screening effi-
ciency. This led to accurate identification and referral for early intervention.

Level 3 source:

 Trivette, O-Herin, & Dunst, 2009

 6. When limited screening is appropriate
Experts determined that adopting a population-based screening program for asthma
is not recommended, given a lack of evidence of improvement in health outcomes.
Limited screening may be appropriate in areas with a high prevalence of undiagnosed
asthma and where identified clients have access to high quality asthma care. The au-
thors recommended applying World Health Organization criteria for assessing
screening programs to decision-making about asthma screening.

Level 4 source:

 Gerald et al., 2007

 7. When screening is harmful
Based on a systematic review the United States Preventive Services Task Force con-
cluded that the harms of screening adolescents for idiopathic scoliosis exceed poten-
tial benefits. Most cases detected during screening are not clinically significant, those
who need aggressive treatment are likely to be detected without screening, and po-
tential harms include unnecessary brace wear and referral for specialty care.

Level 4 source:

 United States Preventive Services Task Force, 2014

 8. Screening for abuse
Using domestic abuse screening tools increases violence disclosure rates and safety
planning. Screening tool strengths include the presence of an opening statement
about the prevalence and impact of abuse (provides justification for the screening),
screening for all types of abuse, and non-judgmental and sensitive questions.

Level 1 source:

 Taft et al., 2015

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Level 2 source:

 Vanderberg, Wright, Boston, & Zimmerman, 2010

Level 5 source:

 Litherland, 2012

 9. Safeguards when screening for Body Mass Index (BMI)
CDC recommended safeguards for Body Mass Index (BMI) screening in schools. Safe-
guards included: a) accurate and reliable equipment, b) staff training, c) follow-up
resources, d) parent notification of results, and e) providing referrals. Barriers to ef-
fective BMI screening practices include lack of screening policy, time-consuming data
gathering process, lack of equipment and referral resources, and school nurse work-
load. Implications for school nursing practice include: be familiar with safeguards;
communicate importance of safeguards to school administrators; participate in train-
ing on the safeguards; and collaborate with other school staff, other schools, and
community partnerships to share safeguard equipment and costs.

Level 3 sources:

 Sliwa, Brener, Lundeen, & Lee, 2018
 Stalter, Chaudry, & Polivka, 2010

 10. Using apps for screening
A qualitative study on mobile screening applications (apps) for men identified three
themes for increasing app use:

 Content: 1) Health risks, benefits, risks of health screening, and available screen-
ing services; 2) Convenient assessment of health status in private in-home set-
ting; 3) Personalized and tailored feedback that is not overwhelming; 4) Secure
data, up-to-date information, and credible sources

 Format: 1) Information delivery in lay terms; 2) Easy-to-use features with pic-
tures and videos; 3) Reminders of the health screening date and daily or weekly
reminders for improving health; 4) Connection to social media for sharing expe-
rience and motivating health screening

 Dissemination strategies: 1) Advertising (hospital, gym, shopping center, men’s
magazines, social media); 2) Recommendations from physicians and celebrities;
3) Incentives, such as a discount voucher, free health screening, or monitory re-
ward; 4) Integrating the app into a basic apps package

Level 3 source:

 Teo, Ng, & White, 2017

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Wheel notes

Common public health nursing screening
activities
Public health nurses target screening activities to the population and setting in which
they work. Some common examples include:

 Tuberculosis screening in a correctional facility
 HIV screening at an HIV/STI clinic
 Anemia screening of pregnant women and infants at a WIC clinic
 Blood lead level checks in at-risk children during well-child assessments
 Hypertension screening at work sites
 Growth and development screening in early childhood clinics
 Pregnancy testing at family planning clinics
 Postpartum depression screening during home visits
 Domestic violence screening during home visits
 Drug and alcohol use screening for adolescents in high schools
 Hearing and vision screening with school-aged children
 Screening for violence risk with women on maternal and child health caseload
 Home hazard screening of elder homes
 Blood glucose screening at senior health clinics
 BMI and cholesterol screening at community health fairs

Evaluating screening tool effectiveness
Many studies provide evidence about the reliability and validity of screening tests and
evaluate the sensitivity (accurate identification of positive cases) and specificity (ac-
curate identification of negative cases). Review current evidence and determine cost-
effectiveness and harm versus benefit. In the past, school nurses offered scoliosis
screening; current evidence does not support scoliosis screening because of the high
rate of false positives and follow-up expense (United States Preventive Services Task
Force, 2014).

Preventing harm: Cultural/racial factors
Consider ethical concerns when conducting screening: preventing harm, self-deter-
mination, confidentiality, and equity. Knowledge about cultural differences and experi-
ence promotes ethical screening actions. For example, a medical provider unfamiliar
with Mongolian spots (variations in skin pigment in babies of African, Asian, Indian, or
Mediterranean descent) may interpret them as bruises related to possible child abuse.
The blue or gray spots are usually gone within a year and require no treatment.

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Screening plus referral and follow-up
Screening without referral options for prevention and/or treatment is unethical. Be-
fore initiating screening activities, ensure that referral and follow-up options exist.
Referral and follow-up options also contribute to the ability to evaluate the effective-
ness of the prevention/treatment in decreasing the health risk or severity of disease.

References
Adams, S. A. & Hilfinger, D. A. (2016). Epidemiology. In M. Stanhope & J. Lancaster (Eds.). Public

health nursing: Population-centered care in the community. St. Louis, MO: Elsevier.

Asuncion, M., Silvestre, A., Dans, L. F., & Dans, A. L. (2011). Trade-off between benefit and harm is
crucial in health screening recommendations. Part II: Evidence summaries. Journal of
Clinical Epidemiology, 64, 240-249.

Centers for Disease Control and Prevention. (2017a). Autism Spectrum Disorder (ASD): Screening
and diagnosis for healthcare providers. Retrieved from
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Centers for Disease Control and Prevention. (2017b). Pediatric developmental screening flowchart.
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Chart

Dans, L. F., Asuncion, M., & Silvestre, A. L. (2011). Trade-off between benefit and harm is crucial in
health screening recommendations. Part I: General principles. Journal of Clinical
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Friss, R. H. & Sellers, T. A. (2014). Epidemiology for public health practice. Burlington, MA: Jones &
Bartlett Learning.

Gerald, L. B., Sockrider, M. M., Grad, R., Bender, B. G., Boss, L. P., Galant, S. P., et al. (2007). An
official ATS Workshop Report: Issues in screening for asthma in children. Proceedings of
the American Thoracic Society, 4, 133-141. doi: 10.1513/pats.200604-103ST

Hanna-Attisha, M. (2017). Flint kids: Tragic, resilient, and exemplary. American Journal of Public
Health, 107(5), 651-652. doi: 10.2105/AJPH.2017.30373

Hanna-Attisha, M., LaChance, J., Sadler, R. C., & Schnepp, A. C. (2016). Elevated blood lead levels
in children associated with the Flint drinking water crisis: A spatial analysis of risk and
public health response. American Journal of Public Health, 106, 283-290. doi:
10.2105/AJPH.2015.303003

Litherland, R. (2012). The health visitor’s role in the identification of domestic abuse. Community
Practitioner, 85(8), 20-23.

Maqsood, J., Stanbury, M., & Miller, R. (2017). 2015 data report on childhood lead testing and
elevated blood lead levels: Michigan. Retrieved from
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Michigan Department of Community Health. (2009). Statewide lead testing/lead screening plan.
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Michigan Department of Health and Human Services. (2016). Lead testing/lead screening plan for
Flint, Michigan. Retrieved from https://www.michigan.gov/documents/mdch/testing-
screening071009_287511_7

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Sliwa, S. A., Brener, N. D., Lundeen, E. A., & Lee, S. M. (2018). Do schools that screen for body
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Stalter, A. M., Chaudry, R. V., & Polivka, B. J. (2010). Facilitating factors and barriers to BMI
screening in schools. Journal of School Nursing, 26(4), 320-330. doi:
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Stifler, M. C. & Dever, B. V. (2015). Mental health screening at school: Instrumentation,
implementation, and critical issues. Switzerland: Springer International Publishing.

Taft, A. J., Hooker, L., Humphreys, C., Hegarty, K., Walter, R., Adams, C., et al. (2015). Maternal and
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Teo, C. H., Ng, C. J., & White, A. (2017). What do men want from a health screening mobile app? A
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Trivette, C. M., O-Herin, C. E., & Dunst, C. J. (2009). Accuracy of nurse provider child screening
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Case-finding
Case-finding locates individuals and families with identified risk factors and connects
them to resources.

Case-finding is a one-to-one intervention operating only at the individual/family level.
Case-finding serves as the individual/family level of intervention for surveillance, dis-
ease and health event investigation, outreach, and screening. Case-finding locates
those most at risk.

In an editorial in the American Journal of Nursing, Kennedy (2016) stated:

[Case-finding] falls within the purview of all nurses. Nursing assessments
must include questions about patients’ homes and neighborhoods and jobs
and pets and military service. All of us, wherever we work and live, must be
alert for patterns of illness and be proactive in bringing them to light (p. 7).

Kennedy highlighted three case-finding examples nurses identified when they asked
the question “What’s been happening?”

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 A school nurse in New York City, Mary Pappas, recognized a pattern of symp-
toms that indicated the onset of the 2001 H1N1 influenza pandemic.

 In 2012, a nurse in rural Washington state, Sara Barron, alerted the state health
department of the occurrence of three infants born with anencephaly at one
hospital. A follow-up investigation revealed an anencephalic birth rate four
times the national average.

 An occupational health nurse in Minnesota, Carole Bower, reported similarities
of slaughterhouse workers’ complaints to the state health department. The fol-
low-up investigation led to identifying a new illness related to pig brain proteins
released into the air during meat processing.

Practice examples: Individual/family

Case-finding from surveillance
Public health nurses (PHNs) routinely inquire about flu-like symptoms with the indi-
viduals, families, groups, and colleagues with whom they work. During staff meetings,
PHNs report and monitor flu activity in the area.

Case-finding from disease and health event
investigation
When providing services to women of childbearing age, PHNs inquire about symp-
toms of infection in women and their partners and history of travel or residence in
environments where infected mosquitoes may be present. Recommending testing
for Zika infection contributes to identifying and reporting possible outbreaks, which
can lead to implementing control measures.

Case-finding from outreach
A rural “street nurse” provided outreach in British Columbia to a marginalized popu-
lation. Services offered included sexually transmitted infection (STI) testing, chla-
mydia treatment, pregnancy testing, emergency contraception support, and financial
form completion assistance. Settings included schools, a drop-in center, a mall, a
youth center, and “the street.” The street nurse collaborated with other PHNs, health
care providers, mental health workers, and social workers, in making and receiving
referrals (Self & Peters, 2005).

Case-finding from screening
For families with young children, PHNs determine risk status and need for referral
using a lead-screening questionnaire: Lead testing/lead screening plan for Flint,
Michigan (Michigan Department of Health and Human Services, 2016).

https://www.michigan.gov/documents/mdch/testing-screening071009_287511_7

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Relationship with other interventions
Case-finding is linked to outreach, screening, surveillance, and disease and health
event investigation. Case-finding, as the individual/family practice level of surveil-
lance, disease and health event investigation, outreach, and screening, often leads to
referral and follow-up.

Basic steps

1. Identify individuals and families at risk through
information from surveillance, disease and
health event investigation, and/or outreach
Effective case-finding occurs when targeting at-risk populations.

Risk severity increases with factors that make individuals and families unaware, una-
ble, or unwilling to respond:

a. Unaware of risk :
 Lacking information or understanding of the risk
 Isolated from media

b. Unable to respond:
 Unable to receive or understand the message, due to illiteracy, hearing and

vision impairments, or cognitive impairment
 Non-English-speaking or other language barriers
 Contrasting cultural beliefs
 Lacking resources, such as financial resources, transportation, child care, or

social skills
c. Unwilling to respond, fearing that negative consequences exceed benefits:

 Fear of deportation
 Unable to afford out-of-pocket costs

2. Connect with formal and informal networks to
find those identified as at-risk
This strategy helps identify the at-risk target population.

 Formal networks include professionals and agencies with whom the PHN com-
municates regularly and maintains a relationship (e.g., hospital and outpatient
discharge planners, follow-along program coordinators for children with special
needs, social workers, and epidemiologists).

 Informal networks include individuals and organizations with whom the individ-
ual or family communicates regularly and maintains a relationship.

 Successful case-finding often depends on the PHN developing a trust relation-
ship with members of the individual’s or family’s network.

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3. Initiate activities providing information about
the nature of the risk, possible solutions, and
service attainment
Once the PHN identifies the target population, resources on risk information and re-
ferral provide accurate and timely information to individuals identified as at-risk for
or having the health problem or disease.

a. The PHN bases the approach on the individual or family rationale for not seeking
services.

b. If the individual or family is unaware of the risk or does not understand its se-
verity or full potential for harm, the PHN provides health teaching to reduce the
knowledge deficit and further engage them using a teaching and counseling
strategy.

c. If the individual or family is unable to respond, the PHN works with them to re-
solve the barriers, providing counseling, consultation, advocacy, and/or referral
and follow-up for transportation, financial assistance, arrangement for inter-
preters, and child-care provision.

d. If the individual or family is unwilling to respond, the PHN establishes a trust
relationship and identifies the source, such as fear or anxiety, of the unwilling-
ness. With trust established, the PHN provides health teaching, counseling,
consultation, advocacy, and/or referral and follow-up as needed.

4. If the level of risk suggests endangerment to
the individual, family, or community, provide
direct access to necessary services
The risk of potential harm requires intervention to prevent that harm, which supports
the ethical principles of prevention, not causing harm, and promoting good.

Examples of endangerment demanding immediate PHN response:

 A client is followed for management of psychotropic medications, and has a dis-
connected phone. The PHN visits his apartment, talks with the landlord, checks
with his family to locate him, and assures his well-being.

 A newborn fails to make a reasonable weight gain. The PHN determines the
mother is ambivalent and not bonding well with the infant. The PHN arrives for
a third visit in a series of planned home visits, hears the baby crying inside the
apartment, and no one answers the door. The PHN finds the building manager,
convinces him to open the door, and contacts child protection.

 A PHN leads a caregiver support group. A participant arrives wearing dark glasses
and a scarf covering her head and neck. She excuses her appearance, saying she
had been cleaning her mother’s house and has dust in her hair and eyes. She
seems unable to relax during the group, and lingers after the others leave. She
divulges she is afraid to go home, because her boyfriend beats her. He accuses her
of having an affair because she is gone much of the time and he refuses to believe
that she is caring for her ailing mother. The PHN helps her develop a plan to pro-
tect herself, considering all relevant state laws and regulations.

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5. Fulfill state law and regulation reporting
mandates
Completing mandatory reporting requirements, such as those regarding reportable
contagious diseases or indicators of child maltreatment, guides public health experts
in the surveillance of health problems and disease and in determining an appropriate
public health response.

Example
Nurse Sara Barron noted the delivery of four babies with anencephaly (born without
all of or without a major part of the brain) in a short time period at rural, local hospi-
tals in Washington state. She had seen only two previous cases in over 30 years of
nursing (Barron, 2016).

1. Identify individuals and families at risk through
information from surveillance, disease and
health event investigation, and/or outreach
Barron notes the delivery of two babies born with anencephaly through her own sur-
veillance of birth defects, and that this occurrence seems unusual.

2. Connect with formal and informal networks to
find those identified as at risk
When talking to a physician who delivers babies, Barron learns he has another patient
expecting a similar outcome. When talking to colleagues in hospitals in the area, she
learns that two other babies were born recently with anencephaly.

3. Initiate activities providing information about
the nature of the risk, possible solutions, and
service attainment
Barron calls the Washington State Department of Health to report the birth defect
cluster. When investigators looked into the problem, they find 23 cases of anenceph-
aly across three counties in Washington, a rate of 8.4 per 10,000 live births (four times
higher than the national average).

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4. If the level of risk suggests endangerment to
the individual, family, or community, provide
direct access to necessary services
To address coping with grief and possible genetic problems, the PHN ensures that
families that have a baby with a neural tube defect have access to counseling. Coun-
seling about the importance of folic acid intake is important for all women of
childbearing age, and Hispanic women are particularly at risk because they favor corn
products that may not be fortified with folic acid; their risk for pregnancy resulting in
a neural tube defect is twice the rate of non-Hispanic white women.

5. Fulfill state law and regulation reporting
mandates

In August 2000, the Washington State Board of Health approved a revised
list of congenital abnormalities notifiable by law to public health
authorities under Chapter 246-101 of the Washington Administrative
Code. Among these were nine birth defects (Washington State
Department of Health, 2018).

This includes anencephaly, defined as “a birth defect that affects the growth of a ba-
by’s brain and skull bones that surround the head” (Washington State Department of
Health, 2018).

Key points from evidence
For a description of evidence levels, visit: Introduction: Overview of evidence-based
practice and related topics.

 1. Case-finding intervention categories
CDC identifies three categories of case-finding interventions for birth defects:

Active case-finding: Staff members continually review medical records from health
care facilities in a geographic area

Passive case-finding with confirmation: There is an agreement to received report
about birth defect cases from health care facilities. The reports are reviewed and
there is verification of the diagnosis.

Passive case-finding: Reports from health care facilities are received, but there is no
follow-up to confirm diagnoses.

Level 4 source:

 Centers for Disease Control and Prevention, 2017

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 2. Settings for active case-finding
Settings for conducting active case-finding include voluntary counseling and testing
centers, homeless shelters, prisons, nursing homes, and impoverished areas. When
resources are limited, symptom screening in clinical community settings is efficient.

Level 5 source:

 Golub, Mohan, Comstock, & Chaisson, 2005

 3. Stepped care case-finding
For delivering care following exposure to a natural disaster, a case-finding stepped care
model calls for screening and triage to the appropriate level of care (cognitive behav-
ioral therapy or skills for psychological recovery), followed by ongoing systematic
reevaluation. In a simulation that compared the initial triage approach versus usual care
for post-traumatic stress disorder after a natural disaster, the stepped-care approach
found more cases, resulted in more effective treatment, and was cost-effective.

Level 2 source:

 Cohen et al., 2017

 4. Case-finding for tuberculosis
A review of case-finding for tuberculosis identified the following as intended out-
comes and strategies of measurement of effectiveness of a case-finding program:

 Using prevalence surveys before and after a case detection program.
 Measuring delays in diagnosis before and after a case detection program.
 Monitoring treatment completion to ensure high completion rates among newly

detected patients.
 If more than one intervention aimed at reducing TB incidence is implemented,

assessment should allow for separation of the intervention effects.
 Reduction in incidence is the goal.

Level 5 source:

 Golub et al., 2005

 5. Case-finding to improve early detection and increase access
to care
A case-finding community project in Ireland aimed to improve early detection of
chronic health conditions and increase access to primary care and nursing services.
Over 350 people attended 17 health fairs in a variety of Belfast venues, and 115 peo-
ple were identified with respiratory, cardiac, diabetes, and hypertension risk factors.
Attendees had their weight, waist, blood pressure, and blood sugar measured and
received materials that focused on health promotion. In follow-up, a district nurse
practitioner provided health assessments to 109 people and made 97 referrals to
other health professionals and agencies. Through the health fair strategies, those
most at risk were identified and referred to needed services.

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Level 3 source:

 Kane, 2008

 6. Using apps for sexually transmitted infection (STI) case-
finding
The use of smartphone apps in case-finding for sexually transmitted diseases (STIs)
can enhance traditional case-finding strategies for STIs.

Level 3 source:

 Pennise, Inscho, & Herpin, 2015

 7. Using brief and evidence-based case-finding tools
A review of common tools for case-finding of depressive disorders in older adults rec-
ommended brief and evidence-based case-finding tools. Using several measures in-
creases the sensitivity and specificity of results.

Level 5 source:

 Roman & Callen, 2008

 8. Identifying potential clients with case-finding
Five stages of case-finding to identify clients who will benefit from case management
are:

a. Scoping: Estimating the expected number of clients
b. Searching: Basing on clear case-finding criteria
c. Adapting to capacity: Consideration of which patients can be accommodated
d. Screening: Determining whether client is appropriate for case management
e. Enrolling: Starting services for clients who can benefit from the program

Level 5 source:

 Toofany, 2008

Wheel notes

Critical thinking
Case-finding goes beyond following a checklist. Kennedy stated,

Nurses at the point of care are usually the first to take stock of a patient’s
problems. But how often do we do it by habit, following a checklist
without the mindfulness that might lead us to ask other, more important
questions? Often, the crucial question is not “What’s the problem?” but

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“What’s been happening?” It makes a huge difference when nurses apply
critical thinking skills to assessment. (Kennedy, 2016, p. 7)

Case-finding requires noticing, recognizing patterns, and making connections.

Opportunities
A PHN, always vigilant and watching for actual or potential threats to health, may
unexpectedly come across case-finding opportunities, events, or observations. These
are cues for further assessment and, perhaps, identification of new cases (for more
information, visit disease and health event investigation)

References
Barron, S. (2016). Anencephaly: An ongoing investigation in Washington state. American Journal

of Nursing, 116(3), 60-66.

Centers for Disease Control and Prevention. (2017). Birth defects: State-based tracking systems.
Retrieved from https://www.cdc.gov/ncbddd/birthdefects/states/

Cohen, G. H., Tamrakar, S., Lowe, S., Sampson, L., Ettman, C., Linas, B., et al. (2017). Comparison
of simulated treatment and cost-effectiveness of a stepped care case-finding
intervention vs usual care for posttraumatic stress disorder after a natural disaster.
JAMA Psychiatry, 74(12), 1251-1258. doi: 10.1001/jamapsychiatry.2017.3037

Golub, J. E., Mohan, C. I., Comstock, G. W., & Chaisson, R. E. (2005). Active case finding of
tuberculosis: Historical perspective and future prospects. International Journal of
Tuberculosis and Lung Disease, 9(11), 1183-1203.

Kane, K. (2008). Case-finding in the community: The results 2. British Journal of Community
Nursing, 13(6), 265-269.

Kennedy, M. S. (2016). Asking more questions: The importance of case finding. American Journal
of Nursing, 116(3), 7.

Pennise, M., Inscho, R., Herpin, K. (2015). Using smartphone apps in STD interviews to find sexual
partners. Public Health Reports, 130, 245-252.

Roman, M. W. & Callen, B. L. (2008). Screening instruments for older adult depressive disorders:
Updating the evidence-based toolbox. Issues in Mental Health Nursing, 29, 924-941. doi:
10.1080/01612840802274578

Self, B. & Peters, H. (2005). Street outreach with no streets. Canadian Nurse, 101(1), 20-24.

Toofany, S. (2008). Where are the cases? Primary Health Care, 18(3), 36-39.

Washington State Department of Health. (2018). Birth defects. Retrieved from
https://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/BirthDefects

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In review
A story:

The Sage Screening Program in Minnesota provides wellness screening and early de-
tection of breast, cervical, and colorectal cancers. Eligible persons, based on age, in-
surance, and income criteria, obtain free screening. The Sage Program sponsors
screening events and completes targeted outreach to find and enroll clients into the
program. Direct mail materials, a financial incentive ($20), and patient navigation
(help finding health care resources) increases targeted screening for these cancers.
The Sage Program offers breast and cervical cancer screening at over 450 clinic sites
in Minnesota to more than 150,000 women (Minnesota Department of Health, 2018).

In one of these sites, a tri-city public health department, a senior public health nursing
student provided wellness screening services for blood glucose and high cholesterol
in the Sage Program along with her public health nurse preceptor. The program of-
fered additional health testing along with cancer screening. The student captured her
experience:

Part of the screening consisted of checking total (fasting) cholesterol and
blood glucose levels. I did a finger stick to draw up a drop of blood into a
little plastic case that fit into a machine, which would give us the

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cholesterol and glucose results in about five minutes. After we had the
results, I entered the data into a computer program created by the
Centers for Disease Control and Prevention (CDC) that analyzes and
creates a bar graph and written description of the results that are very
easy for the average nonmedical person to understand and learn from. It
also generates a diagnostic referral form if any test result is too high. This
form can then be faxed to a health care provider immediately, with no
other data needing to be added.

When I had printed out the report, I went over it in great detail with my
client, asking her to stop me if she needed additional clarification or had
any other questions. She was able to verbalize a general understanding of
her results. The computer program had created a referral form for her to
be evaluated by a physician because of high cholesterol, and she
requested that my preceptor set up an appointment for her. My
preceptor will follow up with the woman in two weeks to find out
whether she has kept the doctor appointment and whether she wants to
participate in the lifestyle interventions and counseling services that are
also offered at the clinic. (Schoon, Porta, & Schaffer, 2019, p. 306)

The Sage Program expanded to offer colorectal screening at eight sites, via a sub-
program called Sage Scopes. Minnesota received funding (one of 25 states and four
tribes) from CDC to offer targeted colorectal cancer screening through the Sage
Scopes Program (Minnesota Department of Health, 2018). According to Minnesota
Cancer Facts and Figures 2015, 25 percent of Minnesota residents have never had
screening for colorectal cancer. Colorectal cancer is the third most common cancer
for men and women. Colorectal cancer incidence is particularly high among Minne-
sotan American Indians, nearly twice the U.S. rate. The White Earth Health Center, a
federal health program for American Indians and one of the Sage Screening Program
sites, offers free colorectal screening. Colorectal cancer screening effectively finds
polyps, precursors of cancer, that when removed prevent cancer from developing.

Consider how the red wedge interventions (surveillance, disease and health event
investigation, outreach, and screening at the community and systems levels, and
case-finding at the individual level) occur from the perspectives of: 1) the student
experience with wellness screening in the Sage Program, and 2) the services provided
by the Sage Scopes Program for colorectal cancer screening.

Application questions

Level of practice
1. What examples of the individual level of case-finding occur in this story?
2. Give one example of community-level practice and one example of systems-

level practice for any of the red wedge interventions.

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Surveillance
3. What is known about the natural history of colorectal cancer that contributes to

the decision to use the intervention of surveillance (consider incidence and who
is at risk)?

Disease and health event investigation
4. What data is important to collect and present to provide justification for contin-

ued funding for the Sage Program?

Outreach
5. What strategies could public health nurses use to develop trusting relationships

in an at-risk community to encourage obtaining colorectal screening?
6. What are public health nursing’s assumptions about cancer screening? To what

extent are those assumptions shared by communities and populations most im-
pacted by colorectal cancer?

7. To what extent does the ability of those screened to access follow-up medical
care impact the ability of a public health nurse to successfully recruit screening
participants?

Screening
8. How is the Sage Program consistent with the goals of screening?
9. What population groups should be prioritized for colorectal screening?
10. How might the red wedge interventions indicate if a health inequity is occurring

among Sage Program participants?

References
Minnesota Department of Health. (2015). Minnesota cancer facts and figures 2015. Retrieved from

https://www.health.state.mn.us/communities/environment/tracking/docs/cancerfandf

Minnesota Department of Health. (2018). Who we are: Sage screening programs. Retrieved from
https://www.health.state.mn.us/diseases/cancer/sage/about/index.html

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Referral and follow-up
Referral makes a connection to necessary resources to prevent or resolve problems
or concerns. Follow-up assesses outcomes related to the utilization of the resources.

Referral includes the development of and the connection to resources for the indi-
vidual/family, community, or system. The key to a successful intervention is follow-
up; making a referral without evaluating its results is ineffective and inefficient.

Practice-level examples
Population of interest: Adults experiencing homelessness.

Problem: The U.S. Department of Housing and Urban Development estimated that in
December 2017 approximately 554,000 persons experiencing homelessness lived in
the United States. Of these a total of 193,000 were living on the streets (Benedict,
2018). Persons experiencing homelessness reveal age-adjusted mortality rates ap-
proximately three times that of the general population (Taylor, Kendzor, Reitzel, &

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Businell, 2010). Conditions such as hypertension, diabetes, and anemia, often inade-
quately controlled, remain undetected for long periods (Canadian Observatory on
Homelessness, 2017). Unsheltered individuals experiencing homelessness exhibit
vulnerability to temperature related injuries. In cold weather conditions, risk of frost-
bite occurs but even above freezing temperatures bring risk for injury in combination
with wetness. Immersion foot (alterations in skin and sensation resulting from cold
and wet conditions) appears not uncommonly among persons living in these condi-
tions (Carpenter, 2007).

Systems level
A significant homeless population, as well as organizations providing services to
them, resides in an urban downtown in a mid-sized metropolitan area. This area is
also home to a group of mainline churches. Part of an interfaith coalition, these
churches house the service organizations and seek solutions to end homelessness.
Faith community nurses volunteering with the member congregations in the coalition
form a subgroup to coordinate and develop health care services and programs for
persons experiencing homelessness. The subgroup developed a referral protocol fa-
cilitating referrals to the health care services and programs. The group disseminated
the protocol to all the churches and service organizations in the interfaith coalition,
and followed-up to address any challenges to the use of the protocol.

Community level
Faith community nurses, partnering with an area baccalaureate school of nursing,
volunteer at a large urban congregation housing a clinic for persons experiencing
homelessness. The nurses observe that, especially during the cold, wet winter
months, immersion foot appears as one of the most common conditions resulting
from long hours spent on the streets in wet footwear and socks. The faith community
nurses sponsor a fundraiser, “Sock Sunday,” encouraging congregational members to
donate new socks for distribution at the clinic and other community organizations
serving persons experiencing homelessness. At the clinic, faith community nurses ad-
vertise the availability of the new socks and follow up with community organizations
regarding challenges and successes in the distribution of socks, and with the clinic
staff to review immersion foot incidence over the winter months.

Individual/family level
Faith community nurses help staff a clinic for persons living with homelessness in
conjunction with the baccalaureate school of nursing. Faith community nurses pro-
vide foot care and access to dry clean socks and footwear. They also assess clients for
chronic health conditions and, if clients are interested, provide referrals for needed
medical care, smoking cessation, and alcohol treatment. Faith community nurses re-
quest contact information for referral follow-up.

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Relationship with other interventions
Referral and follow-up most often proceed from the implementation of another in-
tervention, such as health teaching, counseling, delegated functions, consultation,
screening, and case-finding (as related to surveillance, disease and health event
investigation, or outreach). It is also an important component of case management.
On occasion, it is implemented in conjunction with advocacy.

Basic steps:
Community/systems level

R E F E R R A L
1. Use links with other providers, organizations,
institutions, and networks to monitor the
community’s capacity to provide the resources
and services for populations at risk
Seeking and maintaining links will convince community partners of the need for
referral resources.

 The public health nurse (PHN) may use social marketing, health teaching,
collaboration, and/or coalition-building to create a compelling reason why other
community partners would want to become involved in developing resources.

 For example, in a faith community, the PHN may need to first explain how faith
community members would benefit.

 In another example, if community businesses are viewed as important to de-
velop referral resources, they will need to see how it would benefit their cus-
tomers and their bottom line.

R E F E R R A L
2. Produce strategies for services and resources
development
There may be gaps in the process of connecting to referral resources, as well as the
need to develop specific resources to meet community needs.

 It is important for the PHN to share their extensive knowledge of the special
needs and unique characteristics of target populations with those in the com-
munity who are considering developing resources or services.

 Public health nurses may work with local businesses, community service organ-
izations (such as the Lions, Rotary, or the Business and Professional Women
Foundation), other health care providers, housing agencies, nonprofit agencies,
and others.

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 The PHN may need to explore how other communities have addressed similar
needs, determined what grants are available, have known what their own
agency’s contribution could be, and generated an initial list of strategy ideas.

R E F E R R A L
3. Participate in implementing those strategies
selected consistent with the public health agency
mission and goals
Public health nurses’ extensive knowledge of the target populations is critical to
building the case for changing agency services and implementing selected strategies.

 Depending on gaps in services and resources as identified in the community as-
sessment, the public health agency may or may not decide to alter services and
resources offered.

 The health board for the agency makes those determinations based on the ex-
tent to which the needs fit with the agency’s mission and overall plan.

F O L L O W – U P
4. Evaluate strategy effectiveness of developing
needed services and resources
The large number of referrals PHNs make and receive place them in a good position to
observe how referral systems function and those systems’ strengths and weaknesses.

 Developing objective ways to gather this data contributes to the evaluation
process.

 For example, critical feedback areas for evaluation include information on the
average number of contacts required for completing a referral, barriers encoun-
tered, and observations on what worked well.

Example: Community/systems level
Faith community nurses identified that parishioners sometimes did not complete the
referral process.

1. Use links with other providers, organizations,
institutions, and networks to monitor the
community’s capacity to provide the resources
and services for populations at risk
Based on feedback collected from parishioners, faith community nurses discern that
lacking transportation to primary care providers is a barrier to referral completion.

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Many parishioners no longer drive or are too frail to use available public transporta-
tion. The faith community nurse network conducts a survey of most frequently used
primary care providers to determine their policies and resources on transportation
assistance; they conclude that most have no policies other than charging clients fees
for missed appointments.

2. Produce strategies for services and resources
development
The FCN network identifies transportation resources in the community and develops
an online resource document.

3. Participate in implementing those strategies
selected consistent with the public health agency
mission and goals
In many cases, the parishioners’ own faith community has a group willing to provide
transportation to medical appointments. In others, a fund is available to support taxi
or Uber/Lyft services.

4. Evaluate strategy effectiveness of developing
needed services and resources
The FCN network reviews data regarding transportation needs at its regular meetings.

Basic steps: Individual/Family Level
The referral process facilitates linking the individuals/families with services or re-
sources required to improve population health. The following steps were adapted
from a tool provided in a manual developed for the Agency for Health Research and
Quality, AHRQ health literacy universal precautions toolkit (Brega et al., 2015).

R E F E R R A L
1. Establish resource referral arrangements
Establish and maintain a working relationship with departments and agencies and
organizations that receive referrals.

 Explore with each organization the required referral information and preference
for receiving referrals.

 Establish a process for sharing client information and any related restrictions.

https://www.ahrq.gov/sites/default/files/publications/files/healthlittoolkit2_4

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R E F E R R A L
2. Determine who initiates the referral
 Assure that the client agrees with the referral and understands the rationale.

Discuss how the referral supports the client’s goals. Collaborate with the client
on initiating the referral process.

 Arranging for needed resources can be daunting process, especially if a client is
unfamiliar with resource networks. Action needed may be beyond a client’s per-
ception of their capabilities, requiring PHN involvement.

 Identify supports, if any, needed to accomplish the referral (e.g., arranging for
transportation, translator, childcare, funding).

R E F E R R A L
3. Assist client in anticipating referral resource
response and maximizing resource interaction
Preparation and rehearsal promote clients’ perceptions of self-capacity.

 If the client agrees, work with them to prepare a list of questions ahead of time.
 If needed, rehearse anticipated interactions with the client.

R E F E R R A L
4. Inquire about and address client reservations
or fears
Client hesitancy or resistance may stem from their previous experiences or perceptions.

R E F E R R A L
5. Establish how and what referral-related
information the public health nurse receives
from the client
A plan is needed to determine the response to the referral.

 Various state and federal data privacy laws regulate the amount and types of
client information may be shared.

 Often a document signed by the client is required specifying this information.

F O L L O W – U P
6. Confirm and document referral status
Confirmation determines whether further action is needed. Documentation estab-
lishes a record of referral status.

More than one attempt may be required to complete the process, especially for re-
ferrals involving multiple appointments or connections.

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F O L L O W – U P
7. If the client has not completed the referral,
reinforce the benefits and review barriers
 Not all barriers can be anticipated, such as vehicle breakdowns, sudden unavail-

ability of childcare, technical difficulties, or limited capacity.
 Clients may require additional anticipatory guidance and supports.

F O L L O W – U P
8. Obtain feedback on referral results
Feedback determines whether further action is needed.

 Confirm that client receives and understands the results of any screenings or
assessments that occurred and any further action needed.

 Data privacy laws may regulate this process.

F O L L O W – U P
9. Obtain feedback from clients on referral
resource quality
Consistent or repeating concerns may call for a quality improvement approach.

Example: Individual/family level
The following example is adapted from a Million Hearts collaboration in Washington
County, Maryland involving the county health department, a medical center, and net-
work faith community nurses supported by the medical center.

The faith community nurses recruited 119 parishioners who either were known to
have hypertension or at-risk for hypertension. The faith community nurses provided
screening and health coaching in a series of four face-to-face meetings over three
months. Of the 109 who completed the program, 18 received referrals to primary
care providers for treatment. Overall, participating parishioners achieved a significant
reduction in blood pressure readings and improved lifestyle satisfaction scores. The
only difference between those referred to primary care and those not referred was
diastolic blood pressure, which was higher in the participants who were referred
(Cooper & Zimmerman, 2017).

1. Establish resource referral arrangements
Faith community nurses use the referral criteria established by the Million Hearts re-
ferral criteria protocol.

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2. Determine who initiates the referral
The faith community nurse clarifies the reason(s) for the referral with the parishioner,
discussing the pros and cons of seeing a primary care provider.

3. Assist client in anticipating referral resource
response and maximizing resource interaction
The faith community nurse discusses what would likely transpire during the appoint-
ment and the expected outcomes or next steps.

4. Inquire about and address any client
reservations or fears
During the discussion, the faith community nurse explores any perceptions or con-
cerns the parishioner might hold that could serve as barriers to acting on the referral.

5. Establish how and what referral-related
information the public health nurse receives
from the client
The faith community nurse provides written information for the parishioner to take
to the appointment, including a release of information form and a brief statement of
the services available from the faith community nurse.

6. Confirm and document referral status
No more than a week after the appointment date, the faith community nurse con-
tacted the parishioner regarding action on the referral.

7. If the client has not completed the referral,
reinforce the benefits and review barriers
The faith community nurse helps the parishioner identify barriers and access re-
sources to address them. This may include arranging for transportation, accompani-
ment, or translation.

8. Obtain feedback from clients on referral
resource quality
At the next face-to-face meeting with the parishioner, the faith community nurse re-
views the results of the PCP appointment and assesses the parishioner’s understand-
ing and expected next steps.

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9. Obtain feedback from clients on referral
resource quality
If concerns occur consistently, the faith community nurse provides the supporting
data to the faith community nurse network and coordinator to discern if it is a sys-
tems issue or provider-specific, and designs appropriate actions.

Key points from evidence
For a description of evidence levels, visit: Introduction: Overview of evidence-based
practice and related topics.

 1. Importance of relationships
Develop relationships with referral resources to ensure those referred will be well-
received.

Level 2 sources:

 Cooper & Zimmerman, 2017
 Strass & Billay, 2008

Level 4 source:

 Brega et al., 2015

Level 5 source:

 Ezeonwu & Berkowitz, 2014

 2. Developing client receptiveness
Client receptiveness toward responding to a referral more likely when the PHN:

 Assesses client readiness to change
 Assists client to see discrepancies between the current and desired states
 Listens reflectively
 Asks open-ended questions
 Refrains from directly countering statements of resistance
 Restates positive or motivating statements made by the client
 Acknowledges the client as an active participant in the referral process
 Acts quickly to contact a client referred for public health services

Level 2 source:

 Flaten, 2011

Level 4 source:

 American Public Health Association & Education Development Center, Inc., 2008

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 3. Resistance to following up
Resistance to following up on referral recommendations is often related to:

 Lack of health insurance, or high-deductible health insurance
 Lack of timely available appointments
 Long provider wait times
 Competing demands for time
 Lack of language parity with provider

Level 1 source:

 Olmos-Ochoa, 2017

 4. Referral and follow-up after screening
Referral and follow-up is the natural next step after screening, when screening results
indicate presence of a risk factor, disease, or illness. Examples for implementing re-
ferral steps based on specific types of screening are:

 Individuals at risk for excessive alcohol or drug use
 Health fairs
 Postpartum depression

Level 3 sources:

 Lucky, Turner, Hall, LeFaver, & de Werk, 2011
 Olmos-Ocha, 2017
 Sword, Busser, Ganann, McMillan, & Swinton, 2008

Level 4 source:

 APHA, 2008

Level 5 source:

 Finnell et al., 2014

 5. Improving quality of life with referral, follow-up, and other
interventions
Referral and follow-up, used together with other interventions, resulted in improved
quality of life among older populations living in the United States and other countries.

Level 2 source:

 Schaffer, Kalfoss, & Glavin, 2017

 6. Increasing completion by explaining referral process
A patient navigator in an urban primary care pediatric clinic in Philadelphia met with
families whose children were referred for developmental delays, to explain the refer-
ral process for an early intervention program and assist families in seeking services.
This intervention contributed to a 79 percent referral completion rate by the families.

Level 3 source:

 Guevara et al., 2016

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 7. Low health literacy
Parents with low health literacy had difficulty with the referral process to early inter-
vention for their children; the parents reported confusion and contact problems.
Strategies to address low health literacy may contribute to referral success.

Level 3 source:

 Jimenez, Barg, Guevara, Gerdes, & Fiks, 2013

Wheel notes

Public health nursing wisdom
In April 1962, Ilse Wolff wrote that to be effective, referrals must be timely, merited,
practical, tailored to the client, client-controlled, and coordinated. At the end of her
article, Wolff concludes:

[E]ven the simplest form of referral requires that the public health nurse
know exactly what she is talking about, that she make sure how the
referral she has made strikes home and whether it is understood in all of
its implications. In this sense, even the most factual form of referral
involves much more than writing an address on a piece of paper and
handing it to the patient or some member of his family (p. 253).

Information and referral
Many local health departments provide information and referral services to the pub-
lic. Community members unsure whom to contact often connect with the local health
department. In smaller local health departments, PHNs may share in offering infor-
mation and referral services.

Making referrals easy
In Boston, HelpSteps, a web-based interface, connects individuals to health and hu-
man services resources. Boston Children’s Hospital and the Boston Public Health
Commission jointly developed HelpSteps (Fleegler et al., 2016).

The Agency for Healthcare Research and Quality (AHRQ) offers a tool, Make referrals
easy (tool #21), with links to other tools for making referrals; readers can find this
tool within Health literacy universal precautions toolkit (2nd ed.) (Brega et al. 2015).

https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool21.html

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References
American Public Health Association & Education Development Center, Inc. (2008). Alcohol

screening and brief intervention: A guide for public health practitioners. Washington DC:
National Highway Traffic Safety Administration, U.S. Department of Transportation.
Retrieved from https://www.integration.samhsa.gov/clinical-
practice/alcohol_screening_and_brief_interventions_a_guide_for_public_health_practit
ioners

Benedict, K. (2018). Estimating the number of homeless in America. San Francisco, CA: The
DataFace, LLC. Retrieved from http://thedataface.com/2018/01/public-
health/american-homelessness

Brega, A. G., Barnard, J., Mabachi, N. M., Weiss, B. D., DeWalt, D. A., Brach, C., et al. (2015). Tool
21: Make referrals easy. In Agency for Health Research and Quality, Health Literacy
Universal Precautions Toolkit, Second Edition. AHRQ Publication No. 15-0023-EF.
Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from
https://www.ahrq.gov/professionals/quality-patient-safety/quality-
resources/tools/literacy-toolkit/healthlittoolkit2-tool21.html

Canadian Observatory on Homelessness. (2017). Homeless Hub: Chronic illnesses/diseases and
mortality. Toronto Canada: York University. Retrieved from http://homelesshub.ca/about-
homelessness/health/chronic-illnessesdiseases-and-mortality

Carpenter, D. (2007). Homeless health care case report: Trench foot. National Health Care for the
Homeless Clinical Practice Resources 3(2). Retrieved from http://www.nhchc.org/wp-
content/uploads/2012/01/CaseReportTrenchFoot062707

Cooper, J. & Zimmerman, W. (2017). The effect of a faith community nurse network and public
health collaboration on hypertension prevention and control. Public Health Nursing, 34,
444-453. doi: 10.1111/phn.12325

Ezeonwu, M., & Berkowitz, B. (2014). A collaborative communitywide health fair: The process and
impacts on the community. Journal of Community Health Nursing, 31, 118-129. doi:
10.1080/07370016.2014.901092

Finnell, D., Nowzari, S., Reimann, B., Fischer, L. Pace, E., & Goplerud, E. (2014). Screening, brief
intervention, and referral to treatment (SBIRT) as an integral part of nursing practice.
Substance Abuse, 325, 114-119. doi: 10.1080/08897077.2014.888384

Flaten, C. (2011). Connecting antepartum teens from a federal food program to a public health
nursing agency: a process-improvement project. Western Journal of Nursing Research.
33(1), 144-145.

Fleegler, E. W., Bottino, C. J., Pikcilingis, A., Baker, B., Kistler, E., & Hassan, A. (2016). Referral system
collaboration between public health and medical systems: A population health case report.
NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. doi:
10.31478/201605f Retrieved from https://nam.edu/referral-system-collaboration-
between-public-health-and-medical-systems-a-population-health-case-report/

Guevara, J. P., Rothman, B., Brooks, E., Gerdes, M., McMillon-Jones, F., & Yun, K. (2016). Patient
navigation to facilitate early intervention referral completion among poor urban
children. Families, Systems, & Health, 34(3), 281-286. doi.org/10.1037/fsh0000207

Jimenez, M. E., Barg, F. K., Guevara, J. P., Gerdes, M., & Fiks, A. G. (2013). The impact of parental
health literacy on the early intervention referral process. Journal of Health Care for the
Poor and Underserved, 24, 1053-1062.

Lucky, D., Turner, B., Hall, M., LeFaver, S., & de Werk, A. (2011). Blood pressure screenings
through community health fairs: Motivating individuals to see health care follow-up.
Journal of Community Health Nursing, 28, 119-129. doi:
10.1080/07370016.2011.588589

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Schaffer, M. A., Kalfoss, M., & Glavin, K. (2017). Public health nursing interventions to promote
quality of life in older adult populations: A systematic review. Journal of Nursing
Education and Practice, 7(11), 92-106. doi: 10.5430/jnep.v7n11p92

Strass, P. & Billay, E. (2008). A public health nursing initiative to promote antenatal health.
Canadian Nurse 104(2), 29-33.

Sword, W., Busser, D., Ganann, R., McMillan, T., & Swinton, M. (2008). Women’s care-seeking
experiences after referral for postpartum depression. Qualitative Health Research,
18(9), 1161-1173. doi: 10.1177/1049732308321736

Taylor, R., Kendor, D., Reitzel, L., & Businelle, M. (2016). Health risk factors and desire to change
among homeless adults. American Journal of Health Behavior, 16(4), 455-460. doi:
org/10.5993/AJHB.40.4.7

U.S. Department of Health & Human Services. (2018). MillionHearts. Retrieved from
https://millionhearts.hhs.gov/

Wolff, I. (1962). Referral—a process and a skill. Nursing Outlook, 10(4), 254-256.

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Case management
Case management is a collaborative process of assessment, planning, facilitation,
care coordination, evaluation, and advocacy for options and services to meet client
needs. It uses communication and available resources to promote safety, quality of
care, and cost-effective outcomes.

Case management activities aim to achieve the following outcomes (Case Manage-
ment Society of America, 2016):

 Increased self-care capabilities of clients
 Efficient use of resources
 New services where needed
 Quality care along a continuum of service delivery
 Decreased fragmentation of care across settings
 Enhanced quality of life
 Cost containment

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Practice-level examples
Population of interest: School-aged children with a diagnosis of asthma or presence
of asthma risk factors.

Problem: Poorly controlled or undiagnosed asthma in school-aged children impairs
ability to attend school, affects academic performance, and impacts parents who
miss work in order to care for an ill child.

Systems level
The school nurse engages the school board’s School Health Advisory Committee to de-
velop a comprehensive set of asthma related policies utilizing the National Heart, Lung,
and Blood Institute’s document, Managing Asthma: A Guide for Schools (2014). The
school nurse begins with the document’s assessment tool, which provides a checklist
of family/staff activities and resources used in asthma case management, How asthma-
friendly is your school? (National Heart, Lung, and Blood Institute, 2014).

Community level
At a regional meeting, school nurses identify parental indifference to providing and
maintaining asthma action plans. The group brainstorms and develops a plan to hold
a series of “asthma update” meetings for parents in conjunction with the local chap-
ter of the American Lung Association and a pediatric nurse practitioner specializing in
asthma management. Part of the meeting content focuses on the importance of the
asthma action plan.

Individual/family level
A family new to the community enrolls their second-grade son in his new school mid-
way in the school year. The father reports that his son, recently diagnosed with asthma,
has difficulty participating in activities requiring physical exertion, and uses an inhaler.
The school nurse initiates developing an individualized health care plan and emergency
action plan that incorporates an asthma action plan. The school nurse refers the family
to a community clinic and assists in establishing an appointment. Following the appoint-
ment, the school nurse follows up with the provider and the parent to develop the
asthma action plan, which includes a list of environmental triggers.

Relationship with other interventions
Case management is often implemented in conjunction with or in sequence to other
interventions. Primary among these is referral and follow-up. Case management pre-
sumes the involvement of other providers or organizations; the process of engaging
them is referral. Making sure that the referral arrangements happen is follow-up.

https://www.nhlbi.nih.gov/files/docs/public/lung/asthma_friendly_checklist_en

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Case management is often preceded by surveillance, disease and health event
investigation, outreach, screening, and case-finding. Implementing case management
frequently relies on health teaching, counseling, consultation, advocacy, and
collaboration. Case management often leads to advocacy and collaboration at the com-
munity and systems levels when needed services are not available in a community.

Basic steps
Case management aims to improve the coordination of client services coordination by
reducing fragmentation across multiple service providers, resulting in enhanced well-
being and quality of life. Protocols for case management vary across settings and level
and population(s) served. For instance, case management provided by a school nurse
at the individual level focuses on optimizing a child or adolescent’s capacity to learn.
Case management provided by public health nurses (PHNs) working with the frail el-
derly population at the community level focuses on promoting safety and chronic dis-
ease monitoring. Case management by occupational health nurses at the systems level
focuses on workplace risk reduction and promoting a healthy work environment.

Regardless of level, the steps or process of conducting case management remain con-
stant. The following steps are adapted from Standards of practice for case manage-
ment practice, revised by the Case Management Society of America (2016), which
essentially parallel the nursing process:

1. Select engaged clients
It is important that clients be engaged in the case management process.

Every organization has a set of criteria determining program eligibility. Organizational
vision, mission, and funding sources mandates drive the criteria. Three important el-
ements to keep in mind:

 Clients assent and engagement is required as the ultimate goal of self-
management.

 Not every client needs case management; discern those who want case man-
agement but do not need it, versus those who need it but do not want it.

 When clients do not meet enrollment criteria, every effort should be made to
refer them to appropriate community resources (for more information, visit
referral and follow-up).

2. Assess the client
Gathering holistic data relevant to the client provides the foundation for planning.

Gather necessary information regarding the client’s circumstances, to develop a case
management plan of care. Information-gathering establishes the client-PHN trust re-
lationship, and reveals clients’ understanding of their circumstances and their en-
gagement capacity. Assessment requires effective communication skills, such as

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open-ended questions, active listening, meaningful conversation, and motivational
interviewing.

a. Analyze assessment findings and determine self-management issues, barriers,
and/or gaps in services, to help identify care needs. This includes analyzing formal
and informal caregiver support networks involved in clients’ circumstances.

b. Repeat assessment as needed to determine the efficacy of the case manage-
ment plan of care and clients’ progress toward achieving target goals.

c. For a systematic comprehensive assessment, consider the social determinants of
health, including needs and strengths (such as living conditions, income adequacy,
access to groceries, transportation, neighborhood safety, and community assets);
behavioral health, including substance use and abuse; and levels of vulnerability.

3. Develop a plan
Reaching goals requires client engagement and a thorough, thoughtful discussion of
clear expectations for the case management role.

The case management plan documents activities, responsible parties (person and ser-
vice organization), and timelines.

The process includes:

 Specifying care requirements, barriers and opportunities for collaboration with
the client, and members of the interprofessional care team in order to provide
effective integrated care

 Identifying goals and/or expected outcomes
 Identifying interventions or actions needed to reach the goals

4. Implement the plan
Effective implementation requires tracking and synchronizing “moving parts.”

 Success typically requires a list of ready alternative resources should any of the
component parts fail.

 Facilitating the coordination of care, services, resources, and health teaching
specified in the planned interventions puts the case management plan into action.

 Effective care coordination requires diligent communication and collaboration
with the client, as well as with the provider and the entire interprofessional
health care team.

5. Monitor and evaluate plan effectiveness and
acceptability
Inevitable changes in client status drives associated plan changes.

 Sometimes payment sources direct frequency of plan evaluation.
 In all circumstances, client instability should direct the frequency of evaluation.

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 Checking in with the client on a regular basis to ascertain status, goals, and out-
comes assures goal attainment. Monitoring activities include:
a. Assessing client’s progress
b. Evaluating if care goals and PHN interventions remain appropriate, rele-

vant, and realistic
c. Determining needed revisions or modifications

6. Discontinue intervention
Goal attainment is the criterion for closure.

 In all cases, the ultimate goal is self-management, which may be achieved prior
to realizing the plan’s stated outcomes.

 Bringing mutually agreed-upon closure to the client-PHN relationship and en-
gagement occurs when:
▪ The client has attained the goals established in the plan of care, or
▪ The best possible outcomes are attained, or
▪ The needs and desires of the client have changed.

Example
A school nurse in Orange, California and others designed a study to investigate
whether second- through sixth-grade children with asthma scored higher in academic
achievement and lower in absenteeism when a school nurse provided case manage-
ment compared to students who did not. [Note: The study’s design also illustrates
red wedge interventions and the natural progression between those interventions
and those of the green wedge (Moricca et al., 2012).]

1. Select engaged clients
Study sample:

 Group I (26 students): Students at risk, whose diagnosis cannot be confirmed
 Group II (40 students): Students at risk, with confirmed diagnosis who have ac-

cepted nurse case management and have been seen by a primary care provider
 Group III (76 students): 16 children who have screened positive but did not have

asthma upon evaluation by their primary care provider, plus 60 randomly se-
lected students from the 412 students who screened negative

2. Assess the client
For Group II students, the school nurse completes child health histories and reviews
current asthma status, including levels of severity and personal best peak expiratory
flow, medications, pattern of exacerbation, triggers, and activity restrictions.

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3. Develop a plan
The school nurse communicated with each child’s parent and primary care provider
to develop or update the asthma action plan.

4. Implement the plan
The school nurse shared the asthma action plan and emergency action plan with each
child’s teachers and others regularly involved with the child.

5. Monitor and evaluate plan effectiveness and
acceptability
The school nurse monitors children’s absences and visits to the office for asthma symp-
toms, and regularly checks in with teachers and parents regarding plan effectiveness.

6. Discontinue intervention
With parental approval, it is likely that school nurse case management will continue
until the child is mature enough to self-manage.

Example notes
1. The results of this study indicated that students receiving case management ser-

vices (the intervention in the study) missed one less day of school than those in
either control group. There was no difference in academic performance. Authors
concluded that, in a population of elementary school Hispanic children in a low-
income neighborhood, case management, along with school nurse screening
and collaboration with a medical provider “resulted in early identification, refer-
ral, and subsequent treatment of students at risk for asthma and may have con-
tributed to reduced absences” (Moricca et al., 2012, p. 109).

2. As to the question of population asthma screening among children, the Ameri-
can Thoracic Association recommended that inclusion with other routine
screenings could be useful, but only in schools and populations with higher-
than-expected rates of childhood asthma with available resources for diagnosis
and treatment (Gerald et al., 2007).

Key points from evidence
For a description of evidence levels, visit: Introduction: Overview of evidence-based
practice and related topics.

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 1. Health care utilization and case management
A critique of systematic reviews of health care utilization outcomes shows case man-
agement reduces hospital readmissions, lengths of stay, institutionalizations, emer-
gency room visits, and hospital/primary care visits. Intensity of case management re-
quired to achieve these reductions remains unknown.

Level 3 source:

 Joo & Huber, 2018

 2. Cost savings, cost avoidance, and case management
The following studies suggest that while nurse case management may be more ex-
pensive to provide, reduction in use of other services (cost savings) or preventing
health issues altogether (cost avoidance) offsets costs in some populations:

 Community-dwelling frail elder population
 Single parents receiving public assistance
 Infants at risk for perinatal hepatitis B virus infection (ensuring they receive post-

exposure prophylaxis and follow-up serology)
 Home health care clients
 Homeless clients with latent tuberculosis infection (who were more compliant

with medication regimen and more knowledgeable)
 School-aged children with asthma

Level 1 sources:

 Kneipp et al., 2011
 Markle-Reid, Browne, Roberts, Gafini, & Byrne, 2002
 Nyamathi, Christiani, Nahid, Gregerson, & Leake, 2006

Level 2 sources:

 Engelke, Swanson, & Guttu, 2014
 Oeseburg, Wynia, Middel, & Reijneveku, 2009
 Ruiz et al., 2017

Level 5 source:

 Libbus & Phillips, 2009

 3. Barriers to case management
A qualitative systematic literature review suggests potential barriers to case manage-
ment implementation:

 Unclear scope of practice
 Case diversity and complexity
 Insufficient training
 Poor collaboration with other providers
 Client relationship challenges

Level 3 source:

 Joo & Huber, 2017

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 4. Improved quality of life among the elderly
A review of nurse-led public health interventions demonstrated that case manage-
ment, along with other public health nursing interventions, contributed to improved
quality of life among elderly populations living in the United States and other countries.

Level 2 source:

 Schaffer, Kalfoss, & Glavin, 2017

 5. Lack of consensus on relationship between care
coordination and case management
Current literature lacks consensus on the relationship between care coordination and
case management:

 Case management, sometimes referred to as care coordination (the umbrella or
broader term) or care management, improves the management of complex
physical, psychological, and/or social problems.

 Care coordination includes the many roles that a case manager may assume and
occurs across various care settings.

 Care coordination contains a specialty practice known as case management.

Level 5 sources:

 Ahmed, 2016
 Cary, 2016
 Harris & Popejoy, 2018
 Lamb & Newhouse, 2018

Wheel notes

Case management or care coordination?
Impact of the 2010 Affordable Care Act
The 2010 federal statute, the Affordable Care Act (ACA), introduced an incentive for
primary care providers to provide “care coordination” as one of five key functions of
the “medical home.” Other key functions include comprehensive care (mental health
and a team-based approach to patient-centered care) that incorporates cultural ap-
propriateness, accessible services, and attention to quality and safety. [For additional
information, see 5 key functions of the medical home (Agency for Healthcare Re-
search and Quality, n.d.).] The ACA defined care coordination as:

[The] deliberate organization of patient care activities between two or
more participants (including the patient) involved in a patient’s care to
facilitate the appropriate delivery of health care services. Organizing care
involves marshalling of personnel and other resources needed to carry
out all required patient care activities and is often managed by the

https://pcmh.ahrq.gov/page/5-key-functions-medical-home

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exchange of information among participants responsible for different
aspects of care (Agency for Healthcare Research and Quality, 2014, p. 3).

The concepts of case management and care coordination overlap. For example, the
definition of case management lists care coordination as a one of several actions or
processes, while care coordination includes actions that also fall within case manage-
ment roles.

Since passage and implementation of the ACA, the nursing profession has published
several position papers and other documents addressing implementation of care
coordination.

 The American Nurses Association (ANA) suggested care coordination is an inher-
ent function of nursing (Camicia et al., 2013). A 2018 book published by the ANA,
Care Coordination: A Blueprint for Action for RNs (Lamb & Newhouse) provides
further explanation.

 Rushton (2015) suggests that care coordination as a concept of the ACA is about
achieving care coordination across populations. She proposes a two-step process:
1) Identify high-risk subpopulations within a given larger population; 2) Design
specific applications of care coordination that will benefit an entire population.

 In 2014, Edmonds and Campbell conducted a survey of PHNs inquiring to what
extent the ACA affected public health nursing practice and applied Rushton’s
concept of care coordination. They concluded that PHNs make substantial con-
tributions to implementing the ACA through care coordination in conjunction
with clinical preventive services, establishment of private-public partnerships,
population-heath data assessment, community health assessment, and mater-
nal and child health home visitation.

Professional certifications
Several organizations offer a certification or credential in case management. Eligibil-
ity and requirements vary. Specialty practices, such as working with adults with disa-
bilities or insurance companies, offer additional credentialing opportunities.

American Nurses Credentialing Center

Professional nurses only.

 Registered Nurse-Board Certified (RN-BC) credential
 Nursing case management certification (RN-BC)

Commission for Case Manager Certification

Open to a variety of professionals.

 Certified in Case Management (CCM) credential
 Certification guide to the CCM® examination (PDF)

American Case Management Association

Open to registered nurses and social workers.

 Accredited in Case Management (ACM) credential focuses on professionals em-
ployed in hospital and health care delivery systems and transitions of care

 ACM™ certification exam

https://www.nursingworld.org/our-certifications/nursing-case-management

https://ccmcertification.org/sites/default/files/docs/2018/ccmc-17-guide-certification-web

https://www.acmaweb.org/acm/default.aspx

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Resources
The following resources provide more detailed information about case management
strategies:

 Lamb, G. & Newhouse, R. (2018). Care coordination: A blueprint for action for
RNs. Silver Spring, MD: American Nurses Association.

 Powell, S. & Tahan, H. (2010). Case management: A practical guide for education
and practice, 3rd ed. Philadelphia: Lippincott, Williams, & Wilkin.

 Self-Management Resource Center. (2019). Help your community take charge of
its health. Retrieved from https://www.selfmanagementresource.com/

 Will, S., Arnold, M., & Zaiger, D. (2017). Individualized healthcare plans for the
school nurse: A comprehensive resource for school nursing management of
health conditions. Forest Lake, MN: Sunrise River Press.

References
Agency for Healthcare Research and Quality. (2014). Chapter 2: What is care coordination? In Care

Coordination Measures Atlas. AHRQ Pub. No. 14-0037-EF. Retrieved from
https://www.ahrq.gov/professionals/prevention-chronic-
care/improve/coordination/atlas2014/chapter2.html

Agency for Healthcare Research and Quality. (n.d.). 5 key functions of the medical home. Retrieved
from https://pcmh.ahrq.gov/page/5-key-functions-medical-home

Ahmed, O. (2016). Disease management, case management, care management, and care
coordination: A framework and a brief manual for care programs and staff. Professional
Case Management 21(3), 127-146. doi: 10.1097/NCM.0000000000000147

Camicia, M., Chamberlain, B., Finnie, R. R., Nalle, M., Lindeke, L. L., Lorenz, L., et al. (2013). The
value of nursing care coordination: A white paper of the American Nurses Association.
Nursing Outlook (61), 490-501. doi: org/10.1016/j.outlook.2013.10.006

Cary, A. (2016). Case Management. In M. Stanhope & J. Lancaster (Eds.), Public health nursing:
Population-centered health care in the community, 9th ed. (pp. 476-502). St. Louis, MO:
Elsevier.

Case Management Society of America. (2016). Standards of practice for case management
practice, revised. Retrieved from http://www.cmsa.org/sopcmcourse/

Edmonds, J., Campbell, L., & Gilder, R. (2016). Public health nursing practice in the Affordable Care
Act era: A national survey. Public Health Nursing 34(1), 50-58. doi: 10.1111/phn.12286

Engelke, M., Swanson, M., & Guttu, M. (2014). Process and outcomes of school nurse case
management for students with asthma. Journal of School Nursing, 30(3), 196-205. doi:
10.1177/1059840513507084

Gerald, L., Sockrider, M., Grad, R., Bender, B. G., Boss, L. P., Galant, S. P., et al. (2007). An official
ATS workshop report: Issues in screening for asthma in children. Proceedings of the
American Thoracic Society, (4), 133-141. Retrieved from
https://www.thoracic.org/statements/resources/pldd/screeningforasthma

Harris, R. C., & Popejoy, L. L. (2018). Case management: An evolving role. Western Journal of
Nursing Research, 41(1), 3-5. doi: 10.1177/0193945918797601

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Joo, J. Y.,& Huber, D. (2017). Barriers in case mangers’ roles: A qualitative systematic review.
Western Journal of Nursing Research, 40(10), 1522-1542 online. doi:
10.1177/0193945917728689

Joo, J. Y., & Huber, D. (2018) Case management effectiveness on health care utilization outcomes:
A systematic review of reviews. Western Journal of Nursing Research, 41, 111-133.
Article first published online. doi.org/10.1177/0193945918762135

Kneipp, S. M., Kairalla, J. A., Lutz, B. J., Pereira, D., Hall, A. G., Flocks, A. G., et al. (2011). Public
health nursing case management for women receiving temporary assistance for needy
families: A randomized controlled trial using community-based participatory research.
American Journal of Public Health, 101(9), 1759-1768. doi: 10.2105/AJPH.2011.300210

Lamb, G., & Newhouse, R. (2018). Care coordination: A blueprint for action for RNs. Silver Spring,
MD: American Nurses Association.

Libbus, M., & Phillips, L. (2009). Public health management of perinatal Hepatitis B virus. Public
Health Nursing 26(4), 353-361. doi: 10.1111/j.1525-1446.2009.00790.x

Markle-Reid, M., Browne, G., Roberts, J., Gafni, A., & Byrne, C. (2002). The 2-year costs and effects
of a public health nursing case management intervention on mood-disordered single
parents on social assistance. Journal of Evaluation in Clinical Practice 8(1), 45-59.

Moricca, M., Grasska, M., BMarthaler, M., Morphew, M., Weismuller, P. C., & Galant, S. P. (2012).
School asthma screening and case management: Attendance and learning outcomes.
Journal of School Nursing 29(2), 104-112. doi: 10.1177/1059840512452668

National Heart, Lung, and Blood Institute. (2014). Managing asthma: A guide for schools. NIH
Publication No. 14-2650. Retrieved from
https://www.nhlbi.nih.gov/files/docs/resources/lung/NACI_ManagingAsthma-
508%20FINAL

Nyamathi, A., Christiani, A., Nahid, P., Gregerson, P., & Leake, B. (2006). A randomized control trial
of two treatment programs for homeless adults with latent tuberculosis infection.
International Journal of Tuberculosis Lung Disease 10(7), 775-782.

Oeseburg, B., Wynia, K, Middel, B., & Reijneveku, S. (2009). Effects of case management for frail
older people or those with chronic illness: A systematic review. Nursing Research, 58(3),
201-210. doi: 10.1097/NNR.0b013e3181a30941

Powell, S. & Tahan, H. (2010). Case management: A practical guide for education and practice, 3rd
ed. Philadelphia: Lippincott, Williams, & Wilkin.

Ruiz, S., Snyder, L., Rotondo, C., Cross-Barnet, C., Colligan, E., & Giuriceo, K. (2017). Innovative
home visit models associated with reductions in costs, hospitalizations, and emergency
department use. Health Affairs 36(3), 225-432. doi: 10.1377/hlthaff.2016.1305

Rushton, S. (2015). The population care coordination process. Professional Case Management
20(5), 230-238. doi: 10.1097/NCM.0000000000000105

Self-Management Resource Center. (2019). Help your community take charge of its health.
Retrieved from https://www.selfmanagementresource.com/

U.S. Dept. Health and Human Services. (2015). Asthma and Hispanic Americans. Retrieved from
https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=60

Will, S., Arnold, M., & Zaiger, D. (2017). Individualized healthcare plans for the school nurse: A
comprehensive resource for school nursing management of health conditions. Forest
Lake, MN: Sunrise River Press.

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Delegated functions
Delegated functions include: 1) direct care tasks a registered professional nurse car-
ries out under the authority of a health care practitioner, as allowed by law, and 2)
direct care tasks a registered professional nurse entrusts to other appropriate per-
sonnel to perform.

Delegator: “One who delegates a nursing responsibility—a delegator may be an
APRN [advanced practice registered nurse], RN, or LPN/VN [licensed practical
nurse/vocational nurse] (where the state nurse practice act allows)” (National Coun-
cil of State Boards of Nursing, 2016, p. 7).

Delegatee: “One who is delegated a nursing responsibility by either an APRN, RN, or
LPN/VN (where state nurse practice Act allows), is competent to perform it, and ver-
bally accepts the responsibility. A delegatee may be an RN, LPN/VN, or unlicensed
assistive personnel” (National Council of State Boards of Nursing, 2016, p. 7). Unli-
censed assistive personnel include nurses’ aides, certified nursing assistants, health
aides, community health workers or other non-licensed persons.

Delegated responsibility: “A nursing activity, skill, or procedure that is transferred
from a licensed nurse to a delegate” (National Council of State Boards of Nursing,
2016, p. 7).

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Only registered nurses can perform responsibilities that involve the nursing process
(assessment, diagnosis, planning, intervention, and evaluation). These responsibili-
ties cannot be delegated (Shannon & Kulbecka, 2013a).

Note: Non-public health nurses (PHNs) in the public health workforce conduct assess-
ment, planning, and implementation of interventions in the delivery of public health
services. Prior to delegating an action, PHNs consider the legal definition specified in
nursing licensure requirements.

Practice-level examples
Population of interest: Schoolchildren taking medication during the school day.

Problem: Inadequate staffing of school nurses in school systems, coupled with fed-
eral mandates to serve children with special needs in school settings, results in in-
creased need for medication administration support.

Systems level
School nurses in the school district work with administrators to develop delegation
policies and guidelines for implementation across the school district.

Community level
The school nurse determines the number of children in each school needing medica-
tion administration, and assigns an unlicensed assistive personnel in each school to
administer the medication. The school nurse communicates the plan to school district
administration, teachers, and primary care physicians, and supervises the unlicensed
assistive personnel in medication administration actions.

Individual/family level
The school nurse delegates medication administration to a teacher during a class field
trip for a student with asthma.

Relationship with other interventions
Delegated functions focus on a single aspect of nursing practice—that of delegation.
The intervention occurs in two ways: the PHN as the initiator of delegated functions
to others (that is, the delegator), and as the recipient of delegated functions from
other health professionals (that is, the delegatee). For PHNs whose assignment in-
volves the delivery of home health services or other health care functions under del-

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egation from a medical provider, the concept of the nurse as the delegatee is un-
doubtedly very familiar. The role of PHNs as delegators or initiators of delegated func-
tions deserves further examination.

Public health nurse-led delegation primarily occurs at the individual/family level of
practice. However, the act of PHN delegation to other health personnel is theoreti-
cally possible in every intervention. For example, a PHN may delegate a family health
aide to do health teaching on parenting to a young family, or delegate parts of vision
and hearing screening to a school health aide, or delegate certain outreach tasks to
unlicensed assistive personnel or a community health worker. The interventions of
collaboration and consultation often occur in the process of delegating a task. In each
of these examples, the PHN exercises independent nursing functions.

Delegated functions is the only intervention where another health professional uses
legal authority to direct PHN actions. None of the other public health nursing inter-
ventions requires another health professional’s authority. Public health nurses prac-
tice the other 16 interventions and delegation to aides, unlicensed assistive person-
nel, community health workers, and other similar positions independently under the
authority of their states’ respective nurse practice acts.

Basic steps
The following steps are adapted from a number of sources (American Nurses Associ-
ation, 2012; American Nurses Association & National Council of State Boards of Nurs-
ing, 2006; Mueller & Vogelsmeier, 2013; Schoon, Porta, & Schaffer, 2019; Spriggle,
2009):

1. Assess the situation
Assessment helps PHNs understand the task, and environment of the delegation
situation.

 What are the client’s needs?
 Are any cultural modifications required?
 What are the conditions that determine stability of client and predictability of

outcome?
 What is the environment where the care is provided?
 Who else is in the client’s environment?

2. Develop the plan
The delegation plan is needed to identify the specific steps of the task to be delegated.

 What is the baseline status of the client?
 What are the specific, unchanging performance steps?
 When and to whom does the unlicensed assistive personnel need to report if

the baseline status changes?
 What expectations need documentation?

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3. Analyze delegation factors
The PHN determines if task is appropriate and legal to delegate.

 Is the task within the PHN’s scope of practice?
 Do federal or state laws, rules, or regulations support the delegation?
 Does the employing organization/agency support the delegation?
 Is the delegating PHN competent to make the delegation decision?
 Is the unlicensed assistive personnel competent to make the delegation decision?
 Is PHN supervision of the unlicensed assistive personnel available?

4. Communicate and clarify expectations
Communication about delegation must be a two-way process to ensure successful
delegation.

 Is the communication clear, concise, correct, and complete?
 Are the following components included in communication and interactions

about the delegation?
▪ Client requirements and characteristics
▪ Clear expectations of what to do, what to report, and when to ask for help
▪ What information needs to be reported
▪ Responsibility for documentation
▪ Clarification of the unlicensed assistive personnel’s understanding of

expectations
▪ The willingness and availability of the PHN to guide and support the unli-

censed assistive personnel
▪ An opportunity for the unlicensed assistive personnel to ask questions and

clarify expectations

5. Evaluate client condition and response
Evaluating of the client response will help determine whether the supervision dele-
gation is adequate.

 How frequently is supervision provided?
 Does the supervision include monitoring client needs, health status, response to

care, and complexity of the delegated task?
 Are the resources and support system adequate?
 Is there compliance with practice standards, policies, and procedures?
 Is the level of supervision appropriate for the delegated task?

6. Evaluate unlicensed assistive personnel’s skills
and performance and provide feedback
Evaluating performance helps improve the delegation process and provides feedback
for the unlicensed assistive personnel.

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 Was the delegation successful? (Spriggle, 2009, p. 107)
▪ Was the task/function/activity performed correctly?
▪ Was the client’s desired and/or expected outcome achieved?
▪ Was the outcome optimal, satisfactory, or unsatisfactory?
▪ Was the communication timely and effective?
▪ What went well? What was challenging?
▪ Were there any problems or concerns? If so, how were they addressed?

 Is there a better way to meet the client need?
 Does the overall plan of care need to be adjusted, or should this approach be

continued?
 Were there any learning moments for the assistant or for the nurse?
 Was the appropriate feedback provided to the assistant regarding performance

of the delegated task?
 Was the assistant acknowledged for accomplishing the task/activity/function?

Example
A school nurse provided training and supervision on medication administration for a
new unlicensed assistive personnel recently hired by the school district. (Since most
delegation interventions occur at the individual level, the example provided illus-
trates the individual level of delegation.)

1. Assess the situation
The elementary school integrates children with special needs into classrooms. Alt-
hough new to the school setting, the unlicensed assistive personnel has personal care
aide experience.

2. Develop the plan
The school nurse reviews the steps of the medication administration process with the
unlicensed assistive personnel.

3. Analyze delegation factors
Delegation factors to consider include characteristics of the students receiving med-
ications, the unlicensed assistive personnel’s prior experience with medication ad-
ministration, and supervision frequency.

4. Communicate and clarify expectations
The school nurse allows adequate time for training and ongoing communication. The
school nurse explains the administration policy on school medication and discusses
expectations for medication administration and reporting requirements. The school

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nurse and unlicensed assistive personnel discuss potential challenges, including med-
ication administration, possible responses, and when to consult the school nurse.

5. Evaluate condition of the client and response
Supervision may include direct observation of the unlicensed assistive personnel’s
performance to determine how the student responds during the medication admin-
istration process. Supervision includes determining if the medication administration
performance complies with school policy.

6. Evaluate unlicensed assistive personnel’s skills
and performance of tasks and provide feedback
The school nurse determines the success of the delegation by analyzing what went
well and how problems were addressed. The school nurse provides feedback to the
unlicensed assistive personnel about strengths in performing medication administra-
tion and any areas for growth.

Public health nurse as delegatee
Although PHNs are primarily independent in their practice under the scope of nursing
practice specified in law (nurse practice acts for each state) there are situations when
tasks are delegated to PHNs.

Example: Client-specific medical provider orders or standing orders for a large popu-
lation would not work for vaccine administration. Health departments develop pro-
tocols for vaccine administration. The Minnesota Department of Health (MDH) pro-
vides information about vaccine protocols online: Vaccine protocols (n.d.).

MDH hosts information and templates for writing vaccine administration orders,
known as a protocol. Vaccine protocols are specific to a disease and include:

 Criteria for proceeding or not proceeding with vaccination
 Indications for groups recommended for vaccination
 Contraindications and precautions
 Actions prescribed: Specifically identified in the template for giving vaccines
 Prescription
 What to do in case of medical emergency or anaphylaxis
 Who to contact for questions or concerns
 Signature of prescriber
 Formatting of protocol

Templates incorporate the name of the drug, dosage, administration route, admin-
istration schedule, and any special instructions.

https://www.health.state.mn.us/people/immunize/hcp/protocols/index.html

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The five rights of the public health nurse as
delegatee
The five rights can be adapted for situations in which the PHN accepts delegation
from a health professional as allowed by law (American Nurses Association & Na-
tional Council of State Boards of Nursing, 2006). Consider the following questions that
address the five rights of delegation:

1. Right task: Is the task within the PHN legal scope of nursing practice?
2. Right circumstance: Is the delegated task or function consistent with agency

policies and procedures?
3. Right person: Does the PHN have the knowledge, training, and experience to

assure safe performance of the task?
4. Right direction or communication: Are the orders/protocols accurate and clear?
5. Right supervision: Who is responsible? Who is accountable? The PHN is limited

by the legal scope of nursing practice.

Key points from evidence
For a description of evidence levels, visit: Introduction: Overview of evidence-based
practice and related topics.

 1. Effective delegation
“Effective delegation is based on one’s state nurse practice act and an understanding
of the concepts of responsibility, authority, and accountability” (Weydt, 2010, p. 1).

Authority: Registered nurse (RN) professional licensure allows transfer of selected
nursing activities in a specific situation to a specific, competent individual.

Responsibility: As a two-way allocated and accepted process, RNs delegate the re-
sponsibility to perform an activity, and assistive personnel accept the responsibility
when they agree to perform the activity.

Accountability: The PHN determines the safety and quality of the outcome of the
delegation process. The PHN assures accountability when verifying that the delegatee
accepts the delegated activity and accompanying responsibility. Accountability in-
volves following a professional code of ethics and adhering to the scope and stand-
ards of nursing practice.

Level 4 source:

 Ballard, Haagenson, & Christiansen, 2016

Level 5 sources:

 Schoon et al., 2019
 Turner, 2016
 Weydt, 2010

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 2. Responsibilities in a delegation model
The National Council of State Boards of Nursing (NCSBN) identifies the following re-
sponsibilities in a delegation model:

Licensed nurse responsibilities:

 Determine patient needs and when to delegate
 Ensure availability to delegate
 Evaluate outcomes of and maintain accountability for delegated responsibility

Delegatee responsibilities:

 Accept activities based on own competence level
 Maintain competence for delegated responsibility
 Maintain accountability for delegated activity

Employer/nurse leader responsibilities:

 Identify a nurse leader
 Determine which nursing responsibilities to delegate, to whom, and in what

circumstances
 Develop delegation policies and procedures
 Periodically evaluate delegation process
 Promote positive culture/work environment

Level 4 source:

 National Council of State Boards of Nursing, 2016

 3. Factors to consider when delegating to assistive personnel
Assess the following factors prior to delegation to unlicensed assistive personnel or
nursing assistive personnel:

 Potential for harm
 Complexity of task
 Requirement of problem solving or critical thinking
 Unpredictability of outcome
 Level of caregiver-patient interaction
 Practice setting

A decision tree guides assignment of a task to nursing assistive personnel. The deci-
sion tree takes users through a series of questions that ends with “Yes, proceed with
delegation” or “No, do not delegate.”

Level 4 sources:

 American Nurses Association & National Council of State Boards of Nursing, 2006
 Association of Women’s Health, Obstetric and Neonatal Nurses, 2016

 4. Facilitators and barriers to effective delegation
When delegating a task, consider factors that facilitate effective delegation and/or
create barriers to effective delegation.

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Facilitators of effective delegation:

 Establishing an environment of trust and cooperation between the PHN and un-
licensed assistive personnel

 Using a teaching and learning approach
 Effective communication
 Providing feedback and follow-up evaluation
 Supportive nursing leadership

Barriers to effective delegation:

 Fear of being disliked
 Inability to give up any control of the situation
 Tendency towards isolation and choosing to complete all tasks alone
 Lack of confidence to delegate to staff who are peers
 Thinking of oneself as the only one who can complete the task
 Lack of knowledge about staff’s capability
 Wide variation in terminology and titles
 Lack of standardized training and allowable tasks
 Competency issues
 Lack of time to provide adequate supervision

Level 3 sources:

 Bittner, & Gravlin, 2009
 Kaernested & Bragadottir, 2012

Level 5 sources:

 Hepsi, 2014
 Tompkins, 2016

 5. Situations where delegation is inappropriate
Situations in which a nursing task should not be delegated include:

 The task is not within the nurse’s scope or practice.
 The nurse does not have a clear understanding of the role and function of the

individual receiving the delegation.
 The nurse is uncertain of the delegate’s suitability for the task, and deems the

person is unable to perform the task competently or is otherwise unmatched to
the client’s needs.

 The assistant does not accept the task.
 The nurse does not have access to the client’s health record to verify relevant

information.
 The client is unstable.
 The task is not allowed by law or by policy, endangers the client, or the outcome

is unpredictable.
 The nurse will not be available to supervise or give direction.

Level 5 source:

 Tompkins, 2016

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 6. Reducing delegation risks in school settings
In school settings, procedure checklists can reduce possible risks of delegation by:

 Demonstrating accountability and competence of both school nurses and unli-
censed assistive personnel

 Reflecting the student’s specific health care needs, while simultaneously pro-
moting reliable and uniform execution of skills by different staff members

 Providing an outline of step-by-step actions for reference and reinforcement of
proper techniques, documenting that the school nurse has demonstrated the
procedure and that delegated personnel can correctly return demonstration

 Documenting that the unlicensed assistive personnel accepts responsibility for
assuming the task

 Providing a regular documentation schedule for monitoring, evaluating, rein-
forcing, and remediating unlicensed assistive personnel skills

Level 5 source:

 Shannon, & Kubelka, 2013b

 7. Delegating medication administration in schools
Recommendations for medication administration in schools identified in studies on
school nurses and medication administration include:

 Establishing an ongoing evaluation of medication administration
 Establishing medication policy regarding responsibility for medication admin-

istration, to whom the task can be delegated, and the amount of training needed
by unlicensed assistive personnel

 Using checklists, decision trees, and videos on procedures to facilitate accurate
medication administration when a school nurse cannot be on site with students

Level 3 sources:

 Anderson et al., 2017
 Canham, Bauer, & Concepcion, 2017
 Ficca & Welk, 2006

 8. Delegating to maternity support workers
In five maternity services in London, tasks delegated to maternity support workers
included taking blood, breastfeeding support, parent education, vital sign observa-
tion, and transfer and discharge procedures. A mixed method evaluation showed a
positive impact on breastfeeding rate and length of stay, and improved quality and
continuity of care.

Level 3 source:

 Griffin, Richardson, & Morris-Thompson, 2012

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 9. Delegating medicine support for home care clients
In the United Kingdom, a program titled “Workforce Innovation for Safe and Effective
(WISE) Medicines Care,” established guidelines for nurses to delegate medicine sup-
port for low-risk home care clients to community care aides. Medicine support pro-
vided by community care aides included prompting clients to take medications, re-
moving medications from packages, crushing tablets, and assisting clients with ad-
ministration of oral and topical medications. Outcomes included no medication inci-
dents, developing trust and confidence in the community care aides, and eliminating
duplicate nurse and community care aide visits, which increased the capacity of
nurses to visit clients with more complex needs.

Level 2 source:

 Lee et al., 2015

Wheel notes

Community health workers
The Affordable Care Act (ACA) of 2010 triggered the growth of community health
workers in clinics, public health agencies, and community-based organizations. CHWs
are “frontline” public health workers with knowledge of the community environment
and client culture. Community health workers contribute to improving health out-
comes and reducing mortality and costs for those experiencing medical and social
challenges. Community health workers often work with underserved and racial-
ly/ethnically diverse populations. They provide outreach, offer health education, fa-
cilitate enrollment in health programs, help with system navigation, advocate for cli-
ents, and facilitate the referral process (Brooks et al., 2014; Tri-City Council for Nurs-
ing, 2017; WellShare International, 2015).

With the growth in the community health worker role, so grows the opportunity for
PHNs to delegate to and supervise community health workers as part of a team-based
approach to delivering public health services (Martin, Perry-Bell, Minier, Glassgow, &
Van Voorhees, 2018). Common program areas for the community health worker role
are nutrition, diabetes, and mental health. Examples of populations served include
the elderly, high-risk children and youth, immigrants, and refugees (WellShare Inter-
national, 2015).

References
American Nurses Association. (2012). Principles for delegation by registered nurses to nursing

assistive personnel in all settings [Position Statement]. Silver Springs, MD: Author.

American Nurses Association & National Council of State Boards of Nursing. (2006). Joint Statement
on Delegation. https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA

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Anderson, L. J. W., Schaffer, M. A., Hiltz, C., O’Leary, S. A., Luehr, R. E., & Yoney, E. L. (2017). Public
health interventions: School nurse practice stories. Journal of School Nursing, pp. 1-11,
online. doi: 10.1177/1059840517721951

Association of Women’s Health, Obstetric and Neonatal Nurses. (2016). The role of unlicensed
assistive personnel (nursing assistive personnel) in the care of women and newborns.
Journal of Obstetric, Gynecologic, and Neonatal Nursing, 45(1), 111-113.

Ballard, K., Haagenson, D., & Christiansen, L. (2016). Scope of nursing practice decision-making
framework. Journal of Nursing Regulation, 7(3), 19-21.

Bittner, N.P. & Gravlin, G. (2009). Critical thinking, delegation, and missed care in nursing practice.
Journal of Nursing Administration, 39(3), 142-146.

Brooks, B. A., Davis, S., Frank-Lightfoot, L., Kulbok, P. A., Poree, S., & Sgarlata, L. (2014). Building a
community health worker program: The key to better care, better outcomes & lower
cost. Published by CommunityHealth Works, Chicago, IL: Authors. Retrieved from
http://www.aone.org/resources/PDFs/CHW_resource

Canham, D. L., Bauer, L., & Concepcion, M. (2017). An audit of medication administration: a
glimpse into school health offices. Journal of School Nursing 23(1), 21-27.

Ficca, M. & Welk, D. (2006). Medication administration practices in Pennsylvania schools. Journal
of School Nursing 122(3), 148-155.

Griffin, R., Richardson, M., & Morris-Thompson, T. (2012). An evaluation of the impact of
maternity support workers. British Journal of Midwifery, 20(12), 884-889.

Hepsi, B. J. (2014). Delegation in nursing management: Common errors. Journal of Asian Nursing
Education and Research, 4(2), 242-244.

Kaernested, B., & Bragadottir, H. (2012). Delegation of registered nurses revisited: Attitudes
towards delegation and preparedness to delegate effectively. Nordic Journal of Nursing
Research & Clinical Studies, 32(1), 10-15.

Lee, Y. C., Beanland, C., Goeman, D., Johnson, A., Thorn, J., Koch, S., et al. (2015). Evaluation of a
support worker role, within a nurse delegation and supervision model, for provision of
medicines support for older people living at home: the Workforce Innovation for Safe
and Effective (WISE) Medicines Care study. Health Services Research, 15, 1-11. doi:
10.1186/s12913-015-1120-9

Martin, M. A., Perry-Bell, K., Minier, M., Glassgow, A. E., & Van Voorhees, B. W. (2018). A real-
world community health worker care coordination model for high-risk children. Health
Promotion Practice (early online), 1-10. doi: 10.1177/1524839918764893

Minnesota Department of Health. (n.d.). Vaccine protocols. Retrieved from
https://www.health.state.mn.us/people/immunize/hcp/protocols/index.html

Mueller, C. & Vogelsmeier, A. (2013). Effective delegation: Understanding responsibility,
authority, and accountability. Journal of Nursing Regulation, 4(3), 20-27.

National Council of State Boards of Nursing. (2016). National guidelines for nursing delegation.
Journal of Nursing Regulation, 7(1), 5-14.

Schoon, P. M., Porta, C. M., & Schaffer, M. A. (2019). Population-based public health clinical manual:
The Henry Street model for nurses, 3rd ed. Indianapolis, IN: Sigma Theta Tau International.

Shannon, R. A. & Kubelka, S. (2013a). Reducing the risks of delegation: Use of procedure skills
checklists for unlicensed assistive personnel in schools, Part 1. NASN School Nurse,
28(4), 178-181.doi: 10.1177/1942602X13489886

Shannon, R. A. & Kubelka, S. (2013b). Reducing the risks of delegation: Use of procedure skills
checklists for unlicensed assistive personnel in schools, Part 2. NASN School Nurse,
28(5): 222-226. doi: 10.1177/1942602X13490030

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Spriggle, M. (2009). Developing a policy for delegation of nursing care in the school setting. The
Journal of School Nursing, 25(2), 98-107. doi: 10.1177/1059840508330756

Tompkins, F. (2016). Delegation in correctional nursing practice. Journal of Correctional Health
Care, 22(3), 218-224. doi: 10.1177/1078345816654229

Tri-Council for Nursing. (2017). The essential role of the registered nurse and integration of
community health workers into community team-based care. Retrieved from
http://www.tricouncilfornursing.org/

Turner, L. P. (2016). The nurse leader in the community. In M. Stanhope & J. Lancaster (Eds.),
Public health nursing: Population-centered health care in the community (pp. 867-884).

WellShare International. (2015). Summary of results from a statewide survey of CHWs in
Minnesota: Perspectives on the community health worker workforce. Retrieved from
http://www.epi.umn.edu/mch/wp-
content/uploads/2015/11/PerspectivesOnTheCHWWorkforce_Summary_WellShare_Se
pt2015

Weydt, A. (2010). Developing delegation skills. Online Journal of Issues in Nursing, 15(2), 1. doi:
10.3912/OJIN.Vol15No02Man01

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In review
A story:

Tuberculosis (TB) is a contagious disease spread through airborne exposure. Adhering
to a treatment regime ensures client recovery and prevents the disease from spread-
ing. Successful treatment involves six- to 12-month multi-drug therapy. This ap-
proach—daily, in-person medication delivery—is called directly observed therapy
(DOT), and serves as the standard care for patients with active TB (Minnesota Depart-
ment of Health, 2016).

The Dakota County Public Health Disease Prevention & Control Unit receives referrals
from the Minnesota Department of Health on active TB cases needing follow-up. Pub-
lic health nurses provide case management for clients with active TB. Public health
nurses make home or workplace DOT visits to clients with active TB to ensure suc-
cessful treatment. In some cases, PHNs delegate DOT to a community health worker.

Video directly observed therapy (VDOT) assists in managing the challenges of active
TB cases. Dakota County PHNs are using asynchronous VDOT, during which clients
record a date and time stamped video of themselves for uploading to a secure online
location for PHN review. Asynchronous VDOT makes DOT more convenient for the
client and public health professional, and results in greater flexibility and cost savings.

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This successful approach by Dakota County demonstrates that VDOT provides the
same level of service as DOT, while increasing customer convenience, ensuring pri-
vacy, and reducing staff time (Dakota County Office of Performance and Analysis,
2017; Dakota County Public Health Department, 2018).

Think about how green wedge interventions (referral and follow-up, case manage-
ment, and delegated functions) occur with TB clients and the use of VDOT.

Application questions
Consider the following questions for the story about managing active TB.

Level of practice
1. What levels of practice do you see occurring in this story?

Referral and follow-up
2. When referring a client for VDOT, which of the basic steps are most important

for assuring client readiness for VDOT?
3. What are cultural considerations to address when referring the client for VDOT?

What possible social, economic, and/or geographic barriers might the PHN need
to address when making the referral?

4. What PHN actions lead to a trusting relationship, and contribute to the decision
of VDOT as a viable client option?

Case management
5. How would the public health nurse document that the quality of care for a client

meets VDOT standards?
6. What client resources support VDOT success?
7. How does VDOT reduce costs for TB treatment?
8. How might technology contribute to increasing/decreasing gaps in communities

with fewer resources?

Delegated functions
9. What benefits arise from delegating DOT to a community health worker? For

the patient? For the public health nurse? For the community health worker?
10. What steps should the public health nurse take to delegate client DOT to a com-

munity health worker?
11. What should the public health nurse communicate to the community health

worker to ensure successful delegation?
12. What cultural considerations should be made when determining whether dele-

gating to a community health worker is appropriate?

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References
Dakota County Office of Performance and Analysis. (2017). Dakota County Public Health Department:

Video directly observed therapy for active tuberculosis treatment. Retrieved from
https://www.co.dakota.mn.us/Government/Analysis/ReportsProjects/Documents/VideoD
irectlyObservedTherapyActiveTB

Dakota County Public Health Department. (2018). Video directly observed therapy for active
tuberculosis treatment update July 2018. Retrieved from
https://www.co.dakota.mn.us/Government/Analysis/ReportsProjects/Documents/Vide
oDirectlyObservedTherapyActiveTBUpdate

Minnesota Department of Health. (2016). Video directly observed therapy (VDOT) – A Minnesota
Perspective. Retrieved from
https://www.health.state.mn.us/diseases/tb/lph/vdot/vdotmn

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Health teaching
Health teaching involves sharing information and experiences through educational
activities designed to improve health knowledge, attitudes, behaviors, and skills
(Friedman, Cosby, Boyko, Hatton-Bauer, & Turnbull, 2011).

 Knowledge: Fact or condition of knowing something with familiarity gained
through experience association (Merriam-Webster Dictionary, 2017)

 Attitude: Mental position, feeling, or emotion with regard to a fact or state; may
be negative or positive (Merriam-Webster Dictionary, 2017)

 Behavior: Response of an individual, group, or species to its environment
(Merriam-Webster Dictionary, 2017)

 Skill: Proficiency, facility, or dexterity acquired or developed through training or
experience (The Free Dictionary, 2017)

Practice-level examples
Population of interest: Pregnant and childbearing women.

Problem: Alcohol use during pregnancy.

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Systems level
A public health nurse (PHN) provides an in-service training to physicians, midwives,
and family planning specialists, highlighting new research findings on the effect of
alcohol on pregnancy. The PHN promotes evidence-based and standardized care for
pregnant women that includes screening for alcohol use and counseling regarding
the danger of alcohol use during pregnancy.

Community level
A PHN participates in a county task force that aims to reduce alcohol use by women
during pre-conceptual and child-bearing years. The group develops a series of posters
and distributes them to liquor retailers and establishments serving alcoholic beverages.

Individual/family level
A PHN incorporates information on the impact of alcohol use on fetal development into
the reproductive health class taught to high school and community college students.

Relationship to other interventions
Health teaching is used in conjunction with virtually all interventions. It is frequently
implemented in conjunction with, or sequentially to, counseling and/or consultation.
Counseling focuses on the emotional component inherent in any attempt to change,
while consultation seeks to generate alternative solutions to problems.

Similar to health teaching, social marketing strategies aim to change behavior by
communicating information, but includes marketing techniques. In addition, the PHN
is often in collaboration with others when designing health teaching strategies.

Basic steps
The education process is a “systematic, se-
quential, logical, scientifically based,
planned course of action consisting of two
major interdependent operations: teaching
and learning” (Bastable, 2017, p. 10). Inter-
actions between the teacher and learner are
intended to lead to mutually desired behav-
ior changes (outcomes).

Public health nurses can use the ASSURE
Model (Bastable, 2017) to design health
teaching activities.

ASSURE Model

A Analyze the learner.

S State the objectives.

S Select the instructional
methods and materials.

U Utilize materials.

R Require learner performance.

E Evaluate the teaching plan and
revise as necessary.

Source: Bastable (2017).

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A: Analyze the learner
Assessing the individual/family, community, or system is essential to determine ef-
fective teaching-learning strategies.

Use the Learner Readiness Assessment (PEEK) to assess individuals or small groups
(Schoon, Porta, & Schaffer, 2019).

P: Physical and developmental
health status

 Cognitive abilities
 Communication abilities (verbal,

nonverbal, written)
 Development level
 Individual
 Family
 Physical environment

E: Emotional

 Current stress, coping, resilience
 Motivation for learning
 Readiness for learning

E: Experiential and social

 Culture and language
 Cultural health beliefs and

practices
 Past experiences with health

care and specific health topics

K: Knowledge

 Education/reading level
 Language literacy and learning

style
 Present knowledge on topic/

past health education
 Health literacy

S: State the objectives
Learning objectives help identify client outcomes and guide selection of teaching-
learning strategies.

Stated outcomes should be specific, measureable, achievable, realistic, and time-
bound (SMART) (Centers for Disease Control and Prevention, 2015):

 Specific: Concrete, detailed, and well defined
 Measureable: Provides means of measurement and comparison via numbers

and quantities
 Achievable: Feasible and easy to put into action
 Realistic: Considers capacity and constraints such as resources, personnel, cost,

and time frame
 Time-bound: A time frame that sets boundaries around the objective

S: Select instructional methods and materials
Select instructional methods based upon teaching-learning principles (below) and
whether methods are appropriate to client learning style. Select effective and
evidence-based learning materials.

Public health nurses are intentional about selecting effective methods and materials
from an incredible variety of available tools including presentations, print materials,
and media.

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These teaching-learning principles are adapted from Schoon et al. (2019):

 Target health teaching to a specific audience.
 Learner readiness affects what is learned.
 Motivation affects learning.
 Active learning is best (demonstration).
 Use written learning objectives to guide teaching plan.
 Avoid professional jargon and overwhelming learner with excessive information.
 Use visuals to enhance print and verbal messages.
 Create a comfortable learning environment.
 Integrate a variety of learning styles (VARK) (Inott & Kenney, 2011):

▪ V: Visual learners process information by seeing illustrations and words.
▪ A: Auditory learners prefer discussion, speaking, and talking through

information.
▪ R: Reading or writing learners prefer information displayed in text (words).
▪ K: Kinesthetic learners prefer learning through experience and practice

(physical activity and touch).
 Use best evidence and give credit to information source.
 Link information to prior knowledge.
 Allow time for interaction and applying information.
 Reinforce written materials with verbal messages.
 Use multiple methods to assess understanding of content.

U: Utilize materials
The teaching plan specifies the materials and strategies, based on teaching-learning
principles.

Implement the teaching plan (Schoon et al., 2019)

 Schedule (reasonable time allotted for each activity)
 Location (distraction-free, adequate room, lighting, comfort)
 Learner outcomes (achievable and measureable within time frame)
 Brief content outline (main topics with learning activities)
 Teaching-learning strategies (consider learning styles of individual or group)
 Resources (materials and references)
 Evaluation (specific and measureable)

R: Require learner performance
Including learner interactions, demonstration, or other involvement will increase
learner engagement and learning.

These learner engagement guiding principles are adapted from Yardley, Morrison,
Bradbury, & Muller (2015):

 Promote client autonomy by offering choices where possible (goals, tools, tim-
ing, and method of implementation).

 Promote client competence by providing clear structure and guidance,
examples, stories, modeling, and opportunities for goal setting.

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 Promote a positive emotional experience and sense of relatedness by using pos-
itive language; acknowledging and addressing concerns; creating communica-
tions that are enjoyable, relevant, and helpful to the user; and providing imme-
diate and rewarding feedback.

E: Evaluate and revise
Evaluation and revision cycles enhance implementation effectiveness.

Sample evaluation questions include:

 Were the objectives achieved in a timely manner?
 How do you know the objectives were achieved?
 What strategies contributed to successful achievement of the objectives?
 If the objectives were not achieved, what barriers or factors interfered with

learning?
 What could be done differently to achieve the outcomes?

Example
The PHN teaches a reproductive health class for at-risk high school students regarding
the impact of alcohol use on fetal development. The PHN uses the ASSURE model to
guide the intervention.

A: Analyze the learner
PEEK Model:

 P: Physical and developmental health status: 15 to 18 years old, some are preg-
nant, average communication skills, majority from low-income families living in
an urban area.

 E: Emotional: High level of stress related to unstable family life, pregnancy,
and/or balancing educational and work responsibilities; interested in learning
about reproduction.

 E: Experiential and social: English is a first language for most and a second lan-
guage for others, racially and ethnically diverse, alcohol and fetal health is one
of a series of health topics.

 K: Knowledge: Reading level varies, preferred learning style includes visual and
kinesthetic learning activities.

S: State the objectives
Upon completion of the post-test on the reproductive unit, 80 percent of at-risk high
school students in the reproductive health class will have correctly communicated
two ways that drinking alcohol during pregnancy could affect infant health.

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SMART framework:

 Specific: Effect of alcohol on fetal development during pregnancy is present in
age-appropriate materials

 Measureable: Correct answers on post-test
 Attainable: Content can be learned during the class period
 Realistic: Two ways that drinking alcohol during pregnancy could affect infant

health on the post-test
 Time-bound: The post-test at the end of the reproductive unit

S: Select instructional methods and materials
Students need active learning experiences and materials at appropriate health liter-
acy levels (grade five for English language learners) to promote knowledge attain-
ment. All educational material should be analyzed carefully to ensure that they are at
the recommended fifth grade level (Wilson, 2009). Visuals such as a video and clear
handouts enhance learning. The classroom arrangement includes tables and chairs to
promote small group discussion and room for active learning.

U: Utilize materials
The class is 50 minutes long, including time for interactive activities. The content out-
line proposes the following activities and materials: student discussion about the ef-
fects of alcohol on the mind and body of the pregnant woman and the fetus, a video
on fetal alcohol syndrome with opportunity for questions, small group role-playing of
a peer-to-peer conversation about the effects of alcohol on the fetus, and reviewing
a handout capturing major points of the presentation.

R: Require learner performance
After showing a video on fetal alcohol syndrome:

 Engage students in a discussion about what they have seen or heard in the past
about fetal alcohol syndrome.

 Facilitate a role-playing activity capturing a peer-to-peer conversation regarding
the effects of alcohol on the fetus.

E: Evaluate and revise
Determine what percentage of students correctly answered the post-test questions
about the effects of drinking alcohol on infant health. If the goal is not met, revise the
teaching plan as appropriate.

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Key points from evidence
For a description of evidence levels, visit: Introduction: Overview of evidence-based
practice and related topics.

 1. Best practices for written messages
Use the following to improve written messages:

 Active voice (e.g., “Eat five servings of fruits and vegetables” instead of “Five
servings should be eaten”)

 Subheadings
 Short sentences and paragraphs
 Summarized main points
 Five or fewer items in a list
 Font changes (underline or bold) to emphasize points
 Large, readable font
 Short blocks of text
 White space as part of the design
 Contrast between background and printed text for readability
 Pictures to enhance memory

Level 5 source:

 Schoon et al., 2019

 2. Tailored health interventions
Tailoring health teaching interventions to meet specific needs contributes to improved
health outcomes; this includes cultural factors of individuals, groups, or communities.

Level 1 source:

 Jesse et al., 2015

Level 2 source:

 Ailinger, Martyn, Lasus, & Garcia, 2010

 3. Support and counseling in education
Incorporate support and counseling into education, as it contributes to improved self-
care.

Level 1 source:

 Mohammadpour, Sharghi, Khosravan, Alami, & Akhond, 2015

 4. Shared decision-making
Shared decision-making regarding health teaching strategies results in better health
outcomes for individuals/families, communities, and systems. Shared decision-making

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may be referred to as client- or patient-centered, person-based, or concordance (a
partnership between nurse and client where shared decision-making takes place).

Level 5 sources:

 McKinnon, 2013
 Yardley et al., 2015

 5. Behavior change is an active process
Knowledge and information alone does not lead to behavior change. Knowledge
transmission is an active process that encompasses continuing dialogue, interactions,
and partnerships within and between knowledge creators and users.

Level 3 source:

 Mrazik et al., 2015

 6. Using theories to guide interventions
Health behavior theories are useful for guiding health teaching interventions. The
Health Belief Model and the Stages of Change Model are particularly applicable to
designing and implementing the health teaching intervention. The Health Belief
Model is a framework for motivating people to take positive health actions; it uses
the desire to avoid a negative health consequence as the prime motivator. The Stages
of Change Model proposes five stages that describe the behavior change process:
pre-contemplation, contemplation, preparation, action, and maintenance.

Level 5 source:

 Reimer & Glanz, 2005

 7. Promoting the use of evidence in practice
Organizations promote the use of evidence in practice by providing access to practice
guidelines and protocols.

Level 3 sources:

 Ashby et al., 2012
 Baxter et al., 2010
 Callego, & Geer, 2012

 8. Effective health risk communication
Health risk communication, or crisis communication, is a strategy to improve health
knowledge; attitudes; behaviors; and skills of individuals/families, communities, or
systems in the context of perceived threats of harm or hazard. Risk communication
conveys to the public the reality of the threat, to allay fears and/or increase public
concern and prompt action. Effective health risk communication considers a popula-
tion’s cultural and socioeconomic characteristics, strategies to foster self-efficacy and
trust in the intervention plan, and prepares the population for uncertainty and the

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changing risk event. The following principles summarize best practices for guiding
public health risk communication:

 Accept and involve stakeholders as legitimate partners.
 Listen to what people are saying.
 Be truthful, honest, frank, and open.
 Coordinate, collaborate, and partner with other credible sources.
 Meet the needs (who, what, why, when, where, and how) of the media.
 Communicate clearly and with compassion.
 Plan thoroughly and carefully.

Level 4 sources:

 Centers for Disease Control and Prevention, 2014
 Environmental Protection Agency, 2016
 Vaughan & Tinker, 2009

Level 5 source:

 Covello, 2003

Wheel notes

Social media
Using social media to share information is on the rise and ripe for teaching interven-
tions. The ASSURE Model provides a framework for designing health teaching inter-
ventions using social media. Public health nurses need to consider how social media
impacts health communication and how communication using social media can occur
effectively at the individual/family, community, and systems levels. Measures to pro-
tect confidentiality and client privacy need to be integrated into health teaching in-
terventions that incorporate social media strategies. Public health nurses must also
follow organizational and agency social media policies.

Health literacy
Health literacy is “the degree to which individuals have the capacity to obtain, pro-
cess, and understand basic health information and services needed to make appro-
priate health decisions” (Institute of Medicine of the National Academies, 2009, p. 6).
Clients with low health literacy experience worse health outcomes (Gordon, Barry,
Dunn, & King, 2011; Mayer & Villaire, 2011). The Agency for Healthcare Research and
Quality developed the AHRQ Health Literacy Universal Precautions Toolkit, which
provides tools for simplifying verbal and written communication and integrating self-
management and support systems to improve client health literacy (Agency for
Healthcare Research and Quality, 2016).

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Interprofessional collaboration
Health teaching is often a collaborative activity where the PHN designs and imple-
ments the intervention with a variety of public health practitioners. It is important for
the PHN to recognize that health teaching is a shared interprofessional domain, and
to appreciate the knowledge and skills other practitioners bring to health teaching
(Ashby et al., 2012; Baxter et al., 2010). At a systems level, PHNs may work with a
team to create messages for public health campaigns (Callego, 2012). An example is
communicating the effectiveness and safety of vaccines. Health teaching at a systems
level may overlap with social marketing. For additional strategies for communicating
information at the systems level, visit the social marketing intervention.

References
Agency for Healthcare Research and Quality. (2016). AHRQ Health Literacy Universal Precautions

Toolkit. Access at https://www.ahrq.gov/professionals/quality-patient-safety/quality-
resources/tools/literacy-toolkit/index.html

Ailinger, R. L., Martyn, D., Lasus, H., & Garcia, N. L. (2010). The effect of a cultural intervention
adherence to latent tuberculosis infection therapy in Latino immigrants. Public Health
Nursing, 27(2), 115-120.

Ashby, S. James, C., Plotnikoff, R., Collins, C., Guest, M., Kable, A., et al. (2012). Survey of
Australian practitioners’ provision of healthy lifestyle advice to clients who are obese.
Nursing and Health Sciences, 14, 189-196. doi: 10.1111/j.1442-2018.2012.00677.x

Bastable, S. (2017). Essentials of patient education. Burlington, MA: Jones & Bartlett Learning.

Baxter, S., Everson-Hock, E., Messina, J., Guillaume, L., Burrows, J., & Goyder, E. (2010). Factors
relating to the uptake of interventions for smoking cessation among pregnant women: A
systematic review and qualitative synthesis. Nicotine & Tobacco Research, 12(7), 685-
694. doi: 10.1093/ntr/ntq072

Callego, F. P. & Geer, L. A. (2012). A community-based approach to disseminate health
information on the hazards of prenatal mercury exposure in Brooklyn, NY. Journal of
Community Health, 37, 745-753. doi: 10.1007/s10900-012-9575-7

Centers for Disease Control and Prevention. (2014). Crisis and emergency risk communication
(CERC) manual. Retrieved from https://emergency.cdc.gov/cerc/manual/index.asp

Centers for Disease Control and Prevention. (2015). Develop SMART objectives. Retrieved from
https://www.cdc.gov/phcommunities/resourcekit/evaluate/smart_objectives.html

Covello, V. (2003). Best practices in public health risk and crisis communication. Journal of Health
Communication, 8, 5-8. doi: 10.1080/10810730390224802

Environmental Protection Agency. (2016). Risk communication. Retrieved from
https://www.epa.gov/risk/risk-communication

Free Dictionary. (2017). http://www.thefreedictionary.com/

Friedman, A. J., Cosby, R., Boyko, S., Hatton-Bauer, J. & Turnbull, G. (2011). Effective teaching
strategies and methods of delivery for patient education: A systematic review and
practice guideline recommendations. Journal of Cancer Education, 26, 12-21. doi
10.1007/s13187-010-0183-x

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Gordon, S, C., Barry, C. D., Dunn, D. J., & King, B. (2011). Clarifying a vision for health literacy: A
holistic school-based community approach. Holistic Nursing Practice, 25(2), 120-16. doi:
10.1097/HNP.0b013e3182157c34

Inott, T. & Kenney, B. B. (2011). Assessing learning styles: Practical tips for patient education.
Nursing Clinics of North America, 46, 313-320. doi: 10.1016j.cnur.2011.05.006

Institute of Medicine of the National Academies. (2009). Measures of health literacy: Workshop
summary. Washington, DC: National Academies Press.

Jesse, D. E., Gaynes, B. N., Feldhousen, E. B., Newton, E. R., Bunch, S., & Hollon, S. D. (2015).
Performance of a culturally tailored cognitive-behavioral intervention integrated in a
public health setting to reduce risk of antepartum depression: A randomized controlled
trial. Journal of Midwifery & Women’s Health, 60(5), 578-592. doi:10.1111/jmwh.12308

Mayer, G. & Villaire, M. (2011). Health literacy: An opportunity for nurses to lead by example.
Nursing Outlook, 59(2), 59-60. doi: 10.1016/j.outlook.2011.01.00

Merriam-Webster Dictionary. (2017). https://www.merriam-webster.com/

McKinnon, J. (2013). The case for concordance: value and application in nursing practice. British
Journal of Nursing, 22(13), 776-771.

Mohammadpour, A., Sharghi, N. R., Khosravan, S., Alami, A., & Akhond, M. (2015). The effect of a
supportive educational intervention developed based on the Orem’s self-care theory on
the self-care ability of patients with myocardial infarction: A randomised controlled trial.
Journal of Clinical Nursing, 24, 1686–1692. doi: 10.1111/jocn.12775

Mrazik, M., Dennison, C. R., Brooks, B. L., Yeates, K. O., Babul, S., & Naidu, D. (2015). A qualitative
review of sports concussion education: prime time for evidence-based knowledge
translation. British Journal of Sports Medicine, 49, 1548-1553. doi:10.1136/bjsports-
2015-094848

Reimer, B. K. & Glanz, K. (2005). Theory at a glance: A guide for health promotion practice.
National Cancer Institute. NIH Publication No. 05-3896.

Vaughan, E. & Tinker, T. (2009). Effective health risk communication about pandemic influenza for
vulnerable populations. American Journal of Public Health, Supplement 2(99), S324-S332.

Wilson, M. (2009). Readability and patient education materials used for low-income populations.
Clinical Nurse Specialist CNS, 23, 33-40. doi: 10.1097/01.NUR.0000343079.50214.31

Yardley, L., Morrison, L., Bradbury, K., & Muller, I. (2015). The person-based approach to
intervention development: Application to digital health-related behavior change
interventions. Journal of Medical Internet Research, 17(1), e30. doi: 10.2196/jmir.4055

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Counseling
Counseling involves establishing an interpersonal relationship at an emotional level,
with the goal of increased or enhanced capacity for self-care and coping.

 Counseling, often paired with health teaching, explores the emotional response
to integrating new health information into life’s circumstances.

 The effectiveness of counseling depends on the ability of the public health nurse
(PHN) to develop a supportive, trusting relationship with the client.

 There is a distinction between using counseling skills in public health nursing
practice and being a counselor or psychotherapist. Public health nurses are not
counselors or psychotherapists unless they have had additional education for
those roles. However, like counselors and psychotherapists, PHNs must be good
listeners.

Practice-level examples
Population of interest: All adolescents and their parents.

Problem: Depression and the risk for suicide.

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Systems level
A school suffers a devastating loss when three teens carry out a suicide pact. In re-
sponse to the school’s distress, the PHN partners with parents, students, school social
workers, school service providers, the school nurse, health teachers, and school clubs
to design a teen suicide district-wide response plan to prevent repeats of the suicide
cluster. The plan outlines the roles that each department of the school will play if a
suicide or attempted suicide occurs. The plan also includes the development and im-
plementation of a school-wide resiliency and well-being initiative.

Community level
Public health nurses partner with mental health centers, schools, and faith commu-
nities to raise community awareness about depression in teens. Their goal is to
change community acceptance of depression—from “just something that teens go
through” to the realization that depression is a real, treatable problem. They use bill-
boards, radio spots, movie trailers, and social media to disseminate the message.

Individual/family level
A PHN facilitates a support group for families coping with the loss of a member
through suicide.

Relationship to other interventions
Counseling is an intervention frequently implemented in conjunction with, or sequen-
tially to, health teaching and/or consultation. Health teaching influences the
knowledge, attitudes, values, beliefs, practices, skills, and behaviors of individu-
als/families, communities, or systems. Counseling focuses on the emotional compo-
nent inherent in any attempt to change. Consultation seeks to generate alternative
solutions to problems.

For example, if a PHN provides health teaching about the prevalence, incidence, and
causes of family violence at a community meeting, it is likely to trigger emotional
responses. Implementing counseling strategies in conjunction with health teaching
allows the PHN to build on the energy associated with an emotional response and
further enhances the learning opportunity. A community may respond to information
on family violence with powerful emotions like anger, outrage, fear, and grief. These
emotions can motivate the community to learn more about the problem and its
causes. If the community uses this new information to decide what to do to change
its tolerance of family violence, the PHN may assist the community in exploring alter-
natives. In that situation, the PHN provides consultation. Community and systems-
level counseling may also lead to policy development and enforcement.

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PHNs use collaboration with other professionals, communities, and health care or-
ganizations to identify individuals/families, communities, or systems that could ben-
efit from counseling resources; PHNs can then use referral and follow-up to connect
clients with counseling resources. For example, at the systems level, school nurses in
a large school district may collaborate with a local mental health care organization
and a hospital to provide mental health services to schoolchildren. The school nurses
refer students to after-school social skills groups, therapy provided at school, and
classes on preparing meals and healthy eating.

At the community level, PHNs may use social marketing to influence the community.

Basic steps

1. Establish a therapeutic relationship with the
client (individual/family, community, or systems)
A therapeutic relationship is the foundation for a trusting, supportive relationship
that prepares the PHN and client for the counseling intervention.

The therapeutic relationship is grounded in an interpersonal process that
occurs between the nurse and the client(s). A therapeutic relationship is a
purposeful, goal directed relationship that is directed at advancing the
best interest and outcome of the client (Registered Nurses Association of
Ontario, 2002, 2006, p. 13).

The therapeutic nurse-client relationship protects the patient’s dignity, autonomy,
and privacy and allows for the development of trust and respect (National Council of
State Boards of Nursing, 2014, p. 4).

Expert knowledge can effectively establish a therapeutic relationship. This knowledge
includes the following domains: background (education and life experience); inter-
personal caring and development theory; culture, diversity influences, and determi-
nants of health; person; health/illness; the broad influences on health care and health
care policy; and systems (Registered Nurses Association of Ontario, 2002, 2006).

Abilities PHNs need to establish therapeutic relationships include: 1) self-awareness;
2) self-knowledge; 3) empathy; and 4) awareness of ethics, boundaries, and limits of
the professional role. Active listening, trust, respect, being genuine, empathy, using
a non-judgmental and non-confrontational approach, and responding to client con-
cerns are important qualities of the therapeutic relationship (Duaso & Duncan, 2012;
Registered Nurses Association of Ontario, 2002, 2006).

The therapeutic relationship includes the following three phases (Registered Nurses
Association of Ontario, 2002, 2006):

 Beginning or orientation phase: The PHN and the client establish relationship
parameters, including place of meeting, length, frequency, role or service of-
fered, confidentiality, and duration of relationship. They begin to develop trust,
and recognize one another as partners in the relationship.

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 Middle or working phase: The PHN provides the counseling intervention and other
relevant interventions, such as screening and referral and follow-up. The PHN and
client develop an action plan to address identified problems and concerns.

 Ending or resolution phase: When problems and concerns have been ad-
dressed, the PHN and client end the relationship based on a mutual decision and
celebrate goals met. If the goal(s) have not been accomplished, the PHN assists
the client in identifying another option to address the problem or concern.

2. Maintain professional boundaries
The nature of the counseling relationship requires the PHN to be alert to the possi-
bility of violation of professional boundaries.

A boundary violation may occur if the PHN becomes overly involved in a counseling
intervention. The PHN needs to be aware of the potential for boundary violations
when using the counseling intervention. The National Council of State Boards of Nurs-
ing (2014, p. 5) identified potential red flags leading to boundary violations:

 Discussing your intimate or personal issues with a patient
 Engaging in behaviors that could reasonably be interpreted as flirting
 Keeping secrets with a patient or for a patient
 Believing that you are the only one who truly understands or can help the patient
 Spending more time than is necessary with a particular patient
 Speaking poorly about colleagues or your employment setting with the patient

and/or family
 Showing favoritism
 Meeting a patient in settings besides those used to provide direct patient care

or when you are not at work

Strategies to maintain professional boundaries include discerning the difference be-
tween professional relationships and social relationships, and using reflection to dis-
cuss challenges around client relationships and boundaries with one’s supervisor and
colleagues. Examples of boundary maintenance challenges in PHN-client relation-
ships include a client request to be a Facebook friend, or requests from neighbors for
information about the well-being of an elderly client living in an apartment building
(Schoon, Porta, & Schaffer, 2019).

3. Self-monitor the relationship
Self-monitoring is important for evaluating the appropriateness and effectiveness of
counseling beyond one or two sessions. Ask the following questions:

 Who benefits from the counseling relationship?
 Are the goals mutually determined?
 What progress is being made toward achieving the goals?
 Is the client engaged in the counseling?
 What kind of feedback are you receiving from the client about the effectiveness

of the counseling?
 For long-term counseling relationships, is evaluative supervision available to the

PHN?

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4. Select effective strategies and tailor them
Tailor strategies to address the specific health concern. Consider individual, group,
telephone, email, or web-based sessions. Clients are more likely to positively view
counseling interventions that are tailored to their preference and/or convenience
(Kardeen, Smith, & Thornton, 2010; Pignone et al., 2003; Tahir & Al-Sadat, 2013).

5. Use an evidence-based behavior change model
Consider using the five A’s or motivational interviewing. Evidence supports both
models’ effectiveness in using brief counseling aimed to change health behavior.

The following examples apply the five A’s and motivational interviewing to a
community-level counseling intervention, to address youth depression and the risk
for suicide (Whitlock, Orleans, Pender, & Allen, 2002).

Five A’s
The National Cancer Institute developed the four A’s to guide physicians in talking
about smoking cessation with primary care patients. The Canadian Task Force on Pre-
ventive Health Care added the fifth step, “agree.” The U.S. Public Health Service has
used the five A’s in clinical trials on smoking cessation.

Assess behavioral health risks and factors affecting goals for change

Example: There is a need to address youth suicide prevention in the
community because of an increase in the incidence of suicide among 15-
to 19-year-olds.

Advise by giving clear, specific, and personalized behavior change information about
personal health harms/benefits.

Example: Provide information about the incidence of depression in youth
and the risk for suicide.

Agree by mutually selecting a treatment goals and strategies that are based on client
interest and willingness to change behavior.

Example: Collaborate with mental health centers, schools, and faith
communities to select preferred strategies for addressing youth
depression and suicide.

Assist with behavior change strategies (such as self-help and/or counseling) to help
the client acquire the skills, confidence, and social/environmental supports for be-
havior change.

Example: Provide evidence on strategy effectiveness to team/experts that
develop strategies to promote community awareness about youth
depression and suicide.

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Arrange follow-up contacts to provide ongoing assistance/support and to adjust the
plan as needed.

Example: Make sure referral resources for youth depression and suicide
are in place, and evaluate whether community attitudes have changed to
viewing the problem as significant enough to address.

Motivational interviewing
The theory of motivational interviewing evolved out of scientific study and practice,
beginning with the work of William R. Miller on addressing problem drinking in the
1980s (Richardson, 2012). A relational component emphasizes empathy, and a tech-
nical component promotes client engagement in the behavior change process (Miller
& Rose, 2009).

Expressing empathy: Understand client perspectives.

Example: Acknowledge that community organizations serving youth are
upset about the increase in incidence of youth suicide.

Reducing ambivalence: Evaluate pros and cons of behavior and change.

Example: Discuss the advantages and disadvantages of increasing
community awareness via social media about youth depression and suicide.

Developing discrepancy: Explore conflict between current behavior and important
goals and values.

Example: Dialogue about the increasing incidence of youth suicide in the
community and the connection to the silence surrounding depression.

Rolling with resistance: Acknowledge feelings, accept ambivalence, stay calm, ad-
dress discrepancy.

Example: When different viewpoints and strong emotions surface in
discussion about response to youth depression and suicide, listen to
everyone’s voices, stay calm, and address evidence that supports
promoting community awareness.

Supporting self-efficacy: Recognize strengths, and support ability to change.

Example: Work with team/experts to communicate successful strategies
in promoting community awareness about youth depression and suicide.

6. Identify and address behavior change barriers
The PHN identifies and addresses barriers prior to implementing the counseling in-
tervention to address client motivation for change (Butterworth, 2008):

 They do not think they can.
 They are not ready for it.
 Their values do not support it.
 They do not think it is important.
 They do not believe it is needed.
 They do not have adequate support.

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7. Avoid actions that support resistance
Avoid these actions that may lead to client resistance (Burnard, 2005; Huffman 2014):

 Arguing for the benefit of change
 Telling the client how to change
 Warning the client of the consequences of not changing
 Convincing the client they have a problem
 Interpreting the client’s problem or behavior

8. Take cues from client perspectives
Counseling will be more effective when it is individualized and based on client per-
spectives. Consider the following guidelines (Burnard, 2005):

 Acknowledge that people differ from one another.
 Consider the client’s belief and value system as a clue to problem-solving.
 Encourage the client to identify solutions for their problems.
 Acknowledge that every individual has responsibility for their behavior.

Example
A community sees an increased rate of suicide among its adolescent population.

1. Establish a therapeutic relationship
When meeting with community members to address the problem, respect and em-
pathize with others’ experiences with suicide in the community. Listen actively and
withhold judgment of other’s opinions on needed actions.

2. Maintain professional boundaries
Promote opportunities for community members to share their stories about experi-
ences with suicide. Be mindful of confidentiality and appropriateness of sharing per-
sonal experiences regarding suicide.

3. Self-monitor the relationship
Assess community member engagement in addressing suicide rate reduction among
adolescents in the community, and review progress on plan of action.

4. Select effective strategies and tailor them
With community members and professionals from the community, select strategies
to increase community awareness about the increasing suicide rate, and establish a

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crisis line. Strategies may include pamphlets, social media, messages on local televi-
sion or radio, and messages from primary care providers.

5. Use an evidence-based behavior change model
See above examples for application of the five A’s and motivational interviewing.

6. Identify and address possible barriers to
behavior change
Provide an opportunity for members of the group to identify and discuss challenges
in addressing the problem of increased suicide among adolescents.

7. Avoid actions that support resistance
Provide evidence about best practices or evidence-based interventions for reducing
adolescent suicide. Avoid telling community members what they should do.

8. Take cues from client perspectives
Welcome all suggestions. Provide opportunities for all members to identify possible
solutions in response to the increased adolescent suicide rate.

Key points from evidence
For a description of evidence levels, visit: Introduction: Overview of evidence-based
practice and related topics.

 1. Therapeutic alliance
The concept of therapeutic alliance establishes a foundation for the counseling inter-
vention. Therapeutic alliance happens when the client and PHN interact collabora-
tively to determine goals for improved health through a respectful and trusting rela-
tionship. The three components of a therapeutic alliance are:

1. Collaborative tasks mutually understood
2. Goals mutually derived based on client readiness
3. Bonds that encompass a sense of compatibility, trust, respect, and caring

Level 3 source:

 Spiers & Wood, 2013

Level 5 source:

 Zugai, Stein, & Roche, 2015

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 2. Client attributes for effective response
Client attributes facilitate effective response to behavior change counseling include:

 Strong desire and intent to change
 Few barriers to change
 Skills and self-confidence needed for change
 Belief that change results in benefits
 Support for change from valued persons and community

Level 4 source:

 Whitlock et al., 2002

 3. Adapting strategies for diverse needs
Adapt counseling strategies to address the needs of culturally diverse clients and im-
prove health outcomes. An empowerment-based approach will facilitate the under-
standing client viewpoints, and encourage client involvement in decision-making.

Level 1 source:

 Jesse et al., 2015

Level 3 source:

 Fagerlund, Pettersen, Terragni, & Glavin, 2016

 4. When to refer clients
Refer client when the following occurs:

 The client is non-responsive to the PHN intervention.
 The PHN does not have the capacity or time to continue the intervention.
 The client needs a specialist, or more intensive counseling or psychotherapy.

Level 5 source:

 Freshwater, 2003

 5. Client peer groups
Client peer groups facilitated by PHNs provide support, establish social networks, and
facilitate health promotion.

Level 2 source:

 Hall & Grundy, 2014

Level 3 sources:

 Glavin, Tveiten, Økland, & Hjalmhult, 2016
 Sekse et al., 2014

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 6. Motivational interviewing
Motivational interviewing improves client outcomes for a variety of age groups, set-
tings, and health concerns, including diabetes, chronic disease management, smok-
ing, alcohol consumption, and health promotion behaviors. Motivational interview-
ing is low-risk, is comparably effective to alternative treatments, and can take less
time than other treatments.

Level 1 sources:

 Lindson-Hawley, Thompson, & Begh, 2015
 VanBuskirk & Wetherell, 2014

Level 2 sources:

 Chlebowy et al., 2015
 Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010
 Tse, Vong, & Tang, 2013

Level 5 sources:

 Cummings, Cooper, & Cassie, 2009
 Laakso, 2012

 7. Training in behavior change strategies
Education or training in behavior change strategies improves skill and confidence in
communication skills that facilitate client behavior change.

Level 2 source:

 Phister-Minogue & Salveson, 2010

 8. PHNs as information channels in community risk counseling
In community risk counseling situations, PHNs can function as information channels
in the community and build their risk communication capacities to support residents
in making well-informed decisions.

Level 3 source:

 Goto et al., 2014

Wheel notes

Challenges
PHNs may encounter challenges as they implement the counseling intervention. One
challenge occurs when PHNs do not view themselves as counselors. An example of
this is in school environments where academic counselors are present (Schaffer,
Anderson, & Rising; 2016). In this situation, it is important for the PHN to know that

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they do provide the counseling intervention related to health problems when they
address the emotional component of responding to a health concern.

Public health nurses encounter a second challenge when they do not have time in
their practice for the counseling intervention. However, some PHNs view counseling
capacity as part of their skill set for addressing a population’s needs and as part of an
intervention program. This is the case for practitioners participating in the Nurse-
Family Partnership (2011), an evidence-based program that provides support to new
mothers. In other roles, the PHN may provide brief counseling interventions along
with health teaching. The five A’s and motivational interviewing work well in brief
counseling situations.

A third challenge for PHNs is gaining the expertise to effectively use brief counseling
strategies. Continuing education opportunities assist PHNs in developing motiva-
tional interviewing skills. The Behavior Change Counseling Index (BECCI), a reliable,
short, and easy-to-administer assessment tool, evaluates public health nursing com-
petence in behavior change counseling. The 11 items on the BECCI scale measure
effectiveness of behavior change counseling (Phister-Minogue & Salveson, 2010).

Community- and systems-level counseling
Since counseling is most often understood as an individual-level intervention, PHNs
may find it difficult to implement it at other levels. The following paragraphs detail
the use of the counseling intervention at the community and systems levels and ad-
dress the question, “What is being changed?”

Community level

 The goal of counseling at the community level is to change community norms,
attitudes, awareness, practices, and/or behaviors.

 School nurses provide counseling at the community level when they design
counseling strategies to develop community awareness about bullying behavior
in the school setting and the negative impact on health. The counseling strategy
could involve group meetings, to communicate information and consider a com-
mitment to address bullying behavior among the school community, parents,
and other organizations serving schoolchildren.

Systems level

 At the systems level, the goal of counseling is to change rules within organiza-
tions, infrastructure, policies, laws, and power structures. Stigma against mental
illness is present in many organizations and societal structures. When meeting
with health department colleagues to develop a systems-level plan to address
mental health, PHNs can encourage making a commitment to include mental
health as a priority in designing organizational services, programs, and policies.

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Chlebowy, D. O., El-Mallakh, P., Myers, J., Kubiak, N., Cloud, R. & Wall, M. P. (2015). Motivational
interviewing to improve diabetes outcomes in African American adults with diabetes.
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Cummings, S. M., Cooper, R., L., & Cassie, K. M. (2009). Motivational Interviewing to affect
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Duaso, M. J., & Duncan, D. (2012). Health impact of smoking and smoking cessation strategies:
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Fagerlund, B. H., Pettersen, K. S., Terragni, T., & Glavin, K. (2016). Counseling Immigrant Parents
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Freshwater, D. (2003). Counselling skills for nurses, midwives, and health visitors. Philadelphia:
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Hall, K. & Grundy, S. (2014). An analysis of Time 4U, a therapeutic group for women with postnatal
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Huffman, M. (2014). Using motivational interviewing through evidence-based coaching. Home
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Kardeen, S., Smith, K., & Thornton, K. (2010). Smoking Cessation: Counseling or No Counseling?
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Lindson-Hawley, N.,Thompson, T. P., & Begh, R.(2015). Motivational interviewing for smoking
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Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-analysis of
motivational interviewing: Twenty-five years of empirical studies. Research on Social
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Miller, W. R. & Rose, G. S. (2009). Toward a theory of motivational interviewing. The American
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Pfister-Minogue, K. A. & Salveson, C. (2010). Training and experience of public health nurses in
using behavior change counseling. Public Health Nursing, 27(6), 544-551. doi:
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Pignone, M. P., Ammerman, A., Fernandez, L., Orleans, C. T., Pender, N., Woolf, S., et al. (2003).
Counseling to promote a healthy diet in adults: A summary of the evidence for the U.S.
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Toronto, Canada: Registered Nurses Association of Ontario. Retrieved from
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Richardson, L. (2012). Motivational interviewing: Helping patients move toward change. Journal of
Christian Nursing, 29(1), 18-24. doi: 10.1097/CNJ.0b013e318238e510

Schaffer, M. A., Anderson, L. J. W., & Rising, S. (2016). Public health interventions for school
nursing practice. Journal of School Nursing, 32(3), 195-208.
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Sekse, R. J. T., Blaaka, G., Buestad, I., Tengesdal, E., Paulsen, A., & Vika, M. (2014). Education and
counselling group intervention for women treated for gynaecological cancer: Does it
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Spiers, J. A. & Wood, A. (2010). Building a therapeutic alliance in brief therapy: The experience of
community mental health nurses. Archives of Psychiatric Nursing, 24(6), 373-386.
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Tahir, N. M. & Al-Sadat, N. (2013). Does telephone lactation counselling improve breastfeeding
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Tse, M., Vong, S., & Tang, S. K. (2013). Motivational interviewing and exercise programme for
community-dwelling older persons with chronic pain: a randomized controlled study.
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VanBuskirk, K. A. & Wetherell, J. L. (2014). Motivational interviewing with primary care
populations: A systematic review and meta-analysis. Journal of Behavioral Medicine, 37,
768-780. doi: 10.1007/s10865-013-9527-4

Whitlock, E. P., Orleans, C. T., Pender, N., & Allen, J. (2002). Evaluating primary care behavioral
counseling interventions: An evidence-based approach. American Journal of Preventive
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Zugai, J. S., Stein, J., & Roche, M. (2015) Therapeutic alliance in mental health nursing: An
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Consultation
Consultation seeks information and generates optimal solutions to perceived prob-
lems or issues through interactive problem-solving.

Practice-level examples
Population of interest: Entire community.

Problem: Increase in incidence of measles (rubeola).

Systems level
The public health nurse (PHN) meets with childcare staff to discuss actions staff can
take to prevent an outbreak of measles at a childcare center, resulting in a protocol
for communicating about symptoms of illness.

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Community level
A PHN organizes a community meeting for parents with concerns about immuniza-
tions, to answer questions about risks of measles and prevention.

Individual/family level
After a child has been diagnosed with measles, a PHN mutually develops a plan with his
parents during a home visit to prevent other family members from contracting measles.

Relationship with other interventions
Consultation is frequently implemented in conjunction with or sequentially to health
teaching and/or counseling. Health teaching influences the knowledge, attitudes,
values, beliefs, practices, skills, and behaviors of individuals/ families, communities,
or systems. Counseling focuses on the emotional component inherent in any attempt
to change. Consultation seeks to generate alternative solutions to problems.

For example, a PHN provides health teaching about the prevalence, incidence, and
causes of family violence at a community meeting. The information is likely to trigger
emotional responses. Implementing counseling strategies in conjunction with health
teaching builds on the energy associated with the emotional response, and further
enhances the learning opportunity. A community may respond to information on
family violence with powerful emotions like anger, outrage, fear, and grief. These
emotions can motivate the community to learn more about the problem and its
causes. If the community uses this new information to decide what to do to change
its tolerance of family violence, the PHN assists in exploring different alternatives,
providing consultation.

Collaboration with individuals/families, communities, and systems is essential for an
effective consultation process. The PHN needs to understand the client view of the
problem and possible strategies to resolve the problem.

Basic steps
Consultation models are found in nursing, educational, organizational disciplines, and
business. Consultants may provide consultation internally (within the organization)
or externally (to persons outside the organization or to other organizations).

Consultation may be done informally, such as with clients during home visits or with
colleagues making a professional decision. PHNs informally consult with individu-
als/families, groups, communities, and systems about topics like immunization rec-
ommendations and healthy eating habits. The consultation process may also be for-
mal and involve a contract that specifies clear expectations. The client is responsible
for acting on decisions made during the consultation process.

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A useful model for PHN consultation is the process consultation model developed by
Edgar Schein. “The process model of consultation focuses on the process or problem
solving and collaboration between the consultant and client” (Turner, 2016, p. 872).
The major goal of process consultation is to assist the individual/family, group, com-
munity, or systems to assess and identify the problem as well as determine what help
is needed to solve the problem.

Norwood (2003) describes the steps of the nursing consultation process when work-
ing with communities:

1. Gain entry
With the initial contact, the PHN determines whether they are the best fit for provid-
ing the consultation.

a. Scan the environment. Ask the following questions:
 Who is involved?
 What do they want?
 Am I the right person (values, skills)?

b. Establish a contract for formal consultation at the community or systems level.
What are important items to include in a contract to clarify expectations (Turner,
2016, p. 873)?
 Consultation goals (for both consultant and client)
 Identified problem
 Resources
 Time commitment
 Limitations of contract
 Costs
 Conditions under which contract can be broken or renegotiated
 Intervention strategies
 Expected benefits for client
 Data collection methods
 Evaluation methods
 Confidentiality

c. Gain physical entry: This means the consultant is accepted and is available.
d. Initiate psychological entry: The consultant establishes rapport, trust, and cred-

ibility in the consultation relationship.

2. Identify the problem
The consultant and client assess the problem together and decide what information
the client needs to solve the problem.

Without client input, the correct problem may not be identified.

The problem identification phase includes:

a. Assessment; example assessment questions include (Norwood, 2003, p. 175):
 What is the history and content of this problem?
 What is causing this situation?

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 What is needed to have a healthy community?
 What do we need to address in order to implement the change?

b. Diagnosis
c. Communicating assessment findings

3. Determine action planning
Action planning involves working together to decide what to do in response to the
problem.

Like the nursing process, the plan lays out clear steps needed to bring about a health
improvement.

Action planning tasks include:

a. Setting meaningful, acceptable, and realistic goals
b. Establishing priorities
c. Choosing a problem solution and identify what makes the solution acceptable
d. Developing the specific action plan; this includes identification of objectives,

tasks, who will do what, needed resources, and costs
e. Facilitating action plan implementation: When consulting with a community or

organization, the consultant may need to lay groundwork for implementation;
laying the groundwork includes actions like team-building, managing transitions
that result in new situations and processes, and helping the group or organiza-
tion determine diffusion strategies to motivate change

4. Evaluate effectiveness
The evaluation focuses on the consultation relationship and occurs on a continuing
basis throughout the consultation process. In addition, the evaluation promotes ac-
countability for consultant and client.

Interventions in the action plan are usually not evaluated because the consultee may
not actually implement the proposed action plan. Since the consultant may need to
revise the consultation process, evaluating the consultation relationship will help de-
termine if a change needs to be made in the process.

Evaluation tasks include (Norwood, 2003, pp. 235-241):

a. Identifying evaluation content: 1) goal progress, 2) event evaluation (like team-
building or education sessions), and 3) relationship evaluation (rapport, credibil-
ity, communication)

b. Selecting effectiveness criteria (e.g., cognitive or knowledge change, behavior
change, goal accomplishment, satisfaction)

c. Specifying performance standards for comparing outcomes
d. Identifying data sources
e. Determine data collection strategies (e.g., surveys, interviews, observations,

case study)

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5. Disengage from the relationship
Disengagement is the process of “letting go” and “securing the future” (Norwood,
2003, p. 254). Both the consultant and client agree to end the consultation process.

Disengagement encourages the client to take on the problem-solving role, which they
can transfer to future situations. They become more self-reliant.

Disengagement tasks include (Norwood, 2003, pp. 257-261):

a. Determining readiness to disengage (unlikely to achieve goal/successful outcome)
b. Establishing change maintenance supports; this could include reduced involve-

ment, intermittent follow-up, or establishing community supports
c. Managing psychodynamics; providing a timeline for disengagement may de-

crease the stress of the disengagement process
d. Achieving closure: Be intentional about promoting a sense of satisfaction and

accomplishment; celebrate successes and leave the door open for future con-
tact (Norwood, 2003, p. 262)

Example
A PHN meets with childcare staff at a childcare center to discuss actions staff can take
to prevent a potential outbreak of measles among children at the childcare center.

1. Gain entry
The city health department has a contract with ten childcare centers for a PHN to
provide consultation in monthly meetings with childcare staff about health concerns.
The PHN has provided consultation for the childcare centers for the past two years.

2. Identify the problems
In a monthly meeting with one of the childcare centers, the director asks for assis-
tance with decision-making about how to control the spread of measles, which has
been diagnosed in one of the children.

3. Determine action planning
Together the director and PHN identify realistic strategies that childcare center staff
could take to reduce the spread of measles to children. They discussed how to com-
municate information about the potential for illness to parents of the children.

4. Evaluate effectiveness
The childcare center staff observed the children for any incidence of illness and keep
records of any illness with symptoms that could be caused by measles. In a following

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meeting, the PHN reviews with the day care director their satisfaction with the deci-
sions made during the consultation.

5. Disengage from the relationship
In this example, there is not a formal disengagement task, since the consultation is
part of an ongoing contract. However, disengagement occurs over the specific con-
sultation on the transmission of measles. The PHN and childcare center staff
acknowledge successfully preventing any additional transmission of measles.

Key points from evidence
For a description of evidence levels, visit: Introduction: Overview of evidence-based
practice and related topics.

 1. Cultural context
Knowledge about the culture of the individual/family, community, or system is essen-
tial for establishing an effective consultation relationship. Consider the cultural con-
text in implementing consultation intervention tasks.

Level 5 source:

 Holcomb-McCoy & Bryan, 2010

 2. Empowering clients to make decisions
Empower the individual/family, community, or system to make decisions. When a
PHN provides consultation, they ensure that the client has “the necessary knowledge,
skills, and resources to effectively make the decisions for which they are held ac-
countable” (Turner, 2016, p. 875).

Level 5 sources:

 Holcomb-McCoy & Bryan, 2010
 Turner, 2016

 3. Encouraging clients to actively engage
Encourage clients to actively engage in the consultation process to increase decision-
making capacity. A campaign to promote best practices for bringing a client’s voice into
health care decisions proposed encouraging clients to ask the following questions:

 What are my options?
 What are the pros and cons of each option for me?
 How do I get support to help me make a decision that is right for me?

Level 4 source:

 Pollock, 2012

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 4. Consultation roles
For the consultation intervention, the PHN selects from these relevant roles:

Nursing consultation roles:

 Fact-finding
 Diagnosing
 Advocacy
 Directing solution implementation
 Educating
 Coordinating resources

Process-oriented roles:

 Joint problem-solving
 Process counseling

Universal roles:

 Providing expertise
 Presenting information
 Role-modeling
 Providing leadership

Level 5 source:

 Norwood, 2003

 5. Guidance for the consultation process
Edgar Schein, known for his work on organizational culture theory, expands on the
concept of process consultation, in which the consultant helps the client “to perceive,
understand, and act upon process events that occur in the client’s environment”
(Miner, 2007, p. 317). Schein developed a set of principles to provide guidance to the
consultant for guiding the consultation process:

 Always try to be helpful.
 Always stay in touch with the current reality.
 Access your ignorance.
 Everything you do is an intervention. It is the client who owns the problem and

the solution.
 Go with the flow.
 Timing is crucial.
 Be constructively opportunistic with confrontational interventions.
 Everything is a source of data; errors will occur and are the prime source for

learning.
 When in doubt, share the problem.

Along with practical tips, these principles emphasize the collaborative process in-
volved in consultation.

Level 5 source:

 Miner, 2007

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 6. Ethical principles in conducting research
The following ethical principles are useful for guiding the consultation process when
conducting research with communities:

 Enhanced protection: Identify risks, hazards, and possible protections for sub-
jects and communities.

 Enhanced benefits: Identify benefits for participants in the study as well as the
population in the community.

 Legitimacy: Provide an opportunity for stakeholders relevant to the proposed
research to express their perspectives and concern, before the research proto-
col is finalized.

 Shared responsibility: Promote opportunities for community members to take
some responsibilities for conducting the study.

Level 5 source:

 Dickert & Sugarman, 2005

 7. Specialists and improved quality of care
Using specialists in the consultant role improves quality of care. For example, a men-
tal health specialist provides consultation to PHNs staffing Women, Infant, and Chil-
dren (WIC) Supplemental Food Program clinics and providing home visits. The mental
health specialist provides telephone screening, intervention, and referral. This pro-
gram reaches a maternal child health population with multiple risk factors.

Level 5 source:

 Gaul & Farkas, 2007

 8. Improving the consultation process
Specific strategies to improve the consultation process include:

 Provider training
 Developing condition-specific educational materials
 Teaching patients to ask questions during the consultation

Level 1 source:

 Dwamena et al., 2013

Wheel notes

Contrast with counseling and health teaching
Literature on the PHN consultation intervention is less abundant than for the other two
interventions located in the blue wedge of the Intervention Wheel (health teaching and
counseling). Literature from countries outside the United States sometimes uses the

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term “consultation” to describe public health nursing actions closely aligned with the
counseling intervention. With consultation, the PHN uses knowledge and expertise to
empower client decision making. The difference between consultation and counseling
at the individual level appears to be less distinct than at the community and systems
levels, because both interventions aim to promote effective client decision-making.
Consultation focuses is on collaborative problem-solving. The client is responsible for
choosing the best option. In health teaching and counseling, the PHN is likely support-
ing specific actions for improving health status. The PHN provides information during
the health teaching intervention, and assists the client in addressing emotional and mo-
tivational components during the counseling intervention.

Systems level
Most studies on consultation interventions in public health nursing describe individ-
ual-level interventions. A systematic review found that, out of 23 studies on public
health nursing interventions in elderly populations, consultation interventions oc-
curred at the individual level in seven studies and at the systems level in one study
(Schaffer, Kalfoss, & Glavin, 2017). At the systems level, community nurses and allied
health professionals in Scotland received consultation during a one-day smoking ces-
sation training, which improved the knowledge and attitudes about smoking cessa-
tion strategies for the intervention group compared to the control group (Kerr,
Whyte, Watson, Tolson, & McFadyen, 2011). Anderson and colleagues (2017) found
that topics of systems-level consultation provided by school nurses included medica-
tion policy, the location of automatic external defibrillators in the school building, use
of concussion guidelines, and schoolchildren’s health care needs.

Rigor of evidence
Evidence on nursing consultation at the community and systems levels lacks the rigor
of the research process. Most articles describe non-research evidence related to pro-
gram or project initiatives. For example, an open-access online learning resource was
developed for community nurses in England to use in their consultation with caregiv-
ers (Maskell, Somerville, & Mathews, 2015). In another example, Canadian PHNs with
expertise in domestic violence developed a project to share their knowledge of how
to intervene with clients experiencing domestic violence. The expert PHNs worked
together with other PHNs to develop a referral process, identify resources, and build
a collaborative partnership for a coordinated community response to domestic vio-
lence (Snell, 2015).

References
Anderson, L. J. W., Schaffer, M. A., Hiltz, C., O’Leary, S. A., Luehr, R. E., & Yoney, E. L. (2017). Public

health interventions: School nurse practice stories. Journal of School Nursing, pp. 1-11,
online. doi: 10.1177/1059840517721951

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Dickert, D. & Sugarman, J. (2005). Ethical goals of community consultation in research. American
Journal of Public Health, 95(7), 1123-1127. doi:10.2105/AJPH.2004.058933

Dwamena, F., Holmes-Rovner, M., Gaulden, C. M., Jorgenson, S., Sadigh, G., Sikorskii, A., et al.
(2012). Interventions for providers to promote a patient-centred approach in clinical
consultations (Review). Cochrane Database of Systematic Reviews, 12(12).

Gaul, C. E. & Farkas, C. (2007). Perspectives in psychiatric consultation Liaison Nursing.
Perspectives in Psychiatric Nursing, 43(4), 237-240.

Holcomb-McCoy, C. & Bryan, J. (2010). Advocacy and empowerment in parent consultation:
Implications for theory and practice. Journal of Counseling & Development, 88, 259-268.

Kerr, S., Whyte, R., Watson, H., Tolson, D., & McFadyen, A.K. (2011). A mixed-methods evaluation
of the effectiveness of tailored smoking cessation training for healthcare practitioners
who work with older people. Worldviews on Evidence-Based Nursing, 8(3): 177-186. doi:
10.1111/j.1741-6787.2011.00219.x

Maskell, P., Somerville, M., & Mathews, A. (2015). Supporting carers: A learning resource for
community nurses. British Journal of Community Nursing, 20(7), 335-337.

Miner, J. B. (2007). Edgar Schein’s Organizational-Culture Theory to organization development
(particularly involving process consultation). In Organizational behavior 4: From theory
to practice, (pp. 316-330). New York: Routledge.

Norwood, S. L. (2003). Nursing consultation: A framework for working with communities. New
Jersey: Upper Saddle River.

Pollock, J. (2012). The three questions patients need to ask to speed up consultation times. British
Journal of Community Nursing 17(11), 547.

Schaffer, M. A., Anderson, L. J. W., & Rising, S. (2016). Public health interventions for school
nursing practice. Journal of School Nursing, 32(3), 195-208. doi:
10.1177/1059840515605361

Schaffer, M. A., Kalfoss, M., & Glavin, K. (2017). Public health nursing interventions to promote
quality of life in older adult populations: A systematic review. Journal of Nursing
Education and Practice, 7(11), 92-106. doi: 10.5430/jnep.v7n11p92

Snell, D. (2015). Leading the way: Implementing a domestic violence assessment pilot project by
public health nurses. Nursing Leadership, 28(1), 65-72.

Turner, L. P. (2016). The nurse leader in the community. In M. Stanhope & J. Lancaster (Eds.).
Public health nursing: Population-centered health care in the community (pp. 867-884).
St. Louis, MO: Elsevier.

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In review
A story:

School nurses in a large urban school district note the school is enrolling a large num-
ber of new students recently emigrated from Somalia with their families. The school
nurses realize that they often expect families to come to them with concerns about
their child’s health. The school nurses decide to go to the neighborhood where many
Somali families live in order to make connections with parents.

The school nurses contact the local health department to inquire about any existing
programs and information about health needs and services for Somali families. The
local health department provides resources about the Somali culture and connects
the school nurses with a local housing manager to arrange for a meeting space easily
accessible to Somali families.

School nurses in the district collaborate to offer “Ask a Nurse” sessions at a housing
complex where many Somali families live with their school-aged children. They ar-
range for a space to meet in the housing complex and create a welcoming environ-
ment with culturally appropriate beverages and food. Instead of waiting for the par-
ents to come to them, the school nurses intentionally connect with Somali parents to
develop trusting relationships that will lead to improved population health.

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For the blue wedge, which features health teaching, counseling, and consultation,
think about how these interventions could occur both in the development and imple-
mentation of “Ask a Nurse” sessions.

Application questions
Consider the following questions related to “Ask a Nurse” sessions that school nurses
offered to Somali parents.

Practice level
1. Describe how the story reflects each practice level (individual/family, commu-

nity, and systems).

Health teaching
2. How would you identify topics for the sessions of interest to the families? How

might culture and disparities in this population influence topics identified or
selected?

3. What teaching-learning principles are especially relevant for health teaching
with Somali parents?

4. What actions would you take to engage learners attending these sessions?

Counseling
5. How can school nurses balance developing trusting relationships with Somali

parents with maintaining professional boundaries? How might biases and as-
sumptions affect the relationship?

6. How could the five A’s or motivational interviewing be used in facilitating be-
havior change, counseling parents about childhood immunizations, and devel-
oping school immunization policy?

7. How can school nurses employ an approach that builds on the assets of Somali
families rather than perceived deficits?

Consultation
8. If you were a PHN that had experience working with diverse populations, how

would you use the process consultation model to consult with school nurses de-
veloping and implementing “Ask a Nurse” sessions?

9. Somali parents have expertise on their culture and how that affects their deci-
sions about their children’s health care. School nurses have expert knowledge
about children’s health care needs. What does applying the consultation process
look like for “gaining entry” in interacting with Somali parents about their chil-
dren’s health care needs?

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Collaboration
Collaboration enhances the capacity to promote and protect health for mutual ben-
efit and a common purpose. Collaboration involves exchanging information, harmo-
nized activities, and shared resources (National Business Coalition on Health, 2008).

Developing and sustaining partnerships is crucial for effective collaboration. Partner-
ship requires “a respectful, negotiated way of working together that enables choice,
participation, and equity, within an honest, trusting relationship that is based in em-
pathy, support, and reciprocity” (Bidmead, 2005, p. 203).

Collaboration involves a high level of commitment and a complex partnership en-
deavor. It includes networking, coordinating, and cooperating activities that all lead
to enhancing each partner’s capacity to achieve a common purpose: Partners net-
work when they exchange information for mutual benefit; coordinate when they
adapt activities that result in mutual beneficial and achieve a common purpose; and
cooperate when they share resources (staff, financial, technical) to achieve a com-
mon purpose and mutual benefit (Centers for Disease Control and Prevention, 2011).

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Practice-level examples
Population of interest: Community-dwelling older adults.

Problem: Potential for injury due to falls.

Systems level
A public health nurse (PHN) collaborates on an initiative to prevent falls in older
adults. Collaborative partners in the community include the ambulance service, fire
department, senior centers, university extension services, and several hospital de-
partments (emergency, pharmacy, rehabilitation services, physical therapy, and
home care). The initiative seeks to standardize the provider approach to seniors and
their potential for falls. Service providers agree to address the topic of fall prevention
any time they provide a service to an older adult, complete a short risk screening, and
make referrals for home assessment when indicated.

Community level
A PHN joins forces with older adults at the local senior center to plan a program to
change community perception that falling is inevitable as a person ages. The PHN
provides home safety checklists and educational materials. The older adults add sto-
ries of their experiences and what they would have done differently had they known
more about fall prevention. The older adults and the PHN present the program to-
gether at congregate dining centers located in senior centers, churches, or senior
housing communities.

Individual/family level
Older adults self-refer to a program in which PHNs make home visits to older adults
to prevent falls. Older adults may also be referred from other organizations. Together
the PHN and older adult make a plan to remove or reduce injury risks. This includes
reviewing medications that affect balance; home modifications to reduce fall hazards,
such as installing grab bars, improving lighting, and removing items that cause trip-
ping; and exercise to improve strength, balance, and coordination.

Relationship with other interventions
Community organizing, coalition-building, and collaboration involve partnerships.
Because of this, they share many features, especially at the community level of practice.

Similarities among these three interventions include empowerment, which enables
individuals and communities to take control of their lives and environments. Client
perceptions and experiences are key. At the community level, community engage-
ment is relevant to all three interventions. In community engagement, partners col-
laboratively work with populations grouped by geographic location, special interests,

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or similar health concerns to respond to issues that affect group or population well-
being (U.S. Department of Health and Human Services, 2011).

Unlike coalition-building and community organizing, collaboration requires being
willing to enhance the capacity of one or more collaboration members over and
above one’s own interests, in order to achieve common goals. When collaborating, a
person or organization agrees to the risk (or benefit) of transformation or change
through their involvement. Although coalition-building and community organizing oc-
cur only at the systems and community levels, collaboration occurs at all three prac-
tice levels, including the individual/family level of PHN practice.

Collaboration relates to interventions in other wedges. Like coalition-building and
community organizing, collaboration can be implemented in conjunction with policy
development and enforcement to change the way systems in a community operate,
or to change a community-held norm or belief. Collaboration is also often a co-
intervention with advocacy, and a preferred co-intervention with delegated
functions. The collaboration intervention is potentially useful for any activity in which
the PHN partners with others. At the individual/family level of practice, collaboration
often pairs with health teaching, counseling, consultation, and case management.

Basic steps: Community level
A partnership development guide (Centers for Disease Control and Prevention, 2011)
suggests the following steps to establish and continue collaboration:

1. Determine the need
A partnership facilitates achieving specific goals, which members find more difficult
to achieve without the partnership.

The following questions assess the need for a partnership:

a. How will a partnership contribute to accomplishing the goal?
b. What are some critical activities that members must sustain, expand, or improve?
c. What program activities are more effective with a partner?
d. How might a partnership assist in program efforts?
e. What are the benefits of a partnership, and are there any costs to consider?

2. Assess potential partners
Assessing potential partners’ resources, skills, and knowledge increases the under-
standing of their potential contribution to the partnership.

The following questions assess potential partner contributions:

a. What potential partners do we know?
b. What is the expected outcome of the partnership?
c. Have we sought out new and nontraditional partners?

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d. Do we have a history of good relations with the potential partner? What were
the successes and challenges?

e. What specific resources will this potential partner contribute to the outcomes
or products expected from the partnership?

f. What might be some potential drawbacks in collaborating with this partner?
g. How will the potential partner(s) benefit from the partnership?
h. What resources would be valuable to the partnership? Who has those resources?
i. Does the potential partner understand and support our priorities or have similar

priorities?
j. Is there a person (a champion) who will work to make sure the partnership

happens?

3. Develop the partnership
A concrete, organized, and practical approach to partnership development supports
a common understanding of the perspectives and contributions of each partner.

a. Determine the resources your program can contribute to the partnership.
b. Develop a document that outlines the mutual benefits of partnership.
c. Know your program and be able to describe it in a succinct manner.
d. Learn about the culture of this potential partner to consider when working

together.
e. Meet with the potential partner in person. Because a critical component of a

partnership is relationship building, in-person meetings are preferable.
f. Take the time to establish rapport and build trust.
g. Give a general overview of your program.
h. Explain your program’s specific needs and why the partnership would be helpful.
i. Ask about the potential partner’s organization and perspective, keeping in mind

findings from background research.
j. Ask what needs the partner has, and discuss how your program might help meet

those needs.
k. Ask what resources the partner can contribute to the partnership.
l. Make a clear and specific “ask” of the partner. If possible, your “ask” should be

task-oriented, with a beginning and an end. Do not expect partners to know
what you need; make it as easy as possible for them to collaborate with you.

4. Formalize the partnership
A formal agreement guides partnership relationships and actions.

a. Determine a shared vision or mission statement.
b. Develop a partnership action plan with mutually accepted objectives.
c. Define member roles and responsibilities.
d. Develop timelines.
e. Clarify leadership and communication responsibilities.
f. Determine decision-making procedures, ground rules, and additional needed

resources.

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5. Maintain and sustain the partnership
A professional partnership requires time, nurturing, and respect.

a. Communicate regularly. Agree on a mutually convenient time and method for
checking in, verbally, by email, or by another means.

b. Develop a feedback plan for assessing how the partnership is working for both
parties. Build on successes, address problems, and explore ways to enhance the
partnership.

c. Respect the partner’s boundaries, structure, procedures, and processes.
d. Express appreciation verbally or in writing.
e. With their permission, give your partner credit and recognition in public forums.
f. Be flexible and open to change as the partnership develops.
g. Formalize a review of the partnership by creating an evaluation form that

measures satisfaction with the partnership.
h. Discuss and use the results of the partnership evaluation to improve the

partnership.
i. Discuss each partner’s goals for the partnership over the long term, and what

criteria to use for continuing the partnership. Keep track of partnership activi-
ties, and evaluate progress and accomplishments.

j. Communicate results of partnership activities with partners and with relevant
stakeholders/community members, to show areas of success and areas for
improvement.

6. End the partnership (or not)
When a program outgrows the need for the partner or needs change, the partnership
may no longer be crucial to success or effectiveness.

a. Meet with the partner and talk about the situation.
b. Make sure that the parting is amicable and mutual, which leaves the window

open for future opportunities for collaboration.

Example: Community level
A PHN planning events for an older adult wellness program in a primarily suburban
county public health department noted that several regular attendees missed events.
Further investigation revealed absences often related to a fall. The PHN collaborated
with other professionals and community representatives who work with seniors to
disseminate information about fall risk prevention.

1. Determine the need
A PHN working in an older adult wellness program knows regular attendees miss
events due to falls.

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2. Assess potential partners
The PHN realizes that there are local experts who have greater knowledge about fall
risk prevention and about the community environments of the senior population.
They include a county social worker who works with the senior population, a repre-
sentative from the local senior center, the health educator from the health depart-
ment, and a local clinic’s geriatric nurse practitioner and physical therapist. All affirm
their interest in collaborating on a fall risk reduction initiative.

3. Develop the partnership
At the first meeting, collaborative partners share their expertise in falls risk reduction,
their time commitment, and possible resources available through their organizations.

4. Formalize the partnership
At the second meeting, the group reaches consensus on the partnership’s goals and
develops an action plan with a timeline. One of the group’s first actions is to review
evidence on best strategies for fall risk reduction.

5. Maintain and sustain the partnership
After discussing best evidence for fall risk reduction, the partnership revises its action
plan and proceeds to implement strategies. The social worker volunteers to convene
meetings and be responsible for ongoing communication. The group develops an
evaluation strategy it plans to use at one year and two years after implementing strat-
egies, to determine strategy effectiveness.

6. End the partnership (or not)
Once organizations serving seniors in the community adopt strategies, members of
the group determine they have met their goal. Several members of the collaborative
group present their success story at a state conference. They decide to meet again,
to consider other activities needed to optimize quality of life for older adults.

Basic steps: Individual/family level
A concept analysis of partnership within the nurse-client relationship identified the
following factors foundational to collaborating with clients (Gallant, Beaulieu, &
Carnevale, 2002, p. 152):

 Partners value each individual and cooperation.
 Partners feel committed to sharing responsibility, risk, power, and accountability.
 Partners are open and respectful of what each partner brings to the relationship.

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 Nurses hold positive attitudes towards clients and are willing to relinquish the
status and privilege associated with being a nurse.

 Partners actively encourage the client’s involvement in decision-making.

When working with clients, partnership includes the following phases (Gallant et al.,
2002, p. 153):

1. Initiating phase: Both partners commit to the
partnership
a. Partners actively negotiate roles, responsibilities, and actions.
b. The professional assumes a facilitator role, acts as a resource person, and pro-

vides service in a nonjudgmental way.
c. The client partner takes the role of willing and active participant in a process of

self-determining strengths, problems, and solutions.

2. Working phase: Partners bring their knowledge
and experience to the collaborative process
a. The nurse partner brings nursing knowledge and clinical experiences.
b. The client brings experiential knowledge about health and managing their health

concern.
c. The nurse promotes client empowerment and competency by maintaining the

relationship, reinforcing client progress, supporting decision-making, and assist-
ing the client to learn new knowledge and skills.

Example: Individual/family level
Angela, a PHN who provides public health nursing services in a rural county, attended
a conference on fall risk reduction. She visits the local senior center one afternoon each
week to check blood pressure and offer health teaching, counseling, and consultation.
Angela also collaborates with seniors on a fall risk reduction plan. She meets with
Marion, 78 years old, who has had a recent fall and sustained a few bruises.

1. Initiating phase: Both partners commit to the
partnership
Angela asks Marion if she has time to meet to discuss fall prevention. Angela shares
she has recently attended a conference on preventing falls. Marion affirms she has
time and wants to learn about fall prevention. She is concerned about falling again
and wants to know strategies to prevent a fall from happening.

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2. Working phase: Partners bring their knowledge
and experience to the collaborative process
Marion describes the rooms in her apartment and her daily activities. Angela provides
information about how Marion can arrange her home environment to reduce the risk
for falls. Angela assesses Marion’s risk for falls, using a fall risk assessment tool she
learned about at the conference. Angela then asks Marion about steps Marion thinks
would be helpful for decreasing her fall risk. She also asks what resources Marion may
need to make changes in her environment. Together, they make a plan to implement
needed changes.

Key points from evidence
For a description of evidence levels, visit: Introduction: Overview of evidence-based
practice and related topics.

 1. Knowledge and skills needed for effective collaboration
The following 10 lessons are applicable to identifying knowledge and skills needed for
collaborating effectively:

 Know thyself.
 Learn to value and manage diversity.
 Develop constructive conflict resolution skills.
 Use your power to create win-win situations.
 Master interpersonal and process skills.
 Recognize that collaboration is a journey.
 Take the opportunity to participate in multidisciplinary forums or meetings to

increase collaboration opportunities.
 Appreciate that collaboration can occur spontaneously.
 Balance autonomy and unity in collaborative relationships.
 Remember that collaboration is not required for all decisions.

Level 5 source:

 Gardner, 2005

 2. Creating and sustaining mutual partnerships
Principles for creating and sustaining mutual partnerships include:

 Share common vision, mission, goals, and values.
 Be committed to the community.
 Show mutual trust and respect for all partners.
 Recognize the strengths and contributions of all partners.
 Be open and honest in sharing information and needs.
 Share leadership, decision-making power, resources, and credit among members.
 Use data in assessment, planning, implementation, and evaluation.
 Ensure that each member of the partnership is treated equally.

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 Foster a safe environment for clear and open communication that values feed-
back from all partners.

Level 4 sources:

 Giachello, 2007
 National Business Coalition on Health, 2008

 3. Reducing barriers to effective partnerships
Strategies to reduce barriers to effectively developing community partnerships:

 Take time to learn about the people, politics, and dynamics of the community
before you approach members.

 Allow enough time to build and nurture relationships with your partners.
 Understand group process—that is, how groups develop, mature, and work to-

gether on common problems, and then end or separate once work is complete.
 Develop rules to guide the group’s work.
 Support leadership development and capacity-building among group members.
 Understand how to run meetings, engage in group negotiations, and foster

decision-making.
 Create a flexible timeline for the program.

Level 4 source:

 Giachello, 2007

 4. Trust and leadership
Trust and leadership are the most important predictors of synergy in a partnership.
Synergy is the combination of all partners’ complementary strengths, perspectives,
values, and resources, as partners search for solutions.

Level 3 source:

 Jones & Barry, 2011

 5. Norms for group development
Tuckman’s stages of group development are useful for predicting how collaborative
groups and partnerships develop relationships and patterns of interaction as they
work toward a common goal. The stages are:

1. Forming: Group members determine boundaries and group leadership emerges.
2. Storming: Group members encounter conflict within the group and resist group

influence.
3. Norming: Group members develop cohesiveness, trust in one another, and

adopt new roles.
4. Performing: Group members work together with flexible and functional rules to

accomplish group tasks.

Level 5 sources:

 Keller, Schaffer, Schoon, Brueshoff, & Jost, 2011

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 Schoon, Porta, & Schaffer, 2019
 Tuckman, 1965

 6. Strategies for working together for a common purpose
Himmelman, a consultant in community and systems change collaboration, described
four strategies used by organizations working together for a common purpose:

 Networking: Exchanging information for mutual benefit
 Coordinating: Exchanging information for mutual benefit and altering activities

for a common purpose
 Cooperating: Exchanging information, altering activities, and sharing resources

for mutual benefit and a common purpose
 Collaborating: Exchanging information, altering activities, and sharing resources

and a willingness to enhance the capacity of partners for mutual benefit and a
common purpose

Himmelman noted that one strategy is not preferred over another; the strategy im-
plemented depends on levels of trust among partners and partners’ willingness to
share time and turf. Collaboration, requiring the most trust and willingness to share,
involves sharing risks, resources, and rewards, but also produces the greatest benefit
for all involved.

Level 5 source:

 Himmelman, 2002

 7. Interprofessional collaboration with clients
Interprofessional collaboration occurs when a partnership between professionals in
different professions share decision-making with the client to improve health.

Actions contributing to effective teamwork in interprofessional collaboration include:

 Strive to understand differences among team members’ culture, language, life-
styles, and beliefs.

 Listen and be fully attentive.
 Express appreciation.
 Be empathetic.
 Be courteous and considerate.
 Be accountable and professional.
 Follow the organizational professional code of conduct.
 Pay attention to interpersonal and relationship skills to enhance developing

trust and respect for partners.

Level 3 source:

 Clancy, Gressnes, & Svensson, 2013

Level 5 sources:

 Brewer, 2012
 Bridges, Davisdon, Odegard, Maki, & Tomkowiak, 2011
 Heatley & Kruske, 2011

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 8. Improved outcomes with interprofessional service delivery
Interprofessional public health service delivery contributes to improved outcomes.
Examples include improving mental health symptoms and function for clients in a
community mental health setting and increased fall reduction activities by profes-
sionals after implementing of guidelines to reduce falls for older adults.

Level 2 sources:

 Eckstrom et al., 2016
 Tippin, Maranzan, & Mountain, 2016

 9. Community engagement guidelines
Community engagement guidelines include:

 Be clear about goals and who to engage.
 Become knowledgeable about the community.
 Establish relationships, build trust, and seek commitment from the community.
 Develop local partnerships that collaboratively plan, design, develop, deliver,

and evaluate health initiatives.
 Recognize and respect the diversity of the community.
 Identify and mobilize community assets and strengths by developing the com-

munity’s capacity and resources to make decisions and take action.
 Be prepared to release control of actions or interventions to the community,

and be flexible enough to meet the community’s changing needs.

Level 4 sources:

 Bagnall, White, & South, 2017
 National Institutes of Health, 2011
 U.S. Department of Health and Human Services, 2011

 10. Improving behaviors and outcomes with integrated
strategies
Public health interventions that integrate community engagement strategies demon-
strate positive influences on health behaviors and outcomes in disadvantaged popu-
lations.

Level 1 sources:

 O’Mara-Eves et al., 2015
 Wells et al., 2013

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Wheel notes

Collective impact
The collective impact model strengthens collaboration effectiveness, and involves
cross-sector collaboration (bringing people and organizations together) to achieve
social change. Initiatives that incorporate collective impact require the following
components: 1) a common agenda, 2) ongoing communication, 3) mutual activities,
4) a backbone support organization, and 5) a shared measurement system (Collective
Impact Forum, 2014). Public health initiatives that have used a collective impact ap-
proach include a coordinated community response to teen pregnancy, a breastfeed-
ing promotion program, and a healthy city initiative to address specific community
health challenges (Baretta, 2018; Leruth, Goodman, Bragg, & Gray, 2017; Sagrestano,
Clay, & Finerman, 2018). While collective impact methods contribute to improving
health outcomes, cross-sector collaboration strategies are also likely to be time in-
tensive, to require committed leaders, and to involve overcoming challenges of shar-
ing data between organizations.

Overlap in collaboration, interprofessional
collaboration, and community engagement
Some overlap exists in the principles and actions required for collaboration, and for
two related processes—interprofessional collaboration and community engagement.
Interprofessional collaboration involves collaborating with other professionals, while
community engagement focuses on collaborating with communities. Public health
nurses frequently collaborate with individuals and families in providing public health
nursing services. They also cultivate effective collaborative practices when working
with other professionals and community members on public health initiatives.

Partnering with others
The orange wedge focuses on reaching mutual goals through partnerships. Successful
partnering requires using a skill set honed through group meetings and a self-assess-
ment process. Working effectively on a team is a learned skill, and not an innate hu-
man trait.

Collaboration enhances capabilities
Collaboration enhances the capabilities of all people in the partnership. Partners are
considered equal and all opinions are valued in decision-making.

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References
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for community practitioners. Primary Health Care, 27(6), 29-33. doi:
10.7748/phc.2017.e1192

Baretta, C. C. (2018). From collaboration to collective impact: Baton Rouge’s story. Health
Progress, 99(5), 34-37.

Bidmead, C., & Cowley, S. (2005). A concept analysis of partnership with clients. Community
Practitioner, 78(6), 203-208.

Brewer, K. (2012). Making interprofessional teams work for nurses, patients. American Nurse
Today, 7(3), 32-33.

Bridges, D. R., Davidson, R. A., Odegard, P. S., Maki, I. V., & Tomkowiak, J. (2011). Interprofessional
collaboration: three best practice models of interprofessional education. Medical
Education Online, 16, 1-10. doi: 10.3402/meo.v16i0.6035

Centers for Disease Control and Prevention. (2011). Engaging, building, expanding: An NBCCEDP
partnership development toolkit. Retrieved from
https://www.cdc.gov/cancer/nbccedp/toolkit.htm

Clancy, A., Gressnes, T., & Svensson, T. (2013). Public health nursing and interprofessional
collaboration in Norwegian municipalities: A questionnaire study. Scandinavian Journal
of Caring Sciences, 27(3), 659-668. doi: 10.1111/j.1471-6712.2012.01079.x

Eckstrom, E., Neal, M. B., Cotrell, V., Casey, C., McKenzie, G., Morgve, M. W., et al. (2016). An
interprofessional approach to reducing the risk of falls through enhanced collaborative
practice. Journal of American Geriatrics Society, 64(8), 1701-1707. doi:
10.1111/jgs.14178

Gallant, M. H., Beaulieu, M. C., & Carnevale, F. A. (2002). Partnership: An analysis of the concept
within the nurse–client relationship. Journal of Advanced Nursing, 40(2), 149-157.

Gardner, D. (2005). Ten lessons in collaboration. The Online Journal of Issues in Nursing, 10(1),
Manuscript 1. doi: 10.3912/OJIN.Vol10No01Man01

Giachello, A. (2007). Making community partnerships work: A toolkit. (D. Ashton, P. Kyler, E. S.
Rodriguez, R. Shaner, & A. Umemoto (Eds.). White Plains, NY: March of Dimes
Foundation. Retrieved from http://www.aapcho.org/wp/wp-
content/uploads/2012/02/Giachello-MakingCommunityPartnershipsWorkToolkit

Heatley, M. & Kruske, S. (2011). Defining collaboration in Australian maternity care. Women and
Birth, 24, 53-57. doi: 10.1016/j.wombi.2011.02.002

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Coalition-building
Coalition-building helps promote and develop alliances among organizations or con-
stituencies for a common purpose. It builds links, solves problems, and/or enhances
local leadership to address health concerns.

Reasons for forming a coalition include a desire to work with agencies with greater
expertise or complementary knowledge and skills, empowering groups or a commu-
nity to take action, obtaining or providing services, improving program delivery, shar-
ing resources, and reducing duplicative or competing services (Butterfoss & Kegler,
2012; Center for Community Health and Development at the University of Kansas,
2017; Giachello, 2007).

Practice-level examples
Population of interest: Apartment-dwelling refugees.

Problem: Limited options for inexpensive fresh produce in community.

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Systems level
In the Shenandoah Valley region of Virginia, a community assessment included per-
spectives from the refugee community, and identified the need and desire for a com-
munity garden with culturally familiar produce. Following implementation of a commu-
nity garden, evaluating outcomes demonstrated improved nutrition in the refugee pop-
ulation from growing and eating vegetables consistent with their cultural preferences.
A coalition, formed in response to the assessment, became aware of a faith-based or-
ganization that provided resettlement for refugees. One of their goals was to work with
churches to provide garden plots and gardening resources to help refugee families en-
gage with the community; take part in physical activity; and grow fresh, nutritious food.
The coalition worked with the organization to obtain a grant, funding a coordinator to
continue the community garden project started by the coalition.

Community level
Following the community assessment, public health nurses (PHNs) connected the ref-
ugee community with agencies and advocates who had similar missions and comple-
mentary skill sets, to form a community garden coalition. Coalition members included
a refugee resettlement agency, an urban housing community development organiza-
tion, an immigrant advocacy and resource agency, the local master garden associa-
tion, an organic seed company, and an apartment complex owner (Eggert, Blood-
Siegried, Champagne, Al-Jumaily, & Biederman, 2015).

Individual/family level
This intervention does not apply at this level.

Relationship with other interventions
Along with community organizing and collaboration, coalition-building involves part-
nerships. Because of this, they share many features, especially at the community level
of practice. All three interventions empower individuals and communities to take
control of their lives and environment, emphasizing client perceptions and experi-
ence. At the community level, community engagement (the process of working col-
laboratively with populations who are grouped by geographic location, special inter-
ests, or similar health concerns to respond to issues that affect group or population
well-being; U.S. Department of Health and Human Services, 2011) is relevant to all
three interventions.

Outside organizations or influences may facilitate coalition-building rather than the
community itself—a difference from community organizing. Unlike collaboration, co-
alition-building does not require enhancing the capacity of other organizations or
constituencies within the coalition.

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Coalition-building is also used in conjunction with policy development and
enforcement to change the way systems in a community operate or to change com-
munity-held norms or beliefs. Coalition-building is similar to advocacy at the systems
or community level; coalitions often exist to implement advocacy at the systems or
community level around a single issue. Coalitions may also use outreach interven-
tions at the systems and community level to connect with their target populations,
often paired with social marketing.

Basic steps
The Center for Community Health and Development at the University of Kansas
(2017) Community Toolbox provides online resources for building healthier commu-
nities, including coalition-building. These are steps for starting and maintaining a
community coalition:

1. Put together a core group
A core group will have more resources and knowledge of a community as opposed to
an individual effort.

a. Start with people you know.
b. Contact people in agencies and institutions most affected by the issue.
c. Talk to influential people in the community and those who have many contacts.
d. Recruit people most affected by the concern or problem.

2. Identify potential coalition members
There may be a specific person in the target population or a community official who
you need to include to accomplish the coalition’s goal(s).

a. Potential coalition members include stakeholders (those affected by the issue),
formal and informal helpers, community opinion leaders, and policymakers.

b. Reach out to people with knowledge or skills helpful to the coalition.
c. Consider important organizations in recruiting an organizational representative

to the coalition.

3. Recruit members to the coalition
After identifying potential members important to the coalition’s success, invite them
to join the coalition.

a. Ask individuals in the core group to review the list and identify individuals or
organizations they know.

b. Divide remaining potential members among members of the core group.
c. Contact potential members via face-to-face meetings, phone calls, email com-

munication, personal letters, ads in the media, and flyers or posters. Direct per-
sonal contact is best.

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4. Plan and hold the first meeting
Plan a high-energy, exciting first meeting.

a. Plan specific meeting logistics—where, how long, and what (content).
b. Agenda topics include:

 Introductions
 Defining the problem that brings the coalition together
 Coalition structure
 Discussing a common vision and shared values about the coalition’s direction
 Discussing the procedure for developing an action plan
 Reviewing tasks and responsibilities before next meeting
 Identifying the next meeting date

5. Follow up on the first meeting
Follow-up ensures the next meeting is well-attended and the coalition’s work continues.

a. Distribute minutes of the first meeting with invitations to potential new members.
b. Follow up with groups or individuals working on tasks assigned at the first meeting.
c. If there are committees or task forces, recruit new members for them if needed.

Many people will respond if asked because their expertise is valued.
d. Keep track of upcoming decisions.

6. Move forward on next steps
Focusing on next steps maintains momentum from the first meeting.

a. Gather information about the problem.
b. Finish vision and mission statements.
c. Complete an action plan.
d. Finish designing a coalition structure that is acceptable to members.
e. Elect officers, or a coordinating or steering committee.
f. Examine the need for professional staff.
g. Determine what other resources (financial, material, and informational) are

needed, develop a plan for getting them, and decide who is responsible for car-
rying it out.

7. Maintain until coalition accomplishes its
purpose
Paying attention to the coalition processes and membership experience keeps the
coalition vital and healthy. General rules for coalition facilitation include:

a. Communicate openly and freely with everyone.
b. Be inclusive and participatory.
c. Network at every opportunity.
d. Set achievable goals, in order to engender success.

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e. Hold creative meetings.
f. Be realistic about what you can do. Don’t promise more than you can accom-

plish, and always keep your promises.
g. Acknowledge and use the diversity of the group.

Example
A PHN from a county health department met with a coalition to implement a com-
munity garden project for apartment-dwelling refugees (Eggert et al., 2015).

1. Put together a core group
From a health department community assessment about the health needs of refu-
gees living in the community, a PHN learns refugees have difficulty getting the fresh
vegetables they like to eat. The PHN contacts representatives from a refugee reset-
tlement agency, an immigrant advocacy group, and the manager of a local apartment
complex to discuss the potential for establishing a community garden for use by the
immigrant population.

2. Identify potential coalition members
The first representatives of organizations contacted by the PHN suggested several
other organizations that can contribute expertise and resources to the coalition.

3. Recruit members to the coalition
The PHN puts together a list of possible members and asks the people she initially
contacted in the core group to personally invite additional members. Possible addi-
tional members includes representatives from an urban housing community devel-
opment organization, a local garden association, an organic seed company, and a
member of the refugee community.

4. Plan and hold the first meeting
The PHN reserves space at a local community center for the first meeting, and pre-
pares an agenda. The group starts with introductions. They discuss the problem at
the heart of the coalition and what they hope to accomplish. The refugee resettle-
ment agency representative volunteers to lead the coalition. The group creates a list
of possible objectives, and steps to create an action plan. The refugee community
representative volunteers to learn which vegetables the apartment-dwelling refu-
gees prefer. The garden association representative plans to investigate how the local
soil and climate conditions would support growing the vegetables. The group sets a
date for its next meeting. Group members agree to rotate responsibility for taking
meeting minutes. The PHN agrees to provide minutes for the first meeting.

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5. Follow up on the first meeting
The PHN distributes minutes via email one week after the first meeting. The minutes
identify tasks to accomplish by the next meeting, and who is responsible for each
task. The minutes also include a list of upcoming decisions, and agenda items identi-
fied for the next meeting. The refugee resettlement agency representative plans to
finalize the agenda prior to the next meeting.

6. Move forward on next steps
Coalition members continue to gather information about best practices for establishing
a community garden. In the next two meetings they finalize the coalition’s vision and
mission statements, and complete the action plan. They discuss the need to obtain a
grant to fund a coordinator who can oversee community garden implementation.

7. Maintain until coalition accomplishes its
purpose
After meeting monthly for six months, the coalition learns of a faith-based organiza-
tion that supports resettlement programs for refugees. The coalition invites a repre-
sentative from the organization to attend one of its meetings, to provide information
about the organization’s resources. The coalition starts to arrange for a presentation
related to community gardens at each of its meetings. In the future, when members
mutually agree that the coalition has met its objectives and when the community has
taken over leadership, members will discuss an ending point for the coalition.

Key points from evidence
For a description of evidence levels, visit: Introduction: Overview of evidence-based
practice and related topics.

 1. Guidelines for starting coalitions
Guidelines for starting coalitions include:

 Be sure lines of communication within the coalition are wide open, between the
coalition, the media, and the community.

 Work at making the coalition a group in which anyone in the community will feel
welcome, and continue to invite people to join after the first meeting.

 Involve as many other groups in the community as possible.
 Set concrete, achievable goals.
 Be creative about meetings to retain both membership and interest in the coa-

lition. Consider rotating meeting planning among coalition groups, identifying a
meeting theme, working in committees or task forces, or arranging a captivating
presentation on a topic relevant to coalition planning.

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 Be realistic, and keep your promises.
 Acknowledge diversity among your members, and among their ideas and beliefs.
 Praise and reward outstanding contributions and celebrate your successes.
 Invest the time needed for coalition-building.
 Be flexible and open to change.
 Call in experts when needed, for information and process.

Level 4 source:

 Center for Community Health and Development at the University of Kansas,
2017

Level 5 source:

 Wynn et al., 2006

 2. Understanding coalition environments and context
Contextual factors that provide an understanding of how the coalition’s environment
influences its development, functioning, and outcomes include:

 Geography: Urban or rural, large county or dense metropolitan area
 History of collaboration: Prior experience of working together
 Economics: Local economy, employment opportunities, business practices
 Political climate: Factions and groups in the community and how they interact
 Community norms and values: Social norms, beliefs, and values of community

members

Level 3 source:

 Kegler, Rigler, & Honeycutt, 2010

Level 5 source:

 Butterfoss & Kegler, 2012

 3. Coalition-building stages
Coalition-building includes three stages:

a. Formation: A convener or lead agency that has links to the community brings
together core organizations.

b. Maintenance: The coalition sustains member involvement and creates collabo-
rative synergy. Success depends on mobilizing member resources and external
resources.

c. Institutionalization: The coalition achieves outcomes. Coalition strategies may
become part of a long-term coalition, or be adopted by other organizations in
the community.

Level 5 source:

 Butterfoss & Kegler, 2012

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 4. Factors for success
Internal and external factors that contribute to coalition success include:

 Commitment to a shared social vision
 Competent leadership that facilitates a learning environment and supports

achieving outcomes
 An effective coalition coordinator who oversees coalition activities
 Shared responsibility of financial and staffing resources
 Effective practices
 Commitment to coalition unity and a new way of doing business
 An equitable decision-making structure
 Mutual trust and respect
 A prepared public health workforce
 Establishing links with existing community organizations
 Building new member skills
 Rewarding relationships

Level 1 source:

 Shapiro, Hawkins, & Oesterle, 2015

Level 3 source:

 Mizrahi & Rosenthal, 2001

Level 5 sources:

 Cramer, Atwood, & Stoner, 2006
 Cramer, Lazure, Morris, Valerio, & Morris, 2013
 Salem, 2005

 5. Factors for coalition organizational capacity
Factors that contribute to coalition organizational capacity include resources, the
lead agency of the coalition, governance, and leadership. Characteristics of coalitions
with greater organizational capacity:

 A focus on the community’s priorities and mission
 Receiving more funds dedicated to coalition-building efforts
 A longer wait to establish a new lead agency
 Being housed in lead agencies supportive of coalition development
 Stable, participatory decision-making structures
 Available training and technical assistance
 Seeking active involvement from government agencies
 Practicing collaborative leadership
 Effective and long-term project directors

Level 1 source:

 Gloppen, Arthur, Hawkins, & Shapiro, 2012

Level 3 sources:

 Brown, Feinberg, & Greenberg, 2010
 Brown, Wells, Jones, & Chilenski, 2017

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 Feinberg, Bontempo, & Greenberg, 2008
 Kramer et al., 2005
 Zakocs & Guckenburg, 2007

 6. Challenges to success
Challenges to coalition success include:

 Limited resources (funding and personnel)
 Lack of strong commitment
 Suspicion of government
 Meeting burnout
 A wide variety of perspectives within the coalition
 A slow pace and frustrating process
 Limited time for coalition members to participate
 Few resources or strategies for engaging members’ interest in coalition activities

Level 3 source:

 Desmond, Chapman, Graf, Stanfield, & Waterbor, 2014

Level 5 source:

 Salem, 2005

 7. Satisfaction and sustainability
Key factors of coalition membership satisfaction that are consistent with coalition
sustainability include:

 The lead agency provides support and assistance with logistical activities (sched-
uling meetings and space, providing new member orientation).

 The lead agency assists in providing resources for accomplishing the coalition
mission.

 There is a spokesperson or champion in the leadership role who is recognized
by the organizations and the community.

Level 3 source:

 Desmond et al., 2014

 8. Connecting providers and diverse communities
Community coalitions that connect health and human service providers with racially
and ethnically diverse communities may improve health outcomes, behaviors, and
health delivery systems.

Level 2 source:

 Anderson et al., 2015

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Wheel notes

Public health nurse as coalition catalyst
A coalition may invite PHNs possessing knowledge and skills consistent with its mis-
sion to contribute expertise to coalition activities. Public health nurses also have ex-
pertise to discern the need for a coalition based on community assessment infor-
mation, and know community resources and organizations.

For example, a PHN might identify the need for a coalition focusing on providing den-
tal services in a community where many children lack dental care. The PHN calls a
meeting, inviting a core group of representatives from among providers, community
organizations, and the school system, who all recognize the importance of providing
dental care. In this situation, the PHN functions as a catalyst for coalition develop-
ment, and collaborates with health care and community, organizations, businesses,
and policymakers to work together.

International perspective
Coalition-building and community organizing may not be as necessary in developed
countries that provide universal health care and offer many social resources to promote
population well-being. Countries with greater health care and social resources are less
likely to need communities to provide programs to fill the gaps. For example, in Norway,
PHNs enrolled in a graduate-level public health nursing program offered few examples
of coalition-building and community organizing relative to other interventions.

Public health nurse practice roles are also more individually-focused, with less oppor-
tunity for community- and systems-level practice. Coalition-building may compete
with other demands for a PHN’s time, or may not be supported by public health nurs-
ing administration and agencies. A systematic review of 23 international studies (in-
cluding five studies from the United States) on public health nursing interventions to
promote quality of life in elderly populations yielded no examples of coalition-build-
ing (Schaffer, Kalfoss, & Glavin, 2017). This analysis revealed that most PHN interven-
tions were provided at an individual level. In this analysis, interventions occurring at
the community and systems levels included health teaching, counseling,
consultation, case management, referral and follow-up, screening, surveillance,
policy development and enforcement, and most frequently collaboration.

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References
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Community coalition-driven interventions to reduce health disparities among racial and
ethnic minority populations. Cochrane Database of Systematic Reviews, Issue 6. Art. No.:
CD009905.doi: 10.1002/14651858.CD009905.pub2.

Brown, L. D., Feinberg, M. E., & Greenberg, M. T. (2010). Determinants of community coalition
ability to support evidence-based programs. Prevention Science, 11, 287-297. doi:
10.1007/s11121-010-0173-6

Brown, L. D., Wells, R., Jones, E. C., & Chilenski, S. M. (2017). Effects of sectoral diversity on
community coalition processes and outcomes. Prevention Science, 18, 600-609. doi:
10.1007/s11121-017-0796-y

Butterfoss, F. & Kegler, M. C. (2012). A coalition model for community action. In M. Minkler,
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Center for Community Health and Development at the University of Kansas. (2017). Community
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Kegler, M. C., Rigler, J., & Honeycutt, S. (2010). How does community context influence coalitions
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Kramer, J. S., Philliber, S., Brindis, C. D., Kamine, S. L., Chadwick, A. E., Revels, M. L., et al. (2005).
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Mizrahi, T. & Rosenthal, B. B. (2001). Complexities of coalition building: Leaders’ successes,
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Salem, E. (2005). MAPP in Chicago: A model for public health systems development and
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Shapiro, V. B., Hawkins, J. D., & Oesterle, S. (2015). Building local infrastructure for community
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U.S. Department of Health and Human Services. (2011). Principles of community engagement (2nd
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Wynn, T. A., Johnson, R. E., Fouad, M., Holt, C. L., Scarinci, I., Nagy, C., et al. (2006). Addressing
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10.1353/hpu.2006.008

Zakocs, R. C. & Guckenburg, S. (2007). What coalition factors foster community capacity? Lessons
learned from the fighting back initiative. Health Education & Behavior, 34(2), 354-375.
doi: 10.1177/1090198106288492

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Community organizing
Community organizing is “the process by which people come together to identify
common problems or goals, mobilize resources, and develop and implement strate-
gies for reaching the objectives they want to accomplish” (Center for Community
Health and Development at the University of Kansas, 2017).

The term “community organizing” originated with social workers in the United States
during the late 1800s, to describe the coordination of services for immigrants and the
poor. Collaboration and consensus were important components of assisting commu-
nities to increase their problem-solving abilities through community organizing
(Minkler & Wallerstein, 2012).

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Practice-level examples
Population of interest: Residents between 15 and 24 years old in Minneapolis, the
largest city in Minnesota.

Problem: The leading cause of death for this age group is homicide.

Systems level
A public health nurse (PHN) in a leadership role at the city health department met
with community leaders, elected officials, and the police department to develop a
public health response to increased community violence among youth. City organiza-
tions developed The Blueprint for Action to Prevent Youth Violence, which identified
four objectives: 1) connect youth to trusted adults, 2) intervene at the first sign of
risk, 3) integrate youth from the juvenile system back into the community, and 4)
unlearn the culture of violence (Zanjani, 2011).

The State of Minnesota responded by passing legislation addressing youth violence.
The City of Minneapolis partnered with an organization called UNITY to respond to
the problem of youth violence. UNITY organizes conferences, develops tools and in-
formation, and conducts networking activities across the United States (Urban Net-
works to Increase Thriving Youth, 2011). 2015 Youth Violence Prevention (City of Min-
neapolis Health Department, 2016) listed city initiatives resulting from the Blueprint
for Action: 1) the Juvenile Supervision Center (JSC) works with low level offenders to
prevent further involvement in the juvenile justice system; 2) the STEP-UP internship
program offered in the summer served 90 percent youth of color; and 3) Next Step,
a violence prevention program, has been funded by a Centers for Disease Control and
Prevention (CDC) grant that targets young male athletes and street-based outreach
to young people in North Minneapolis.

Community level
In response to the problem of violence among city youth, community leaders sup-
ported a public health approach, which addressed factors beyond a law enforcement
approach. The public health approach employed strategies to decrease factors that
put people at risk for violence, like dysfunctional families, lack of access to mentors,
drug and alcohol use, poverty, a media environment saturated with violence, hope-
lessness about the future. It also worked to increase protective factors like school
success, youth employment, and quality out-of-school time programming. As a result
of these efforts, the Minneapolis City Council adopted a resolution naming youth vi-
olence as a public health issue and created a plan, The Blueprint for Action: Preventing
Youth Violence in Minneapolis (City of Minneapolis Health Department, 2013). The
PHN leader acted as a convener in bringing over 60 groups together and engaging
members of the community in mobilizing a community response (Musicant, 2011).

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Individual/family level
The intervention does not apply at this level.

Relationship with other interventions
Community organizing, coalition-building, and collaboration all involve partnerships.
Because of this, they share many features, especially at the community level of practice.
All three interventions empower individuals and communities to take control of their
lives and environment, emphasizing client perceptions and experience. At the commu-
nity level, community engagement (the process of working collaboratively with popu-
lations who are grouped by geographic location, special interests, or similar health con-
cerns to respond to issues that affect group or population well-being [U.S. Department
of Health and Human Services, 2011]) is relevant to all three interventions.

The community identifies the impetus for community organizing, rather than an out-
side organization or change agent as in coalition-building. Unlike collaboration, com-
munity organizing does not aim to provide opportunities for organizational or per-
sonal transformation, and does not occur at the individual/family level of practice.
Community organizing occurs primarily at the community level of practice. However,
community organizing may result in coalition-building, as people and organizations
come together to address community problems.

The initial steps for community organizing are similar to successful methods for im-
plementing the outreach intervention at the systems and community practice lev-
els—for example, identifying and specifying the issue of concern, describing the tar-
get population, and considering demographic implications. Community organizing of-
ten uses advocacy and social marketing as companion interventions when an organ-
ization intends to raise awareness or change a population’s health behavior. Commu-
nity organizing is also implemented in conjunction with the policy development and
enforcement intervention, especially when one intends to change policy at the sys-
tems level.

Basic steps
The Center for Community Health and Development at the University of Kansas
(2017) Community Toolbox, provides online resources for building healthier commu-
nities. The Community Toolbox identifies the following strategies for bringing about
change through community organizing:

1. Involve people in your community efforts
Emphasize building excitement for change among community members, not an out-
side expert telling the community what needs to be done.

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2. Identify community members’ #1 issue
Learning what is important to the community helps identify the goal for change.

Consider these three questions when choosing a problem to tackle:

a. Is it important enough to people that they are willing to take action about it?
b. Is it specific? For example, violence may be a problem—but what kind of vio-

lence are people concerned about? Domestic violence? Violence in schools?
Muggings after dark?

c. Can something be done to affect the problem in a reasonable amount of time?

3. Develop your strategy
Identifying a strategy will guide the plan for community change.

The group should meet and agree on answers to the following questions.

a. What are your long and short-term goals?
b. What are your organizational strengths and weaknesses?
c. Who cares about this problem?
d. Who are your allies?
e. Who has the power to give you what you want?
f. How can you make your work enjoyable for community members to participate?

4. Develop specific tactics for selected strategy
Select tactics to fit the situation, target the appropriate group, and be effective (not
too extreme or too weak). Examples include boycotts, petitions, demonstrations, and
meetings with people with power.

5. Choose specific actions
Choose actions to carry out your strategies and tactics. Actions need to be concrete
and clear to move community organizing forward. Specify who will do what, in what
way, and by when.

6. Set goals and celebrate wins
Group members need to feel they are making progress and that their work is important.

7. Plan for sustainability if indicated
Community organizing work can take a long time to result in change. At regular inter-
vals, evaluate and update the goals to maintain sustainability. The group may disband
if goals are not revised and updated.

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Example
A PHN leader in a large city noted a spike in youth homicides and injuries (Musicant,
2011). Although law enforcement responds to community violence, the nurse leader
realized that law enforcement alone insufficiently addressed community violence.
The nurse leader convened a group of community representatives who wanted to
reduce the incidence of youth violence in the city.

1. Involve people in your community efforts
A PHN leader at a city health department convenes a group of community leaders,
elected officials, and the police department to address concerns about increasing vi-
olence among youth in the city.

2. Identify community members’ #1 issue
Group members discuss factors that contribute to the increasing rate of violence
among youth. Stakeholders in the community ask, “What are you doing to address
violence?”

3. Develop strategy
Local leaders in government, education, law enforcement, social services, neighbor-
hoods, and business come together to address the problem. They developed the co-
operative plan called Minneapolis Blueprint for Action to Prevent Youth Violence,
which “represents a community-driven, grassroots response to the issue of youth vi-
olence” (City of Minneapolis Health Department, 2013, p. 17).

4. Develop specific tactics for selected strategy
The Blueprint for Action results in many youth violence prevention initiatives, includ-
ing North4, a collaboration between the City and Emerge Community Development
to engage and employ gang-affiliated youth; Picturing Peace, a partnership between
Hennepin County Libraries and the Downtown Improvement District for youth to doc-
ument their hopes for peace through photography; and BUILD, a youth development
curriculum that promotes social and emotional learning and fosters positive decision
making to prevent gang activity (City of Minneapolis Health Department, 2013).

5. Choose specific actions
Specific actions to foster violence-free social environments included:

 The Minneapolis Health Department hosts community dialogues to increase
awareness of youth violence prevention initiatives.

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 A citywide collaborative group, Ending Youth Violence Roundtable, continues to
focus efforts on violence prevention.

 The Minneapolis Health Department Youth Development Coordinator and
Youth Coordinating Board implement projects to promote youth engagement in
media and art initiatives (City of Minneapolis Health Department, 2013).

6. Set goals and celebrate wins
The plan specified goals, goal achievement indicators, and performance measures.
Semi-annual progress reports communicate strategies, resources, and programs that
contribute to reducing youth violence.

7. Plan for sustainability if indicated
Minneapolis is one of many cities across the United States that partners with UNITY
(Urban Networks to Increase Thriving Youth), an initiative of the Prevention Institute.
UNITY (2011) focuses on building community safety in cities through comprehensive
and multi-sector strategies that prevent violence and support community resilience.

Key points from evidence
For a description of evidence levels, visit: Introduction: Overview of evidence-based
practice and related topics.

 1. Important concepts
Important concepts in a community organizing model include:

a. Empowerment: Individuals and communities develop an awareness of their
own problem solving skills and resources.

b. Partnership: Relationships are based on mutual respect, exchanging ideas, and
shared power.

c. Participation: Community members are engaged in all phases of community or-
ganization and have decision-making authority.

d. Cultural responsiveness: Methods and plans incorporate cultural factors that
inform what health means to community members.

e. Community competence: The community collaborates effectively to manage
threats to well-being and move toward improved health.

Level 3 source:

 Bezboruah, 2013

Level 5 sources:

 Anderson, Guthrie, & Schirle, 2002
 Minkler & Wallerstein, 2012

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 2. Effective community organizing
Guidelines for effective community organizing include:

 Gain an understanding of the community.
 Generate and use power:

▪ Political or legislative power
▪ Consumer power
▪ Legal regulatory power
▪ Disruptive power

 Articulate issues clearly.
 Plan purposeful action.
 Involve other people (strength in numbers, accomplish more together).
 Generate and use other resources (cash, gifts in kind, other forms of donations

or support).
 Communicate with your community.

Level 4 source:

 Center for Community Health and Development at the University of Kansas,
2017

 3. Focusing on health equity
Focusing on health equity in community organizing activities promotes equal access
to health care and resources, with the goal of reducing health disparities between
population groups. To promote health equity, community organizing activities ad-
dress structural causes that contribute to unequal health, e.g., poverty, racial discrim-
ination, etc.

Community organizing activities were effective in moving toward health equity in Cal-
ifornia. Examples include:

 Legislation to provide health care through Medicaid to undocumented children
 Policies to improve the well-being of communities of color with exposure to

health-impairing pollution
 Promoting educational justice by changing school discipline laws that contribute

to unequal treatment for students of color

Level 5 source:

 Pastor, Terriquez, & Lin, 2018

 4. Empowering communities
Community organizing strategies that empower communities to promote health
through systems change include:

 Developing a community base that is supportive of public health change
 Building a leadership base by providing training in workshops, conferences, and

seminars
 Building an ally base, of organizations with shared interests and values
 Reframing messages to explain that systemic inequities are precursors to public

health disparities

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 Mobilizing the community base for ongoing participation in public health
initiatives

 Working to understand communities’ cultural dynamics
 Listening to and being prepared to challenge views and perceived needs
 Fostering a culture of collaboration and action in response to these views and

perceived needs while using accessible language
 Ensuring credit or recognition for project success goes to community members

Level 5 sources:

 Douglas, Grills, Villanueva, & Subica, 2016
 Piper, 2011

 5. Advantages of community organizing
There are a number of advantages to community organizing, including:

 A greater ability to bring about change, since a collective voice is more powerful
than a single voice

 Empowering people to improve the conditions that shape their lives (especially
those who traditionally have not had power)

 Increasing self-sufficiency among community members through ownership of
outcomes

 Increasing social support, by bringing together diverse groups of people working
on the same goal

 Greater equity in society, because the balance of power is spread out and dis-
tributed more equally

Level 4 source:

 Center for Community Health and Development at the University of Kansas, 2017

 6. Challenges to effective community organizing
Challenges that may interfere with effective community organizing include:

 Disagreement over strategies to accomplish goals
 Low or disproportionate participation of community members
 Variable knowledge of successful health care service delivery methods
 Leadership from backgrounds that are very different from the targeted population

Level 3 source:

 Bezboruah, 2013

 7. Ethical problems in community organizing
Differing values in participants’ political, economic, cultural, and social contexts may
lead to ethical problems as a group comes together to respond to a community prob-
lem. Ethical problems that might occur when using community organizing as an inter-
vention include:

 Authentic or real community participation vs. symbolic participation
 Conflicting community priorities

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 Requirements of funding sources and regulatory organizations, which may neg-
atively impact access and innovation

 Cultural conflict
 Unanticipated consequences of organizing
 Consideration of whose “common good” is being addressed

To avoid ethical problems in community organizing, start where the people are, work
with communities to translate their goals into reality, and engage community mem-
bers in discussion and reflection.

Level 5 source:

• Minkler, Pies, & Hyde, 2012

 8. Examples of effective activities and campaigns
Examples of effective community organizing activities and campaigns:

 A New Zealand initiative led by Pacific Island youth contributed to improved
mental health and a sense of agency over health (empowerment) for a disem-
powered population.

 ISAIAH, a faith-based community organizing group of 90 organizations, worked
for policy and systems change to increase community access to grocery stores,
employment, schools, and affordable neighborhoods. ISAIAH formed partner-
ships with a wide variety of organizations committed to the same goal.

 Three churches, an Islamic Center, and a faith-based charity in South London
organized to develop and pilot a community-led mother’s group to increase so-
cial capital, reduce stress, and improve well-being in mothers who were preg-
nant or had young children. Outcomes included reduced distress (self-reported)
and facilitating community engagement in health.

Level 2 source:

 Bolton, Moore, Ferreira, Day, & Bolton, 2015

Level 3 source:

 Han, Nicholas, Aimer, & Gray, 2015

Level 5 source:

 Speer, Tesdahl, & Ayers, 2013

Wheel notes

Related concept: Social capital
The concept of social capital frequently occurs in the literature, in descriptions of
community organizing interventions. Social capital refers to the amount of resources
available in a community or other social structure. In a study on building social capital
in a refugee community, Im and Rosenberg (2015) identified structural and cognitive

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social capital themes: 1) gathering together as a community; 2) training leaders to
build community capacity; 3) participating in solving community issues; and 4) foster-
ing mutual respect, connectedness, and unity. These themes address strategies and
resources that exist within a community and are consistent with the basic steps of
community organizing.

Related concept: Community activism
Similar to community organizing, in community activism individuals, groups, or or-
ganizations work together to bring change in social, economic, environmental, and
cultural policies and practices. Nurses have been involved in community activism
from the time of Florence Nightingale and Lillian Wald to present-day public health
nursing practice. Current examples of nurses engaging in community activism include
promoting smoke-free policies, physical activity opportunities in neighborhoods,
standards for clean air and water, maternity care for underserved populations, hos-
pital breastfeeding policies, and policies on human trafficking. Community activism
requires the ability to envision a different reality, engage diverse communities, com-
mit to change, take action through organizing, and sustain partnerships and collabo-
ration (Messias & Estrada, 2016).

References
Anderson, E., Guthrie, T., & Schirle, R. (2002). A nursing model of community organization for

change. Public Health Nursing, 19(1), 40-46.

Bezboruah, K. C. (2013). Community organizing for health care: An analysis of the process. Journal
of Community Practice, 21, 9-27. doi: 10.1080/10705422.2013.788328

Bolton, M., Moore, I. Ferreira, A., Day, C., & Bolton, D. (2015). Community organizing and
community health: piloting an innovative approach to community engagement applied
to an early intervention project in south London. Journal of Public Health, 38(1), 115-
121. doi: 10.1093/pubmed/fdv017

Center for Community Health and Development at the University of Kansas. (2017). Community
Toolbox. Strategies for Community Change and Improvement: An Overview. Retrieved
from https://ctb.ku.edu/en/table-of-contents/assessment/promotion-
strategies/overview/main

City of Minneapolis Health Department. (2013). Minneapolis Blueprint for Action to Prevent Youth
Violence. Retrieved from
http://www.minneapolismn.gov/www/groups/public/@health/documents/webcontent
/wcms1p-114466

City of Minneapolis Health Department. (2016). 2015 Youth Violence Prevention: A Results
Minneapolis report. Retrieved from
http://www.minneapolismn.gov/www/groups/public/@health/documents/webcontent
/wcmsp-189736

Douglas, J. A., Grills, C. T., Villanueva, S., & Subica, A. M. (2016). Empowerment praxis: Community
organizing to redress systemic health disparities. American Journal of Community
Psychology, 58, 488-498. doi: 10.1002/ajcp.12101

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Han, H., Nicholas, A., Aimer, M., & Gray, J. (2015). An innovative community organizing campaign
to improve mental health and wellbeing among Pacific Island youth in South Auckland,
New Zealand. Australasian Psychiatry, 23(6), 670-674. doi: 10.1177/1039856215597539

Im, H. & Rosenberg, R. (2015). Building social capital through a peer-Led Community health
workshop: A pilot with the Bhutanese refugee community. Journal of Community
Health, 41, 509–517. doi: 10.1007/s10900-015-0124-z

Messias, D. H. & Estrada, R. D. (2016). In D. Mason, D. Gardner, D., F. Outlaw, F., & E. O’Grady
(Eds.), An introduction to community activism (pp. 651-659). Policy and Politics in
Nursing and Health Care, 7th ed. St. Louis, MO: Elsevier.

Minkler, M., Pies, C., & Hyde, C. A. (2012). Ethical issues in community organizing and capacity
building. In M. Minkler (Ed.), Community organizing and community building for health
and welfare (pp. 110-229). New Brunswick, NJ: Rutgers University Press.

Minkler, M. & Wallerstein, (2012). Community organization and improving health through
community building. In M. Minkler, Community organizing and community building for
health and welfare (pp. 37-90). New Brunswick, NJ: Rutgers University Press.

Musicant, G. (2011). A call to action-preventing community violence. Public Health Nursing 28(4),
295-296. doi: 10.1111/j.1525-1446.2011.00962.x

Pastor, M., Terriquez, V., & Lin, M. (2018). How community organizing promotes health equity,
and how health equity affects organizing. Health Affairs, 37(3), 358-363. doi:
10.1377/hlthaff.2017.1285

Piper, S. M. (2011). Community empowerment for health visiting and other public health nursing.
Community Practitioner, 84(8), 28-31.

Speer, P. W., Tesdahl, T. A., & Ayers, J. F, (2013). Community organizing practices in a globalizing
era: Building power for health equity at the community level. Journal of Health
Psychology, 19(1) 159-169. doi: 10.1177/1359105313500255

U.S. Department of Health and Human Services. (2011). Principles of community engagement (2nd
Ed.). NIH Publication No. 11-7782. Retrieved from
http://www.ucdmc.ucdavis.edu/crhd/images/pdf/PCE2_En

Urban Networks to Increase Thriving Youth (UNITY). (2011). Mission and activities. Retrieved from
https://www.preventioninstitute.org/unity/general/mission-a-activities

Zanjani, B. (2011). Blueprint for action-preventing violence in Minneapolis.
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2011

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In review
A story:

The Healthy Start Coalition in Pinellas County, Florida, a community-based organiza-
tion, oversees and funds initiatives addressing perinatal care in the community. To
pinpoint areas with a higher risk of prematurity and infant mortality, the coalition
created and analyzed maps of the county using GIS software.

“GIS, or geographic information systems, are computer-based tools used to store,
visualize, analyze, and interpret geographic data. Geographic data (also called spatial,
or geospatial data) identifies the geographic location of features” (Centers for Disease
Control and Prevention, 2016). Public health practitioners can use GIS to answer spe-
cific data-related questions by collecting and analyzing geo-coded data on a wide va-
riety of health problems. Examples include access to health care services or food, su-
icide mortality, or violent crime, among many others.

Pinellas County had a higher rate of prematurity (associated with infant mortality)
when compared to all other Florida counties, higher rates of black infant mortality
and low birthweight when compared to other racial and ethnic groups in the county,

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and saw the Latinx infant mortality rate double in 10 years. The community-specific
data engaged and motivated community members to respond (Detres, Lucio, &
Vitucci, 2014).

Coalition members included program clients, the local health department, commu-
nity agencies, health care providers, businesses, managed care representatives, and
policymakers. As a coalition member, a local public health nurse (PHN) experienced
in maternal and child health suggested feasible and practical coalition strategies that
met the needs of this population.

The coalition used GIS to analyze Florida birth and infant death records from county
data, and then reviewed the maps, discussing risk areas and changes over time for
infant mortality and prematurity. The maps helped coalition members more easily
identify high-risk zip codes (where prematurity and infant mortality rates were
higher). The coalition asked for community feedback on how to address infant
mortality and prematurity. The community identified demographic and housing
changes needed, including new mobile home areas in high-risk neighborhoods. The
group worked with the local community and developed a holistic plan to address risk
factors affecting birth outcomes, including expanding services by hiring a nutritionist
and contracting with a health system navigator to assist clients in accessing health
care coverage and services.

The orange wedge features collaboration, coalition-building, and community organ-
izing. Think about how a PHN, as a member of this group, could contribute to the
implementation of these interventions.

Application questions
Consider the following questions for the story about using GIS as a community en-
gagement tool.

Level of practice
1. What levels of practice do you see occurring in this story?

Collaboration
2. What factors contribute to a successful partnership for improving maternal and

child health in the population?
3. How could a public health nurse use community engagement principles and cul-

tural humility to guide collaboration efforts in this story?
4. How might the social and economic conditions experienced in these communi-

ties impact collaboration?

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Coalition-building
5. What actions does a coalition take to develop itself more effectively?
6. What strategies might a public health nurse use to ensure coalition participants

represent the population served?
7. What might a public health nurse do to ensure that public health professionals

value the experience of those most impacted?
8. How might a public health nurse involved in this coalition contribute to effective

coalition strategies?

Community organizing
9. How did the coalition use community organizing strategies to facilitate commu-

nity empowerment?
10. What community organizing strategies did the coalition use to ensure group

members came together to address the problem?
11. In the process of analyzing data, coalition members discussed changing de-

mographics and housing patterns as indicated by the data (such as new mobile
homes in high-risk areas).
a. What actions might a public health nurse or the coalition take to address

these community concerns?
b. What ethical problems might emerge as the group discusses changes sup-

ported by the data?

References
Centers for Disease Control and Prevention. (2016). What is GIS? Retrieved from

https://www.cdc.gov/gis/what-is-gis.htm

Detres, M., Lucio, R. & Vitucci, J. (2014). GIS as a community engagement tool: Developing a plan
to reduce infant mortality risk factors. Maternal and Child Health Journal, 18, 1049-
1055. doi: 10.1007/s10995-013-1337-3

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Advocacy
Advocacy is the act of promoting and protecting the health of individuals and com-
munities “by collaborating with relevant stakeholders, facilitating access to health
and social services, and actively engaging key decision-makers to support and enact
policies to improve community health outcomes” (Ezeonwu, 2015, p. 123).

There are three ways to view public health nursing advocacy:

 A response to a client’s right to information and self-determination
 A means of addressing client safety
 A philosophical principle

Practice-level examples
Population of interest: Individuals and communities at risk for childhood traumatic
experiences.

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Problem: Adverse child experiences, known as ACEs, are traumatic experiences in a
person’s life occurring before age 18, which the person remembers as an adult. Types
of ACEs include physical abuse, sexual abuse, verbal abuse, mental illness of a house-
hold member, problematic drinking or alcoholism of a household member, illegal
street or prescription drug use by a household member, divorce or separation of a
parent, domestic violence towards a parent, and incarceration of a household mem-
ber. ACEs are linked to poor health outcomes, including risky health behaviors,
chronic health conditions, low life potential (e.g., lower graduation rates, time lost
from work), and early death (Centers for Disease Control and Prevention, 2016; Min-
nesota Department of Health, 2013).

Systems level
The Philadelphia ACE Task Force (PATF), a citywide coalition of representatives from
organizations serving children and families, focused on two areas to increase aware-
ness of and response to ACEs in service and professional education systems: 1) un-
derstanding existing interventions in Philadelphia addressing childhood adversity and
trauma; and 2) integrating ACEs content into medical, nursing, allied health, and hu-
man services curricula. Pachter, Lieberman, Bloom, and Fein (2017) recommended
that local and national advocates encourage including ACEs as a core component of
professional education.

Community level
The Philadelphia ACE Task Force provided education to the community about ACEs
(Pachter et al., 2017).

Individual/family level
Through the Nurse-Family Partnership, public health nurses (PHNs) provide home vis-
its to pregnant and parenting mothers until their children are 2 years old. The PHNs
and mothers develop trusting relationships, and PHNs provide support that helps
mothers take control of their lives, nurture their children, and build strong families
(Nurse-Family Partnership, 2018).

Relationship with other interventions
PHNs frequently use advocacy with other interventions, such as community
organizing, coalition-building, and collaboration as well as policy development and
enforcement. Policy development success often occurs in conjunction with advocacy.
Health teaching at the systems and community levels and consultation build com-
munity awareness prior to implementing advocacy. Media advocacy occurs when me-
dia promotes an issue or a cause.

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A PHN uses advocacy at the individual level alongside case management. Selecting
case management as an appropriate intervention assumes the PHN has assessed a
client’s need and is partnering with the client to determine a course of action to pro-
mote and protect health.

Basic steps
The following steps are adapted from the International Council of Nurses’ Promoting
health: Advocacy guide for professionals (2010).

1. Determine whether the organizational,
positional, professional, and personal willingness
exists to take action and overcome obstacles
Unfair and unjust practices, funding allocations, and unhealthy environments are sit-
uations that motivate PHNs to act and react with advocacy.

 A PHN may invite others to join advocacy action.
 A PHN may join advocacy initiatives already in process with other individuals,

organizations, or communities.

2. Clearly select the advocacy focus
The focus of a PHN’s or organization’s advocacy should take into account political
environment, resources, time, and potential allies and opponents.

Consider these questions selecting the focus:

 Will a solution to this problem or issue result in improving people’s lives?
 Is this an issue or problem we think we can resolve?
 Is this an issue or problem easily understood?
 Can we tackle this issue or problem with the resources available?

3. Match the action to the situation
Selecting one’s relevant role matches the advocacy action with the situation.

Possible roles:

 Representative: Speaking for people
 Accompanying: Speaking with people
 Empowering: Enabling people to speak for themselves
 Mediating: Facilitating communication between people
 Modeling: Demonstrating practice to people and policymakers
 Negotiating: Bargaining with those in power
 Networking: Building coalitions with other individuals or organizations

http://www.whcaonline.org/uploads/publications/ICN-NEW-28.3.2010

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4. Understand political context and identify key
people to influence
A strategy that works in one situation may not be effective in another situation.

Tailor strategies to each situation. Consider:

 Who is the ultimate decision-maker (organization board, chair, executive com-
mittee, or CEO; clergy member; person who has the most power or authority in
a family)?

 What is to be decided (program priorities, work plans, policies, budgets)?
 How are decisions made (simple majority vote, consensus development, single

decision-maker after receiving input; citizen involvement)?
 How are decisions to be enforced, implemented, and evaluated (who is account-

able to whom, sanctions for failures or rewards for successes, evaluation
strategies)?

5. Build a solid evidence base
The PHN grounds the issue in the best science-based evidence available and antici-
pates and understands the evidence of those with opposing perspectives.

 One may interpret evidence based on perspective. Policymakers may selectively
use research to support pre-determined positions.

 Interpret evidence so that others understand its implications.
 Evidence is one source of information for policymakers in addition to beliefs,

values, skills, resources, legislation, protocols, and client preferences.
 Public health decision-makers desire implementation suggestions, including

what works and does not work for different populations. They view systematic
evidence reviews and executive summaries as time-savers (Dobbins, Jack,
Thomas, & Kothari, 2006).

6. Engage others—win the support of key
individuals and organizations
Those with an interest in the advocacy outcome are more willing to support the issue
if they can see the benefit of collective action advocacy.

 Individuals and organizations may have interests that are at odds.
 Help others see the common interest and benefit.

7. Develop a strategic plan
A plan provides a template for advocacy actions and provides criteria for evaluating
those actions.

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 If the advocacy focuses on systems- or community-level change, stakeholders
must collectively identify what they consider as success and the methods to
achieve it. The plan should identify who will do what and when.

 If the advocacy focuses on individuals or families, the plan must be negotiated
with them and focus on developing the individual or family’s capacity to advo-
cate on their own behalf.

8. Communicate messages, implement the plan
Attention to a message’s content and delivery increases its effectiveness.

 Deliver the message about what needs to change and why in the clearest, most
succinct manner possible. Tailor the message to fit the audience.

 If the advocacy concerns communities and systems, include strategies to ad-
dress opposing interest groups’ messaging.

 If the advocacy concerns individuals and families, anticipate barriers and strate-
gies to overcome them. Role-playing with the individual or family develops their
capability to respond.

9. Seize opportunities
It is important to identify at what points the individual/family, community, or system
may be most open to hearing the advocacy message.

 Time interventions and actions for maximum impact.
 Developing a trusting relationship facilitates openness to the message.

10. Be accountable
The plan needs constant monitoring and evaluation to make sure advocacy is moving
forward.

 Compare and evaluate actual outcomes related to the expected outcomes.
 If the message is not received as anticipated or the plan encounters unexpected

barriers, alter the plan and/or the message accordingly.

Example
Philadelphia has a high rate of child abuse and childhood food insecurity. Many of the
city’s organizations address the needs of children and families, but do not collaborate
on services or specific issues. The Philadelphia ACE Task Force formed and conducted
research on ACEs in the urban context, and identified focus areas for practical interven-
tions around adversity, trauma, and resiliency (Pachter et al., 2017). Because PHNs have
the knowledge and skills relevant to addressing ACEs, they contributed their expertise
to task force discussions and decision-making about the advocacy focus.

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1. Determine whether the organizational,
positional, professional, and personal willingness
exists to take action and overcome obstacles

[The Institute for Safe Families, or ISF] brought together several child
health leaders in Philadelphia to conceptualize building a local initiative
around childhood adversity and trauma. ISF’s mission was to prevent
family violence and child abuse and to strengthen families to create
nurturing, healthy environments that promote children’s positive
development. (Pachter et al., 2017, p. S130)

This group created the Philadelphia ACE Task Force.

2. Clearly select the advocacy focus
The Philadelphia ACE Task Force chose to focus on integrating ACEs screening into
primary care.

3. Match the action to the situation
The task force assumed a networking role (building coalitions with other individuals
or organizations) to help other organizations and individuals share their experiences
addressing childhood adversity.

4. Understand political context and identify key
people to influence
Because the Philadelphia ACE Task Force chose to focus on integrating ACEs screening
into primary care, initial membership grew from invitations to pediatricians. As the
group collected evidence, it transformed into a collaborative cutting across institu-
tions and disciplines to focus on developing cross-system solutions to ACEs in Phila-
delphia. The work of the task force spread by word of mouth, leading to a broader
and more diverse membership.

5. Build a solid evidence base
Research professionals conducted two focus groups with black and Latinx adults to
identify childhood adversities as well as resilience and coping strategies experienced
by adults who grew up in Philadelphia. The Philadelphia ACE Task Force contracted
with a nonprofit public health organization to survey Philadelphia residents on ACEs
and other toxic stressors and adversities (witnessing violence, experiencing racism,
living in unsafe neighborhoods, experiencing bullying, being in foster care).

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6. Engage others—win the support of key
individuals and organizations
The Philadelphia ACE Task Force, the Institute for Safe Families, and the Robert Wood
Johnson Foundation co-sponsored a national ACE meeting in 2013: the National Sum-
mit on Adverse Childhood Experiences. The meeting offered sessions on ACEs re-
search, community-based ACE interventions, and policy and advocacy issues.

7. Develop a strategic plan
Three major areas of focus were identified by members of the task force: 1)
educate the community about ACEs and their effect, 2) develop a better
understanding of interventions available in Philadelphia to address
childhood adversity and trauma, and 3) incorporate ACEs research and
work into curricula of undergraduate and graduate medical, nursing, allied
health, and human services programs. (Pachter et al., 2017, pp. S132-S133)

8. Communicate messages, implement the plan
The ACEs Connection Network website facilitated communication about models, bar-
riers, successes, and examples of ACE interventions across the country. A Philadel-
phia-specific group used the website to share information among local individuals
and organizations, and for keeping Philadelphia ACE Task Force members current
with task force activities.

9. Seize opportunities
The Philadelphia ACE Task Force established workgroups for each of the three focus
areas; two of the workgroups had funding support. The Professional Development
workgroup collaborated with a fellow from the Annie E. Casey Foundation to develop
and pilot an ACEs curriculum for health professionals.

10. Be accountable
The Philadelphia ACE Task Force succeeded because of external staff support and or-
ganizational leadership in the community. Local funding organizations provided fi-
nancial and staff support that contributed to sustainability.

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Key points from evidence
For a description of evidence levels, visit: Introduction: Overview of evidence-based
practice and related topics.

 1. Public health nurses as advocates for health improvement
As advocates for improving the health of individuals and communities, PHNs:

 Promote and protect health and safety
 Provide assistance to access health resources and social support
 Speak up and work on behalf of clients throughout the care continuum
 Push for legislative action to bring about change
 Consider the impact of policy decisions on human rights and social justice
 Adhere to truth and honesty in advocacy strategies

Level 3 sources:

 Ezeonwu, 2015
 Falk-Rafael & Betker, 2012
 Freudenberg, Bradley, & Serrano, 2009
 Toda, Sakamoto, Tagaya, Takahashi & Davis, 2015

Level 5 sources:

 Racher, 2007
 Selanders & Crane, 2012

 2. Traits of a public health nurse advocate
Public health nurses who engage in advocacy:

 Care about an issue
 Have knowledge about the issue and the community
 Have knowledge about organizational communication challenges
 Have public health competency in needs assessment, communication, cultural

understanding, leadership, and systems thinking
 Have the ability to build strong working relationships
 Have collaboration skills for networking with other agencies and organizations

Level 3 sources:

 Ezeonwu, 2015
 Joyce, O’Brien, Belew-LaDue, Dorjee, & Smith, 2014

 3. Effective strategies and tools
Effective advocacy strategies and tools include:

 Mobilizing the public and multiple stakeholders
 Using multiple strategies
 Being sensitive to changing political environments
 Working with the media

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 Networking
 Social marketing
 Coalition-building
 Lobbying
 Letter writing
 Internet-based advocacy

Level 3 source:

 Freudenberg et al., 2009

Level 4 source:

 International Council of Nurses, 2008

 4. Effective advocacy message components
Effective advocacy messages integrate policy demands with value statements. The
following questions address message components:

a. What’s wrong? Make a clear statement of concern.
b. Why does it matter? Address values and what is at stake.
c. What should be done about it? Clearly state the policy objective with a specific,

feasible solution.

Level 5 source:

 Dorfman, Wallack, & Woodruff, 2005

 5. Framing advocacy messages for media
Possible questions to address when framing advocacy messages for media include:

 Can this story be associated with a local, national, or topical historical event?
 What is new or different about this story?
 Is there a celebrity already involved with or willing to lend their name to the issue?
 Are there adversaries or other tensions in this story?
 Are there basic inequalities or unfair circumstances?
 What is ironic, unusual, or inconsistent about this story?
 Why is this story important or meaningful to local residents?
 Is this story an important historical marker?
 Who is the face of the victim in this story? Who has the authentic voice on this

issue?
 Can this story be attached to a holiday or seasonal event?

Level 4 source:

 International Council of Nurses, 2008

Level 5 source:

 Wallack, Dorfman, Jernigan, & Themba, 1993

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 6. Consequences of advocacy actions
A concept analysis of advocacy identified the following five consequences from ad-
vocacy actions that address human rights and social justice perspectives:

 Improved access
 Equity
 Social justice
 Empowerment
 Health and social reform

Level 3 source:

 Ezeonwu, 2015, p. 120

 7. Ethical challenges
Public health nurses may encounter the following ethical challenges during advocacy
actions with clients:

 Conflict regarding client selection (possible conflict between advocating for parent
or child, individual vs. family views, individual rights vs. good of the community)

 Conflict with the PHN’s values
 Putting oneself at risk (e.g., advocating for a client experiencing domestic violence)
 Disagreements with colleagues or other health professionals about the advo-

cacy action
 Considering risk vs. benefit when supporting a client’s right to choose in a situa-

tion where that choice potentially results in harm (e.g., a parent refuses to ob-
tain immunizations for their child)

 Maintaining professional boundaries

Level 3 source:

 Oberle & Tenove, 2000

 8. Challenges at the systems level
Challenges to policy advocacy at the systems level include:

 Some organizations and policymakers view systems-level advocacy as beyond
the scope of nursing influence.

 Nursing education does not adequately prepare nurses for involvement in
health policy.

 Philosophical divisions within nursing may prevent collaboration on policy
development.

 Nursing practice factors (heavy workloads, understaffing, powerlessness in or-
ganizations, lack of time) contribute to political apathy among nurses.

Level 5 source:

 Spenceley, Reutter, & Allen, 2006

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 9. Policy-level intervention suggestions
For families living in poverty, PHNs primarily focus on helping family members access
services rather than intervening at the policy level. Suggestions for PHNs to increase
advocacy for policy change include:

 Initiate public discussion on how poverty affects health, and how policies keep
families living in poverty.

 Raise the issue of family poverty during meetings of professional organizations.
 Support local anti-poverty groups.
 Use information from monitoring activities to advocate for healthy public policies.
 Inform the public about the impact of poverty on families and children.

Level 5 source:

 Cohen & Reutter, 2007

Wheel notes

Human rights and social justice perspectives
Nursing literature highlights the use of advocacy to address both human rights and
social justice issues. Researchers framing advocacy from a human rights perspective
often address advocacy at the individual level, while those working from a social jus-
tice perspective more often focus on advocating for change in systems to improve
population health. Historically, nursing advocacy has emphasized human rights, be-
ginning with the writings of Florence Nightingale. Although nursing literature contin-
ues to feature a human rights emphasis (Vaartio & Keino-Kilpi, 2004), current litera-
ture also highlights policy advocacy at the systems level (Ezeonwu, 2015; Falk-Rafael
& Betker, 2012; International Council of Nurses, 2008).

Medical paternalism
“Medical paternalism” occurs when a professional makes a decision on what consti-
tutes the client’s best interest (Zomordi & Foley, 2009). To counteract paternalism,
PHNs can use advocacy-focused communication strategies like open-ended questions,
terms understood and preferred by clients and families, and responding fully to ques-
tions. Relational ethics promotes advocacy actions through the nurse/client relation-
ship (MacDonald, 2007). Questions that can lead to an advocacy intervention include:

 How does the current situation affect the client’s autonomy and capacity for
critical thinking?

 How does the client embody or balance the implications of the scientific
knowledge presented and its emotional ramifications?

 Does mutual respect exist?
 Does the client understand their values and wishes are held in regard?
 Does true engagement exist, where the nurse and the client are sufficiently in-

vested in each other to assure mutual concern?

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Advocacy or empowerment?
The literature reveals that advocacy and empowerment overlap, with both enabling
self-reliance in others, communities, and systems. Empowerment involves assisting
others to discover and use the power within individuals/families, communities, or sys-
tems; advocacy is not something done or given to another. While empowerment may
be a consequence of advocacy actions, some individuals, families, groups, communi-
ties, and systems may continue to require someone to speak or act on their behalf.

References
Centers for Disease Control and Prevention. (2016). About adverse childhood experiences.

Retrieved from https://www.cdc.gov/violenceprevention/acestudy/about_ace.html

Cohen, B. E. & Reutter, L. (2007). Development of the role of public health nurses in addressing
child and family poverty: a framework for action. Journal of Advanced Nursing, 60(1),
96-107. doi: 10.1111/j.1365-2648.2006.04154.x

Dobbins, M., Jack, S., Thomas, H., & Kothari, A. (2007) Public health decision-makers’
informational needs and preferences for receiving research evidence. Worldviews on
Evidence-based Nursing, 4(3), 153-167.

Dorfman, L., Wallack, L., & Woodruff, K. (2005). More than a message: Framing public health
advocacy to change corporate practices. Health Education & Behavior, 32(3), 320-336.
doi: 10.1177/1090198105275046

Ezeonwu, M. C. (2015). Community health nursing advocacy: A concept analysis. Journal of
Community Health Nursing, 32(2), 115-128. doi:10.1080/07370016.2015.1024547

Falk-Rafael, A. & Betker, C. (2012). Witnessing social injustice downstream and advocating for
health equity upstream: “The trombone slide” of nursing. Advances in Nursing Science,
35(2), 98-112. doi: 10.1097/ANS.0b013e31824fe70f

Freudenberg, N., Bradley, S. P., & Serrano, M. (2009). Public health campaigns to change industry
practices that damage health: An analysis of 12 case studies. Health Education &
Behavior, 36(2), 230-249. doi: 10.1177/1090198107301330

International Council of Nurses. (2008). Advocacy guide for health professionals. Retrieved from
http://www.whpa.org/PPE_Advocacy_Guide

Joyce, B. L., O’Brien, K., Belew-LaDue, Dorjee, T. K., & Smith, C. M. (2014). Revealing the voices of
public health nurses by exploring their lived experience. Public Health Nursing, 32(2),
151-160. doi: 10.1111/phn.12113

MacDonald, H. (2007). Relational ethics and advocacy in nursing: Literature review. Journal of
Advanced Nursing 57(2), 119-126. doi: 10.1111/j.1365-2648.2006.04063.x

Minnesota Department of Health. (2013). Adverse childhood experiences in Minnesota. Retrieved
from http://www.health.state.mn.us/divs/chs/brfss/ACE_ExecutiveSummary

Nurse-Family Partnership. (2018). A young family’s bright future begins with a great nurse.
Retrieved from https://www.nursefamilypartnership.org/nurses/

Oberle, K. & Tenove, S. (2000). Ethical issues in public health nursing. Nursing Ethics, 7(5), 425-438.

Pachter, L. M., Lieberman, L., Bloom, S. L., & Fein, J. A. (2017). Developing a community-wide
initiative to address childhood adversity and toxic stress: A case study of the
Philadelphia ACE Task Force. Academic Pediatrics, 17(7S), S130-S135.

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Racher, F. E. (2007). The evolution of ethics for community practice. Journal of Community Health
Nursing, 24(1), 65-76. doi.org/10.1080/07370010709336586

Selanders, L. C. & Crane, P. C. (2012). The voice of Florence Nightingale on advocacy. Online
Journal of Issues in Nursing 17(1). doi.org/10.3912/OJIN.Vol17No01Man01

Spenceley, S. M., Reutter, L., & Allen, M. N. (2006). The road less traveled: Nursing advocacy at
the policy level. Policy, Politics, & Nursing Practice, 7(3), 180-194. doi:
10.1177/1527154406293683

Toda, Y., Sakamoto, M., Tagaya, A., Takahashi, M., & Davis, S. J. (2015). Patient advocacy:
Japanese psychiatric nurses recognizing necessity for intervention. Nursing Ethics, 22(7),
765-777. doi: 10.1177/0969733014547971

Vaartio, H. & Leino-Kilpi, H. (2005). Nursing advocacy—a review of the empirical research 1990-
2003. International Journal of Nursing Studies, 42, 705-714.

Wallack, L., Dorfman, L., Jernigan, D., & Themba, M. (1993). Media advocacy and public health:
Power for prevention. Thousand Oak, CA: Sage Publications.

Zomorodi, M. & Foley, B. J. (2009). The nature of advocacy vs. paternalism in nursing: Clarifying
the ‘thin line.’ Journal of Advanced Nursing 65(8), 1746-1752. doi: 10.1111/j.1365-
2648.2009.05023.x

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Social marketing
“Social marketing is a process that uses marketing principles and techniques to
change target audience behaviors to benefit society as well as the individual” (Lee &
Kotler, 2016, p. 9).

Key social marketing themes include:

 Influencing behaviors
 Applying marketing principles and techniques via a systematic planning process
 Focusing on priority audience segments
 Delivering a positive benefit for individuals and society

“In the case of health-related social marketing, the social good can be articulated in
terms of achieving specific, achievable, and manageable behavior goals, relevant to
improving health and reducing health inequalities” (Quinn, Ellery, Thomas, &
Marshall, 2010, p. 335). An initiative is consistent with social marketing when its driv-
ing concern focuses on understanding the customer (client) and on achieving and sus-
taining specific behaviors (French & Blair-Stevens, 2010).

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Practice-level examples
Population of interest: Adolescents.

Problem: Bullying among adolescents occurs worldwide, resulting in negative health
consequences like school absenteeism, lower academic achievement, and adverse
mental and physical health outcomes. Bullying includes physical aggression, verbal
harassment, discriminatory harassment targeting a person’s characteristics, and
more recently cyber victimization (Salmon, Turner, Taillieu, Fortier, & Afifi, 2018).

Systems level
A school nurse convenes a district task group, including student representatives, to
discuss and identify anti-bullying social marketing interventions at the district level.
The school nurse asks the group to consider using systems-level strategies found at
StopBullying.gov, which provides organizations with social marketing strategies to ad-
dress bullying and cyberbullying.

Community level
The Howard County Public School System in Maryland joined together with students
and the community to create bully-free zones. The school system hosted a bully pre-
vention event, and school nurses and PHNs used the video, Bullying Prevention
Message, to help convey messaging when meeting with adolescents, their parents,
and community organizations (Timmons-Mitchell, Levesque, Harris, Flannery, &
Falcone, 2016).

Individual/family level
School nurses marketed bullying prevention messages to adolescents, their families,
and school staff with posters, online communication, newsletters, and classroom
presentations. The school nurses adapted messages from resources like StandUp, an
online school-based bullying prevention program that focuses on developing healthy
relationships (Timmons-Mitchell et al., 2016).

Relationship with other interventions
Social marketing, first introduced in 1971, contains similarities to some longer-
established interventions. Like health teaching, social marketing aims to change atti-
tudes and behaviors, and some see it as a special application of health teaching. Public
health nurses (PHNs) use health teaching most frequently at the individual/family and
systems practice levels, and use social marketing more frequently at the community
level of practice, incorporated with principles of marketing. At the community level,
social marketing overlaps with advocacy, often implemented as media advocacy.

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Basic steps
Public health nurses adapt the basic steps for social marketing from several sources
that apply marketing principles to health behavior change (Brown, 2006; Evans &
McCormack, 2008; Grieg & Bryant, 2006; Lee & Kotler, 2016; Stellefsen & Eddy, 2008).
Lee and Kotler focused specifically on the social marketing planning stage.

1. Describe plan background, purpose, and focus
 Prior to developing a targeted plan, identify the social issue or problem, and fac-

tors that contribute to the issue or problem.
 Develop a purpose statement that communicates the benefit of the social mar-

keting plan.
 To narrow the scope of the problem, choose from potential options that address

the plan’s purpose. For example, in order to improve water quality (purpose),
one could choose to address pesticide use (option).

2. Conduct a situation analysis
Understanding factors and forces in the environment determines the relevance of
planning decisions.

 Analyze strengths to maximize and weaknesses to minimize, using a SWOT anal-
ysis (SWOT stands for strengths, weaknesses, opportunities, and threats). Inter-
nal factors include available resources, expertise, administrative support, and
partners, which may constitute strengths or weaknesses. External factors in-
clude cultural, technological, demographic, economic, political, and legal forces
that represent opportunities or threats.

 Investigate colleague experiences, LISTSERVs, and the literature for lessons
learned from similar social marketing campaigns.

3. Select target audience
Identifying the audience determines additional planning steps. Target market char-
acteristics include stages of change, demographics, geography, behaviors, psycho-
graphics, and size of market. Segment the market or population (break it into smaller
groups) based on specific criteria, and choose one or more groups for marketing strat-
egies.

 Primary audience or population of interest: Subgroup, family, or individual in
which the behavior change is desired

 Secondary audience: Those who help the primary audience make the desired
behavior change

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4. Set behavior objectives and goals
Goals and objectives guide social marketing decisions.

 Goals: Desired long-term aims
 Objectives: Specific and concrete accomplishments needed to reach goals

▪ Knowledge objectives: Information and facts included in the social market-
ing strategies

▪ Belief objectives: Feelings and attitudes the social marketing strategies
need to influence

▪ SMART objectives: Specific, measureable, attainable, relevant, and time-
bound

5. Identify benefits, motivators, barriers, and
change strategies
Understand the target market’s preferred behavior (competition).

 What makes the current behavior attractive?
 Why do people not want to change their behavior?
 What real or perceived barriers exist to behavior change?
 What behavior change strategies does the target market embrace?

6. Craft a positioning statement
A positioning statement “[explains how you] want the target audience to see the tar-
geted behavior, highlighting unique benefits” (Lee & Kotler, 2016, p. 51).

 Include a description of the target audience, competitors, barriers, and motiva-
tors to action.

 Use the positioning statement to guide the development of the marketing mix.

7. Develop a strategic marketing mix (four P’s)
Use the four P’s (product, price, place, and promotion) when developing a marketing
strategy.

Product
Using the example of promoting mammograms, the product is the benefits associ-
ated with the behavior change:

 Core product: Bundle of benefits (i.e., peace of mind and early detection from
obtaining a mammogram)

 Actual product: Desired behavior (i.e., obtaining a mammogram)
 Augmented product: Tangible goods and services (e.g., low cost, accessible,

friendly mammogram services)

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One could ask the following questions about the mammogram screening example:

 What should be done to increase screenings?
 How should the screening be described?
 What are the client benefits?

Price
The price is the cost or sacrifice exchanged for the promised benefit:

 Consider the cost from the client’s view.
 The price may include intangible costs that accompany the change (loss of time,

psychological hassle, embarrassment).

Questions about the cost for the mammogram screening example include:

 Is there a significant financial cost?
 Is comfort with screening a concern for women?
 Do women feel susceptible to breast cancer?

Place
The place includes where and when the target market performs the desired behavior:

 Where considers physical location, organizations and people who provide infor-
mation, goods and services, attractiveness and comfort, and accessibility (park-
ing and public transportation).

 When includes operating hours.

Consider the following questions about place for the mammogram screening example:

 Where do women obtain the screening?
 What partners help gain the interest of women?
 What communication channels best distribute the screening message?

Promotion
Promotion includes persuasive messages communicating product benefits, services,
pricing, and place:

 Consider multiple elements, including specific communication objectives for
each target example, guidelines for developing prominent, effective messages,
and designating communication channels.

 Integrate the marketing mix of the four P’s
 Consider a spokesperson who can share their story related to the product.

Questions to consider when developing a promotional strategy include:

 What is the product?
 Who is the customer?
 What is your purpose for promoting the product?
 What message will you convey?
 What promotional tools will you use?
 What promotional communication materials will you use? (Thackeray, Neiger,

& Hanson, 2007)

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8. Outline a monitoring and evaluation plan
Develop an evaluation strategy prior to plan implementation to ensure outcomes are
monitored on an ongoing basis:

 Clarify the evaluation purpose and audience.
 Refer to established goals for the desired levels of change in behavior,

knowledge, and beliefs.
 Establish three categories of measures:

▪ Output measures (campaign activities)
▪ Outcome measures (the responses of the target market, including changes

in knowledge, beliefs, and behavior)
▪ Impact measures (contributions to the plan purpose)

9. Establish budgets and find funding sources
Determine if available budget and funding stream(s) support the selected strategies:

 Summarize funding requirements and potential funding sources for product
benefits, features, and distribution channels.

 Revise goals, target audience, and strategies based on secured funding sources,
including partner contributions.

10. Implement the plan
After completing planning steps, implement the plan.

 Facilitate as needed who does what, when.
 Produce products and materials as planned.
 Coordinate with partners.
 Remain open to new opportunities.
 During implementation, pay attention to client response (Thackeray & Neiger,

2009):
▪ Structure interactions so clients focus on the positive outcomes.
▪ Provide clients with messaging that encourages them to talk about prod-

ucts to friends and family.
▪ Note social media posts about the product and the organization.

 Use a planning matrix on market segmentation. Market segmentation uses les-
sons learned about a subgroup within a priority population to create programs
and services that target that subgroup’s wants and needs (Stellefson & Eddy,
2008). For each segment, identify the following components in a matrix:
▪ Segment
▪ Relevant characteristics
▪ Message
▪ Channels
▪ Evaluation

 For example, a social marketing campaign that promotes immunization might
include the segments “unaware,” “afraid and untrusting,” and “religious oppo-
nents” (Slater, Kelly, & Thackeray, 2006).

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11. Monitor and evaluate plan implementation
Monitoring and evaluating social marketing activities during implementation helps
identify mid-course revisions, and can help refine the social marketing program.

 Answer the question: “Did we change what we intended to change (knowledge,
behaviors, or attitudes)?”

 Include intermediate measures and/or process measures to determine program
effectiveness.

 Use feedback to refine implementation strategy.

Example
The Howard County Public School System in Maryland joined with community part-
ners to implement a campaign to prevent cyberbullying and other bullying behaviors
(Howard County Public School System, 2017a; StopBullying.gov, 2013). A school
nurse contributed knowledge and skills to planning and implementing bullying pre-
vention social marketing strategies.

1. Describe the plan background, purpose, and
focus
After serious bullying incidents (including a suicide), Howard County Public School
System, including school nurses throughout the district, decided to tackle bullying
and cyber harassment by raising awareness.

2. Conduct a situation analysis
Planners reviewed current laws and discussed whether to advocate for new state leg-
islation. They looked at how the public schools collected and handled bullying reports
and incidents.

3. Select target audience
After exploration and discussion, planners chose a multi-faceted and comprehensive
approach including community partners.

4. Set behavior objectives and goals
The planners invited community partners and identified three approaches:

a. Developing a social marketing awareness campaign about the severe effects of
bullying and what to do when it occurs: The public library system took the lead in
creating the “Choose Civility” campaign to communicate positive messages about

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treating others with respect. The bullying prevention campaign used lessons
learned from that work to develop a similar message around bullying.

b. Developing a tool to report bullying when it happens, in real time: The planners
used a customized web-based reporting application called Sprigeo, in which a
person anonymously reports bullying in schools, at a park or library, or else-
where in the community.

c. Making materials and training available for those who work with students on
the skills and knowledge needed to address bullying: For example,
StopBullying.gov created Bullying Prevention Training Center: Bullying
prevention continuing education course (2017).

5. Identify benefits, motivators, barriers, and
change strategies
Bullying prevention messages needed to address motivators for bullying and behaviors
to change. The planners met with students to identify barriers and motivators, and to
discuss perceptions of factors that contribute to and prevent bullying behavior.

6. Craft a positioning statement
[The Howard County Public School System] has taken a strong stand
against bullying with a goal to eradicate bullying. No act of bullying in
Howard County schools will be ignored. Unfortunately, bullying is a reality
that lives within the hallways of our schools and one that we must root
out once and for all. We know that those who are bullied may experience
depression, anxiety, sadness and loneliness. They can suffer from changes
in sleep and eating patterns and loss of interest in activities that they
typically enjoy. Children who have suffered through bullying have gone so
far as to injure themselves and even take their own life. (Howard County
Public School System, 2017b)

7. Develop a strategic marketing mix (Four P’s)
Product: The core product was the assurance that bullying behaviors will be ad-
dressed. The actual product was fewer bullying incidents. The augmented product
was a safe school and community environment.

Price: Although there was a cost involved in developing and implementing the bully-
ing prevention plan, fewer bullying incidents decreased the staff burden related to
response, and results in a cost savings.

Place: The target market was the community served by the Howard County Public
School System.

Promotion: One example of a promotional tool was the public service announcement
at a school-sponsored prevention event, Bullying prevention message (2017c). The

https://www.stopbullying.gov/prevention/training-center/index.html

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video featured two spokespeople: the interim school superintendent, and a mother
of a daughter who committed suicide following cyberbullying incidents.

8. Outline a monitoring and evaluation plan
The Howard County Public School System developed a Bullying, harassment, or
intimidation reporting form (PDF):

[The reporting form helps individuals] report alleged bullying,
harassment, or intimidation that occurred during the current school year
on school property, at a school-sponsored activity or event off school
property, on a school bus, on the way to and/or from school, or on the
Internet, sent on or off school property; or that substantially disrupted
the orderly operation of the school. (2017b)

The form included definitions of bullying. The number of forms submitted provides a
strategy for measuring change in the incidence of bullying behaviors.

9. Establish budgets and find funding sources
Contributions from partners included the federal government, the Health Resources
and Services Administration (HRSA), local leaders, and local organizations including
youth sports leagues and the YMCA.

10. Implement the plan
During implementation, the planners noted the response of different market seg-
ments within the community—students, parents, school staff, community organiza-
tions, and the public.

11. Monitor and evaluate plan implementation
The evaluation plan initially called for evaluating whether the bullying prevention
campaign changed knowledge, behaviors, and attitudes related to bullying. Interme-
diate measures on community responses were important for refining social market-
ing messages. Later measures would compare bullying incidence rates to the rate oc-
curring during the 2016-2017 (baseline) school year.

https://www.hcpss.org/f/parents/form_harassment

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Key points from evidence
For a description of evidence levels, visit: Introduction: Overview of evidence-based
practice and related topics.

 1. Theories supporting social marketing
Several theories support social marketing: Exchange theory, the Theory of Planned
Behavior, and the health belief model. These theories explain how motivation and
incentives lead individuals or groups to adopt healthy behaviors.

Level 5 sources:

 Opel, Diekema, Lee, & Marcuse, 2009
 Slater et al., 2006
 Thackeray, 2010

 2. Identifying social marketing interventions
Interventions can be categorized as social marketing if they meet the following crite-
ria:

 The intervention focuses on actual change of behavior rather than a change in
awareness or knowledge.

 The identified behavior is measurable and observable.
 Research is conducted to provide insight into the consumer experience and to

drive decision-making.
 Consumer research analysis provides those planning the intervention with in-

sight into targets of opportunity.
 The intervention strategy is tailored to targets of opportunity and marketing mix

(product, price, place, promotion, exchange, competition).
 Concepts related to the intervention strategy and the marketing mix are pre-

tested with the intended audience.
 The strategy is implemented consistent with the plan.
 The intervention is evaluated, and change in behavior occurs.

Level 5 source:

 Quinn et al., 2010

 3. Effective social marketing
Tips for effective social marketing include:

 Develop a plan that includes attention to all aspects of the marketing mix—prod-
uct, price, place, and promotion—as well as policy and partnerships.

 Use research throughout the process—carefully review existing literature, and
collect new data through focus groups, surveys, and observation.

 Involve the target population, including opinion leaders, to actively participate
in and co-create the development process.

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 Locate opinion leaders—people who have social influence and have adopted the
desired behavior or attitude—who can serve as catalysts for behavior change
through role-modeling and social relationships.

 Consider socioeconomic factors, cultural beliefs, values, geographic location,
and local norms and values.

 Focus on voluntary behavior.
 Know that exchange theory is fundamental. The target audience must perceive

benefits that equal or exceed perceived costs associated with performing the
behavior.

 Address costs and benefits of behavior change.
 Employ marketing techniques, including consumer-oriented market research,

segmentation and targeting, and marketing mix of strategies.
 Focus on the end goal of improving individual and societal well-being, rather

than focusing on the organization.
 Avoid message clutter and information overload.
 Use stories and anecdotes when presenting risk data.
 Use multiple approaches (written, oral, visual graphics, electronic) and repeti-

tion to maximize your promotion messaging.
 Anticipate and manage controversy and conflict.
 Avoid terminology, phrases, or visual cues that reinforce stereotypes or contra-

dict verbal messages.
 Remember that social marketing is not social media marketing. Social media is

one valuable marketing channel, but do not neglect other methods like
radio/podcasts, television, posters, periodicals, and other written material.

Level 2 source:

 Firestone, Rowe, Modi, & Sievers, 2017

Level 3 source:

 Stead, Gordon, Angus, & McDermott, 2007

Level 5 source:

 Schoon, Porta, & Schaffer, 2019

 4. Augmented products and questions to consider
Consider the following when designing a new augmented product (tangible good or
service) or modifying an existing one:

 Should a new service be developed and offered?
 Does an existing service need to be enhanced?
 Should a new product be developed (or be encouraged to be developed) to en-

courage behavior change?
 Does a current product need to be improved or enhanced?
 Is there a need or opportunity for a substitute product?

Level 5 source:

 Brown, 2006

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 5. Criteria for identifying and validating good practice
Specific benchmark criteria for identifying and validating good social marketing prac-
tice include:

 Customer (client) orientation
 Behavioral goals
 Theory-based factors that contribute to behavior (biological and physical, psy-

chological, social, environmental)
 Insight into what motivates people
 Exchange (what is the person willing to give in order to get expected benefits?)
 Competition (identifying and minimizing competitors)
 Segmentation (identifying specific audiences based on demographic and epide-

miological data)
 Marketing mix (examining the most effective approaches and including more

than one approach)

Level 5 source:

 French & Blair-Stevens, 2010

 6. Ethical norms and values
Ethical norms and values for social marketing include:

 Do no harm by avoiding harmful actions and omissions. Adhere to all applicable
laws and regulations.

 Foster trust in the marketing system by avoiding deception in design, communi-
cation, and/or distribution.

 Embrace ethical values by building relationships and adhering to core values of
honesty, responsibility, fairness, respect, transparency, and citizenship.

 Promote the understanding and use of information by avoiding information
overload and complexity.

Level 5 sources:

 Evans & McCormack, 2008
 Lee & Kotler, 2016

 7. Developing strategies
Use the following questions to develop social marketing strategies:

 What is the nature and scope of the (social) issue?
 Which factors do you want to address?
 How? What’s the evidence?
 Who do you want to reach (key audience)?
 What do you want them to do?
 What are the most important characteristics of the audience and context?
 What does the audience prefer?
 What are you going to do (your produce, price, and place strategies to make the

behavior more attractive, less costly, and/or easier)?

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 What are you going to say (your promotional strategy, including messages and
channels)?

 What is your time frame?
 What levels of human and financial resources are required, including tools and

material costs?
 How and when will you know if you implemented your strategy successfully

(process evaluation?)
 How and when will you know if you measurably impacted the factors you wanted

to influence (outcome evaluation, including indicators and methodologies)?

Level 5 sources:

 Lagarde, 2006
 Thackeray et al., 2007

 8. Social media
Social media is a social marketing tool that can motivate people to make safer and
healthier decisions. Consider the following when using social media in social marketing:

 Make strategic choices and understand the level of effort.
 Go where the people are.
 Adopt low-risk tools first.
 Make sure messages are science-based.
 Create portable content.
 Facilitate viral information sharing.
 Encourage partner and public participation.
 Tailor content to population group needs.
 Provide multiple formats.
 Consider mobile technologies.
 Set realistic goals.
 Learn from metrics and evaluate your efforts.

Level 4 source:

 Centers for Disease Control and Prevention, 2011

 9. Examples of successful campaigns
Social marketing interventions increased knowledge about health problems or risks
and/or contributed to behavior change for the following social marketing initiatives:

 The “Could It Be Asthma?” campaign targeted parents and caregivers of children
in a rural New York community via television advertising, brochures, and posters.

 A mass media campaign in a rural area of the United States disseminated mes-
sages emphasizing the health risks of sugar-sweetened beverages via television,
digital channels, and local organizations, over a 15-week time period.

 A social marketing intervention targeted parents and guardians of inner-city
youth in the Midwestern United States to provide drowning prevention mes-
sages using a variety of channels (brochure, e-mail, text message, postcard,
Facebook post, window cling).

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 American Indian adults recruited at a community health fair viewed messages
promoting dental sealants for young children.

 Rhode Island Health Department staff developed a social marketing intervention
focusing on emergency preparedness.

 A social marketing initiative promoted the use of folic acid to Hispanic women.
 In Spain, a peer-led social marketing approach, titled,” We Are Cool” focused on

increasing healthy eating and physical activity.

Level 1 source:

 Aceves-Martin et al., 2017

Level 2 sources:

 Farley, Halper, Carlin, Emmerson, Foster, & Fertig, 2017
 Glassman, Castor, Karmakar, 2018

Level 3 sources:

 Briones, Lustik, & LaLone, 2010
 Larsson et al., 2015
 Marshall et al., 2007
 Quinn, Hauser, Bell-Ellison, Rodriguez, & Fr´ıas, 2006

Wheel notes

Historical example
Using social marketing to target tobacco use was one of the first examples of social
marketing to promote public health in modern history. Tobacco became a social mar-
keting target for public health when research in the 1950s linked smoking with can-
cer. Public health messaging has consistently competed with the tobacco industry.
Social marketing strategies, along with smoking bans and tobacco products taxes,
have contributed to a decrease in smoking rates. Today social marketing strategies
address how to quit, target youth, and focus on the effects of secondhand smoke
(Centers for Disease Control and Prevention, 2018; Wright, 2011).

Know your audience
Although most of the literature on social marketing focuses on the community and
systems levels, social marketing interventions are also relevant at the
individual/family level. When PHNs “begin where the client is,” they use the social
marketing assessment process to learn about their audience (the client). Knowledge
about client demographics, culture, and behavior determine the “marketing mix” or
strategies that motivate health behavior change. One example of social marketing in
this context is an app for new mothers that promotes breastfeeding by tracking time
fed, from which breast infants were fed, and infant response.

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The Six P’s
Most social marketing literature identifies four P’s—product, price, place, and pro-
motion. In a systematic review of articles on social marketing interventions, Luca and
Suggs (2010) identified two additional P’s: policy and partnerships, applicable at the
community and systems levels. Policy encompasses organizational or governmental
policy change that promotes behavior change through social marketing—for exam-
ple, when using social marketing strategies to communicate about laws that mandate
seat belt use. Partnerships are formed with other organizations and stakeholders to
promote societal behavior change—for example, when cities and health departments
partner on promoting smoke-free environments.

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Policy development and
enforcement
Policy development places health issues on decision-makers’ agendas, establishes a
plan of resolution, determines needed resources, and results in laws, rules and regu-
lations, ordinances, and policies. Policy enforcement compels others to comply with
the laws, rules, regulations, ordinances, and policies created in conjunction with pol-
icy development.

Organizations like public health departments create policies that guide organizational
procedures. Federal, state, and local governments enact public policies. The following
basic steps focus primarily on the process governmental policymaking; however, the
steps are applicable to organizational policy development.

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Policy categories include:

 Constituent policies, which establish government structure, rules or procedures
for how government works, or rules that distribute power (e.g., creating a new
government department, such as the Department of Homeland Security)

 Distributive policies, which allocate benefits or services to particular segments
of the population (e.g., funds allocated to public health departments for emer-
gency preparedness activities)

 Regulatory policies, which place restrictions or limitations on the behavior of
individuals or groups (e.g., a policy that prohibits smoking in public places)

 Self-regulatory policies, which protect or promote the interests of the group
(e.g., licensing health care professionals)

 Redistributive policies, which shift the allocation of wealth, income, property,
or rights among population groups (e.g., a Medicaid program that provides
health care services to low-income families, qualified pregnant women and chil-
dren, and persons with disabilities; Anderson, 2015)

Practice-level examples
Population of interest: Children and adolescents in school.

Problem: Obesity contributes to heart disease, diabetes, and other chronic diseases.
Three in five Minnesotans are overweight or obese due to unhealthy eating and a lack
of physical activity (Minnesota Department of Health, 2017a). Results from the 2016
Minnesota Student Survey indicated that fifth graders in Minnesota reported eating
just one fruit or vegetable a day in the last week (Minnesota Department of Health
2017b). Childhood is an opportune time to establish healthy eating patterns.

Systems level
The Statewide Health Improvement Partnership (SHIP), funded by the Minnesota state
legislature in 2008, uses policy, systems, and environmental approaches to reduce
chronic disease risk factors, such as obesity and tobacco use/exposure. Independent
School District 197 in Dakota County, Minnesota, used SHIP funding to increase student
consumption of a variety of fruits and vegetables. School nurses contributed to policy
development, adoption, and implementation encouraging students to try new foods
and informing parents about the benefits of new fruits and vegetables. Policy decisions
led to the following initiatives (Schoon, Schaffer, & Porta, 2019, p. 156):

 During lunch each week, students tasted a less common fruit or vegetable.
 After tasting, students filled out a survey on their interest in adding the new food

to the lunch menu.
 The district added foods with favorable ratings to school lunch menus when

feasible.

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Community level
School nurses continued to collaborate with school administration, teachers, staff,
and parents on implementing the policy in the school setting:

 Parents were encouraged to send lunches or snacks that included vegetables
and fruits, instead of less healthy alternatives like chips and candy.

 The school district banned sugary drinks from school vending machines, using a
policy developed by the Minnesota Department of Health (Schoon et al., 2019).

Individual/family level
A school nurse noted that in several classrooms, parents sent sugary snacks with their
children for them to share with their classmates. The new school policy discouraged
this practice. The school nurse worked with classroom teachers to determine the best
way to communicate and enforce the change in school policy (Schoon et al., 2019).

Relationship with other interventions
Since policy development and enforcement brings health issues to the attention of
decision-makers, and provides technical assistance for changing laws, rules, regula-
tions, ordinances, and policies, it frequently pairs with other interventions operating
predominantly at the community or systems practice levels, such as collaboration,
coalition-building, and community organizing. Advocacy frequently co-intervenes at
the systems level. In contagious disease outbreaks, policy development and enforce-
ment frequently pairs with surveillance, disease and health event investigation,
screening, outreach, case-finding, referral and follow-up, and case management.

At the individual/family level, policy development often pairs with health teaching,
counseling, consultation, case management, and/or advocacy.

Basic steps
The following steps are adapted from Anderson (2015) and Edelstein, Gallagher,
Hansen, Ebeling, & Turner (2010):

1. Identify the problem and set the policy agenda
Identifying and assess a problem receiving the attention of public officials. Not all
problems identified move forward and are placed on a policy agenda.

Questions to explore include:

 What is the need, current issue, or problem?
 Is there a legal mandate? If so, what is it?

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 What will the new initiative address?
 What are the demographics of the community of interest?
 Does data from federal, state, and local levels consistently identify a need, issue,

or problem?
 What potential and actual disparities exist?
 Is a cultural assessment of the target group available? If not, begin one.
 What are the social norms of the community of interest?
 Is there an interest in change? Who might support and oppose the change?
 What resources are available (internal and external)?
 Who are the stakeholders? What are the local, state, and federal laws that need

to be addressed?
 Who are the partners of interest?
 What are the existing policies?
 How have other policies moved through the adoption process?
 What is the membership composition of the governing body’s board (Edelstein

et al., 2010, p. 8)?

2. Formulate the policy
Develop alternative courses of action or options for dealing with the problem.

Questions to explore include:

 Who participates in formulating the policy?
 How are alternatives for dealing with the problem developed?
 What are the conflicts in developing policy proposals?
 What are the goals?
 What resources are available, including financial needs?
 What is the timeline?

3. Adopt the policy
Support must legitimize or authorize the policy to be adopted.

The legislative, executive, or judicial branches adopt policies. At the national and
state levels, health policy adoption requires majority approval by a legislature.

Consider the following questions:

 How is the policy alternative adopted or enacted?
 What are the budget and funding requirements that must be met for the policy

to be adopted?
 Who are the adopters?
 What is the content of the adopted policy?
 Are hearings offered to seek input from stakeholders?

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4. Implement and enforce the policy
Implementation entails putting the policy into effect. Policymakers develop rules and
guidelines, including conditions that require enforcement, and disseminate them to
those impacted by the policy.

Explore the following questions:

 Who is involved in implementation?
 Who will monitor implementation?
 Are resources adequate for implementation?
 How well does the intended population follow policy mandates, recommenda-

tions, or guidelines?
 How will the policy be enforced?
 How can compliance be encouraged through education about the policy and its

rationale?
 How is due process built into policy enforcement?
 What methods are needed to force compliance if the policy’s conditions are not

met?

5. Evaluate the policy’s effectiveness
Evaluation determines whether the policy achieved its goals and/or resulted in any
consequences.

Consider the following questions:

 What is the feedback loop for data evaluation (population response, health
outcomes)?

 What are the expected and unexpected outcomes?
 Who does the policy advantage or disadvantage?
 What are the consequences of the policy?
 Are new problems identified?
 What are the future health and budget policy implications?
 What is needed to promote policy sustainability?
 Are there any unintended consequences?

Example
A school district developed and implemented a policy to encourage healthy eating.

1. Identify the problem and set the policy agenda
School nurses recognized the contribution of childhood obesity and unhealthy eating
habits to future chronic disease. Along with administrators, a school nurse assessed
the problem, determined a policy agenda focusing on nutrition, and obtained related
funding.

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2. Formulate the policy
The school district convened a school wellness team, including students, parents,
health teachers, a school nurse, the school food service director, and administrators.
The team completed a wellness assessment that identified school policy gaps and
recommended evidence-based practices to address the gaps. The team reviewed sev-
eral model policies, and then drafted its own school wellness policy to address nutri-
tion in the school setting.

3. Adopt the policy
The school wellness team brought the policy to the school board for consideration.
The school board adopted the policy. The school wellness team met again and deter-
mined steps needed to enact the policy; created a communications plan and an eval-
uation plan; and applied for funding from federal, state, and local resources.

4. Implement and enforce the policy
The school wellness team disseminated the policy, including communicating about
strategies to offer fruits and vegetables to students during school lunches. The food
service director offered the students the opportunity to try new fruits and vegetables,
and to complete a survey on the food item, after which the food could potentially be
added to the school lunch menu. School staff disseminated the policy to parents dur-
ing school conferences, and school administration included policy information in
school media outlets. School staff encouraged students to bring snacks and lunches
that included fruits and vegetables. Policy enforcement occurred when sugary drinks
were banned from school vending machines.

5. Evaluate the policy’s effectiveness
The school wellness team surveyed the school district and reported that the policy
was implemented as written. The student survey indicated students’ willingness to
try new foods. The school wellness team planned to review and update the policy and
policy implementation annually.

Key points from evidence
For a description of evidence levels, visit: Introduction: Overview of evidence-based
practice and related topics.

 1. Models of the policymaking process
Policy models or frameworks explain the policymaking process. Examples include:

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Policy stream model

All three of the following streams must come together to enact a policy.

 Problem stream: Potential problems that could be addressed by policymakers
 Policy stream: Competing ideas and solutions for addressing policy issue
 Political stream: The political will to advance the policy

Longest’s policy cycle model

1. Policy formulation phase: There is a window of opportunity where an agenda
comes together—integrating the problem, possible solutions, and the political
circumstances—which leads to enacting legislation.

2. Policy implementation phase: The executive branch of the government estab-
lishes rules and regulations. Stakeholders have the opportunity to influence ad-
justments and decisions in this phase.

3. Policy modification phase: Previous decisions may be revisited/modified in response
to unintended consequences, circling back to the policy formulation phase.

Level 5 sources:

 Berkowitz, 2012
 Kingdon, 1995
 Longest, 2010
 O’Grady, 2016
 Watson, 2014

 2. Effective policy advocacy strategies
Effective policy advocacy strategies include:

 Understand the steps of the legislative process.
 Know the key players who influences proposed legislation.
 Understand how legislative committees work.
 Meet with legislative staff about the policy issue.
 Attend and testify at legislative hearings.
 Communicate with legislators (in person, at day on the hill events, by phone, or

via email).

Level 5 source:

 Abood, 2007

 3. Responsibilities consistent with policy development and
enforcement
In a qualitative study, public health nursing leaders reported the following responsi-
bilities consistent with policy development and enforcement in their leadership role:

 Developing, implementing, and assuring compliance of policy initiatives
 Supervising and leading programs
 Managing fiscal resources
 Collaborating with local and state organizations
 Collecting and analyzing data

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 Serving as a legislative liaison within county guidelines
 Overseeing core public health functions

Level 3 source:

 Deschaine & Schaffer, 2003

 4. Barriers to development and implementation
Public health nurse (PHN) leaders in local health departments reported encountering
the following barriers in policy development and implementation activities:

 Political barriers to getting a public health issue on the agenda at health board
or county commissioner meeting

 Lack of public understanding about the policy issue
 Lack of dedicated funding for public health programs and policy mandates
 Resource limitations, like inadequate technology and staffing
 Lack of female representation on county boards

Level 3 source:

 Deschaine & Schaffer, 2003

 5. Assessing the policy environment
Questions useful for assessing a policy environment include:

 What is the problem?
 Where is the process?
 How many are affected?
 What possible solutions could be proposed?
 What are the ethical arguments involved?
 At what level is the problem most effectively addressed?
 Who is in a position to make policy decisions?
 What are the obstacles to policy intervention?
 What resources are available?
 How can I get involved?

Level 5 source:

 Malone, 2005

 6. Promoting evidence in policy decisions
Consider the following recommendations for promoting use of evidence in policy
decisions:

 Analyze and prepare data ahead of time so that evidence can be quickly availa-
ble when there is a window of opportunity for policy decisions.

 Organize data to clearly and quickly communicate: a) the burden to public
health, b) the priority of the policy issue over other issues, c) relevance to voters,
d) benefits of intervention, e) a personal and compelling story of how lives are
affected, and f) cost estimate of intervention.

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 Have systems in place to monitor patterns and trends (public health policy sur-
veillance) and use evidence from a variety of sources to track outcomes.

Level 5 source:

 Brownson, Chriqui, & Stamakatis, 2009

 7. Building relationships to promote equality
“Political action requires listening to communities prior to acting as advocate, inter-
preter of science, or activist” (Carnegie & Kiger, 2009, p. 1982). Public health nurses
can contribute to policies that promote equality by building relationships with local
government, community organizations, and citizen groups, and by thinking critically
about injustice and inequities in the distribution of health resources.

Level 5 source:

 Carnegie & Kiger, 2009

 8. Examples of successful policy initiatives
Consider the following examples of policy initiatives that increase awareness about
health improvement strategies:

 Shape Up Somerville: Eat Smart, Play Hard in Massachusetts, established criteria
for Shape Up Somerville-designated restaurants, based on federal National School
Lunch Program regulations. Restaurant owners and managers reported a greater
awareness of nutrition among staff and customers following the intervention.

 Washington state developed and implemented policies prohibiting smoking in
public places following assessment, using broad public support through previous
tobacco prevention work, relying on health department leadership to support
and defend secondhand smoke policy.

 Health visitors (PHNs) in the United Kingdom worked with preschool leaders on
developing and implementing sun safety policies for children. For the interven-
tion group, 88 percent of schools developed and implemented sun safety poli-
cies, while there were no changes in sun safety policy in the control group.

 Lexington, Kentucky, enacted smoke-free laws with the support of a coalition of
health care providers and systems, tobacco control expertise, a strong legal
team, and a deliberate strategy to expose the tobacco industry.

Level 1 source:

 Syson-Nibbs, Peters, & Saul, 2005

Level 3 sources:

 Economos et al., 2009
 Gizzi, Klementiev, Britt, & Cruz-Uribe, 2009

Level 5 source:

 Greathouse, Hahn, Chizimuzo, Warnick, & Riker, 2005

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 9. Developing evidence-based organizational policies
An evidence-based practice council at a Colorado hospital developed an algorithm to
identify steps needed to facilitate development of evidence-based organizational pol-
icies. Public health departments may find these steps useful for guiding organiza-
tional policies:

a. Select the policy to revise (or identify the need for a new policy).
b. Search for evidence.
c. Conduct a systematic evaluation of the evidence.
d. Compare evidence to the current policy and make a decision.
e. Arrange for stakeholders and/or experts to review the policy.
f. Make revisions based on comments from stakeholders and experts.
g. Obtain signatures of approval.
h. Submit the policy to the policy committee or other decision-makers.
i. Provide staff education as needed.
j. Place the policy on the organization’s internal website.

Level 5 source:

 Oman, Duran, & Fink, 2008

Wheel notes

Facilitation and conflict mediation skills
Public health policy development and enforcement seeks to improve population
health; limited funding and/or differing perspectives may lead to conflict about which
policies are placed on the policy agenda and eventually adopted and implemented,
bringing conflict into the decision-making process. Public health nurses use facilitation
and conflict mediation skills to support successful policy adoption and implementation.

Local level
Nursing literature focuses on the policy development and enforcement process at the
federal and state levels. The same basic steps can be applied to policy development
in all levels of government. Public health nurses use their expertise to influence and
guide policy development. Public health nurses communicate evidence about effec-
tive policies and policy implementation. They have the opportunity to influence poli-
cies related to school wellness, worksite wellness, active living, vaccine requirements,
protected health information, tobacco, and head lice, among other issues.

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References
Abood, S. (2007). Influencing health care in the legislative arena. The Online Journal of Issues in

Nursing, 12(1), Manuscript 2. doi:10.3912/OJIN.Vol12No01Man02

Anderson, J. E. (2015). Public policymaking: An introduction. Stamford, CT: Cengage Learning.

Berkowitz, B. (2012). The policy process. In D. Mason, J. Leavitt, & M. Chaffee (Eds.), Policy and
politics in nursing and health care (pp. 49-58). St. Louis, MO: Elsevier.

Brownson, R. C., Chriqui, J. F., & Stamakatis, K. A. (2009). Understanding evidence-based public
health policy. American Journal of Public Health, 99(9), 1576-1583.

Carnegie, E. & Kiger, A. (2009). Being and doing politics: An outdated model or 21st century
reality? Journal of Advanced Nursing 65(9), 1976-1984. doi: 10.1111/j.1365-
2648.2009.05084.x

Deschaine, J. E. & Schaffer, M. A. (2003). Strengthening the role of public health nurse leaders in
policy development. Policy, Politics, & Nursing Practice, 4(4), 266-274. doi:
10.1177/1527154403258308

Economos, C. D., Folta S. C., Goldberg J., Hudson, D., Collins, J., Baker, Z., et al. (2009). A
community-based restaurant initiative to increase availability of healthy menu options
in Somerville, Massachusetts: Shape Up Somerville. Preventing Chronic Disease, 6(3), 1-
8. Retrieved from https://www.cdc.gov/pcd/issues/2009/jul/pdf/08_0165

Edelstein, J., Gallagher, R., Hansen, J. M., Ebeling, J. M., & Turner, M. J. (2010). Shaping public
health nursing practice: A policy development toolkit. Rockville, MD: Health Resources
and Services Administration.

Gizzi, C., Klementiev, A., Britt, J., & Cruz-Uribe, F. (2009). The Use of assessment in promoting
secondhand smoke policy in a local health jurisdiction. Journal of Public Health
Management and Practice, 15(1), 41-46.

Greathouse, L. W., Hahn, E. J., Chizimuzo, T. C., Warnick, T. A., & Riker, C. A. (2005). Passing a
smoke-free law in a pro-tobacco culture: A multiple streams approach.

Kindgon, J. W. (1995). Agendas, alternatives, and public policies. Boston: Little, Brown.

Longest, B. (2010). Health policymaking in the United States. Chicago, IL: Health Administration Press.

Malone, R. E. (2005). Assessing the policy environment. Policy Politics Nursing Practice, 6(2), 135-
143. doi: 10.1177/1527154405276141

Minnesota Department of Health. (2017a). The Statewide Health Improvement Partnership.
Retrieved from http://www.health.state.mn.us/ship/

Minnesota Department of Health. (2017b). Creating better health together by helping kids learn
and grow. Retrieved from
http://www.health.state.mn.us/divs/oshii/ship/pdfs/summaries/schools

O’Grady, E. T. (2016). The Policy Process. In D. J. Mason, D. B. Gardner, F. H. Outlaw, E. T., & O’Grady
(Eds), Policy and politics in nursing and health care (pp. 61-72). St. Louis, MO: Elsevier, Inc.

Oman, K. S., Duran, C., & Fink, R. (2008). Evidence-based policy and procedures: An algorithm for
success. Journal of Nursing Administration, 38(1), 47-51.

Syson-Nibbs, L., Peters, J., & Saul, C. (2005). Can health visitor intervention change sun safety
policies and practice in preschool establishments. A randomized controlled study.
Health Education Journal, 64(2), 129-141.

Watson, T. (2014). Political science theory for public health practice. American Journal of Health
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In review
A story:

Lia Roberts is a public health nurse and the Public Health Preparedness Coordinator
for Dakota County in Minnesota. To learn about her work in emergency prepared-
ness, watch the video Dakota County Public Health Emergency Preparedness (Dakota
County, 2018).

Think about this example of pandemic flu planning. Consider how the yellow wedge
interventions of advocacy, social marketing, and policy development and enforce-
ment occur when conducting emergency preparedness activities for pandemic flu.

The Department of Homeland Security website contains many resources for emer-
gency preparedness planning for your analysis of effective advocacy, social market-
ing, and policy development/enforcement interventions. PHNs access these re-
sources at Ready.gov.

https://www.ready.gov/

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Application questions

Level of practice
1. What levels of practice occur in the story about pandemic flu planning?

Advocacy
2. What advocacy role occurs during pandemic flu planning?
3. Which key stakeholders need to be influenced?
4. What evidence determines which groups are vulnerable or at greatest risk?

What health disparities should be considered?
5. Which key individuals and organizations offer support for the pandemic flu plan?

Social marketing
6. Who is the target audience? Is anyone missing?
7. What is the goal for behavior change?
8. What potential barriers, benefits, motivators, cultural considerations, and com-

petition need to be considered?
9. What are the differences in how various community members receive information?
10. What product, price, place, and promotion need to be considered in the

marketing mix?

Policy development and enforcement
11. Who participates in the policy development process? Who benefits from the

policy? Who might be harmed as an unintended consequence?
12. What assumptions do planners hold about emergency response that may not be

shared among all community members? Hint: Various community members
have varying levels of trust of people in uniform.

13. What resources are available for implementing the pandemic flu policy response?
14. Although the pandemic flu response occurs here at the local level, what state

and federal policies might be applicable to the plan?
15. How might public health nurses be involved in policy enforcement related to the

pandemic flu policy?
16. How could a public health nurse evaluate the effectiveness of pandemic flu pol-

icy response? (Hint: Think about the numbers reported in the video on emer-
gency preparedness activities in Dakota County).

References
Dakota County [Dakota County Videos]. (2018, May 8). Dakota County Public Health emergency

preparedness . Retrieved from https://youtu.be/qTUHoztIFYY

00COVERTITLE

Public health interventions: Applications for public health nursing practice

01eIntroFINAL

Acknowledgements

Reviewers

Project staff

Reviewer notes

Foreword

Introduction

Background

How has public health nursing practice changed?

How has the Public Health Intervention Wheel changed?

Method

Public health nursing interventions

The Intervention Wheel: The “how” of public health nursing practice

Intervention wedges

Population-based interventions

1. Public health interventions are population-based if they focus on entire populations possessing similar health concerns or characteristics

2. Public health interventions are population-based if they are guided by an assessment of population health status determined through a community health assessment process

3. Public health interventions are population-based if they consider the broad determinants of health

4. Public health interventions are population-based if they consider all levels of prevention, with a preference for primary prevention

5. Public health interventions are population-based if they consider all levels of practice

Cornerstones of public health nursing

The Intervention Wheel and the core public health functions, essential services

Using the public health intervention framework

Overview of evidence-based practice and related topics

What is evidence-based practice?

Why is evidence-based practice important to public health nurses?

When do public health nurses use evidence-based practice?

What are the levels of evidence that inform evidence-based practice?

Table 1: Evidence levels, key features, and public health nursing practice examples

What are some terms and definitions related to evidence level?

Where is evidence found?

How is the quality of evidence determined?

What process does a public health nurse use to evaluate evidence?

Table 2: PET process

References

Foreword

Introduction

Overview of evidence-based practice and related topics

02eRedFINAL

Surveillance

Practice-level examples

Systems level

Community level

Individual/family level (case-finding)

Relationship with other interventions

Basic steps

1. Consider whether surveillance is appropriate

2. Acquire necessary knowledge of the problem

3. Establish criteria for what constitutes a “case”

4. Collect data from multiple sources

5. Maintain ethical standards

6. Analyze data

7. Effectively interpret and disseminate data

8. Evaluate impact of the surveillance system

Example

1. Consider whether surveillance is appropriate

2. Acquire necessary knowledge of the problem

3. Establish criteria for what constitutes a “case”

4. Collect data from multiple sources

5. Maintain ethical standards

6. Analyze data

7. Effectively interpret and disseminate data

8. Evaluate the impact of the surveillance system

Key points from evidence

( 1. Surveillance as a nursing intervention

( 2. Types of surveillance

( 3. Criteria for surveillance

( 4. Characteristics of surveillance

( 5. Surveillance in conjunction with other systems

( 6. Surveillance examples from the literature

( 7. Web-based surveillance advantages and disadvantages

( 8. Using surveillance for influenza

( 9. Developments in surveillance

( 10. Increasing data accuracy and usefulness with surveys

Wheel notes

Epidemiology

Innovations

Resources

References

Disease and health event investigation

Practice-level examples

Systems level

Community level

Individual/family level (case-finding)

Relationship with other interventions

Basic steps

1. Identify investigation team and resources

2. Confirm the existence of the disease or threat

3. Verify the diagnosis/define a case

4. Estimate the number of cases

5. Collect data including persons, place, time, lab results, and relevant records or reports

6. Develop and evaluate a hypothesis

7. Institute control measures and communicate findings

8. Maintain surveillance

Example

1. Identify investigation team and resources

2. Confirm the existence of the disease or threat

3. Verify the diagnosis/define a case

4. Estimate the number of cases

5. Collect data including persons, place, time, lab results, and relevant records or reports

6. Develop and evaluate a hypothesis

7. Institute control measures and communicate findings

8. Maintain surveillance

Key points from evidence

( 1. Considering subgroup characteristics

( 2. Risk assessment tools

( 3. Recommendations for effective investigation

( 4. Recommendations following an outbreak investigation

( 5. Measures to control outbreaks

( 6. Novel strategies for investigation

( 7. Skills for outbreak investigation

( 8. School nurses and student immunizations

( 9. Efficacy of simulation

Wheel notes

Public health nurses identify health concerns that need disease and health event investigation

Non-infectious diseases and other health events

Using disease and health event investigation to resolve local health concerns

References

Outreach

Practice-level examples

Systems level

Community level

Individual/family level (case-finding)

Relationship with other interventions

Basic steps

1. Define the community served by the outreach

2. Identify the health issue and the health outcomes you hope to promote

3. Conduct research on the health issues, including previous programs and outreach campaigns

4. Organize outreach team

5. Build trusting relationships in the community

6. Prepare and implement plan for approaching potential clients in outreach setting

7. Evaluate results of the outreach intervention

Example

1. Define the community to be served by the outreach

2. Identify the health issue and the health outcomes you hope to promote

3. Conduct research on the health issues, including previous programs and outreach campaigns

4. Organize outreach team

5. Build trusting relationships in the community

6. Prepare and implement plan for approaching potential clients in outreach setting

7. Evaluate results of the outreach intervention

Key points from evidence

( 1. Focusing outreach on populations most in need of screening

( 2. Considering social network characteristics

( 3. Utilizing workers within communities’ social networks

( 4. Best practices for community-focused outreach activities

( 5. Improving client health behavior and access

( 6. Maximizing online reach

( 7. Supplement health promotion with art

( 8. Tailoring interventions to populations

Wheel notes

Joining forces in outreach

Level of evidence

Outreach by community health workers

References

Screening

Practice-level examples

Systems level

Community level

Individual/family level (case-finding)

Relationship with other interventions

Basic steps

1. Assess the situation

2. Develop the program

3. Prioritize risk groups

4. Use evidence-based algorithm and approach

5. Plan, budget, and implement

6. Monitor and evaluate

Example

1. Assess the situation

2. Develop the program

3. Prioritize risk groups

4. Use evidence-based algorithm and approach

5. Plan, budget, and implement

6. Monitor and evaluate

Key points from evidence

( 1. Principles and guidelines for effective health screening

( 2. Successful screening programs

( 3. Asking the right questions

( 4. Considering ethical issues

( 5. Using standardized screening instruments

( 6. When limited screening is appropriate

( 7. When screening is harmful

( 8. Screening for abuse

( 9. Safeguards when screening for Body Mass Index (BMI)

( 10. Using apps for screening

Wheel notes

Common public health nursing screening activities

Evaluating screening tool effectiveness

Preventing harm: Cultural/racial factors

Screening plus referral and follow-up

References

Case-finding

Practice examples: Individual/family

Case-finding from surveillance

Case-finding from disease and health event investigation

Case-finding from outreach

Case-finding from screening

Relationship with other interventions

Basic steps

1. Identify individuals and families at risk through information from surveillance, disease and health event investigation, and/or outreach

2. Connect with formal and informal networks to find those identified as at-risk

3. Initiate activities providing information about the nature of the risk, possible solutions, and service attainment

4. If the level of risk suggests endangerment to the individual, family, or community, provide direct access to necessary services

5. Fulfill state law and regulation reporting mandates

Example

1. Identify individuals and families at risk through information from surveillance, disease and health event investigation, and/or outreach

2. Connect with formal and informal networks to find those identified as at risk

3. Initiate activities providing information about the nature of the risk, possible solutions, and service attainment

4. If the level of risk suggests endangerment to the individual, family, or community, provide direct access to necessary services

5. Fulfill state law and regulation reporting mandates

Key points from evidence

( 1. Case-finding intervention categories

( 2. Settings for active case-finding

( 3. Stepped care case-finding

( 4. Case-finding for tuberculosis

( 5. Case-finding to improve early detection and increase access to care

( 6. Using apps for sexually transmitted infection (STI) case-finding

( 7. Using brief and evidence-based case-finding tools

( 8. Identifying potential clients with case-finding

Wheel notes

Critical thinking

Opportunities

References

In review

Application questions

Level of practice

Surveillance

Disease and health event investigation

Outreach

Screening

References

03eGreenFINAL

Referral and follow-up

Practice-level examples

Systems level

Community level

Individual/family level

Relationship with other interventions

Basic steps: Community/systems level

Referral 1. Use links with other providers, organizations, institutions, and networks to monitor the community’s capacity to provide the resources and services for populations at risk

Referral 2. Produce strategies for services and resources development

Referral 3. Participate in implementing those strategies selected consistent with the public health agency mission and goals

Follow-up 4. Evaluate strategy effectiveness of developing needed services and resources

Example: Community/systems level

1. Use links with other providers, organizations, institutions, and networks to monitor the community’s capacity to provide the resources and services for populations at risk

2. Produce strategies for services and resources development

3. Participate in implementing those strategies selected consistent with the public health agency mission and goals

4. Evaluate strategy effectiveness of developing needed services and resources

Basic steps: Individual/Family Level

Referral 1. Establish resource referral arrangements

Referral 2. Determine who initiates the referral

Referral 3. Assist client in anticipating referral resource response and maximizing resource interaction

Referral 4. Inquire about and address client reservations or fears

Referral 5. Establish how and what referral-related information the public health nurse receives from the client

Follow-up 6. Confirm and document referral status

Follow-up 7. If the client has not completed the referral, reinforce the benefits and review barriers

Follow-up 8. Obtain feedback on referral results

Follow-up 9. Obtain feedback from clients on referral resource quality

Example: Individual/family level

1. Establish resource referral arrangements

2. Determine who initiates the referral

3. Assist client in anticipating referral resource response and maximizing resource interaction

4. Inquire about and address any client reservations or fears

5. Establish how and what referral-related information the public health nurse receives from the client

6. Confirm and document referral status

7. If the client has not completed the referral, reinforce the benefits and review barriers

8. Obtain feedback from clients on referral resource quality

9. Obtain feedback from clients on referral resource quality

Key points from evidence

( 1. Importance of relationships

( 2. Developing client receptiveness

( 3. Resistance to following up

( 4. Referral and follow-up after screening

( 5. Improving quality of life with referral, follow-up, and other interventions

( 6. Increasing completion by explaining referral process

( 7. Low health literacy

Wheel notes

Public health nursing wisdom

Information and referral

Making referrals easy

References

Case management

Practice-level examples

Systems level

Community level

Individual/family level

Relationship with other interventions

Basic steps

1. Select engaged clients

2. Assess the client

3. Develop a plan

4. Implement the plan

5. Monitor and evaluate plan effectiveness and acceptability

6. Discontinue intervention

Example

1. Select engaged clients

2. Assess the client

3. Develop a plan

4. Implement the plan

5. Monitor and evaluate plan effectiveness and acceptability

6. Discontinue intervention

Example notes

Key points from evidence

( 1. Health care utilization and case management

( 2. Cost savings, cost avoidance, and case management

( 3. Barriers to case management

( 4. Improved quality of life among the elderly

( 5. Lack of consensus on relationship between care coordination and case management

Wheel notes

Case management or care coordination? Impact of the 2010 Affordable Care Act

Professional certifications

Resources

References

Delegated functions

Practice-level examples

Systems level

Community level

Individual/family level

Relationship with other interventions

Basic steps

1. Assess the situation

2. Develop the plan

3. Analyze delegation factors

4. Communicate and clarify expectations

5. Evaluate client condition and response

6. Evaluate unlicensed assistive personnel’s skills and performance and provide feedback

Example

1. Assess the situation

2. Develop the plan

3. Analyze delegation factors

4. Communicate and clarify expectations

5. Evaluate condition of the client and response

6. Evaluate unlicensed assistive personnel’s skills and performance of tasks and provide feedback

Public health nurse as delegatee

The five rights of the public health nurse as delegatee

Key points from evidence

( 1. Effective delegation

( 2. Responsibilities in a delegation model

( 3. Factors to consider when delegating to assistive personnel

( 4. Facilitators and barriers to effective delegation

( 5. Situations where delegation is inappropriate

( 6. Reducing delegation risks in school settings

( 7. Delegating medication administration in schools

( 8. Delegating to maternity support workers

( 9. Delegating medicine support for home care clients

Wheel notes

Community health workers

References

In review

Application questions

Level of practice

Referral and follow-up

Case management

Delegated functions

References

04eBlueFINAL

Health teaching

Practice-level examples

Systems level

Community level

Individual/family level

Relationship to other interventions

Basic steps

A: Analyze the learner

S: State the objectives

S: Select instructional methods and materials

U: Utilize materials

R: Require learner performance

E: Evaluate and revise

Example

A: Analyze the learner

S: State the objectives

S: Select instructional methods and materials

U: Utilize materials

R: Require learner performance

E: Evaluate and revise

Key points from evidence

( 1. Best practices for written messages

( 2. Tailored health interventions

( 3. Support and counseling in education

( 4. Shared decision-making

( 5. Behavior change is an active process

( 6. Using theories to guide interventions

( 7. Promoting the use of evidence in practice

( 8. Effective health risk communication

Wheel notes

Social media

Health literacy

Interprofessional collaboration

References

Counseling

Practice-level examples

Systems level

Community level

Individual/family level

Relationship to other interventions

Basic steps

1. Establish a therapeutic relationship with the client (individual/family, community, or systems)

2. Maintain professional boundaries

3. Self-monitor the relationship

4. Select effective strategies and tailor them

5. Use an evidence-based behavior change model

Five A’s

Motivational interviewing

6. Identify and address behavior change barriers

7. Avoid actions that support resistance

8. Take cues from client perspectives

Example

1. Establish a therapeutic relationship

2. Maintain professional boundaries

3. Self-monitor the relationship

4. Select effective strategies and tailor them

5. Use an evidence-based behavior change model

6. Identify and address possible barriers to behavior change

7. Avoid actions that support resistance

8. Take cues from client perspectives

Key points from evidence

( 1. Therapeutic alliance

( 2. Client attributes for effective response

( 3. Adapting strategies for diverse needs

( 4. When to refer clients

( 5. Client peer groups

( 6. Motivational interviewing

( 7. Training in behavior change strategies

( 8. PHNs as information channels in community risk counseling

Wheel notes

Challenges

Community- and systems-level counseling

References

Consultation

Practice-level examples

Systems level

Community level

Individual/family level

Relationship with other interventions

Basic steps

1. Gain entry

2. Identify the problem

3. Determine action planning

4. Evaluate effectiveness

5. Disengage from the relationship

Example

1. Gain entry

2. Identify the problems

3. Determine action planning

4. Evaluate effectiveness

5. Disengage from the relationship

Key points from evidence

( 1. Cultural context

( 2. Empowering clients to make decisions

( 3. Encouraging clients to actively engage

( 4. Consultation roles

( 5. Guidance for the consultation process

( 6. Ethical principles in conducting research

( 7. Specialists and improved quality of care

( 8. Improving the consultation process

Wheel notes

Contrast with counseling and health teaching

Systems level

Rigor of evidence

References

In review

Application questions

Practice level

Health teaching

Counseling

Consultation

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Collaboration

Practice-level examples

Systems level

Community level

Individual/family level

Relationship with other interventions

Basic steps: Community level

1. Determine the need

2. Assess potential partners

3. Develop the partnership

4. Formalize the partnership

5. Maintain and sustain the partnership

6. End the partnership (or not)

Example: Community level

1. Determine the need

2. Assess potential partners

3. Develop the partnership

4. Formalize the partnership

5. Maintain and sustain the partnership

6. End the partnership (or not)

Basic steps: Individual/family level

1. Initiating phase: Both partners commit to the partnership

2. Working phase: Partners bring their knowledge and experience to the collaborative process

Example: Individual/family level

1. Initiating phase: Both partners commit to the partnership

2. Working phase: Partners bring their knowledge and experience to the collaborative process

Key points from evidence

( 1. Knowledge and skills needed for effective collaboration

( 2. Creating and sustaining mutual partnerships

( 3. Reducing barriers to effective partnerships

( 4. Trust and leadership

( 5. Norms for group development

( 6. Strategies for working together for a common purpose

( 7. Interprofessional collaboration with clients

( 8. Improved outcomes with interprofessional service delivery

( 9. Community engagement guidelines

( 10. Improving behaviors and outcomes with integrated strategies

Wheel notes

Collective impact

Overlap in collaboration, interprofessional collaboration, and community engagement

Partnering with others

Collaboration enhances capabilities

References

Coalition-building

Practice-level examples

Systems level

Community level

Individual/family level

Relationship with other interventions

Basic steps

1. Put together a core group

2. Identify potential coalition members

3. Recruit members to the coalition

4. Plan and hold the first meeting

5. Follow up on the first meeting

6. Move forward on next steps

7. Maintain until coalition accomplishes its purpose

Example

1. Put together a core group

2. Identify potential coalition members

3. Recruit members to the coalition

4. Plan and hold the first meeting

5. Follow up on the first meeting

6. Move forward on next steps

7. Maintain until coalition accomplishes its purpose

Key points from evidence

( 1. Guidelines for starting coalitions

( 2. Understanding coalition environments and context

( 3. Coalition-building stages

( 4. Factors for success

( 5. Factors for coalition organizational capacity

( 6. Challenges to success

( 7. Satisfaction and sustainability

( 8. Connecting providers and diverse communities

Wheel notes

Public health nurse as coalition catalyst

International perspective

References

Community organizing

Practice-level examples

Systems level

Community level

Individual/family level

Relationship with other interventions

Basic steps

1. Involve people in your community efforts

2. Identify community members’ #1 issue

3. Develop your strategy

4. Develop specific tactics for selected strategy

5. Choose specific actions

6. Set goals and celebrate wins

7. Plan for sustainability if indicated

Example

1. Involve people in your community efforts

2. Identify community members’ #1 issue

3. Develop strategy

4. Develop specific tactics for selected strategy

5. Choose specific actions

6. Set goals and celebrate wins

7. Plan for sustainability if indicated

Key points from evidence

( 1. Important concepts

( 2. Effective community organizing

( 3. Focusing on health equity

( 4. Empowering communities

( 5. Advantages of community organizing

( 6. Challenges to effective community organizing

( 7. Ethical problems in community organizing

( 8. Examples of effective activities and campaigns

Wheel notes

Related concept: Social capital

Related concept: Community activism

References

In review

Application questions

Level of practice

Collaboration

Coalition-building

Community organizing

References

06eYellowFINAL

Advocacy

Practice-level examples

Systems level

Community level

Individual/family level

Relationship with other interventions

Basic steps

1. Determine whether the organizational, positional, professional, and personal willingness exists to take action and overcome obstacles

2. Clearly select the advocacy focus

3. Match the action to the situation

4. Understand political context and identify key people to influence

5. Build a solid evidence base

6. Engage others—win the support of key individuals and organizations

7. Develop a strategic plan

8. Communicate messages, implement the plan

9. Seize opportunities

10. Be accountable

Example

1. Determine whether the organizational, positional, professional, and personal willingness exists to take action and overcome obstacles

2. Clearly select the advocacy focus

3. Match the action to the situation

4. Understand political context and identify key people to influence

5. Build a solid evidence base

6. Engage others—win the support of key individuals and organizations

7. Develop a strategic plan

8. Communicate messages, implement the plan

9. Seize opportunities

10. Be accountable

Key points from evidence

( 1. Public health nurses as advocates for health improvement

( 2. Traits of a public health nurse advocate

( 3. Effective strategies and tools

( 4. Effective advocacy message components

( 5. Framing advocacy messages for media

( 6. Consequences of advocacy actions

( 7. Ethical challenges

( 8. Challenges at the systems level

( 9. Policy-level intervention suggestions

Wheel notes

Human rights and social justice perspectives

Medical paternalism

Advocacy or empowerment?

References

Social marketing

Practice-level examples

Systems level

Community level

Individual/family level

Relationship with other interventions

Basic steps

1. Describe plan background, purpose, and focus

2. Conduct a situation analysis

3. Select target audience

4. Set behavior objectives and goals

5. Identify benefits, motivators, barriers, and change strategies

6. Craft a positioning statement

7. Develop a strategic marketing mix (four P’s)

Product

Price

Place

Promotion

8. Outline a monitoring and evaluation plan

9. Establish budgets and find funding sources

10. Implement the plan

11. Monitor and evaluate plan implementation

Example

1. Describe the plan background, purpose, and focus

2. Conduct a situation analysis

3. Select target audience

4. Set behavior objectives and goals

5. Identify benefits, motivators, barriers, and change strategies

6. Craft a positioning statement

7. Develop a strategic marketing mix (Four P’s)

8. Outline a monitoring and evaluation plan

9. Establish budgets and find funding sources

10. Implement the plan

11. Monitor and evaluate plan implementation

Key points from evidence

( 1. Theories supporting social marketing

( 2. Identifying social marketing interventions

( 3. Effective social marketing

( 4. Augmented products and questions to consider

( 5. Criteria for identifying and validating good practice

( 6. Ethical norms and values

( 7. Developing strategies

( 8. Social media

( 9. Examples of successful campaigns

Wheel notes

Historical example

Know your audience

The Six P’s

References

Policy development and enforcement

Practice-level examples

Systems level

Community level

Individual/family level

Relationship with other interventions

Basic steps

1. Identify the problem and set the policy agenda

2. Formulate the policy

3. Adopt the policy

4. Implement and enforce the policy

5. Evaluate the policy’s effectiveness

Example

1. Identify the problem and set the policy agenda

2. Formulate the policy

3. Adopt the policy

4. Implement and enforce the policy

5. Evaluate the policy’s effectiveness

Key points from evidence

( 1. Models of the policymaking process

( 2. Effective policy advocacy strategies

( 3. Responsibilities consistent with policy development and enforcement

( 4. Barriers to development and implementation

( 5. Assessing the policy environment

( 6. Promoting evidence in policy decisions

( 7. Building relationships to promote equality

( 8. Examples of successful policy initiatives

( 9. Developing evidence-based organizational policies

Wheel notes

Facilitation and conflict mediation skills

Local level

References

In review

Application questions

Level of practice

Advocacy

Social marketing

Policy development and enforcement

References

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Who Will Be There?
Ethics, the law, and a nurse’s duty to respond in a disaster

When disaster strikes, nurses are needed
Registered nurses have consistently shown to be reliable responders, and their compassionate nature
typically compels them to respond to those in need, even when it puts their own safety or well-being at risk.
There is a strong relationship between the nurse and the public who expects that nurses and other health
care providers will respond to their needs in an infectious disease emergency or in other types of disaster
resulting in mass injury or illness. Society, as such, sanctions professions to be self-regulating on the
understanding that such a response would occur. But do registered nurses have a contractual “duty” to
answer a call to help in disaster situations? Do they have an ethical obligation to respond? Can the law
require them to respond?

A nurse’s duty to care is an ethical component of the nurse-patient relationship that can be inferred from
Provision 2 of the ANA Code of Ethics for Nurses with Interpretive Statements which states that “the nurse’s
primary commitment is to the patient.” However, nurses not only have an ethical obligation to care for
others but also to care for themselves. Provision 5 of the Code states that the nurse owes the same duty to
self as to others. This conflict of obligation is especially prominent during times of disaster when nurses are
put in the position to provide care to critically ill or wounded patients for extended periods of time. During
these times of pandemics or natural catastrophes, nurses and other health care providers must decide how
much high quality care they can provide to
others while also taking care of themselves.

Registered nurses, especially those in non-
emergency response functions, may find
themselves in a difficult predicament. They
are called upon to respond in times of mass
casualty—such as a catastrophic weather
event (hurricanes/floods) — or when the
nature of their work puts them at risk for
exposure—such as influenza or other
infectious disease pandemics. It is
reassuring to know that because of their
compassionate nature and the nature of
their role as caregiver, registered nurses are
typically willing to respond. But many other
registered nurses struggle with the call to respond. This is especially true if the nurse feels physically unsafe
in the response situation, if there is inadequate support for meeting the nurses own family’s needs, or if the
nurse is concerned about professional ethical and legal protection for nursing care in a crisis situation.

http://www.nursingworld.org/Code-of-Ethics

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Who will be there? Ethics, the law, and a nurse’s duty to respond in a disaster
2017

These concerns faced by nurses represent a gap in our nation’s disaster preparedness and response systems.
Critical questions remain unanswered as to what the registered nurse’s duty to respond is, especially if
called upon to serve in a nontraditional role, and what expectations the registered nurse should have for
physical, emotional, and legal protections. Resolving these problems would ultimately support registered
nurses responding to a call for help will meet those needs and assure a robust response from registered
nurses.

A Careful Assessment
National associations like the American Nurses Association (ANA) are partnering with government groups,
nongovernment organizations, employers and individual registered nurses to achieve systems, policies, and
laws that enable the registered nurse and other providers to respond confidently, and to ensure that the
needs of the American public will be met during a disaster.

In times of disaster we need to know that there will responders. But who will respond? It is evident that
nurses have such a defined duty and this duty has
some basis in licensure, regulations, and ethics.

There may be times when a registered nurse must
make a choice between duties based on moral
grounds. These choices are an important part of
disaster planning and preparedness. Each nurse
must know what line he or she will or will not cross
when it comes to maintaining professional
integrity. These concerns should be discussed prior
to times of disaster. This is critical in disaster
preparedness and planning. Hospitals, institutions,
managers, administrators, and health care
providers need to understand employer and
employee expectations during times of disaster.
Effective communication regarding a nurse’s ability
to commit to providing any level of care to patients
is essential when such events occur.

Nurses have a duty to uphold the standards of their
profession. As such, they have a commitment to
help care for and protect their patients while also protecting their own right to self-preservation and self-
care. Nurses need to be proactive to address such issues. Nurses and the ANA are positioned to drive
decisions regarding the conflict between a nurse’s duty to care versus duty to self.

Questions a Registered Nurse Might Ask

A hurricane rages through several states, destroying buildings, flooding roads, and falling countless trees and
power lines. In several towns and cities, hospitals are struggling to remain open and serve the injured and ill
victims from the storm, as well as to meet the routine medical needs of the community. Registered nurses
are told to report to work, and a call is made for nurse volunteers. Some nurses are given patient
assignments in areas and in physical locations that they are not accustomed to due to the austere
conditions. What questions would go through a nurse’s mind in this instance?

Registered nurses think about safety. How can the nurse get to the hospital safely? Are there structural
damages to the hospital that could cause injury? Is there risk of disease or exposure to the elements, which

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Who will be there? Ethics, the law, and a nurse’s duty to respond in a disaster
2017

could cause the nurse illness or something that could spread to family or others in the home? Are security
services at the hospital or at the site of care to prevent violence? What if the registered nurse has family
members or other dependents that are affected by the disaster and need help at home? How can the
registered nurse balance this obligation with a practice obligation to provide care to patients?

Registered nurses think about ethics. Registered nurses have an ethical obligation to put patients ahead of
themselves, but in times where the registered nurse is in imminent danger by providing patient care, how
can the nurse balance the ethical obligation to protect oneself? How will the nurse deal with being unable to
provide care to everyone, especially if supplies and resources are scarce? What if the nurse or the medical
teams face very difficult— almost unthinkable— situations and decisions regarding life and death?

Registered nurses would think about legal implications. Is there a law compelling the registered nurse to
respond, even if the nurse has concerns about security and ethics? Is the nurse’s license protected? Are
there assurances that the nurse would not become an easy target for lawsuits for negligence or malpractice,
especially in circumstances of scarce resources or where practicing outside of the normal specialty area?

These are complicated questions, and individual registered nurses would answer them differently. The
challenge, however, is before a disaster occurs, policies are in place that assure protections make clear the
expectations of the registered nurse, the employer, and the government response systems.

Legal Elements

The legal elements of response can help or hinder a nurse’s decision to respond. In some cases, states have
implemented laws that require licensed health care professionals to respond, and refusal to comply can be
punishable. This approach does not help nurses feel comfortable about responding, especially when the
other assurance systems for professional and personal protection are lacking.

A more helpful approach via the legal route is policymakers and governing bodies setting protocols for
disaster medical responses that take account for the constraints of a disaster situation. Disasters can test the
capacity of licensed practitioners to offer what would be deemed appropriate care in “normal”
circumstances. They must ensure the legal protections such as liability standards, license verification, and
definition of scope of practice for nurses and other licensed practitioners providing care in disasters.

The Uniform Emergency Volunteer Health Practitioners Act (UEVHPA) is model legislation drafted to
alleviate some of these legal concerns. Produced by the National Conference of Commissioners on Uniform
State Laws, the act establishes a system for rapid, streamlined deployment of licensed human service
providers in areas of declared emergency. In addition, it provides legal safeguards for practitioners acting
within their scope and in good faith, clarifies some interstate practice differences, and deems the legal
scope of practice authority to the state requesting the practitioners to maximize their participation. Read
the UEVHPA and see what states have adopted it as law.

Battlefield Medicine vs. Ingrained Ethics

One of the most difficult policies to hammer out deals with ethics. Ethics are certainly not black and white,
and in a disaster situation, they become even more blurred. As a nurse, it may be difficult to fathom walking
past a mortally wounded person to treat someone else, or to take a terminally ill patient off a ventilator to
allocate it to a patient with a better chance of survival. But during a disaster, those and other ethical
dilemmas can and do arise. For example, in New Orleans following the floods after Hurricane Katrina in
2005, nurses and physicians found themselves in terrible ethical situations, unable to provide life-sustaining

https://www.facs.org/advocacy/state/uevhpa

8515 Georgia Avenue, Suite 400
Silver Spring, MD 20910

www.nursingworld.org

Page | 4
Who will be there? Ethics, the law, and a nurse’s duty to respond in a disaster
2017

care for patients, and faced with dire circumstances.

While every response situation is not that extreme, nurses and other health care personnel can find
themselves operating in altered standards of care environments during a disaster. There is no clear
consensus about mitigating ethical considerations, and continued uncertainty about applying altered
standards of care. A utilitarian framework usually guides decisions and actions with special emphasis on
transparency, protection of the public, proportional restriction of individual liberty, and fair stewardship of
resources. Conforming to international emergency management standards and collaboration with public
health officials and members of the healthcare team are essential throughout the event.

ANA works alongside government,
non-government organizations and
professional and academic medical
groups as part of a forum on
disaster medicine to confront some
of these complicated and difficult
policy questions. One deliverable
has been a document written at the
request of the U.S. Assistant
Secretary for Preparedness and
Response called Guidance for
Establishing Crisis Standards of Care
for use in Disaster Situations: A
Letter Report. ANA, as a member of
the Institute of Medicine’s Forum
on Medical and Public Health

Preparedness for Catastrophic Events, participated in writing this framework. It suggests tenets that
policymaking bodies should adhere to when designing the crisis standards of care for medical providers.
Nothing in the framework will change nurses’ obligation practice ethically, but they do outline how
protocols can be designed to protect medical professionals operating in extreme conditions and scarcities,
and to ensure that the public receives the most adequate medical services possible in the situation.

This is the first step to establishing the ethical and legal framework, but the issue remains far from
unresolved. ANA will continue to work with its partners to see these recommendations implemented at the
state level, and will ensure that the ethical provisions in crisis standards of care mirror those in the Code of
Ethics for registered nurses. Also, ANA will strive to educate individual registered nurses on the existence
and application of this framework, as well as help them professionally prepare to be functioning in stressful
and ethically challenging situations.

Together a Solution is Possible
A concerted effort is essential to bringing some of these very difficult and high-level concepts into practice.
The federal government has a role in setting the vision for seamless, coordinated, safe response efforts. The
states—legislatures, planners, policymakers and response agencies—have a role in creating non-punitive
environments that enhance the registered nurse’s efficiency and capacity to provide ethical care in response
efforts. Employers need to create, maintain, and constantly improve disaster plans that help meet the
medical needs of the community within a system that protects registered nurses and other employees or
volunteers. This should include the provision of sufficient, appropriate personal protective equipment,
immunizations, physical security, and operational protocols.

8515 Georgia Avenue, Suite 400
Silver Spring, MD 20910

www.nursingworld.org

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Who will be there? Ethics, the law, and a nurse’s duty to respond in a disaster
2017

ANA and other national associations must continue working to ensure that policies and plans for disaster
response, including the creation of crisis standards of care, meet the needs and expectations of
communities and registered nurses. As the largest nursing organization in the U.S., and one of the few
nursing organizations actively engaged in national disaster response policy conversations, ANA is poised to
continue this work. Visit ANA’s disaster preparedness webpage to learn more about efforts to advocate for
nurses in disasters.

Individual registered nurses are critical participants in this work. They must be aware of their employers’
emergency response plans, as well as have a general sense of what state and local disaster preparedness
and response efforts are taking place where they live and practice. They should be aware of their expected
role in any response efforts—some employers make plans for their registered nurse staff that the individual
nurse might not even know about. If they know they want to be an integral responder in a disaster, they
should volunteer with a disaster registry, such as federal Disaster Medical Assistance Teams, nationally or
locally with the American Red Cross, or their local Medical Reserve Corps. This will ensure they have the
proper credentialing and training for responding to a disaster, and will be part of an organized system.

Nurses must be professionally and personally prepared. They should know in advance that they may be
called upon, and will need to make arrangements with their families for communication, and even for care
of children or dependents during their absence. Registered nurses need to be aware of the ethical
situations they may encounter, especially in times of scarce resources and supplies when they may face
unimaginable patient care decisions. They need to advocate for systems and protocols that protect their
ethical obligations as nurses, as well as ensure equity and fairness in disaster medical care planning. Human
rights may be jeopardized in extraordinary contexts related to fields of battle, pandemics, political turmoil,
regional conflicts or environmental catastrophes where nurses must necessarily practice under altered
standards of care. Provision 8 of the Code obligates nurses to always “stress human rights protection under
all conditions, with particular attention to preserving the human rights of vulnerable groups such as women,
children, the elderly, prisoners, refugees and socially stigmatized groups.”

Future disasters all are but guaranteed to occur. We cannot stop them, but we can be better prepared to for
them. Creating better systems for nurses to respond, including ensuring an ethical and safe environment for
response and recovery, will give some assurance that when the call for nurses goes out, there will be a
robust answer.

http://nursingworld.org/MainMenuCategories/HealthcareandPolicyIssues/DPR.aspx

COVID-19: How to Protect Yourself & Others
PPE and Infection Control in Schools

August 25, 20

Paula Conrad, MSN, RN, CNL, CCRN, CPN
Infection Preventionist

Renee LeHane, BSN, RN
Infection Preventionist

Disclosures / Disclaimer

 I have no financial disclosure or conflict of interest concerning the material
discussed in this presentation

 The COVID-19 pandemic is a rapidly evolving incident: please refer to the Centers
for Disease Control and Prevention’s COVID-19 website for the most up-to-date
information and resources.

 The information in “The School Nurse & COVID-19” series are recommendations at
this point in time on August 20, 2020, based on CDC and DESE guidance.

DESE Guidelines

 Health and safety/PPE supplies: Per the initial supply guidance issued by DESE, schools should have
an inventory of standard healthcare supplies (e.g., masks and gloves). Use of additional supplies
may be optional based on type of tasks performed (e.g., teachers do not need to wear gloves while
teaching but may need to during necessary contact with students, such as when providing physical
support to students with disabilities). All districts are eligible for federal CARES Act funds to support
these purchases.

 Additional safety precautions are required for school nurses and/or any staff supporting students
with disabilities in close proximity, when distance is not possible: These precautions must include
eye protection (e.g., face shield or goggles) and a mask/face covering. Precautions may also include
gloves and disposable gowns or washable outer layer of clothing depending on duration of contact
and especially if the individual may come into close contact with bodily fluids

per DESE guidelines 6/25/20

What is PPE?

 Personal Protective Equipment (PPE) protects you (the nurse, teacher or staff) from COVID-19 (or other
potentially infectious patients or materials) when interacting with others (students or other staff)

 Worn to minimize/eliminate exposure

 Cloth face coverings are NOT PPE and should not be worn for the care of people with suspected or
confirmed COVID-1

 For COVID-19 it includes:

 Ear-loop or surgical mask

 NIOSH-approved

Respirator (N95)

 Eye protection



Gown

 Gloves

PPE Recommendations for Direct Service Providers

per DESE guidelines 6/25/20

Classifications N95 or KN95 Face Shield
Disposable

Gown
Disposable

Gloves
Gowns/

Coveralls
Cloth Face
Covering

Surgical
Mask

In care areas of students with suspected
COVID-19

X X

(w/ face shield if
N95 not available)

In the same facility but not in the care
areas for students with suspected COVID-

Providing personal care to students
without suspected COVID-19 but who
may potentially be exposed to bodily
fluids

X
(preferred)

X X

Performing or present during aerosol
generating procedures such as nebulizer
treatments, chest PT, suctioning, trach
care

X X X X

Transportation personnel/monitors who
must come in direct physical contact with
passengers (e.g. buckling/unbuckling,
performing wheelchair safety services)

X X

Disposable Gloves

 Clean, non-sterile gloves are to be used to protect your hands

 Gloves do not replace hand hygiene

 Can have micro-perforations

 Change gloves when going from dirty to clean

 Change gloves if they become torn or heavily contaminated

 Change gloves between children

Disposable Gowns

 Gowns protect your clothes from contamination

 Gowns should be worn as part of standard precautions if there is anticipated spray or splash

 Gowns are to be worn for an suspected or confirmed person with

COVID-19

 Gowns should be change between patients:

 If disposable, discard after each use

 If reusable, launder after each use

Eye Protection

 Eye protection protects your eyes from splashes and sprays of infectious matter

 Creates a barrier so droplets cannot spray/land in the eyes

 Eye protection includes goggles or a face shield that covers the front and sides of the face

 Eye protection does not include safety glasses, trauma glasses or eyeglasses with gaps
between the glasses and the face

 If a child is not wearing their mask for > 15 minutes and someone is within 6 feet of the child,
then eye protection should be worn

Surgical Mask

 Barrier

 Protects against large droplets, splashes or sprays of bodily fluids

 Need to be fluid resistant

 Do hand hygiene prior to donning/doffing

 Discard when visibly soiled or wet

 Follow extended use policy on CDC if necessary

Respirator (N95)

 Offer a higher level of protection than ear-loop/surgical masks

 It covers the nose and mouth and reduces the person’s risk of inhaling hazardous airborne
particles, gases or vapors

 Certified by CDC/NIOSH (National Institute for Occupational Safety) and cleared by the FDA

 They are not all the same or created equal

 https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/n95list1.html

 People wearing an N95 (nurse) need to be medically cleared and fit tested prior to using this device

https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/n95list1.html

11https://www.cdc.gov/niosh/npptl/pdfs/UnderstandDifferenceInfographic-
508 ?fbclid=IwAR2I4JUGxc4DMmKk-yU4lmTVOqU7UQajjFMGsI04GE8B7yPpodDCSs3DbUE

Counterfeit Respirators

 Respirators falsely marked and sold as being NIOSH
approved and may not provide the same level of
protection

 Signs that it may be counterfeit:

 No markings at all on the filtering facepiece
respirator

 No approval TC number on the respirator or
headband

 No NIOSH markings

 NIOSH spelled incorrectly

 Presence of decorative fabric or add-ons (e.g.
sequins)

 Claims for approval for children

 Earloops instead of headbands

https://www.cdc.gov/niosh/npptl/pdfs/UnderstandDifferenceInfographic-508 ?fbclid=IwAR2I4JUGxc4DMmKk-yU4lmTVOqU7UQajjFMGsI04GE8B7yPpodDCSs3DbUE

N95 versus KN95

N95 KN95

Made in the US or overseas Made in China

Tested and certified by NIOSH NOT tested and certified by NIOSH

Approved by the FDA Approved by FDA Emergency Use Authorization

Filter 95% of particles Filter 95% of particles

Headstrap method Earloop method

Continue to achieve > 95% filtration after disinfection Have failed to achieve 95% filtration after disinfection

Take Home Message – NIOSH certified respirators are recommended.
If an organization is not able to obtain NIOSH respiratory protection, a KN95 could

be used for suspected or confirmed COVID-19 patients if it meets regulatory
requirements under the EUA

PPE for Aerosol Generating Procedures (AGP)

 Aerosol generating procedures (open suctioning, nebs) create infectious aerosols that can travel in the air

 PPE for AGPs

 N95 respirator

 Eye protection

 Gown

 Gloves

 The number of people should be limited in the ro

 AGPs should be done in an isolation room with the door closed

 Surfaces should be cleaned and disinfected following an AGP

Aerosol Generating Procedures
 AGP Procedures include:

 Bronchoscopy

 Resuscitation involving emergency intubation or CPR (including mask bag ventilation)

 Endotracheal intubation or extubation

 Open suctioning of airway secretions or cough assist

 Sputum induction

 HFNC

 CPAP/BiPAP

 High-frequency oscillatory ventilation

 Nebulized treatments

 Upper airway surgeries (including tracheostomy replacement)

 Upper and lower endoscopy

 Transesophageal echocardiography (only during insertion or removal of the probe)

 Aerosol-generating dental procedures

 Autopsy

NOT Aerosol Generating Procedures
 AGP Procedures do not include:

 Regular (i.e. not high flow) nasal cannula oxygen delivery

 Face mask oxygen delivery

 Humidified air/face tent/cool mist

 Chest physiotherapy without open suctioning

 Chest physiotherapy vest without open suctioning

 Collection of nasopharyngeal or oropharyngeal specimens (if collected on a PUI, an N95 respirator would
be used as this is part of routine care for a suspected COVID-19 case)

 Patient talking, coughing, or sneezing

 Routine oral care or oral suctioning

 Uncuffed ETT/trach with leaks

 Hand ventilation via endotracheal tube or tracheostomy tube

 Mechanical ventilation using ventilator without a filtered exhalation limb

 Ventilator circuit disconnections, including opening installation ports for in-line suctioning

 In-line suctioning (closed suctioning)

 Nebulized treatment in a closed ventilator circuit including an artificial airway without a leak

Donning & Doffing

 Reminders:

 Riskiest activity is doffing

 Store PPE in a clean location

 Hand hygiene is part of the donning/doffing process

Putting it on (donning) and taking it off (doffing)

Donning a Surgical Mask

Perform hand
hygiene

Hold mask with colored side
facing out, pleats going down

Open pleats

Pull ear loops over ears

Press the metal nose
piece to the bridge

of your nose to
ensure a secure fit

Doffing a Surgical Mask

Perform hand
hygiene

Avoid touching the front of the mask
as it is the most contaminated.

Only touch the loops/ties/bands
for doffing Grasp loops around ears and gently

lift and pull mask away from face

Discard into
waste basket

Donning/Doffing an N95 Respirator

Video: Easy Technique for Doffing Gown

Video: Donning PPE for Aerosol Generating Procedures

Video: Doffing PPE for Aerosol Generating Procedures

Additional Resources

 CDC Website: Using Personal Protective Equipment

 CDC PDF: Guidance for the Proper Use of Protective Equipment

 CDC PDF: Sequence for Putting On or Removing PPE

 BU Shields Video: PPE for COVID-19
material developed by MA DPH Bureau of Infectious Disease & Laboratory Sciences

https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html

https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE_11x17

https://www.cdc.gov/hai/pdfs/ppe/ppe-sequence

https://mymedia.bu.edu/media/PPEforCOVID-19/1_7asqqmdw

Donning Personal Protective Equipment (PPE):
Reusing Respirator and Eye Protection with Wrap-Around Gown

Perform Hand Hygiene1.

Alcohol-based hand sanitizer

7. Perform Hand Hygiene

Ensure gloves go over cuff of gown

9. Perform Hand Hygiene

6. Remove Gloves

8. Put on Eye Protection

10. Put on Gloves

Don PPE outside of patient’s room. Ensure hair is pulled back away from face.

2. Put on Gown

4. Remove Respirator from Storage Container

3. Put on Gloves

5. Put on Respirator

or soap and water for 20 seconds

Face shield or goggles

Ensure gown fully covers
entire body when closed or tied

Ensure gloves go over cuff of gown

Alcohol-based hand sanitizer

Hold respirator
in one hand

Pinch nose clip to ensure
tight seal of mask

Close eyes, bring lower elastic
band over head and below ears

Open eyes, grab upper elastic band,
close eyes and pull upper elastic
band over head and above ears

Bring to face, grab
lower elastic band

Grasp glove in palm of hand
and pull glove off

Dispose of glove or
hold in other hand

Slowly and gently, slide finger under other
glove, between glove and cuff of gown.

Dispose of glove(s)
in waste container

April 5, 2020

9. Perform Hand Hygiene

7. Perform Hand Hygiene

Remove Gloves 1.

8. Remove Respirator and Place in Storage Container

5. Perform Hand Hygiene

Grasp glove in palm of hand
and pull glove off

Doffing Personal Protective Equipment (PPE):
Reusing Respirator and Eye Protection with Wrap-Around Gown
Doff gown and gloves in patient’s room. Respirator and Eye Protection will be doffed outside the patient’s
room. Remember gloves, face shield, front of gown and sleeves are CONTAMINATED. Clean hands
immediately if you touch any of these surfaces with your bare hands.

2. Remove Gown

Dispose of glove or
hold in other hand

Slowly and gently, slide finger under other glove,
between glove and cuff of gown.

Dispose of glove(s)
in waste container

In
p

at
ie

nt
‘s

ro
om

3. Perform Hand Hygiene

6. Remove Eye Protection – Avoid touching front, contaminated surface of eye protection

Place face shield or goggles
on paper towel

Tilt head forward, grasp strap and gently pull strap
over head, pulling face shield away from face

Grasp ear pieces behind ears and
pull goggles away from face

Alcohol-based hand sanitizer

Pull lower elastic
band over head

Gently pull upper elastic
band over head and pull

mask away from face

Close storage container and ensure
your first initial, last name,

BCH ID#, and unit is written on it

or soap and water
for 20 secondsAlcohol-based hand sanitizer

Place respirator in
storage container with
outside surface down

4. Set-up for Reusing Eye Protection and Respirator

Place storage container and
paper towel on countertop

Alcohol-based hand sanitizer

April 5, 2020

O
ut

si
de

p
at

ie
nt

‘s
ro

With respirator and Eye Protection in place, leave patient’s room and enter anteroom or hallway.

soiled linen

Disinfection and Storage of Eye Protection

Disinfect Reusable Eye Protection

Put on Gloves1.

2. Disinfect Reusable Eye Protection

3. Dispose of of wipe and contaminated paper towel in trash

5. Perform Hand Hygiene

6. Store Resuable Eye Protection for Later Use

Wipe eye protection thoroughly
with an alcohol wipe, cleaning the
inside first, and then the outside

Place on a clean surface to dry

Grasp glove in palm of hand
and pull glove off

Dispose of glove or
hold in other hand

Slowly and gently, slide finger under other
glove, between glove and arm.

Dispose of glove(s)
in waste container

or soap and water for 20 secondsAlcohol-based hand sanitizer

At end of your shift, store the eye protection in a clean location. Each healthcare worker will keep their
eye protection for repeated use.

4. Remove Gloves

April 5, 2020

COVID-19 School Nurse Training for the
Return to School

How to Protect Yourself and Others:
PPE and Infection Control in Schools

Presenters:
Arlene Swan-Mahony, DNP, MHA, BSN, RN
Sharon L. D. Harrison, MSN, MEd, BSN, RN
Velma Glover, MEd, BSN, RN, RYT 200 hr
Mary Jane O’Brien, PhD, RN, CPNP, NCSN Boston Public Schools

August 25, 2020

Disclosures / Disclaimer

We have no financial disclosure or conflict of interest concerning the material
discussed in this presentation.

The COVID‐19 pandemic is a rapidly evolving incident: please refer to the
Centers for Disease Control and Prevention’s COVID‐19 website for the most
up‐to‐date information and resources.

The information in “The School Nurse & COVID‐19” series are
recommendations at this point in time on August 25, 2020, based on CDC and
DESE guidance.

Overview
❏ Risk task classifications: Low-Moderate-High
❏ PPE use for school nursing activities
❏ Don & Doff Considerations
❏ Protective wear for caring for students with special health care

needs: feeding, diapering
❏ Infection Control Considerations

▪ Health Room
▪ Classroom

❏ Medical Waiting Area/Isolation Room
❏ Nursing assessment: Student with COVID-19 symptoms &

Return to School protocol

COVID-19 will not be the only health concern addressed by school nurses–
state mandated screenings; flu, pertussis, asthma, diabetes, severe

allergies, behavioral health, medication administration &
management,education, & care coordination.

School nurses are called upon to lead, educate, and practice following the
tenets of Framework for the 21st Century School Nursing PracticeTM through
the principles of Leadership, Standards of Practice, Quality Improvement,

Care Coordination, and Community/Public Health.

The School Nurse will play an essential role in the mitigation of COVID-19
and requires every tool available to practice with confidence and safety.

THE VALUABLE ROLE OF SCHOOL NURSES
DURING THE COVID-19 PANDEMIC

Unique challenges arise when
implementing recommended
infection control measures for

students and staff in one building.
NASN, 2020

PPE: Guidelines for Use in the School
Health Room

PPE is determined by Task Classification

Low Risk School personnel and students must interact, and physical
distancing cannot always be maintained.

Moderate Risk

Tasks include those that require close/direct contact with
(i.e., within 6 feet of) people who are not known or suspected to have
COVID-19.

High Risk

Tasks include the physical assessment of any individual
suspected of having COVID-19 & Aerosol generating procedures.

NASN 2020

Low Risk

Activities include:

❏ Conversation with student or staff
❏ General interactions
❏ Receiving notes, letters from student
❏ Handing/receiving supplies, medications

Reccomended PPE:

❏ Surgical face mask OR
❏ Cloth face mask

Activities include:

❏ Medication administration: oral,
MDI, parenteral

❏ Procedural care: catheterization,
g-tube care/feeds

❏ Diabetes care-blood glucose
checks, site assessment

❏ General nursing care for illness
and injury

❏ Population screening-vision,
hearing, ht/wt, postural

Recommended PPE
❏ Surgical face mask
❏ Disposable Gloves

▪ Situation dependent
❏ Eye protection (Goggles OR Face

Shield) with surgical mask
▪ Situation dependent
▪ Procedures that may cause fluid

entry into eyes,
▪ Caring for students who are

unable to control secretions
▪ Developmental level of student

Moderate Risk

Activities include:
❏ Physical assessment of any individual

suspected of having COVID-19
❏ Duration/Spatial considerations
❏ Aerosol generating procedures:

nebulizer treatments, oral or tracheal
suctioning

❏ Trach care
❏ Manual ventilation
❏ BIPAP, CPAP, Mechanical ventilation

Recommended PPE
❏ Disposable gloves
❏ Disposable gown, OR
❏ Long sleeved washable covering

▪ Lab Coat
▪ Scrub coat

❏ N-95 mask OR
❏ Surgical mask & face shield
❏ Kn95 Face Mask & face shield

High Risk

Recommended PPE by Risk Level and School Nurse Activity NASN, 2020

Risk Level School Nursing Activities PPE Type

LOW RISK Conversation & general interaction with student/staff:
● administering/receiving notes/letters/provider’s

orders
● receiving supplies, medications

Cloth Face Covering (Not PPE)

MODERATE
RISK

● Medication administration: oral, MDI, parenteral
● Procedural care: catheterization, g-tube care/feeds
● Diabetes care: blood glucose checks, site assessment
● General nursing care for illness and injury
● Screenings: Vision, Hearing, etc.

Surgical face mask, disposable gloves.
Eye protection (not eyeglasses) for
procedures that may cause fluid entry
into eyes, or when caring for students
unable to control secretions – consider
developmental level and situation
(goggles or face shield).

HIGH RISK ● Physical assessment of any individual suspected of
having COVID-19

● Aerosol generating procedures: nebulizer treatments,
oral or tracheal suctioning, trach care, manual
ventilation, BIPAP, CPA, mechanical ventilation

Disposable gown OR long sleeved
washable covering such as a lab coat,
scrub coat or smock.
IN ADDITION:
N-95 respirator mask AND eye
protection/face shield (not eyeglasses)
OR surgical mask & face shield
OR Kn-95 face mask & face shield

Envision Your Practice
as a School Nurses & COVID-19

❏ Steps prior to entering/leaving isolation room
❏ Job Aides
❏ How to better fit a surgical mask
❏ Suggested storage of N95
❏ Suggested placement of mask

during mask breaks
❏ Share a video, COVID-19 &

Schools Fear Out-Learning In

Envision Your Practice
as a School Nurses & COVID-19

❏ Envision your steps prior to entering/leaving PPE
donned area:
■ Make a schedule of nursing intervention
■ Ready your supplies
■ Bundle activities (meds, feeding…) to effectively

use face-to-face time & cut down on repeated
donning/doffing

■ Share your schedule with school staff–Job Aid

Envision Your Practice
as a School Nurses & COVID-19

❏ Job Aides are visuals to help remind people
■ They are often posted to communicate

● Salient safety concern
● Prevent mistakes
● Support compliance with a standard of practice

Envision Your Practice
as a School Nurses & COVID-19

❏ How to better fit a surgical mask–Demonstrate
■ Fold face mask in half
■ Take one of the elastic ear loops, make a knot as close and

tight as possible to the mask
■ Repeat on the other elastic ear loop
■ Tuck/fold the mask opening inward face side

The mask will now better fit a child’s or an adult’s face

Envision Your Practice
as a School Nurses & COVID-19

❏ Suggested storage of N95
■ Tupperware container–Make holes in the lid and container for air

circulation:
● N95 on face–don’t touch the mask
● Put the tupperware container to your face, mask is inside the

container
● Secure the lower elastic, pull it over your head and onto the back

of the container
● Repeat the upper elastic, pull it over your head and onto the

back of the container
● Reverse steps to put back on N95

Envision Your Practice
as a School Nurses & COVID-19

❏ Suggested placement of mask during mask breaks

Envision Your Practice
as a School Nurses & COVID-19

I am going to show you another version of donning and doffing.
As you look at it, please start imagining and personalizing, when,
where, how, and why, you would perform donning and doffing in
your school.

CDC’s Don Video

http://www.youtube.com/watch?v=H4jQUBAlBrI

CDC’s Doff Video

http://www.youtube.com/watch?v=PQxOc13DxvQ

Envision Your Practice
Children with Special Healthcare Needs
❏ PPE considerations for:

▪ Feeding
▪ Diapering

❏ Reinforcement of universal
precautions

❏ Reinforcement of universal
control measures by staff

Gown

Envision Your Practice
as a School Nurses & COVID-19

❏ Share a video, COVID-19 & Schools: Fear Out-Learning In
A Training Module for Boston Public Schools Staff Caring for
Students with Special Health Needs

“https://drive.google.com/file/d/1FLv4kIF71sEI-bMX2DRyWO7mtkyR19g9/preview”

https://drive.google.com/file/d/1FLv4kIF71sEI-bMX2DRyWO7mtkyR19g9/preview

Infection Control:
Empowering Nurses with Best Practice

on cleaning considerations
Goals:

❏ Understand the basics & guidelines
❏ Develop a plan
❏ Implement the plan

Health room:

❏ Daily
❏ Between student interactions

School Nurse Experience
❏ Form a committee to ensuring proper cleaning & disinfecting

■ Establish regular meeting times.
■ Look at the current needs, policy and talk about realistic plans.
■ Develop plan – what, who, when
■ The principal and custodial staff implement the plan; school

nurse, teachers, and other personnel support the plan.
❏ Include: Custodian, Principal or representative, teachers and

paraprofessionals, community representatives, i.e. Asthma Coalition,
Mass COSH, Children’s Hospital

❏ OSHA – Occupational Safety & Health Administration
❏ CDC- Center for Disease Control
❏ Public Health Department
❏ DESE – Dept of Education and Secondary Education
❏ -responsible for all services in the school
❏ Superintendent Circulars – district policy guidelines
❏ Each School

■ Facilities Department – determines the cleaners used in
our school and will provide the training on how to use the
cleaning materials

Understand the system and who sets
the guidelines

Occupational Safety & Health Administration
(OSHA) is an agency of the US Department of

Labor

❏ OSHA rules and regulations are designed to protect workers and keep
work environments safe and healthy.

❏ The Hazard Communication Standard (HCS) requires chemical
manufacturers, distributors, or importers to provide Safety Data Sheets
(SDSs) (formerly known as Material Safety Data Sheets or MSDSs) to
communicate the hazards of hazardous chemical products.

https://www.osha.gov/Publications/OSHA3493QuickCardSafetyDataSheet

UNDERSTAND THE RIGHT TO KNOW

Read the label of the product:
❏ Is it a cleaner, sanitizer or disinfectant?
❏ Note the “dwelling time”
❏ Go to the company site and print out the Material Safety Data

Sheet
■ Note the toxic effect on the human body

❏ Start a binder on the cleaning products used at your school
■ keep it in your office for reference
■ Refer to this information if you needed to call the poison

control center

Developing the Plan for School
Cleaning & Disinfecting

DESE Guidance – Facilities
Department responsibility:

❏ Update cleaning and
disinfecting protocols

❏ Obtain additional supplies,as
needed

❏ Train staff appropriately

DESE, 2020

DESE Protocols include
cleaning & disinfecting:

❏ At least daily for shared
spaces & furniture

❏ Multiple times/day high-touch
surfaces like door handles,
light switches, handrails

Remember the basics

❏ Germs/ COVID 19

❏ How are germs/microorganisms transmitted?

❏ Who is a carrier?

❏ Germs / microorganisms on various surfaces.

❏ Precautions we take to prevent the transmission in the school setting

❏ CDC guidelines on infection control

Know the Basics:
Difference between cleaning, disinfecting, & sanitizing
Cleaning
❏ Removes dirt from surface – soap and water commonly used.

Disinfecting
❏ Stronger chemicals used to kill a wider range of organisms

Sanitizing
❏ Lowers the amount of organisms to a safe level; requires custodians or a

special cleaning company

Hand sanitizer
❏ Reduces organisms on surface of hands; CDC recommends 60% alcohol

content

School Health Room/Classroom

❏ Reduce sharing of common spaces and frequently touched objects.
❏ Clean visibly dirty surfaces with soap and water prior to disinfection.
❏ Frequently explain cross contamination. People forget.
❏ Best practice would be to clean after every student.
❏ Do not spray disinfectants while a student is in the room.
❏ Keep disinfectant out of the reach of students.

https://www.cdc.gov/coronavirus/2019-ncov/community/cleaning-disinfecting-decision-tool.html

Medical Waiting Room
(MWR)

The purpose of the MWR is to minimize transmission of COVID-19 by providing
a place for those students who await pick-up because while in school they:

❏ Exhibit symptoms of COVID-19
❏ Discover positive COVID-19 test results for themselves or a close contact

Ideally, one student per MWR but if more than one student in MWR:

❏ At least 6 feet apart (spaced as far apart as possible)
❏ Wearing a surgical mask provided by the school (non-N95 and non-cloth)
❏ If a student is unable to wear a mask, then no other students in MWR

MWR Staffing

The MWR must be supervised by an adult staff member at all times when
students are present. The supervising staff person:

▫ Is trained in CPR/AED
▫ Is in close communication with the school nurse
▫ Wears appropriate PPE provided by the school

▪ Surgical mask and goggles/face shield if distanced 6 feet from
student

▪ If unable to maintain 6 feet distance, then N95 respirator or
disposable mask and face shield, gloves, and gowns

Equipment/Supplies for MWR

Outside MWR:

❏ Surgical masks
❏ Gloves
❏ Disposable gowns
❏ Hand sanitizer
❏ Receptacle – storage of nurse’s

N95 mask & face shield
❏ Post job aides

Inside MWR:
❏ Hand sanitizer
❏ Tissues
❏ Several waste baskets

and plastic liner bags

Assessing the Student with
COVID-19 Symptoms

When assessing students who have underlying conditions that present
as symptoms of COVID-19, use nursing judgement! Treat, and if there
is improvement, the student may return to class. Examples include:

❏ Asthma
❏ Seasonal allergies
❏ Migraine
❏ Food sensitivity

Fever Only
Fever of 100.0°F or higher.

Respiratory Symptoms
Cough, difficulty breathing, SOB.

No fever or other symptoms.

Does the student have
asthma?

Yes

Multiple Symptoms

Send Home
Nurse advise

parent/guardian to contact
student’s PCP for possible

testing for COVID-19.

Nurse assesses symptom for
historically known etiology of

symptom: migraines, IBS, lactose
intolerance, etc.

Is nurse suspicious that the symptom
is COVID-19 related?

If non COVID-19
underlying cause
is identified, &
nurse is
convinced that
this is the cause
of the symptom,
then student may
be treated and
may
Return to Class

Send Home
Nurse contacts the

parent/guardian, notifies of
symptom and the need to pick-up

the student (NO school bus);
student is to continue to wear

surgical mask and is monitored in
the medical waiting/isolation room
until parent/guardian arrives. Nurse
advises parent/guardian to consult
with student’s PCP & if their student

develops other symptoms of
COVID-19 to seek testing. Nurse

reviews symptoms and how to get
the student tested/testing sites.
If symptoms worsen quickly, call

911

Yes

BPS Nurse Screening Guide for COVID-19

Send
Home

If nurse is
not

convinced
that the

symptom
is not

COVID-19

Send Home or
Call 911

Nurse assesses symptoms
deciding if 911 is needed

and discusses with parent
guardian.

YesNo

No Yes

Do symptoms
improve after
taking
medication?

Nurse
Administer

Is rescue medication
MDI available?

A student sent to the nurse with any symptom of COVID-19 (possible fever, cough, difficulty breathing, sore throat,
congested or runny nose, loss of taste or smell, chills, headache, nausea, vomiting, diarrhea, poor feeding) is masked and

seated in the medical waiting/isolation room.
No Fever – One

Non-Respiratory
Symptom Only

Terms: Isolation, Quarantine, Close Contact, and
COVID-19 related fever

Isolation: Separates people infected with Covid-19 from those not infected. Separates those people
with COVID-19 symptoms as well as those who have tested positive for COVID-19 who may be
symptomatic or asymptomatic.

COVID-19 related fever: A fever as a COVID-19 symptom is defined as 100.0˚F or higher.

Close Contact – close contacts will be defined as only those who have been within 6 feet of distance
of the person testing positive for at least fifteen minutes, while the person was infectious. The
infectious period begins 2 days prior to symptom onset. If someone is asymptomatic, the infectious
period is considered to begin 2 days prior to the collection of their positive test.

Quarantine is used to keep someone who might have been exposed to COVID-19 but who are not yet
feeling symptoms away from others. People in quarantine should stay home, separate themselves
from others, monitor their health, and follow directions from their state or local health department.

Protocol for return to school if identified
as a close contact

All close contacts should be tested
Close contacts (CCs) must self-quarantine for 14 days after their last
exposure to the person who tested positive, regardless of the CCs test
result. Even with a negative test result, the CC must continue to
self-quarantine for the full 14 days as the virus may take up to 14 days to
cause illness.

Protocol for return to school for an
individual testing positive for COVID-19

Self-isolation for COVID-19 positive cases is a minimum of 10 days

People who test positive may return to school after 10 days isolation and once they have:

a. gone for 3 days without a fever (and without taking fever-reducing medications like Tylenol); and

b. experienced improvement in other symptoms (for example, their cough has gotten much better);
and

c. received clearance from public health authority contact tracers (the local board of health or
Community Tracing Collaborative).

Repeat testing prior to return is not recommended. Return to school should be based on time and
symptom resolution.

Protocol for return to school after
experiencing COVID-19 symptoms if there

is an alternative diagnosis

If a provider has documented an alternative diagnosis, the
individual may return to school based on the recommendations for
that alternative diagnosis (e.g., influenza or strep pharyngitis).

Protocol for return to school after
experiencing COVID-19 symptoms and

the result of COVID-19 test is negative

If the individual with COVID-19 symptoms has tested negative for
COVID-19, then the individual may return when there is:
❏ Improvement in symptoms

AND

❏ No fever (100.0F) for > 24 hours without fever reducing meds

Protocol for return to school after
experiencing COVID-19 symptoms and

not tested for COVID-19

Those not tested for COVID-19 may return to school 10 days from
start of symptoms as long as:

❏ Symptoms have improved

AND

❏ No fever for > 24 hours without fever reducing medication

BPS School Nurse Flowchart – Protocols for COVID-19 Related
Return-to-School Scenarios (from DESE/MDPH Joint statement 8/19/20)

The student is identified as having:
Close contact to
a person who
tests positive
for COVID-19

COVID-19
symptoms

diagnosed as an
alternative
diagnosis

COVID-19
symptoms &

negative
COVID-19 test

result

COVID-19
symptoms but
not tested for

COVID-19

Must self-quarantine
for 14 days after the
last exposure to the
person who tested
positive; even if this
CC tests negative,
the CC must
continue to self-
quarantine for the
full 14 days as
COVID-19 may take
up to 14 days to
cause CC to be ill.

If a provider has
documented an
alternative diagnosis,
the individual may
return to school
based on the
recommendations for
that alternative
diagnosis (e.g.,
influenza or strep
pharyngitis).

The individual may
return when there is:

● Improvement
in symptoms

AND

● No fever for
more than 24
hours without
fever reducing
medications

The individual may
return to school 10
days from start of
symptoms if:

● Symptoms
have improved

AND
● No fever for

more than 24
hours without
fever reducing
medications

Individuals who
have tested
positive for
COVID-19

May return to school
after 10 days isolation
and:

● Improvement
in symptoms

● No fever for 3
days without
fever reducing
medications

● received
clearance from
public health
authority

Questions

References

Boston Teachers Union, Nurse Faculty Senate (2020). COVID-19 & Schools: Fear Out – Learning In. A Teaching Module for
Boston Public Schools Staff Caring for Students with Special Health Care Needs.

htttps://drive.google.com/file/d/1FLv4kIF71sEI-bMX2DRyWO7mtkyR19g9/preview

Centers for Disease Control and Prevention (CDC). (2020). How to Use PPE. Retrieved from:

https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html

CDC Healthcare Infection Control Practices Advisory Committee (HICPAC). (2017). Core Infection Prevention and Control

Practices for Safe Healthcare Delivery in All Settings –Recommendations of the HICPAC.retrieved from:
https://www.cdc.gov/hicpac/recommendations/core-practices.html

CDC (2020). When to Quarantine. Retrieved from:

https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov
%2Fcoronavirus%2F2019-ncov%2Fif-you-are-sick%2Fquarantine-isolation.html

CDC. Understanding and Selecting Respiratory Protection Devices

https://www.cdc.gov/niosh/npptl/pdfs/N95-Infographic-REACH-II-508 /

Comprehensive Personal Protective Equipment (PPE) Guidance

https://www.mass.gov/doc/updated-comprehensive-personal-protective-equipment/download / accessed 8/13/20

https://drive.google.com/file/d/1FLv4kIF71sEI-bMX2DRyWO7mtkyR19g9/preview

https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html

https://www.cdc.gov/hicpac/recommendations/core-practices.html

https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fif-you-are-sick%2Fquarantine-isolation.html

https://www.cdc.gov/niosh/npptl/pdfs/N95-Infographic-REACH-II-508

https://www.mass.gov/doc/updated-comprehensive-personal-protective-equipment/download

Guidance for Healthcare Personnel on the Use of Personal Protective Equipment (PPE) in Schools During COVID-19

https://www.nasn.org/nasn-resources/practice-topics/covid19/ accessed 8/13/20

Jones E, Young A, Clevenger K, Salimifard P, Wu E, et al. (2020). Healthy Schools: Risk Reduction Strategies for Reopening

Schools. Harvard T.H. Chan School of Public Health Healthy Buildings program. Retrieved from:

https://schools.forhealth.org/wp-content/uploads/sites/19/2020/06/Harvard-Healthy-Buildings-Program-Schools-For-Health-Re
opening-Covid19-June2020

Massachusetts Department of Elementary and Secondary Education (DESE). (2020). COVID-19 Information and Resources,Joint Memo

Clarifying Key Health and Safety Requirements for Schools, Protocols for Responding to COVID-19 Scenarios, and, Fall Reopening
Facilities and Operations Guidance Retrieved from: http://www.doe.mass.edu/covid19/

National Association of School Nurses. (2020). Guidance for healthcare personnel on PPE use in schools.Retrieved from:

https://higherlogicdownload.s3.amazonaws.com/NASN/3870c72d-fff9-4ed7-833f-215de278d256/UploadedImages/PDFs/Guida
nce-for-Healthcare-Personnel-on-PPE-Use-in-Schools

National Association of School Nurses (2016), Framework for 21st Century School Nursing Practice. Retrieved from:

https://www.nasn.org/nasn/nasn-resources/professional-topics/framework

References

https://www.nasn.org/nasn-resources/practice-topics/covid19

https://schools.forhealth.org/wp-content/uploads/sites/19/2020/06/Harvard-Healthy-Buildings-Program-Schools-For-Health-Reopening-Covid19-June2020

http://www.doe.mass.edu/covid19/on-desktop.html

http://www.doe.mass.edu/covid19/on-desktop/2020-0722facilities-operations-guide x

http://www.doe.mass.edu/covid19/

https://higherlogicdownload.s3.amazonaws.com/NASN/3870c72d-fff9-4ed7-833f-215de278d256/UploadedImages/PDFs/Guidance-for-Healthcare-Personnel-on-PPE-Use-in-Schools

https://www.nasn.org/nasn/nasn-resources/professional-topics/framework

Session II How to Protect Yourself and Others_PPE and Infection Control in Schools 8_25_20

School Nurse Training – Session 2 FINAL 2020_08_25

BPS_BCH COVID-19 School Nurse Training for the Return to School UPDATED

Social Science & Medicine 282 (2021) 114171

Awareness of ethical dilemmas enhances public support for the principle of
saving more lives in the United States: A survey experiment based on
ethical allocation of scarce ventilators

Birendra Rai a, Liang Choon Wang a,*, Simone Pandit a, Toby Handfield b, Chiu Ki So a

a Department of Economics, Monash University, Clayton, Victoria, 3800, Australia
b School of Philosophical, Historical, and International Studies, Monash University, Clayton, Victoria, 3800, Australia

A R T I C L E I N F O

Keywords:
The principle of saving more lives
Allocation of scarce medical resources
Ethical dilemmas faced by public health experts
Trust in science and experts

A B S T R A C T

Recommendations by health experts to deal with public health emergencies are primarily guided by the principle
of “saving more lives”. It is unclear whether people perceive this principle as ethically more legitimate than some
other principle such as “saving more life-years”. Understanding the answer to this question is particularly
relevant to the allocation of scarce medical resources during public health emergencies. Different principles
typically lead to different allocations, and consequently have dramatically different implications as to who
survives and who dies. We fielded an online randomized controlled survey experiment in the context of scarce
ventilator allocation with a demographically representative sample of US adults (n = 700) from October 22 to
October 30, 2020. Participants faced hypothetical situations where they had to allocate few available ventilators
among several needy patients. The experiment was designed such that the allocation decision made by a
participant can be used to infer the principle in line with their personal ethical values. We interpret this inferred
principle as the one that the participant perceives to be most legitimate. The treatment group, but not the control
group, was provided balanced information that described the ethical dilemmas faced by experts in developing
ventilator allocation guidelines. Nearly half of the participants in the control group perceive saving more lives
the most legitimate principle. Despite the balanced nature of the information, the perceived legitimacy of saving
more lives was 7⋅6 percentage points higher in the treatment group. The magnitude of this impact was partic-
ularly strong among republican-leaning participants, a subgroup that has less trust in experts according to
previous research. Our findings suggest that enhancing public awareness of ethical dilemmas faced by health
experts can increase the perceived legitimacy of their proposed guidelines even among those with lower trust in
experts.

1. Introduction

Recommendations by public health experts to deal with public
health emergencies, including the Covid-19 pandemic, are primarily
guided by the principle of saving more lives (SML). For example, social
distancing guidelines, mandatory mask wearing, and lockdown mea-
sures to “flatten the epidemic curve” are primarily motivated by SML
(Sen-Crowe et al., 2020; Iacobucci, 2020). The guidelines for allocating
scarce life-saving medical resources such as ventilators and intensive
care beds also are primarily, if not exclusively, guided by SML (Piscitello
et al., 2020; Emanuel et al., 2020; Truog et al., 2020; White and Lo,
2020). However, it is unclear whether the majority of the general public

perceives SML to be the most legitimate principle. One prominent
alternative is the principle of saving more life-years (SMLY). For
instance, there have been reports of hospitals refusing admission to
elderly patients during the ongoing pandemic despite the availability of
hospital beds, perhaps in anticipation that a younger patient might soon
need one (Amnesty International, 2020). Such examples highlight the
simple fact that differences in the principles that guide allocation of
scarce medical resources create substantive differences in terms of who
lives and who dies.

This study investigated which principle is perceived to be most
legitimate by the general public for allocating scarce ventilators during
public health emergencies. We focused on three principles – saving more

* Corresponding author.
E-mail address: liang.c.wang@monash.edu (L.C. Wang).

Contents lists available at ScienceDirect

Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

https://doi.org/10.1016/j.socscimed.2021.114171
Received 4 March 2021; Received in revised form 13 June 2021; Accepted 19 June 2021

mailto:liang.c.wang@monash.edu

www.sciencedirect.com/science/journal/0277953

https://www.elsevier.com/locate/socscimed

https://doi.org/10.1016/j.socscimed.2021.114171

http://crossmark.crossref.org/dialog/?doi=10.1016/j.socscimed.2021.114171&domain=pdf

Social Science & Medicine 282 (2021) 114171

lives (SML), saving more life-years (SMLY), and saving healthier lives
(SHL) – that are prominently discussed in ventilator allocation guide-
lines (Piscitello et al., 2020; Emanuel et al., 2020; Truog et al., 2020;
White and Lo, 2020). SML recommends allocating scarce resources in
order to maximize the expected number of lives that can be saved. SMLY
seeks to maximize the expected number of life-years that can be saved.
SHL essentially recommends using SML as the primary principle; and,
using SMLY as the subordinate tie-breaking principle if multiple de-
cisions are consistent with SML. SHL is thus a refinement of SML. A
decision consistent with SHL is consistent with SML, but typically
inconsistent with using SMLY alone.

Ventilator allocation guidelines are formulated by expert committees
after careful deliberation. The guidelines specify which patient charac-
teristics (e.g., age, occupation, and comorbidities) should be used to
determine priority orderings in cases of scarcity. The general public is
likely unaware of the arguments and counterarguments regarding the
use of these patient characteristics, and thus may not fully appreciate the
ethical dilemmas that health experts have to grapple with in formulating
the guidelines. Our experiment primarily focused on investigating the
impact of balanced information about the ethical dilemmas faced by
health experts on the perceived legitimacy of the underlying principles
among the general public. We are not aware of any previous study aimed
towards exploring this question.

During the main part of the experiment, participants faced hypo-
thetical situations and had to decide who among several needy patients
should receive the few available ventilators. The experiment was
designed such that allocation decisions made by participants permit us
to infer the principles behind their decisions. We assumed that a
participant whose decisions are consistent with a particular principle
perceives that principle to be more legitimate than other principles. As
SML and SMLY are the two core principles, the situations presented to
the participants were designed to ensure that decisions consistent with
SML differ from those consistent with SMLY. The primary objective was
to understand the impact of balanced information on the perceived
legitimacy of these principles. The treatment group was provided this
balanced information, while the control group was not.

Our interest in investigating the legitimacy of various principles is
grounded in both pragmatic and principled reasons. For instance, the
Massachusetts state guidelines for allocating critical care in response to
Covid-19 that were first released on April 7, 2020 had to be revised
within two weeks following a public outcry (After Uproar and Mass.,
2020). Further, scholars across several academic disciplines have argued
that the more the general public understands and accepts the arguments
behind policies and guidelines, the greater their legitimacy among the
public (JusticeHealthHealthcare, 2001; Rawls, 2005). In fact, some
existing guidelines explicitly call for efforts to publicly justify the
guidelines to enhance their perceived legitimacy among the general
public. For instance, the New York state guidelines for the allocation of
scarce ventilators state that “[I]mplementation of the guidelines re-
quires clear communication to the public about the goals and steps of the
clinical ventilator allocation protocol.”

At a more general but closely related level, prior studies across a
variety of contexts have shown that people are more likely to comply
with official guidelines if those recommendations are derived from
principles that people perceive to be legitimate (Murphy, 2004; Jackson
et al., 2012). Hence, while our experiment was conducted in the context
of ventilator allocation, the findings may hint towards a broader mes-
sage. It is possible that in many contexts increasing awareness of the
ethical dilemmas that experts grapple with in formulating the relevant
recommendations can increase compliance with those recommenda-
tions. In the context of the Covid-19 pandemic, experts have largely
relied on the unbiased communication of scientifically accurate infor-
mation to justify their recommendations regarding social distancing and
mask wearing. While our study is admittedly narrow, the broader
motivation was to inquire whether ethical awareness can complement
scientific information.

Before proceeding we would like to clarify that our investigation was
largely exploratory. It would be internally inconsistent on our part to
claim that (a) our goal is to assess the impact of balanced information,
and yet (b) confidently hypothesize the direction of its impact. For
instance, it is unclear whether support for saving more lives (SML) will
be greater among older participants in the treatment (“Info”) group or in
the control (“No Info”) group. Balanced information containing the
competing ethical principles may lead some older participants in the
treatment group to better appreciate that SML discriminates against the
young. Other older participants in the treatment group may view the
balanced information as providing, on the net, additional arguments as
to why SML is the more legitimate principle. This argument applies for
all population subgroups, and thus prevents us from hypothesizing
about the impact of balanced information not only at the subgroup level
but also at the aggregate level.

2. Methods

2.1. Overview

Ventilator allocation protocols typically have four components: (i)
which patients are to be categorically excluded, (ii) how the eligible
patients are to be prioritized, (iii) what tie-breaking criteria to use
within the same priority ranking, and (iv) when to withdraw the
ventilator from a patient (Piscitello et al., 2020; Emanuel et al., 2020;
Truog et al., 2020; White and Lo, 2020). Our design implicitly accounted
for the first three components and ignored withdrawal of ventilators.

All the 700 participants in our experiment were first asked a series of
questions regarding their exposure to Covid-19, their willingness to
accept a vaccine for Covid-19 that has been deemed safe and offered for
free by health authorities, and familiarity with ventilator allocation
guidelines. Then, the kind of situations they would face during the main
part of the experiment was explained in ten steps, and an incentivized
quiz question was included in each step. We are confident participants
understood the situations they were going to face during the main
experiment as the average number of correct quiz responses out of ten
was 9.3 in the control group and 9.4 in the treatment group.

Participants that were randomly assigned to the treatment group (n
= 355) were then provided balanced information about the competing
ethical considerations before moving to the main part of the experiment.
In contrast, participants that were randomly assigned to the control
group (n = 345) did not receive this information, and moved to the main
part of the experiment after the explanation stage.

In the main part of the experiment, participants faced hypothetical
situations where several patients have contracted Covid-19 and need a
ventilator to survive, but there is a shortage of ventilators. Participants
had to choose a subset of patients who should receive the available
ventilators. Finally, subjects answered a post-experiment survey.

2.2. Study sample

The experiment was conducted on the online platform Prolific that
has approximately 36,000 USA-based participants who have registered
to participate in research studies. At the time we conducted the exper-
iment, there were approximately 25,000 eligible US participants who
were deemed active (participated in a study in the past 90 days) and
provided sufficient information about their characteristics for us to
obtain a demographically representative sample. 722 respondents
initiated our study, and 22 did not complete the study. While initiating
the study, participants did not know whether they are in the treatment
or control group. Incomplete responses are not due to assignment to the
treatment or the control group. Our analysis is based on the 700 re-
spondents who provided complete responses, and we refer to these re-
spondents as the participants. The sample of participants was slightly
more educated and slightly younger than the general US adult popula-
tion but otherwise demographically similar. Further, there is no

B. Rai et al.

Social Science & Medicine 282 (2021) 114171

statistical difference between the participants in the control and treat-
ment groups on a variety of demographic and socioeconomic di-
mensions, prior familiarity with ventilator allocation guidelines, and
attitudinal dimensions such as vaccine hesitancy and political orienta-
tion (see Table S2 in Supplementary Material).

2.3. Information treatment

Before making decisions in the choice experiment, participants in the
treatment group were informed about the competing ethical consider-
ations that public health experts consider in developing guidelines for
the allocation of scarce ventilators. This information contained argu-
ments and counterarguments for using four patient characteristics – age,
occupation, comorbidities, and survival chances conditional on
receiving a ventilator – that are prominently discussed in ventilator
allocation guidelines (Piscitello et al., 2020; Emanuel et al., 2020; Truog
et al., 2020; White and Lo, 2020).

The arguments and counterarguments were not intended to prime
the participants to favor any particular principle, but to instead increase
their awareness of the ethical dilemmas that experts have to grapple
with in formulating the guidelines. For instance, an argument for
prioritizing younger patients over older patients is to provide them a fair
chance to experience all stages of life. An obvious counterargument is
the clear discrimination against the elderly. Table 1 provides the exact
arguments and counterarguments provided to the treatment group
regarding all the four patient characteristics.

2.4. The main choice experiment

The main experiment involved two stages: the “personal preference”
stage and the “social agreement” stage. All participants faced the same
five choice situations in both stages. The situations were presented in the
same order across both stages to all participants.

In the personal preference stage, participants had to choose a subset
of patients who should receive the scarce ventilators based on their own
preferences. We refer to the subset of patients chosen by a participant in
a situation as the participant’s “decision” in that situation. The personal
decisions help identify which principle is personally most preferred. In
the social agreement stage, participants played an incentivized

coordination game (Cooper et al., 1990). For each situation in the social
agreement stage, a participant earned a monetary bonus if their patient
choices in a situation matched the most frequent patient choices among
all the participants in that situation. The coordination decisions help
identify which principle is socially focal, i.e., the most likely principle
upon which social agreement can emerge despite differences in personal
preferences.

We designed the five choice situations to ensure that the decisions
consistent with SML in any situation are different from the decisions
consistent with SMLY in that situation. Each situation involved eight
patients who had contracted Covid-19: two were 5-year-old children,
two were 45-year-old doctors, two were 45-year-old general adults
working in a sector other than healthcare, and two were 75-year-old
elderly. It was explained to the participants that every patient needed
a ventilator to survive Covid-19, but there was a shortage of ventilators.
The participants were told to assume any patient who did not receive a
ventilator was expected to die within a week.

The patients differed in their chances of surviving Covid-19 condi-
tional on receiving a ventilator. One patient in each age/occupation
category had a relatively lower conditional survival chance (60%) and
the other had a relatively higher conditional survival chance (90%). The
conditional survival chances were used as a proxy for Sequential Organ
failure Assessment scores and other such measures that are used in
ventilator allocation guidelines (Piscitello et al., 2020). It was explained
to the participants that these chances indicate the very near-term
chances of surviving Covid-19 upon receiving a ventilator. Partici-
pants were told to assume any patient who survived Covid-19 upon
receiving a ventilator was expected to recover fully from Covid-19 and
get discharged from the hospital within one month.

2.5. The choice situations

The five choice situations differed in the number of available venti-
lators and which patients had comorbidities (Table 2). Incorporating
decreased life-expectancy due to comorbidities is a challenging but
important component of ventilator allocation guidelines (Piscitello
et al., 2020; Emanuel et al., 2020; Truog et al., 2020; White and Lo,
2020). Presence of comorbidities was explained as affecting survival
chances of patients beyond the immediate episode. While comorbidities

Table 1
Arguments for and counterarguments against using patient characteristics to prioritize the allocation of scarce ventilators.

Characteristic Argument Counter-argument

Young age An argument for prioritizing younger patients over older patients is that it
allows the young to have a fair chance to experience all stages of life, and
saves more life-years.

A counter-argument is that this clearly discriminates against the elderly and may
not account for economic or public health considerations. It is debatable
whether the right to life of the elderly can be ignored to satisfy the right to a long
life of children and adults. Further, from an economic and public health
perspective, general adults and healthcare workers may be more likely to keep
the economy and the healthcare system functioning.

Healthcare
worker

An argument for prioritizing healthcare workers is that society should
provide some insurance to healthcare workers for the risks they face in caring
for others. One way to do this would be to prioritize healthcare workers for
receiving ventilators, if they contract Covid-19 while caring for others.

A counter-argument is that healthcare workers (i) should have priority in
receiving Personal Protective Equipment so that they do not get sick, but (ii) if
they get sick while working, then they should be regarded as a general member
of the population and should not have priority in receiving ventilators.
• This counter-argument highlights the difficulties in clearly distinguishing

between “critical” and “non-critical” healthcare workers, since the smooth
operation of health services during a pandemic relies on a whole range of
workers in the healthcare sector, not just doctors and nurses. In addition, one
may ask, why not prioritize “critical” workers in occupations other than
healthcare. For example, adults who are not healthcare workers may
contribute significantly to keep the economy going during a pandemic.

No
comorbidities

An argument for prioritizing patients without co-morbidities is that if
ventilators are given to patients with co-morbidities, then scarce medical
resources will get wasted because patients with co-morbidities are unlikely to
live long even if they fully recover from Covid-19.

A counter-argument is that this discriminates against certain groups (e.g., some
ethnic or racial groups, and some income groups) who may be systematically
more likely to suffer from chronic illnesses.

High survival
chances

An argument for allocating ventilators solely on the basis of who is more
likely to survive Covid-19 if they receive a ventilator is that a greater number
of people are likely to be saved.

A counter-argument is that this may implicitly discriminate against some groups
of people. For example, people from low socio-economic backgrounds may be
much more likely to get seriously sick if they contract Covid-19. This could be
due to the poor environment they live in, the high-risk occupations they work in,
and lack of nutrition or health services.

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and the immediate conditional survival chances are likely correlated,
our experimental design manipulates them as independent factors.

In situation NONE, four ventilators were available and no patient
had comorbidities. In each of the remaining four situations – which we
label as ELDERLY, ADULT, DOCTOR, and CHILD – only three ventilators
were available and both the patients in a particular age/occupation
category had comorbidities. For instance, in situation ELDERLY the two
elderly patients had comorbidities, while the remaining six patients did
not have comorbidities.

Participants were told to assume that, conditional on receiving a
ventilator and surviving Covid-19, a patient without comorbidities was
expected to live for the remainder of their natural term of life (specified
as 80 years of age). A patient with comorbidities was described as
someone expected to die within two years even if they fully recovered from
Covid-19 upon receiving a ventilator.

2.6. Key design choices

We made two key design choices. First, we ignored situations
involving withdrawing a ventilator from a patient in order to allocate it

to another patient. Second, we specified the remaining life-expectancy
of patients with comorbidities to be the relatively short period of two
years. In the following, we describe the rationale behind these design
choices.

Withdrawing a ventilator raises fundamentally different ethical
questions relative to withholding (i.e., not allocating in the first place):
withdrawal may be viewed as active killing, while withholding as pas-
sive killing (Cartwright, 1996; Chu et al., 2020). The differences relate to
acts of commission versus acts of omission. Previous research has
documented that this difference substantially influences moral and legal
judgments across a wide range of settings (Spranca et al., 1991; Feldman
et al., 2020). We were concerned participants may be induced to think
about both aspects – omission and commission – while making choices
in a situation where only one is relevant.

In light of these considerations we chose to focus on withholding
rather than withdrawing because withholding decisions have to be made
much more often by healthcare professionals. Further, most guidelines
view withdrawal as the more difficult decision. In fact, all publicly
available guidelines contain details regarding withholding ventilators
but some do not contain any information about withdrawing ventilators
(Piscitello et al., 2020). Finally, we were concerned that situations
involving withdrawal decisions might be more disturbing for the par-
ticipants, and may thus cause greater attrition.

We specified the remaining life-expectancy of patients with comor-
bidities to be the relatively short period of two years. There is significant
variation in ventilator allocation guidelines across states in the USA on
this matter. Four states in the USA use life-expectancy of less than 6
months as an exclusion criterion, but it can range up to fifteen years in
some other states (Piscitello et al., 2020). A detailed explanation of this
design choice is included in the Supplementary Material. Here we simply
highlight that even a participant who finds SML the most legitimate
principle may hesitate in allocating the ventilator to a patient with
comorbidities if it can be allocated to a patient without comorbidities.
Hence, the shorter the life-expectancy for patients with comorbidities,
the greater the implicit force against SML. Consequently, if we find that
balanced information increases support for SML despite this implicit
force against SML, then we can be reasonably confident that balanced
information indeed increases support for SML. We chose to trade off
some realism for greater confidence in the potential impact of balanced
information.

2.7. Measures

A participant’s choice of patients in a situation allows us to infer
whether the decision was consistent with SML, SMLY, or inconsistent
with both SML and SMLY (see Table 2). For instance, 70 different de-
cisions are feasible in situation NONE, and they correspond to the 70
different ways in which four people can be chosen out of eight to receive
the available ventilators. Out of these 70 decisions, the unique decision
consistent with SML involves choosing the four patients with higher
conditional survival chance. Given that the maximum conditional sur-
vival chance is 90%, the maximum expected number of lives saved is 3⋅6
in situation NONE and 2⋅7 in each of the four situations other than
NONE. In contrast, the unique decision consistent with SMLY involves
choosing both the children, and the doctor and the general adult with
higher conditional survival chance, because the expected number of life-
years saved corresponding to a decision is calculated by weighting the
remaining life-years of the chosen patients with their conditional sur-
vival chances.

Arguably, even people who are guided by SML may prefer to save
“healthier lives” when multiple decisions are consistent with SML,
especially under severe resource constraints. The ventilator allocation
guidelines in some states (e.g., Colorado, Michigan and Pennsylvania)
effectively suggest using SML as the primary principle, and SMLY as the
subordinate principle if multiple decisions are consistent with SML
(Piscitello et al., 2020; Subject Matter Experts Ad, 2020; Michigan

Table 2
Features of the five choice situations faced by the participants.

Feature Situation

NONE ELDERLY ADULT DOCTOR CHILD

No. of ventilators 4 3 3 3 3
No. of patients 8 8 8 8 8
Patients with 60%

conditional
survival chance

E1, A1,
D1, C1

E1, A1, D1,
C1

E1, A1,
D1, C1

Patients with 90%
conditional
survival chance

E2, A2,
D2, C2

E2, A2, D2,
C2

E2, A2,
D2, C2

No. of feasible
decisions

70 56 56 56 56

Patients with
comorbidities

None E1 and E2 A1 and
A2

D1 and D2 C1 and
C2

No. of decisions
consistent with
SML

1 out of
70

4 out of
56

Decisions consistent
with SML

E2, A2,
D2, C2

A2, D2, C2;

A2, D2,
C2;

E2, D2, C2; E2, D2,
C2;

E2, A2, C2; E2, A2,
C2;

E2, A2, D2 E2, A2,
D2

No. of decisions
consistent with
SMLY

1 out of
70

2 out of
56

1 out of
56

2 out of
56

Decisions consistent
with SMLY

A2, D2,
C1, C2

A2, C1, C2; D2, C1,
C2

A2, C1, C2 A1, A2,
D2;

D2, C1, C2 A2, D1,
D2

Note. The easiest way to read this table is to fix attention on a particular column.
For instance, consider the column labelled ELDERLY that refers to Situation
ELDERLY presented to the participants. As we move down the ELDERLY column,
we find information about the relevant features of Situation ELDERLY: 3 ven-
tilators are available; there are 8 patients who need a ventilator to survive; 4
patients – E1, A1, D1, and C1 – have 60% survival chance if they receive a
ventilator; the remaining 4 patients – E2, A2, D2, and C2 – have 90% survival
chance if they receive a ventilator; two patients – E1 and E2 – have comorbidities;
there exist a total of 56 different ways of allocating the 3 available ventilators
among the 8 patients; only 4 out of these 56 decisions are consistent with the
principle of saving more lives (SML); the 3 patients who receive the ventilators
in the 4 decisions consistent with SML are reported and the 1 decision that is
consistent with the principle of saving healthier lives (SHL) is italicized; only 2
out of the 56 decisions are consistent with the principle of saving more live-years
(SMLY); the 3 patients who receive the ventilators in the 2 decisions consistent
with SMLY are reported. All the other columns can be read analogously.

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Department of Community Health and Office of Public Health Pre-
paredness, 2012; Pennsylvania Department of Health, 2020). The four
situations other than situation NONE allowed us to investigate this
possibility.

There are 56 feasible decisions in each of these situations, and they
correspond to the 56 different ways in which three patients can be
chosen out of eight. Four out of these 56 decisions are consistent with
SML (see Table 2). These four decisions involve choosing any three out
of the four patients with higher conditional survival chance. Among
these four decisions consistent with SML, the decision that involves
choosing the three patients without comorbidities is deemed consistent
with “saving healthier lives” (SHL). We label the remaining three de-
cisions that are consistent with SML but not with SHL as being consistent
with “saving any lives” (SAL).

There is a fundamental difference between decisions guided by SHL
versus those guided primarily by SMLY. For instance, SMLY permits
categorical exclusion of patients with limited remaining years of life (e.
g., the very elderly and patients with severe comorbidities) from
receiving ventilators. In contrast, categorical exclusion is prohibited by
SHL because it utilizes SML as the primary principle, and SMLY as the
subordinate tie-breaking principle when multiple decisions are consis-
tent with SML. Table 2 highlights that decisions consistent with SHL are
different from the decisions consistent with SMLY in all the four situa-
tions other than situation NONE. The decision consistent with SHL is the
one that has been italicized among the decisions consistent with SML.

2.8. Statistical analyses

Our analysis focused on the principles described above: SML, SHL,
SAL, and SMLY. In order to identify the causal effect of information
about competing ethical considerations on the share of decisions
consistent with a principle p, we estimated the following Ordinary Least
Squares regression model (which was pre-specified in the analysis plan):

Yijp = a + b Informationi + εij (1)

where the outcome variable Yijp equals 1 if the decision by participant i
in situation j is consistent with principle p and 0 otherwise; Informationi
is an indicator variable for the participant being in the treatment group;
a and b are coefficients to be estimated; and εij is a random error term.

The estimated value of a provides the share of decisions in the con-
trol group that are consistent with principle p. The estimated value of b
captures the impact of information about the competing ethical con-
siderations by providing the difference in the share of decisions
consistent with principle p between the treatment and the control
groups. We estimated equation (1) separately for the personal decisions
and the coordination decisions. Standard errors are clustered at the
participant level since each participant made five personal decisions and
five coordination decisions. When reporting the results, we also report
the odds ratio between the treatment and the control groups that was
estimated by a logistic regression.

For the subgroup analysis, we estimated equation (1) across popu-
lation subgroups by focusing on three factors: (i) differential vulnera-
bility to Covid-19, as captured by differences in age and race (Mueller
et al., 2020; Hooper et al., 2020; Price-Haywood et al., 2020); (ii) po-
tential differences in prior awareness of the competing ethical consid-
erations, as captured by differences in educational attainment and prior
familiarity with ventilator allocation guidelines; and, (iii) potential
differences in sources of public health information as captured by dif-
ferences in the willingness to take a freely available Covid-19 vaccine
deemed safe by health experts and differences in political orientation
(Motta et al., 2018; Figueiredo et al., 2020; Ecker and Ang, 2019;
Mitchell et al., 2014).

3. Results

We first examine whether any particular principle received majority
support. Each decision by every participant in all the five situations was
categorized into one of three mutually exclusive and exhaustive cate-
gories: consistent with SML, consistent with SMLY, and other (which
was the residual category containing decisions inconsistent with both
SML and SMLY). We shall refer to treatment and control groups as “Info”
and “No Info” groups, respectively.

3.1. Saving lives versus saving life-years

We first discuss the findings in the No Info group. Fig. 1A shows the
share of personal and coordination decisions consistent with SML and
SMLY across all the five situations, and the impact of information about
the competing ethical considerations. The underlying regression results
are presented in Table 3A. The main finding is that decisions consistent
with SML are the modal personal decision and the modal coordination
decision among participants in the No Info group. The share of personal
decisions consistent with SML is 0⋅50 (95% CI, 0⋅45 to 0⋅54) while the
share of personal decisions consistent with SMLY is 0⋅31 (95% CI, 0⋅28
to 0⋅33).

For coordination decisions in the No Info group, the share of de-
cisions consistent with SML is 0⋅47 (95% CI, 0⋅42 to 0⋅52), while the
share of decisions consistent with SMLY is 0⋅35 (95% CI, 0⋅31 to 0⋅39).
Overall, participants in the No Info group seem to perceive SML more
legitimate than SMLY. However, for almost half of the participants SML
is not the most legitimate principle.

3.2. Impact of balanced information

The left panel in Fig. 1A shows that balanced information about the
competing ethical considerations increases personal decisions consistent
with SML by 7⋅6 percentage-points (95% CI, 0⋅01 to 0⋅14; P = 0⋅02). This
increase comes at the expense of personal decisions consistent with
SMLY which decline by 6 percentage-points (95% CI, − 0⋅11 to − 0⋅01; P
= 0⋅02).

The right panel in Fig. 1A shows that balanced information also in-
creases the likelihood of SML being the socially focal principle. The
share of coordination decisions consistent with SML in the Info group is
5⋅7 percentage-points higher than that in the No Info group (95% CI,
− 0⋅01 to 0⋅12; P = 0⋅08).

Comparing the left and the right panels in Fig. 1A highlights that
among the participants in the No Info group, the share of coordination
decisions consistent with SML is 3⋅0 percentage-points lower (95% CI,
− 0⋅06 to 0⋅001; P = 0⋅06) than the share of personal decisions consistent
with SML. Similarly, among the participants in the Info group, the share
of coordination decisions consistent with SML is 4⋅8 percentage-points
lower (95% CI, − 0⋅08 to − 0⋅01; P = 0⋅005) than the share of personal
decisions consistent with SML.

The comparison of personal and coordination decisions suggests as if
some participants who personally perceive SML to be the most legiti-
mate principle are doubtful whether others also perceive SML to be the
most legitimate principle.

3.3. Saving healthier lives

To assess the support for SHL, SAL, SMLY, and other (i.e., the residual
category), we next utilized the data from the four situations other than
situation NONE. The underlying regression results are presented in
Table 3B. Fig. 1B highlights that the shares of personal and coordination
decisions consistent with SHL are significantly larger than the shares of
corresponding decisions consistent with SMLY in both the No Info group
and the Info group.

The comparison between the Info and No Info groups suggests that
balanced information about competing ethical considerations increases

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Social Science & Medicine 282 (2021) 114171

the share of personal decisions consistent with SHL by 6⋅2 percentage-
points (95% CI, 0⋅00 to 0⋅12; P = 0⋅05), and significantly decreases
the share of personal decisions consistent with SMLY by 6 percentage-
points (95% CI, − 0⋅11 to − 0⋅01; P = 0⋅03). The impact of balanced
information on coordination decisions is qualitatively similar but
quantitatively weaker.

Overall, balanced information increases support for SML at the

expense of support for SMLY. Also, the increased support for SML is
largely driven by the increased support for SHL. These two findings
suggest that balanced information induces some participants, that would
have otherwise used SMLY, to use SHL (i.e., SML as the primary and
SMLY as the subordinate principle).

All the findings reported above are robust to excluding the 64 par-
ticipants with significantly less or significantly more response times

Fig. 1. Share of personal and coordination
decisions consistent with various principles.
Note. Mean differences between the No Info
group and the Info group are shown. (A)
Share of decisions consistent with SML,
SMLY, and other principles pooled across all
the five situations. (B) Share of decisions
consistent with SHL, SAL, SMLY, and other
principles pooled across the four situations
other than NONE. The P values reported in
square brackets are based on t tests of dif-
ferences in means with standard errors
clustered at the participant level. Error bars
represent mean ± SEM.

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Social Science & Medicine 282 (2021) 114171

compared to the average response time (see Table S3 in the Supple-
mentary Material). Also, we had included a quiz question in between the
“personal preference” stage and the “social agreement” stage. It served
as an attention-check, and also helped assess whether participants un-
derstood the incentive mechanism used to determine their payment in
the coordination games. Only about 4% of the participants (27 out of
700) answered this question incorrectly, and all the findings reported
above hold upon excluding these 27 participants from the analysis.

3.4. Impact of balanced information on subgroups

Given that SML is the modal preferred principle at the aggregate
level, we focus on investigating the support for SML in the subgroup
analysis. Fig. 2 shows the share of personal decisions consistent with
SML across the various subgroups categorized by differences in age,
race, education, prior familiarity with ventilator allocation guidelines,
vaccination attitude, and political orientation. The underlying regres-
sion results are presented in Table S4 (see Table S5 and Fig. S1 for co-
ordination decisions).

There exists significant heterogeneity in the extent of support for
SML among the participants in the No Info group. For instance, the
support for SML is highest among participants aged more than 47 years
(mean, 0⋅55; 95% CI, 0⋅48 to 0⋅62), followed by non-white participants
(mean, 0⋅54; 95% CI, 0⋅46 to 0⋅63). In comparison, the support for SML
seems weaker among vaccine hesitant participants (mean, 0⋅46; 95% CI,
0⋅37 to 0⋅54), participants without a college degree (mean, 0⋅45; 95%
CI, 0⋅39 to 0⋅51), and republican or republican-leaning (GOP-leaning)
participants (mean, 0⋅43; 95% CI, 0⋅36 to 0⋅51).

Balanced information about the competing ethical considerations
does not decrease the support for SML in any subgroup, and significantly
increases the support for SML in several subgroups. The support for SML
increases among Covid-19 vulnerable groups, such as older adults
(mean, 0⋅09; 95% CI, − 0⋅003 to 0⋅17; P = 0⋅06) and non-white (mean,
0⋅13; 95% CI, 0⋅01 to 0⋅25; P = 0⋅03). It is perhaps more noteworthy that
the support for SML increases by 16 percentage-points (95% CI, 0⋅04 to
0⋅28; P = 0⋅008) among vaccine hesitant participants, and 16
percentage-points (95% CI, 0⋅05 to 0⋅27; P = 0⋅003) among GOP-leaning
participants. As in the aggregate level analysis, balanced information
shifts some participants within a particular subgroup that would have
used SMLY as the primary principle, to using SML as the primary and

SMLY as the subordinate principle. The estimates of the impact of
balanced information in the subgroup analysis are similar when we use
SHL, rather than SML, as the outcome measure (see Table S6 and
Table S7).

Differences in political ideology predict differential levels of trust in
experts, which in turn explains individual-level variation in vaccine
hesitancy (Baumgaertner et al., 2018; Callaghan et al., 2021). While
vaccine hesitancy seems positively correlated with negative views of
experts, there is insufficient evidence to treat vaccine hesitancy as a
proxy for lower trust in experts. However, there is broad agreement in
the existing literature that political orientation is a proxy for lower trust
in experts (Motta, 2018; Pennycook et al., 2020). Our finding for the
GOP-leaning participants suggests that balanced information about the
relevant ethical dilemmas can potentially increase support for SML even
among those population subgroups that have lower trust in experts.

4. Discussion

We investigated whether the general public finds saving more lives
(SML) the most legitimate principle in allocating scarce ventilators in a
survey experiment. Participants who were not provided information
about the underlying ethical dilemmas were split: half perceive SML is
the most legitimate principle, while the other half do not. Among those
who do not, the substantial majority seem to perceive saving more life-
years (SMLY) as the most legitimate principle.

Lack of factually correct and scientifically accurate information is
often viewed as an important driver of differences between expert views
and public opinion. Provision of facts and scientific information is
therefore often the primary tool to bridge such differences (Pennycook
et al., 2020; Blastland et al., 2020; Islam et al., 2021). Our study focused
on a largely neglected channel, i.e., provision of balanced information
about the competing ethical considerations that health experts have to
grapple with. Balanced information about the competing ethical con-
siderations underlying allocation of scarce ventilators enhances the
perceived legitimacy of SML at the expense of SMLY, at least to some
extent, regardless of differences in age, race, education, attitudes to-
wards vaccination, and political orientation. However, these findings
are weaker for coordination decisions than for personal decisions. It
seems people are doubtful whether others perceive SML as the most
legitimate principle.

Table 3
Mean fraction of participant decisions consistent with various principles.

(1) (2) (3) (4) (5) (6) (7) (8)

———————— Personal decisions —————— —————— Coordination decisions ——————

No info Info Diff. Odds ratio No info Info Diff. Odds ratio

A. All 5 situations
SML 0⋅50 0⋅57 0⋅08** 1⋅36** 0⋅47 0⋅53 0⋅06* 1⋅25*

(0⋅02) (0⋅02) (0⋅03) (0⋅17) (0⋅02) (0⋅02) (0⋅03) (0⋅16)
SMLY 0⋅31 0⋅25 − 0⋅06** 0⋅74** 0⋅35 0⋅31 − 0⋅04 0⋅83

(0⋅02) (0⋅02) (0⋅03) (0⋅10) (0⋅02) (0⋅02) (0⋅03) (0⋅10)
Other 0⋅20 0⋅18 − 0⋅02 0⋅91 0⋅18 0⋅16 − 0⋅02 0⋅89

(0⋅02) (0⋅02) (0⋅02) (0⋅13) (0⋅02) (0⋅01) (0⋅02) (0⋅14)

B. Situations except NONE
SHL 0⋅44 0⋅51 0⋅06** 1⋅28** 0⋅44 0⋅48 0⋅05 1⋅20

(0⋅02) (0⋅02) (0⋅03) (0⋅16) (0⋅02) (0⋅02) (0⋅03) (0⋅16)
SAL 0⋅06 0⋅07 0⋅02 1⋅30 0⋅04 0⋅05 0⋅01 1⋅30

(0⋅01) (0⋅01) (0⋅01) (0⋅25) (0⋅01) (0⋅01) (0⋅01) (0⋅30)
SMLY 0⋅32 0⋅26 − 0⋅06** 0⋅75** 0⋅37 0⋅32 − 0⋅04 0⋅83

(0⋅02) (0⋅02) (0⋅03) (0⋅10) (0⋅02) (0⋅02) (0⋅03) (0⋅11)
Other 0⋅18 0⋅16 − 0⋅02 0⋅88 0⋅16 0⋅14 − 0⋅02 0⋅88

(0⋅02) (0⋅02) (0⋅02) (0⋅14) (0⋅02) (0⋅01) (0⋅02) (0⋅15)

Note. In panel A, each mean estimate is based on 3500 observations made up of 700 participants across the five situations. In panel B, each mean estimate is based on
2800 observations made up of 700 participants across four situations, excluding situation NONE. Each mean estimate for the No Info group corresponds to a in
regression equation (1). Each mean estimate for the Info group corresponds to a + b in regression equation (1). The odds ratios are estimated using logistic regressions.
Standard errors clustered at the participant level are reported in parentheses. *, **, and *** indicate statistical significance for t tests at the 10, 5, and 1% levels,
respectively.

B. Rai et al.

Social Science & Medicine 282 (2021) 114171

Fig. 2. Share of personal decisions consistent with SML across
population subgroups. Note. Each panel shows the mean differences
between the No Info group and the Info group pooled across all the
five situations in the personal decision stage. (A) Participants aged
47 years or more were categorized as “Older” and the rest were
categorized as “Younger”. (B) Participants who reported belonging
to any race other than “White” were categorized as “Non-White”. (C)
“No degree” refers to participants who reported not having a college
degree. (D) Participants who reported they never heard of any
guidelines for the allocation of ventilators or ICU beds were cate-
gorized as “Never Heard”. (E) Willingness to take a Covid-19 vaccine
was ascertained based on responses to the following question:
“Suppose a vaccine is developed for Covid-19 that health authorities
consider safe. If the government offers this vaccine for free, would
you take it?” Participants who responded “No” were categorized as
“Vaccine-Hesitant” and participants who responded “Yes” were
categorized as “Vaccine-Confident” (F) Political orientation was
ascertained based on responses to the following question: “In current
politics, which category do you consider yourself more of?” Partic-
ipants who responded “Republican” or “Independent, leaning to-
wards Republican” were categorized as “GOP”. The remaining
participants were categorized as “Non-GOP”. The P values reported
in square brackets are based on t tests of differences in means with
standard errors clustered at the participant level. Error bars repre-
sent mean ± SEM.

B. Rai et al.

Social Science & Medicine 282 (2021) 114171

The increased support for SML due to provision of balanced infor-
mation is largely driven by the increased support for the principle of
saving healthier lives (SHL). This suggests that a significant fraction of
participants that would have otherwise used SMLY as the primary
principle, use SML as the primary and SMLY as the subordinate principle
when they become aware of the underlying ethical dilemmas.

The finding at the aggregate level seem to hold for several population
subgroups we analyzed. In particular, our subgroup analysis suggests
that even the participants without a college degree and GOP-leaning
participants are significantly more likely to perceive SML as the legiti-
mate principle once they become aware of the ethical dilemmas. This is
worth noting because previous research has shown that sources of in-
formation and trust in science vary with educational attainment and
political orientation (Kahan et al., 2017; Funk et al., 2019).

There are some noteworthy limitations of our study. First, our sample
is not perfectly representative of the general US adult population. The
average age of participants in our sample is slightly lower and the
educational attainment is slightly higher than the corresponding actual
means. Second, ignoring withdrawal of ventilators is a clear limitation of
our study because withdrawal and (re)allocation decisions are not in-
dependent of each other. Third, while the short life-expectancy of pa-
tients with comorbidities (two years) offers greater confidence in the
observed impact of balanced information, it suffers from the fact that
life-expectancy of people with comorbidities is typically a function of
their age.

The choice situations were presented to all participants in the
treatment and control groups in a particular fixed order rather than a
randomized order. We cannot be certain about the biases due to the
particular order we used. However, since the same order was used for
both the treatment and the control groups, such biases are unlikely to
cause major concern about the estimates of the impact of balanced in-
formation. Another potential limitation relates to our indirect inference
method. We inferred the principle preferred by a participant via the
allocation decisions. An alternative is to describe the principles, and
have the subjects directly indicate their preferred principle. However, it
is debatable whether the direct response approach or the indirect
inference approach is more likely to suffer from responder bias.

As findings from survey experiments often suffer from generaliz-
ability concerns, it is useful to clarify the particular sense in which these
concerns are pertinent to our study. Most participants in our study were
not healthcare professionals, and thus are unlikely to make ventilator
allocation decisions in practice. Consequently, we cannot generalize the
findings as to how ventilator allocation decisions by healthcare pro-
fessionals might change if they are fully aware of the underlying ethical
considerations. However, our interest was not in the decision-making of
healthcare professionals. The central goal of our study was to investigate
perceived legitimacy of the principles behind these guidelines among
the general public because public opinion can also influence policies.
Hence, given the nature of our question, external validity concerns are
likely to be minimal.

Our work does not presuppose that SML is a more legitimate prin-
ciple than the alternatives. Given that most public health experts and
authorities do endorse SML as the primary principle, our findings sug-
gest that, in addition to disseminating scientific facts and combating
misinformation about scientific facts, promoting public awareness about
the competing ethical considerations that public health experts grapple
with can help increase the perceived legitimacy of SML, even among
subgroups with lower trust in experts. Skeptics may erroneously but
plausibly hold the belief that some factual or scientific information is
produced and propagated by profit-seeking entities. Such a belief is
harder to hold when the information is balanced, and relates to the
underlying ethical dilemmas in the allocation of scarce medical re-
sources. While further research is needed to better understand the
behavioral mechanisms behind our findings, this difference between
scientific and ethical information could be an important driver.

Credit author statement

BR and LCW conceived and designed the study with input from all
the authors. CKS and LCW conducted the online experiment. LCW and
SP analyzed the data with input from BR and TH. BR, SP, and LCW wrote
the manuscript with input from TH.

Acknowledgements

We thank two anonymous reviewers for comments and suggestions
that significantly improved this paper. We also thank Yee (Lisa) Chan,
Gaurav Datt, Marwa El Zein, Vai-Lam Mui, and Richard Tee for useful
comments. We gratefully acknowledge funding from the Centre for
Development Economics and Sustainability and the Department of
Economics at Monash University.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.
org/10.1016/j.socscimed.2021.114171.

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Awareness of ethical dilemmas enhances public support for the principle of saving more lives in the United States: A survey …

1 Introduction

2 Methods

2.1 Overview

2.2 Study sample

2.3 Information treatment

2.4 The main choice experiment

2.5 The choice situations

2.6 Key design choices

2.7 Measures

2.8 Statistical analyses

3 Results

3.1 Saving lives versus saving life-years

3.2 Impact of balanced information

3.3 Saving healthier lives

3.4 Impact of balanced information on subgroups

4 Discussion

Credit author statement

Acknowledgements

Appendix A Supplementary data

References

OR I G I N A L P A P E R

COVID 19: Ethical dilemmas in human lives

Smadar Bustan PhD1 | Mirco Nacoti MD2 | Professor Mylene Botbol-Baum PhD3 |

Katherine Fischkoff MD4 | Professor Rita Charon MD, PhD5 | Laure Madé MSc6 |

Jeremy R. Simon MD, PhD7 | Meinhard Kritzinger MD8

1Institute of Humanities, Sciences et Societies,

University of Paris Diderot,

Paris, France

2Department of Anesthesia and Intensive

Care, Pediatric Intensive Care Unit, Papa

Giovanni XXIII Hospital, Bergamo, Italy

3Bioethics Center, University of Louvain,

Woluwe UCL, Louvain-la-Neuve, Belgium

4Department of Surgery, Columbia University

Medical Center, 177 Ft. Washington Ave.,

New

York, New York

5Department of Medical Humanities and

Ethics, Columbia Vagelos College of

Physicians & Surgeons, Columbia University,

New York, New York

6Department of Infectious and Tropical

Diseases, Hospital Bichat Claude Bernard,

Paris, France

7Department of Emergency Medicine,

Columbia University, 622 W. 168th St., New

York, New York

8Department of Anesthesia and Intensive

Care, City Clinic Hospital, Waltraud Gebert

Deeg Strasse 3G, Bozen, South Tyrol, Italy

Correspondence

Smadar Bustan, PhD, University of Paris

Diderot, Institut Humanités, Sciences et

Sociétés, 5 Rue Thomas Mann, 75013 Paris,

France.

Email: smadyil@gmail.com

Abstract

On 7 May 2020, Columbia University Global Centers hosted an online international

symposium on ethical dilemmas during the COVID-19 pandemic. This interdisciplin-

ary engagement between philosophers and Covid medical professionals reports the

challenges as well as the discrepancies between ethical guidelines and reality. This

collection of presentations identifies four key ethical dilemmas regarding responsibil-

ity, fairness, dignity and honouring death. In looking into accountability and consis-

tency in medical humanities, it examines whether the contextuality of coronavirus

across countries and cultures affected the ethical decision-making processes. This

work aims to provide a seminal resource for the development of a high-quality

roadmap in medical ethics for future health crises.

K E YWORD S

epistemology, healthcare, humanity, medical ethics, philosophy of medicine, public health

1 | GENERAL INTRODUCTION

Dr Smadar Bustan, Philosopher

The novelty of the global outbreak of the highly contagious coro-

navirus disease brought the entire world together as it shared a collec-

tive experience, while at the same time, it pulled us apart with closed

borders, home lockdowns, extreme social distancing, and isolation.

This coronavirus threat presented a unique set of features: everyone

had to be treated as potentially positive as it is possible to be infec-

tious while being asymptomatic. Consequently, the disease often

became a death sentence since there is no treatment or vaccine.

Moreover, our contemporary evidence-based medicine was chal-

lenged as the notion of knowledge became in transitu, knocking the

solid bottom of the entire healthcare practice. Decisions need to be

grounded in science but there was no science to rely upon. Informa-

tion has been confirmed and refuted on a daily basis: face masks were

publicly announced as protective measures but then their viability

was debated; medical protocols at hospitals changed continually, con-

fusing the frontline medical staff trying to save lives while feeding

substance back to the experiential knowledge of medical care. Nations

became indistinguishable by the worry and grief that joined hands:

the long lists of hospitalized people shared on social media, the death

Received: 8 June 2020 Accepted: 11 July 2020

DOI: 10.1111/jep.13453

https://orcid.org/0000-0002-9574-9289

mailto:smadyil@gmail.com

http://wileyonlinelibrary.com/journal/jep

http://crossmark.crossref.org/dialog/?doi=10.1111%2Fjep.13453&domain=pdf&date_stamp=2020-09-14

tolls portrayed by endless lines of military fleet transporting bodies of

coronavirus fatalities for burial in northern Italy, the mass graves in

Latin America or the extent of reported cremations of the COVID-19

victims in China, as well as the alarming cry of healthcare personnel

worldwide.

The risk and prevention, required to limit the coronavirus

spread and rapidly work out the most efficient containment mea-

sures, divided the tasks between the political, medical-scientific,

public, and industrial sectors. Despite their exceptional collabora-

tion, we seem to have turned back to population-oriented medicine

after an accomplished era of personalized medicine, looking at the

mass instead of the ill human being. In addition, when the whole

world seemed to be coping as one, differences emerged in regard

to national or even regional anti-COVID-19 management strategies,

including sanitary and medical forms of intervention. Since the

onset of the outbreak, while keeping people alive has certainly

been the immediate and primary imperative, healthcare profes-

sionals have been overwhelmed by pressing ethical challenges, hav-

ing to make hard decisions for which they were accountable and

to provide reasons for their actions and omissions. Clearly, clini-

cians are trained for ethical decision-making, but in view of the

pandemic chaos paired with the incredible shortage of medical

resources, ethics committees or advisory groups had to help by

providing specific guidelines such as those endorsed by the

“COVID-19 ethical decision-making tool.”1

The reality was and still is represented as being constituted in

the same fashion as that of decision-making in times of war where

the urgency, scarcity of medical supply or critical care beds, rapid

spreading of new cases, time-sensitive procedures, and fighting

the unknown during a public health emergency continue to weigh

efficiency (Is it the most effective? What will be the end result?) over

the ethical (Is it the right thing to do?). The sensitive issue of medi-

cal rationing raised very important questions about “fairness” in

the context of broader social injustice and was particularly notice-

able during this global healthcare urgency. The dramatic phrasing

regarding “the war against COVID-19” announced by politicians

and health organization directors-general became integrated into

the healthcare system. It forced challenges that no longer strictly

applied to individual patient care (allocation of limited resources

such as ventilators, the sharing of patients’ confidential informa-

tion with relatives or even the media, denying opportunities for

families to say goodbye before a death) but also applied to the role

of practitioners who found themselves in a newly created chain of

command.

The essential service of medical ethics and its decision-making

process, as I see it, consists in allowing for one part of the decision

to lean upon another part of the decision in order to become unam-

biguous. In this way, each one of the several aspects in which the

ethical decision may be considered, assures the fundamental values

of the right and the good. Such deliberation is based on having a

choice regarding which end to pursue. However, moral dilemmas

put us in a situation of conflict where a difficult choice has to be

made between different options where neither resolve the issue in

an ethically ideal acceptable fashion. Medical ethical dilemmas cre-

ate even more conflict because they touch upon human lives. The

COVID-19 pandemic obliged us all to handle many dilemmas, some

of which we took upon ourselves as philosophers, ethicists, doctors

and nurses to discuss during the online symposium COVID-19: Ethi-

cal Dilemmas in Human Lives, held on 7 May 2020, and hosted by the

Paris Global Center of Columbia University and the Columbia Global

Centers. We may not provide ready-made solutions here, especially

as the epidemics storm still rages. This discussion testifies to the

ongoing pandemic emergency and its difficult challenges while eval-

uating whether the ethical guidelines in the official healthcare rec-

ommendations were able to meet the lived reality. Looking at

accountability and consistency in regard to the context of this global

health crisis, it seemed equally important to examine, through an

international exchange, whether the contextuality of COVID-19

across countries and cultures affected the ethical decision-making

processes. The following collection of the symposium’s presenta-

tions maintains the original discussion format, whereby each

dilemma is addressed by a COVID clinician and then analysed by a

philosopher or an ethicist, who, at times, is also a practicing physi-

cian. I organized the discussion around four notions depicting four

key ethical dilemmas with leading questions, even though others

clearly come up in the various discourses.

1.1 | The four ethical dilemmas

The following are the identified four key ethical dilemmas:

1. Responsibility: Can medical responsibility change in times of

pandemic?

2. Fairness: In times of emergency, scarce healthcare resources, and

risk of infection to the medical staff, how do we decide where we

draw the line of whom we treat, who will live and who will die and

how to ration

treatment without denying care (triaging resources)?

3. Dignity: Does the need for increased awareness of public harm in

a pandemic justify impinging on patients’ rights to bodily and per-

sonal dignity

and privacy?

4. Honouring death: Does public interest in social distancing out-

weigh the patient’s right not to die alone and the family’s right to

be with their dying relative?

The challenging questions raised here are intended to reinforce

our ethical values and speak of the well-being of the sick human

being, the dignity of the dead person, and refer to a patient as a per-

son to be cared for rather than a critical case or a contaminating

agent. And while the coronavirus continues to widely spread across

the globe, we hope that our discussion can serve as a resource for

advanced care planning, helping medical providers and other special-

ists to consider the shared important aspects of medical ethics in

times of great uncertainty.

For the symposium video, please view https://www.youtube.

com/watch?v=07Nup9eMROA.

BUSTAN ET AL. 717

I would like to thank the Paris Global Center of Columbia Univer-

sity and their wonderful team for hosting the symposium in these

exceptional times along with the Columbia Global Centers in Amman,

Nairobi, and Istanbul. And last, I would like to thank all the healthcare

and essential workers worldwide for their daily engagement to over-

come the COVID-19 virus.

2 | FIRST ETHICAL MEDICAL DILEMMA:
RESPONSIBILITY

Can medical responsibility change in times of pandemic?

2.1 | Responsibility: Mirco Nacoti, Clinician

Mirco Nacoti, MD (Italy), is an emergency, anaesthesia and intensive care

physician at Bergamo Hospital, Italy. He has extensive field experience in

humanitarian crises and community approach to vulnerable people.

Two months after the beginning of the crisis, I still have major

problems sleeping.

I have dragged the corpse, from the bathroom to the bedroom, of

a 50-year-old man who had died at home.

I have seen dozens of people piled up in emergency rooms with

severe dyspnoea and frightened eyes.

I have spoken on the phone to a friend of mine and said to her:

you must choose between your father and your mother.

I have run at night to my hospital, taken a drug for sedation and

come back to look after an old man dying, as my hospital was too

crowded.

I have obeyed an order to transfer to Germany by flight an

intubated man and he has died on his way. I have never spoken to his

parents.

I know many young anaesthetists in my hospital who have

decided alone who were to live and who were to die.

I feel a persistent smell of people suffering on my skin.

The pale light of an old humanitarian actor, with some studies in

bioethics, is now a fire. Forty years later, the Alma Ata definition2 of

primary health care seems vital to me.

I have done and watched a lot over these past 2 months. But my

night-time question is: have I thought enough? That is why I am very

grateful to have this occasion to think.

Bergamo is a rich and populous city of northern Italy (1 000 000

people) and one of the epicentres of the worldwide COVID 19.

Despite the generosity of health workers, we are undergoing a severe

humanitarian crisis that is stressing every aspect of daily life.

From outside it is very hard to understand, because houses are

closed for lockdown and are not destroyed as they would be in an

earthquake. Furthermore, in regard to the dilemma of moral responsi-

bility, the World Health Organization (WHO) figures do not represent

the reality. WHO is doing a great job, as usual, but the figures pro-

vided are a dilemma, as usually occurs during an outbreak. Today

WHO shows about 3 500 000 confirmed cases with 240 000 deaths3

worldwide and in Bergamo 13 000 confirmed cases with about 2500

deaths.4 Unfortunately, the actual deaths reported by town halls are

about 6000 to 7000 (nearly 1% of the population).5 Considering that

a fatality rate of 20% is a non-sense, because the Chinese experience

(even in Hubei province) reports a rate between 1% and 3%,6 the

number of people contaminated in Bergamo is likely to be between

250 000 and 500 000 (which means 25%-50% of the population).

More than 2000 people with mild-severe hypoxia, at the peak of the

outbreak, stayed home because all the hospitals were overcrowded.

These are the real figures. This is the picture of Bergamo’s disaster.

For this reason, we wrote a paper, which appeared in the New

England Journal.7 In regard to the dilemma of moral responsibility,

when the global medical community is called on to face a pandemic of

unprecedented scale, with little scientific evidence and “crazy num-

bers” describing the situation, honest and forthcoming advocacy is an

ethical duty, and that paper was a wake-up call for those involved in

system preparedness and strategic planning.

An outbreak is neither a simple disaster casualty incident like an

earthquake nor a “simple” disease, but it is a social phenomenon. His-

torical and social elements are key factors for development (eg, inten-

sive promiscuity between animals and humans) and spread (eg, health

workers and ambulance rapidly become vector of the virus) of an

epidemic.7

A first consequence of this translation into a social horizon con-

cerns the theme of responsibility. And in regard to the dilemma of

moral responsibility, how much does the social narrative about the

infection numbers weigh, for example, on the decisions to be taken

and on the concepts that guide them (eg, that of proportionality)?

How do inaccurate narratives, from an epidemiological point of

view, affect the “judgement in situation,” that takes place in triage or

in prevention strategies in other countries? How many shocking

images are needed if figures are not reliable?

Another aspect of the dilemma of moral responsibility concerns

the care of decision-making process and the fragmentation of respon-

sibility. Modern Western medicine has centralized the care of patients

in the hospitals (and our region does represent this process),

preventing the community from being the main actor in the sphere of

public health and putting into practice an “expropriation of health,” as

Ivan Illich says in Medical Nemesis.8 Body has been progressively frag-

mented in small pieces by super-specialized doctors and responsibility

has ended up being a question of legal responsibility, an economic

matter, and not an ethical one. In this fragmentation, it has been

acceptable for us to execute orders, even if epidemically dangerous or

not ethical, because we were living an urgent situation, and during the

fight against COVID 19 the mantra was “to do and not to think.” It

seems, as Hannah Arendt writes in her “Banality of evil,” that “nobody

was responsible, or rather, nobody felt they were; they just did their

job.”9 Would it have been useful to have a mechanism of control of

decision makers in close contact with territories? Only the awareness

that the weight of a decision is to be shared can prevent us from turn-

ing the triage into a moment of irresponsible superhomism.1

A further aspect of the dilemma of moral responsibility is the

ethics of the research in urgent situation. As Derek C. Angus wrote in

718 BUSTAN ET AL.

a JAMA view point,10 one stark example is the debate over prescrib-

ing available drugs, such as chloroquine, or testing these drugs in ran-

domized clinical trials. At the heart of the problem is one of the oldest

dilemmas in human organizations: the “exploitation-exploration” trade

off. Exploitation refers to the “just do it” option. Exploration refers to

the “must learn” option.

During his captivity in the 1940s, Archibald Cochrane treated

many prisoners, often ill with tuberculosis, by observing how the

disease benefited more from a good caloric intake than from drugs

of uncertain or zero efficacy. The germs of Evidenced Based Medi-

cine arose from those observations. Eighty years later, in regard to

the dilemma of moral responsibility, how many helmets to deliver

respiratory assistance have been placed without any enteral feed-

ing in Bergamo? Chloroquine, antiviral, anti-IL6, anti-complement,

steroids, and antibiotics have been distributed without a real meth-

odological approach, without monitoring, with people arriving at

the hospital worn out after days of dyspnoea. What data, what

ethical research can be produced in such a mess, what if you pub-

lish on an important indexed medical journal but the “garbage in,

garbage out” approach is still considered the right one11? Further-

more, in regard to the dilemma of moral responsibility, what about

signatures extorted for consensus from a dyspnoeic patient with

no family member nearby? Such a touchy a matter would require

competence and experience, and yet it was often managed by resi-

dents instead of specialists. Not everything is lawful in urgency

and there is an ethics of research even in urgency.

Derek C. Angus suggests at the end of JAMA view point10 that

an integrated approach of “learning while doing” is essential in a crisis.

Nevertheless, in our current context, it is very important not to lose

the capacity to think and probably we have to subtly shift from Angus’

suggestion to a “thinking/learning while doing,” as Hannan Arendth

writes.12

Goisis, a philosopher, co-author of the New England article, says

that it is not true that nothing will be as it used to be before COVID-

19. Millions of people in the world will be more vulnerable and iso-

lated. But the economic, scientific, political, and social mechanisms

leading to this pandemic humanitarian disaster are still there. “Doctors

have to give back to the community the capacity to promote health,”

could have said Ivan Illich today.

2.1.1 | Acknowledgements

The author thanks Dr Matteo Cavalleri and Dr Giuseppe Goisis for

their help with philosophic suggestions and English editing.

2.2 | Responsibility: Smadar Bustan, Philosopher

Smadar Bustan, PhD (France), is a philosopher, ethicist, and scientist at

the University of Paris Diderot. In her research on human suffering and

pain, she developed a tool for evaluating the disease-related suffering of

patients following experimental and clinical studies in Luxembourg,

Germany and France. She co-founded at Harvard and heads the Interna-

tional Program on Suffering and Pain (www.suffering-pain.com).

The dilemma discussed here bears on responsibility, a Latin term

from 1590 resp�ons(us) or response, which became philosophically

prominent rather late in the 18th century. Our question is, does

responsibility, and more specifically medical responsibility, change

during a global health crisis? Is responsibility limited in the avalanche

of an infectious transcontinental disease, obliging us to relieve clini-

cians from the burden of decision-making process carried out in indi-

vidual cases?

A broader conceptualization of the nature of responsibility is

necessary in order to deal with this dilemma, by first asking: what

does it mean to be responsible in times of pandemic? Responsible

behaviour during the coronavirus infection outbreak was very much

present in every household and country around the globe. Yet the

lack of adequate knowledge caused significant inconsistency lead-

ing to public panic and raised doubt about what it means to act in

a responsible manner, both personally and collectively. The problem

with a pandemic is that the personal and the social intermingle to

the extent that the most casual individual acts, such as coughing,

sneezing, going out of our homes, or walking around maskless,

turns a person into a biological agent engaging into irresponsible

behaviours that some would qualify as criminal or immoral. This

COVID-19 Epidemic has been enhancing mutual accountability to

such an extent that individual responsibility is transferred from an

autonomous self to a self intrinsically bound to others. One can no

longer exert free will to live carelessly and be prepared to risk

contamination.

What we have learnt from this epidemic as a globalized society is

that individual responsibility is no longer exclusively centred on what

we are bound to undertake by duty, of a person being responsible for

something or someone (a parent for their child, a doctor for their

patient) since simply by being, breathing, existing, we are accountable, all

of us together and every one of us individually.

Unfortunately, under such circumstances, our responsibility

becomes as vulnerable as we are.

The fragility of a pandemic causing this involuntarily responsibility

by existence, with its inevitable sharing of accountability, leads us back

to our main ethical dilemma when asking what motivates us to make

the right choice for a responsible act during a health crisis. For the

overwhelmed practitioner inquiring how to fully know what the right

act is, how to best choose in relation to the available resources and to

whatever is in one’s power, the resignation to do “the best we can”

may provide protection from liability but not necessarily satisfaction

or peace of mind. When the medical model of responsibility is guided

by reasoned thought in regard to what we can do and the means that

lead us to better ends, It is difficult not to notice the unrest when this

intellect-based definition of being responsible entails a sense of feel-

ing morally, medically or even humanly irresponsible. When reading

Dr Nacoti’s testimony, it becomes clear that even though a well-

regarded thought led him and his colleagues to make decisions for

saving lives, the strong remorse experienced following the death of

their patients shows that a reason-based decision for acting

BUSTAN ET AL. 719

http://www.suffering-pain.com

responsibly with a negative end result may leave clinicians with a feel-

ing that they are partially at fault for the failure.

The severity of the pandemic has exposed many of the medical

workers, as those in the frontline in north Italy where Dr Nacoti

works, to face the toughest triage procedures in medical care with

the prospect of having to ration equipment and care, sacrificing cer-

tain people for saving others and facing unthinkable choices regard-

ing life and death. The lack of treatment led to the use of drugs on

the basis of limited evidence concerning their effectiveness and

therefore not without risk while trying to assure the highest rate of

survival. In this respect, even when providing immunity against mal-

practice during the emergency of COVID-19 and hence excluding

any legal responsibility, as Dr Fischkoff recounts about the State of

New York in her discussion on fairness, the problem with ethical

responsibility persists not only in regard to the possible damage cau-

sed by one’s own act, but also to the consequences of this act on

the people to whom they must answer. We find here the two

aspects of the modern idea of responsibility, associating legal and

moral responsibilities. The interdependence of these two aspects

may explain why, despite excluding any legal sanctions and there-

fore legal responsibility in a time of unprecedented crisis (facing

scarce resources and exceptional emotional burden on healthcare

personnel), the ethical dilemma persists because medical decisions

remain attached to our moral obligations. Treating clinicians whose

actions are based on well-justified rational decisions may still carry

blame, unable to wash away the guilt, because these fail to comply

with their moral convictions.

The lived reality of the pandemic obliges us to go beyond the first

form I named responsibility by existence to better examine the medi-

cally relevant form of responsibility by deliberation, introducing the idea

of making a choice as a result of deliberation and of fully knowing

what is the right thing to do. Two philosophers who represent this

strand of thought with the traditional concept of responsibility as

dependent on knowledge, striving to certainty and regulatively know-

ing everything or at least as much as possible, are Aristotle (4th cen-

tury BC), in his account of Ethics, and John Stuart Mill almost two

millennia later with his utilitarianism13 (19th century). In the third

book of Nicomachean Ethics,14 Aristotle examines what is good for the

human being – what we need to undertake, aim at, and act upon, in

order to do good. In our case, medicine aims at health, and physicians

aim at healing. In this respect, what Aristotle also taught us is that

when we deliberate, we always have some end in view. If I deliberate

about whether to put a mask, I consider this in light of a future end in

view, which is to avoid catching or spreading the COVID-19 virus. If I

deliberate about whether to respect the extreme social distancing of

the quarantine and stay at home, I consider this in light of a future

end in view which is to slow down and eventually stop the epidemic’s

spread.

Aristotle claims, however, that there are two things we cannot

deliberate about: facts (which could only be examined) and end views,

for the simple reason that we cannot change them. Hence our choice

based on deliberation of doing good and acting responsibly are depen-

dent on end purposes and on sticking to the facts, and basically on

knowledge. At the same time, if during the COVID-19 pandemic we

apply this philosophical recipe with reason-based choices regarding

medical responsibilities, we soon realize that clinicians are being

severely undermined, which only intensifies our dilemma. In reality,

we have witnessed misinformation emanating from situation reports

and official communications, including from public health authorities,

through inaccurate or misguided information. For example, It was said

that smokers are less likely to be contaminated, ibuprofen or aspirin

can worsen the coronavirus symptoms, or the virus is unstable at high

temperatures and therefore will go away when the weather warms

up. In the upheaval of the aggressively spreading epidemic, scientific

facts continuously evolved so action based on facts had to adapt,

inducing further confusion relative to our standard approach of

evidence-based medicine that cancelled out knowing beforehand and

making a contingency plan accordingly. Furthermore, at the outbreak

of the pandemic, the end view of medicine and its therapeutic goals

shifted from healing to prevention from dying, totally destabilizing the

standard therapeutic goals.

Under a state of emergency and threatening rapid death, we

could simply proclaim that without a solid foundation to rely upon for

making choices, the entire undertaking of medical and social responsi-

bility is bound to perplexities. Medical professionals must respond

when facing flows of COVID patients with severe respiratory distress

out of active commitment to vulnerable patients. De facto, they do

respond. But do they need, in this unique scenario, to take responsi-

bility for their medical response? In respecting their devotion and dili-

gence, can we relieve clinicians from a part of the responsibility in the

decision-making process as normally carried out in individual cases?

A comprehensive approach should be compatible with extant

principles of responsibility under the given circumstances. A broad

approach to analyse responsibility for pandemic diseases should con-

sider both forms of responsibility, by existence and by deliberation.

This would be better overall for society and healthcare, considering

the disruption due to shifting facts and undermined medical ends, thus

promoting more careful policies and actions.

At the same time, the outcome of the discussion so far has been

to show us that a person or an act can be considered responsible so

far as one is bound by it, or thinks it to be right. My first observation

in examining “what is it to be responsible” in times of pandemic con-

sists in introducing the idea of responsibility by existence for all, regret-

tably excluding the freedom to be able to do otherwise. And my

second observation examining “what is it to act responsibly” consists

in introducing the idea of responsibility by deliberation, of accountabil-

ity for our actions and their consequences, and the praise and blame

attributed to the moral agent. Deliberation is a reasoned thought

about what we can change by our efforts and where we need to act

differently in various occasions. And yet, in times of pandemic the

foundation for well-reasoned and thoroughly discussed decisions, fos-

tering a collegial consultation as standardly required, is damaged

because neither the facts nor the end views are stable enough to

serve as references for deliberately acting responsibly. Dr Nacoti

raised this point when he spoke about referring to the general qualifi-

cation of the COVID pandemic as a war with a chain of command

720 BUSTAN ET AL.

whereby clinicians were to simply obey, following the mantra of “do

and do not think” and inexperienced doctors found themselves having

to decide alone who will live and who will die. The resulting epistemo-

logical helplessness of the coronavirus pandemic sheds a new light on

the idea of responsibility due to the conflict within the medical profes-

sion, naturally based on knowledge but confronted with a new situa-

tion of not knowing. This novel chaotic situation cancels Aristotle and

Mill’s rationalist view of acting by virtue and for the benefit of good

on the ground of knowledge, as clinicians who have an occupation

requiring them to be well informed in order to act responsibly lack in

effect the necessary knowledge.

This outcome for the practice of medicine and our philosophical

inquiry requires to rethink the notion of responsibility and moral obli-

gation by moving philosophical fields, going from Aristotle’s guiding

but failing rationality to Levinas’ field of ethical phenomenology. The

reason is that none of the perspectives that have been actually pres-

ented here has paid full attention to a third form of responsibility,

based on an entirely different philosophical pattern and that provides

a way out of this dilemma regarding acceptable or unacceptable

changes in medical responsibility in times of pandemic. This alternative

view consists in arguing that responsibility is involuntary, not bound

by rational choice, certainly not a deliberate one and is totally experi-

ential. Becoming responsible for a sick person is imposed upon us by

his needy, vulnerable presence when calling for help, often without

words, in an appeal conveyed by the misery and helplessness of their

facial expressions. This sense of ethical responsibility goes beyond

that of a reflective commitment. And just like the first form of respon-

sibility by existence, it separates one from oneself by giving prece-

dence to the other person, while emphasizing here that this other

person is weaker and more at risk. Levinas considers the experience of

responsibility as what binds one person to another, as the foundation

for humanity and ethics, which he demonstrates through the well-

known theme of the meeting face-to-face, when encountering the

face of the other person causes a phenomenological shock that makes

one feel inevitably responsible for their fellow human being.15

I have to admit that in my writings on ethics and the sufferer and

especially in my review of what I call the “French School of the Ethics

of Suffering,”16 I always criticized this uncompromising level of

responsibility and priority Levinas claims we can grant another person,

even when we are ourselves sick, exhausted and emotionally

strained.17 But when I caught the Corona virus at the beginning of the

outburst here in France, the sense of responsibility and giving priority

for the well-being of another took over me. My symptoms were mild,

but sudden. I fell down on the floor without being able to get up

again, feeling the chill and honestly the fright of the unknown progres-

sion of this aggressive virus that literally took control over my body

within minutes. While lying on the floor, what bothered me most was

the possible contamination of my children and particularly of my asth-

matic elder son who was designated as part of the COVID-19 risk

group. I was sick, not being able to give anything, let alone move my

body, and yet, just as Levinas claims, the disinterested sense of

responsibility towards another invaded me and my responsibility for

not contaminating them became my absolute priority. It was not a

voluntary or deliberated sense of responsibility and it very much

obsessed me when I was most helpless.

Obviously, one could contest this example by rightfully claiming

that children are an extension of the parent (and therefore, in this

case, of myself) and do not represent a “real Other” in the full

Levinasian sense. And as I demonstrate in my book on Levinas’ ethics,

the unreflective encounter with the other person rather represents a

situation that makes me surrender myself to them, often against my

own will and without being able to expect anything in return.18 The

other could be a stranger one has to commit oneself to despite want-

ing to walk away, a patient entering an already overbooked COVID

unit whom an overburdened doctor would rather put to wait or a con-

taminated elderly person placed in the care of a scared nurse, wearing

a plastic bag due to lack of proper protective equipment (reminding us

of the institutional responsibility towards the caregivers and the

safety protocols). The other person may even constitute a threat but

since their urgent call for help precedes me and is imposed upon me

immediately, I am obligated to be there for them, unable “to get out

from under responsibility.”19 It is the lived experience and encounter

between human beings that make us responsible, not knowledge or

deliberation on the account of facts. Human responsibility is simply

being there for the other, claims Levinas.20 The activated sense of

responsibility towards the survival of others places them first, prior to

worrying about our own survival and prior to any conscientious

processing. One is compelled to worry and care for the other says

Levinas, since responsibility does not originate from within oneself,

but is rather an order or command that one receives. It precedes us in

the sense that it originates from a prior time and our ascendants

(ancestors or past generations), as Ezekiel Mkhwanazi beautifully

explains,21 it is pre-original.2223

In transposing this view to our discussed dilemma of medical

responsibility, it soon becomes clear that what stems from this sense

of duty, of a caregiver or a medical worker, is not a Greek agency or

freedom to choose the good, but a fundamental archaic obligation of

oneself towards another, and that it “commands me and ordains me

to the other.”24 In this perspective, this amounts to saying that our

dilemma is cancelled since no judgement can be made about treat-

ment or availability of the medical caregivers during a pandemic. Their

mere presence beside a COVID patient’s bed is a celebration of being

there for the patient and of human responsibility at its best.

2.2.1 | Acknowledgements

The author thanks Dr Jeremy Simon and Dr Javier Escartin for their

help with English editing.

3 | SECOND ETHICAL MEDICAL DILEMMA:
FAIRNESS

In times of emergency, scarce healthcare resources, and risk of infec-

tion to the medical staff, how do we decide where we draw the line

BUSTAN ET AL. 721

of whom we treat, who will live and who will die and how to ration

treatment without denying care (triaging resources)?

3.1 | Fairness: Katherine Fischkoff, Clinician

Katherine Fischkoff, MD, MPA (USA), is an Acute Care Surgeon and inten-

sivist at Columbia University and is the Medical Director of the Surgical

Step Down Unit. She is an active member of the Columbia Ethics Com-

mittee, the SCCM Ethics Committee and an ethics consultant.

Fairness has been a driving principle of the treatment of COVID

patients throughout the pandemic response. However, given the

overwhelming number of patients in New York City, the challenges to

fairness evolved as the COVID crisis unfolded.

To begin with, on 18 March 2020, all elective and semi-elective

surgeries and other procedures were cancelled in New York City to

allow hospitals to free up resources in anticipation of the surge of

patients.2526 This presented the first questions of fairness. Patients

who were scheduled for often time-sensitive treatments were post-

poned in order to be able to care for the thousands of COVID+

patients. This was, of course, not just a question of fairness, but also

of patient safety, reallocation of resources and preservation of PPE.

However, any time one group of patients is prioritized over another,

we must ask ourselves whether the outcomes were proportional. In

this case, the overwhelming answer is yes. Shutting down normal hos-

pital operations was essential in being able to safely take care of the

enormous crush of patients that presented. However, should there be

another wave, the proportionate harm to those patients who would

be postponed needs to be considered and alternative options pro-

posed in order to avoid interrupting their care again.

The second question of fairness came when questions of triage

arose. In the United States, there is a strong cultural and legal empha-

sis on patient and family autonomy. This American phenomenon per-

sists in part because the health care system is so resource rich. As an

example, New York State law in the form of the Family Health Care

Decision Act27 does not permit physicians to withhold or withdraw

life-sustaining therapy over the objection of patients and their fami-

lies. In this cultural and legal context, when the COVID surge began

and there were serious concerns about scarcity of resources, the gov-

ernor of New York decided that rather than approve a triage system

to decide which patients would get a ventilator and which would not,

he would work to provide ventilators for everyone and New York hos-

pitals committed to rapidly expanding their intensive care unit (ICU)

capacity.28 My hospital typically has 117 ICU beds but over the

course of 2 weeks, we expanded to nearly 300 ICU beds and pop up

tents provided extra inpatient beds. This was done without a compen-

satory increase in staffing. But because of this, no patient was

turned away.

In 2008 after the H1N1 flu outbreak, many states put together a

resource allocation plan that could be used in the case of crisis when

resources were overwhelmed. The New York State Ventilator Alloca-

tion Guidelines29 were built on the ethical principle of fairness that all

patients would be given equal access to ventilators regardless of

socioeconomic factors. It begins with a set of immediate exclusion

criteria that are applied to a patient when he or she is determined to

need a ventilator, such as unwitnessed or recurrent cardiac arrest,

severe traumatic brain injury or irreversible hypotension refractory to

fluids and pressors. If a patient meets any of those criteria, he or she is

not given a ventilator but is offered either best medical management or

palliative care. If a patient needs a ventilator but does not meet any of

the immediate exclusion criteria, he or she goes on to evaluation by a

“Triage Committee” which follows a very specific pre-determined algo-

rithm to decide whether a patient would be given access to a ventilator.

The goal of the Allocation Guidelines is to determine a patient’s

access to a ventilator based on prediction of likelihood of survival and

not based on value judgements. In fact, to uphold the fairness of the

process and to ensure there would not be any decisions based on

social or economic factors, the triage committee is a third party whose

representatives are not directly involved in the care of the patient and

does not receive any demographic information.

As noted above, the Allocation Guidelines were not activated dur-

ing the COVID crisis. With an incredible show of collaboration, crea-

tivity and immense hard work, hospitals in New York City were able

to care for all patients who had COVID. The question must now be

asked, is it ever fair to activate a triage process and deny access to

critical care resources if there is the option to stretch resources fur-

ther? The Institute of Medicine describes the spectrum of hospital

expansion in response to a public health emergency.30 Conventional

capacity is the normal operating capacity of a hospital. Contingency

capacity is defined as operating significantly above a hospital’s usual

capacity but is a state in which normal standards of care can be deliv-

ered. Crisis capacity is the final stage in which hospital resources are

stretched so thin that normal standards of care cannot be provided. It

is often recommended that triage systems be activated before a hos-

pital enters crisis capacity as a mechanism to help avoid providing cri-

sis standards of care.

New York made a decision to enter crisis capacity rather than

activate a triage system. This necessarily meant that hospitals were

providing crisis standards of care to all patients rather than normal

standards of care to fewer patients. Nursing and physician ratios were

tripled, non-ICU trained physicians were caring for ICU patients and

all manner of hospital spaces were repurposed to create rooms for

ICU level patients. One particular example was the provision of dialy-

sis. So many critically ill patients required dialysis that hospitals

quickly ran out of machines and supplies.31 This meant that in some

cases, in a manner not consistent with typical standards of care,

patients received fewer hours of dialysis than normal or had perito-

neal dialysis as a manner of stretching the supply of dialysis to meet

the demand.

As an acknowledgement of crisis standards of care and in order

to support clinicians’ ability to continue to care for so many patients,

the governor of New York passed the Emergency Disaster Treatment

Protection Act.32 The Act’s stated purpose is to broadly protect health

care facilities and professionals from liability for the treatment of

patients during the COVID-19 pandemic. The Act shields health care

professionals from civil and criminal liability in connection with

722 BUSTAN ET AL.

services provided to any patient as a result of and during the COVID-

19 crisis, so long as decisions are made in good faith. For decisions

that are alleged to be unlawful, the Act also provides immunity if they

result “from a resource or staffing shortage.” Such legal protections

were imperative to allow healthcare workers to continue to practice

in the crisis environment but also are a recognition that the provision

of crisis standards of care may contribute to adverse events.

While there are many ongoing conversations about whether

New York should have activated triage systems, I have never been

prouder of my city and my colleagues for their response to the

COVID crisis. Taking care of nearly 120 000 New York City

patients required perseverance, courage, resourcefulness and a will-

ingness to accept personal risk. It will be months before we have

outcomes data on the COVID patients and even longer before we

will fully understand the consequences of our decision to treat all

New Yorkers. But until then, we can stand tall in the knowledge

that while our healthcare system was under unprecedented stress,

we performed heroically and fairly.

3.2 | Fairness: Triage in the name of quality of life?
Mylène Botbol-Baum, Philosopher

Mylène Botbol-Baum, PhD (BELGIUM), is full professor in the faculty of

Medicine and Public Health IRSS in the Biomedical Ethics Unit (HELESI),

member of the Ethics Committee (INSERM France) and Professor in the

Philosophy Department, at UCLouvain, Belgium.

Katherine Fishkoff has been addressing the issue of fairness from

a regulatory perspective and the responsibility of the mayor of

New York who has decided to protect medical doctors from trials

when they take a reasonable decision in a context of emergency.

These decisions raise dilemmas linked to conflict of interests and

interpretations around the word fairness and even about what consti-

tutes a fairness dilemma.

My first question, as a European benefiting from a providence

state, is at what condition can we have fairness in an unfair system,

that is, a non-egalitarian context? What are our basic assumptions

about moral reasoning when we address dilemmas in situation of

uncertainty?

We must take seriously the health system capacity of anticipation

that refers to public health at large since the issue of fairness is essen-

tially a biopolitical issue, which has global consequences during a

pandemic.

We know that the pandemic reduction was not a priority for the

US government, and many other opulent countries did not prepare

adequately for it, so that the enormous responsibility to confront it

befell on the medical providers. This imposed on them an uneven

focus on present day patients, rather than the actual and prospec-

tively sick. If we speak of fairness, we state that reducing the pan-

demic risk is a global public good inscribed in a complex temporality.

• Who gets healthcare resources?

• Can it be based on meritocracy, age, or function?

• Can we apply the same principles to all COVID-19 and non-

COVID-19 patients?

• How to prioritize access to healthcare?

According to American bioethicists, referring to utilitarian princi-

ples, maximizing benefits is the most important principle, followed by

the principle of care vs stewardship of resources.

Prioritization should aim at both saving the most lives and all-

owing empowerment of individuals post-treatment (definition of

Dalys: to ensure future years of life with minimum handicap).

But what about the subjective perception of quality of life?

What kind of dilemmas are we confronted with, if we take the

subjective dimension of quality of life seriously and not only Qualys?

Dr Fishkoff underlines the dilemma of providing medical assis-

tance below our standard of care to all patients, vs normal standards

to fewer patients.

Is this a dilemma between equality vs quality of care?

How does the notion of fairness lead us to respond and resolve,

or not, the dilemma? It seems to me that there is no dilemma here

when the basic principle is care. We should indeed maximize care. For

instance, New York has a good public health system and has pro-

longed the obligation of social distancing. It should therefore not suf-

fer too much of scarcity of medical resources leading to dilemma.

If we want to solve this dilemma in terms of rational arguments,

we can address:

• Moral intuition

• Symmetry

• Incommensurability of the previous point

Dr Fishkoff tells us that the extreme shortage of dialysis machines

conflicts with caring for all, which does not support a systematic

account of triage. The difficulty is that the modern notion of dilemma

confronts us with an impossible choice, even though to exclude the

possibility of dilemma moral rules are precisely established to pre-

scribe the choice of one action and exclude the other. This dilemma

problem can thus be divided into two correlated parts:

1. The epistemological choice where it is logically difficult to deter-

mine what is my duty, when facing scarcity of ventilators for

instance (either/or).

2. When both actions are necessary, but I can only do one of them, I

encounter my finitude and my own vulnerability to act as an agent

of choice.

So that any agent of care, or doctor here, is confronted with two

sorts of conflict of obligation narratives:

1. One obligation is stronger than the other (so the conflict is not a

real one).

2. The two obligations are equivalent, and I am facing an unsolvable

dilemma because, in terms of fairness, there is no hierarchy

between the two choices.

BUSTAN ET AL. 723

But during a pandemic, which is a natural and societal threat, we

are facing the fact that rules can be consistent only if the context of

disruptions of my narrative representations, my narrative world, can

remain a consistent world as well.

In this disruptive moment, one realizes that rules are only useful if

there are circumstances in a possible world of coherence, which is

precisely what we lose in a situation of emergency, where all priorities

seem to be reversed.

Choosing is the first duty in a situation when there is a clear

hierarchy between the duty of care and the efficiency rule. In a

state of uncertainty and urgency, the agent chooses first and fore-

most according to what I called her moral intuition. Facing a

dilemma, she will use reason or moral rules to prioritize her deci-

sions. These two states might be in tension with the efficiency

logic of a public health ethics, where the collectivity is supposed

to come before the individual interest of the singular patient, as if

the collectivity was not constituted by individuals. Therefore, in a

situation of uncertainty, I would prefer to advise the bottom up

approach that combines moral intuition and rationality around the

notion of quality of life. The reason is that it associates fairness as

a form of loyalty to a subjective vision of quality of life or stan-

dard of living.

Indeed, the concept of fairness was developed within a frame-

work in which tastes or values, although varying among individuals,

remain constant.

We understand at this stage that the notion of fairness is hard to

use in the contingencies of a pandemic. Perhaps his is because, during

a pandemic, socially accepted values can be toppled upside down.

This could explain that, in New York, egalitarian care became the pri-

ority over the rationing of care, which is the accepted cultural model

in a highly competitive society based on meritocracy.

The climate of uncertainty and the sudden lockdown allowed for

the surrealist scenario that all former economic priorities have been

put aside from a quasi-species survival instinct.

So, what could have been a dilemma in normal settings? Econom-

ics vs Health becomes evidence in terms of moral intuition in times of

pandemics.

This fact is very reassuring about the human pragmatic capacity

to develop solidarity, above the logic of distributive justice and the

utility level associated with it.

In Amartya Sen’s terms, “Quality of life should come before

Qualys in order to maintain capabilities and functioning.”33 Life expec-

tancy after the pandemic in opulent societies, in terms of future

opportunities and capabilities, are precisely not invariant. They are

related to the well-being and capabilities of surviving individuals. Dalys

is a measure of the burden of diseases, which combines time lived

with a disability and the time lost due to premature mortality, esti-

mated with respect to a standard age-dependent life expectancy. So,

the notion of time lost because of the burden of a disease is very

important to correct the abstract notion of fairness.

This leads me to have a critical gaze on a notion of fairness based

on mere rationality.

3.2.1 | Rationality and consistency

In terms of rationality, the main rule of public health ethics is that

whatever rule is chosen must be applied consistently. Reasonable life

expectancy does not consider the dimension of narrative or care

ethics. Is it fair, can it be justified? For instance, young vs old, and the

equal value of life. One of the main issues of triage is the discrimina-

tion based on age. When do we begin to count the value of life? Is a

foetus more important than a teenager? The idea of withdrawing

treatment in a situation of scarce resources, in order to provide a res-

pirator to a younger person for instance, may reach consensus in

times of war, but here the metaphor of war is certainly not appropri-

ate. This pandemic emphasizes mostly a bad governing of resources

and not a lack of resources in the long term. The lack of anticipation

cannot justify withdrawing treatment. It would be unfair.

In a utilitarian model, scarce resources go first to efficient

patients. What do we lose in such a simplistic model? Should we pro-

vide care only to those who have instrumental value? This should be a

societal choice, which goes far beyond medical ethics and raises true

biopolitical dilemmas of distributive justice. Do we want to survive in

a society of care, or in a mere society of efficiency? We have known

this situation in Africa for access to drugs during the HIV/AIDS epi-

demic. Drugs were so scarce that medical doctors had access priority,

but then nothing was left for the patients. The efficiency model can

thus lead to absurd decisions, if no good decisions can be made to

resolve the dilemma.

3.2.2 | Rationing policies and the limit of their
rationality

Is a pandemic the appropriate moment to erase the plurality of judge-

ments and stop weighing each particular case in the name of urgency?

The risk of non-transparent rules of experts is to lose the confidence

of the public. Real time decisions are certainly harder than applying

efficiency rules. We should make room to moral intuition in entering

the framework of decision that leads to adapt the rules in context.

Should ethicists then help apply guidelines or assist with rationalizing

decisions? I doubt it. It would mean to transfer the responsibility from

the patient or his/her family to other efficiency bodies. I would sug-

gest avoiding these real and false dilemmas to prevent the scarcity of

medical resources by collaborating in solidarity with those who are

still handling the matters, the medical doctors themselves.

Paradoxically, this pandemic has isolated half of humanity. It

reminds us first that we are all mortals, and that is what makes us

equals. Secondly, solidarity is the main ethical principle to escape from

false dilemmas. What is a false dilemma? It questions rational evi-

dence in the face of moral intuition. It is interesting to note that no

regulation of triage rules has been adopted internationally, which rein-

forces the decision-making dimension associated with the survival

and the preservation of people’s abilities to survive. It could simply

mean that it is a matter of isolating patients at risk of dying or losing

724 BUSTAN ET AL.

their motor or cognitive abilities, if they are not treated, as an arbitrary

priority of these rules, or at least their relativity and adaptability.

These reflections force us to redefine the fairness models intro-

duced in this rationalizing, and to rethink a model of public health

founded not only on data driven medicine, but on deep and responsi-

ble democracy.

Can we really talk about scarcity, in our societies of abundance,

or is it more linked to ineffective management of priorities for the

social good, or to inadequate assets management?

The question will be why, and many speakers in the public debate

have stressed the unpreparedness of most states. It will also be neces-

sary to ask in what healthcare model this unpreparedness has been

possible, to clearly determine the responsibilities shared among the

different actors. We talk in peace time about the prioritization of care,

but some rulers preferred to talk about war, a term used to justify all

ethical transgressions. The wording of scarcity conditions is not

acceptable. It is necessary to give common reasons to all caregivers as

well as to the patients and their loved ones.

The procedural decision grids exist, but they do not free the med-

ical doctors from the difficult freedom of personal responsibility in the

heat of the moment. These tools are necessarily incomplete and

therefore do not exist, because a clinician will always have to use his

ethical imagination to practice a coherent care, adapted to any con-

text and to a diversity of needs in terms of gender, race, or class, hav-

ing fairness as its main horizon.

Indeed, if these decision-making grids are tools that have some

effectiveness in the emergency, we must not overlook the after-effect

of these decisions on the doctors and nurses in the aftermath of

pandemics.

Prioritization is a societal choice that makes us all co-responsible.

The main issue remains prevention, which can avoid both lockdown

and tracking, and foster collective intelligence instead of infantiliza-

tion. Fairness is thus more than equality because it is sensible to plural

forms of vulnerability, while always aiming at the recovery of capabili-

ties for each person. Fairness is a plastic notion that implies the articu-

lation of care and justice.

4 | THIRD ETHICAL MEDICAL DILEMMA:
DIGNITY

Does the need for increased awareness of public harm in a pandemic

justify impinging on patients’ rights to bodily and personal dignity

and privacy?

4.1 | Dignity: Laure Madé, Nurse

Laure Madé (FRANCE) is a practicing COVID-19 Nurse at Hospital

Bichat, Paris, and Epidemiologist. Trained as a nurse in France, she com-

pleted the MSc in Epidemiology at the London School of Hygiene and

Tropical Medicine. She has been working on emerging infectious diseases

at Institut Pasteur.

I worked as a nurse in a COVID-19 ward in a French hospital in Paris

during the COVID-19 outbreak. The Bichat hospital is a referral hospital

for the treatment of emerging infectious diseases and a leading player for

the management of epidemic and biological hazards. During this unprece-

dented sanitary crisis, I witnessed numerous situations where health pro-

fessionals faced ethical dilemmas in human lives. After fighting tirelessly

against COVID-19 in France and overseas, I am still wondering whether

we can effectively control this outbreak while treating both patients and

the deceased with sensitivity, dignity, and respect.

In early April 2020, we were overwhelmed with the media cov-

erage on COVID-19. Many patients in an artificial coma were

exposed to French TV news as an attempt to raise awareness of the

threat of the unseen virus. In France, patients have to give consent

to appear on TV, but this is not mandatory if they are unconscious

as long as their face is covered. According to French law, the con-

sent of the people filmed is not required when the image is illustrat-

ing a topical subject. I did not experience this specific situation as I

was not working in the ICU, but I know some colleagues who felt

uncomfortable dealing with this specific situation and found it par-

ticularly inappropriate.

We experienced other dilemmas during the outbreak that went

beyond the media issue. What called my attention was how the

patients were extremely terrified by being infected with COVID-19. It

was indeed a new disease, very contagious with no proven treatment

available. Every single health worker was entirely covered up with

protective personal equipment: mask, gloves, gown, cap, glasses, and

so on. All doctors looked similar and patients could not differentiate

the many different nurses. This was a very stressful environment for

them. On top of that, we could not enter the COVID-19 rooms as

often as we wanted because we had to restrict our visits to limit the

risk of contamination. Relatives and close friends were denied access

for the same reason. In many rooms, COVID-19 related news was dis-

played repeatedly on TV screens leaving these patients with feelings

of loneliness, isolation, and fear. They were fortunately allowed to

keep their phones with them and could, therefore, maintain a much-

needed virtual contact with their loved ones. Despite these chal-

lenges, we tried our best to reassure them, and we made sure to pro-

vide emotional support every time we interacted with them.

The fact that our country was unevenly affected meant that a lot

of human and material resources were allocated to the most affected

areas. We did not experience a lack of staff, as hundreds of health

workers came to help from different cities, including medical and

nursing students. We were lucky to have at least one nurse for every

four patients in the non-ICU. However, we had severe issues

accessing personal protective equipment, especially appropriate

masks.34 This was a major challenge because we really wanted to give

the best care possible to our patients, but we also needed to feel safe

and protected ourselves. We had an incredibly high number of sick

colleagues, and we even had to resuscitate one of them who was hos-

pitalized in our ward. The feeling of fear was shared by everyone,

patients, and health workers alike.

Finally, COVID-19 protocols in place at the time also impacted

the way we handled the deceased bodies. Whenever we had a death

BUSTAN ET AL. 725

in our ward, which was unfortunately frequent during the outbreak,

we had to put the body entirely naked in the mortuary bag.35 This sit-

uation was distressful as we felt that we could not honour the

deceased properly. We were not allowed to dress them up and the

family was not allowed to view them. The rationale behind this recom-

mendation was to limit the risk of contamination after death even

though no evidence of transmission of SARS-CoV-2 through the han-

dling of the body of a deceased person has been documented. The

French High Council for Public Health amended its recommendations

end of March36 when the risk of infectious transmission from bodies

was proven to be lower than for living patients. They allowed the

viewing of the body for mourners immediately and the presentation

of the body to the family. However, these less stringent guidelines did

not reach our hospital.

During this pandemic, health professionals faced ethical dilemma

situations more frequently due to various factors such as time

required for the healthcare system to adjust to the crisis (hiring extra

staff, set up of space/beds for patients, procurement of appropriate

protective equipment, etc.), intensive workload among others, and

potentially impacting the standard of care. But despite this stressful

period, our intent was always to keep humanity in the care provided.

Finding the right balance between the need to control the infection

and the respect of the patient’s and families’ rights is a difficult exer-

cise, but the dignity of the patients and the deceased should be

respected and must remain a priority, even in such chaotic time.

4.2 | Dignity: Rita Charon, Ethicist, Narrative
Medicine

Rita Charon, MD, PhD (USA), is Chair of Medical Humanities and Ethics

at Columbia University. A general internist and literary scholar, she is the

founder of the discipline of narrative medicine. With an MD from Har-

vard, PhD in English from Columbia, she conducts research on the impact

of humanities in medicine and is the author or co-author of four books on

narrative medicine.

I want to thank the Columbia Global Centers in Paris, Amman,

Nairobi, and Istanbul for sponsoring this symposium and insisting that

the pandemic is an international pandemic. The more we can remem-

ber that we are not isolated and not solving our own parochial prob-

lems, the more effective and just will be the outcomes of our actions.

Ms. Madé has just given us major testimony not only about the

privacy and dignity of the patient’s body but also about the privacy

and dignity of the other bodies in the room. I am very impressed with

what she just did. Here is why. I am a general internist and a literary

scholar. I study narratology – how stories are told and understood and

received and what happens in the world by virtue of the accounts we

give to one another. A group of humanities scholars and clinicians at

Columbia University developed the field of narrative medicine in the

early 2000s.37 We knew that the humanities, especially literary stud-

ies and creative arts, could make powerful contributions to health care

practices and concepts not just through the content of great novels

like Magic Mountain and Frankenstein but by harnessing literary and

aesthetic concepts of representation, close reading, inter-subjectivity,

temporality, and embodiment for use in the clinic. Our work over the

years has demonstrated that narrative skills can improve clinical care

in many ways, including expanding clinicians’ knowledge of individual

patients, strengthening teamwork, and reducing burnout.383940 It is

through the many-focaled lenses of narrative medicine that I have

approached this essay’s effort to reflect on issues of privacy and dig-

nity in the time of COVID.

The impressive part of what Ms. Madé just did, speaking from a

narrative medicine perspective, was to nest the clinical dilemma of the

nurses and physicians within the more encompassing clinical dilemma

of the patient, allowing her listeners or readers to consider the

embodied landscape of care as a whole. She started with the privacy

of patients’ bodies before and after death, outlining France’s policies

of privacy and confidentiality accorded to patients and their surro-

gates. Then she seamlessly drew in the opposite face of privacy of the

clinicians’ bodies – not that they are unduly exposed but that they are

unduly concealed in their personal protective equipment to the point

that patients and families cannot distinguish among their encapsulated

bodies. Through that deft narrative turn, Ms. Madé encourages us to

consider the patient and the clinician as a unit – one sick, perhaps

dying, the other risking sickness, perhaps death in the effort to care

for the patient. The fear for the clinicians’ own lives and the fear for

their colleagues’ lives cannot be separated from their fear for the lives

of their patients, levelling the typical hierarchy by the mournful, terri-

fying facts of this crisis.

We know that physicians in particular hold strict taboos regarding

their physicality within their professional actions. Usually, the body of

the physician does not enter the picture of medical practice. Touching

of patients is strictly governed (although such rules do not prevent

the occurrence of sexual assault on patients by their doctors). Gruel-

ling medical training drills the importance – and heroic implications –

for doctors to do without sleep and food and ordinary physical self-

care. It is not a surprise to learn that doctors are found to have greater

levels of anxiety about death than non-doctors but find powerful

ways to repress such fears.41 So Ms. Madé’s testimony gives us an

important and rarely articulated aspect of not just the ethical

dilemmas of this crisis but a profound paradox of health care in which

some who work very closely with dying persons are perhaps ill-

prepared to deal with their own and others’ mortality.

Doctors’ fear of death notwithstanding, Ms. Madé’s testimony

emphasizes the collective nature of our ethical responses to this

plague. Moral philosopher Charles Taylor situates his understanding

of personhood within the collective: “One is a self only among other

selves. A self can never be described without reference to those who

surround it… A self exists only within what I call ‘webs of inter-

locution’.”42 Framed by Taylor’s recognition of our webs of meaning-

making, I will emphasize in the rest of this essay those relational, cul-

tural sources of the moral compass that governs the actions of any

one of us. Like literature itself with its invisible and necessary con-

gress between writer and narrator, narrator and reader, and reader

and character, our inner lives and our consequential outward actions

are influenced by and opened up by our inter-subjective contact with

726 BUSTAN ET AL.

the other. With our patients and clinical colleagues, we are fellow

mortals, siblings under the planetary and even cosmic horizons that

locate us in time, space, and being.

Questions about the privacy of patients’ bodies are old, old

questions. Read the Journal of the Plague Year of Defoe and

Camus’s Dr Rieux in La Peste again if you have not done so

recently to see how these questions of privacy, ownership, and

custody of patients’ bodies dead and alive have been with us in all

the plagues of the 16th and 17th centuries and beyond.4344

Remember too, and this has been mentioned in earlier testimonies

in this symposium, that the hospital is a strange insoluble mix of

public and private. Illness itself is a subjective experience, a mean-

ingful experience that happens within the context of an individual

life as it is at the same time a public situation where some infor-

mal or professional group has to do the best they can to care for

and protect others. The public functions, however, risk precluding

attention to the individual’s subjectivity; as phenomenologist Hans-

Georg Gadamer asked, “Can science be connected once again with

our own lived experience, or must the experience of one’s own

individuality be lost irrevocably in the context of modern data

banks and new technology?”45

It was in the 18th and 19th centuries that the hospital became,

in the works of Foucault anyway, a place not where persons were

cared for but the place where physicians and scientists were able to

study and objectify their human bodies.46 Physician and philoso-

pher Mark Sullivan observes that “[i]n the new secular hospital

[of the 18th and 19th centuries] organized by disease categories,

the patient’s body became the object of scientific study and the

focus of clinical medical efforts. Patients with chronic illness that

could not be treated successfully within the hospital or clinic were

generally sent away.”47 The reductive efforts to study the heart,

the lungs, the kidneys so as to learn and not necessarily to be with

those who were suffering altered the nature of medicine indelibly

towards a time when hospitals needed public policies to protect

patients from medicine’s intrusions and instrumental uses of the

bodies of others.

But it was not until 1914 when Benjamin Cardozo wrote his deci-

sion in Schloendorff v. Society of New York Hospital that we had a

firm legal platform, at least in the US, to say the patient’s body

belongs to the patient. The plaintiff had given permission for an exam-

ination under anaesthesia, but while the patient was anaesthetised,

the surgeon removed a tumour from the abdomen. Cardozo’s judge-

ment was very clear. If a surgeon were to operate on a patient with-

out their consent, the surgeon would be liable to charges of criminal

assault.

With that rather sordid history as a background to this ques-

tions of privacy and dignity of patient’s bodies in our hospitals, let

me turn to the traditions and schools of thought that were not

available to Defoe or Rieux in their prior very similar plagues and

that now might help to guide us towards respectful and ethical care

of patients in this time of COVID. Professor Bustan referred to the

work of phenomenologist Emmanuel Levinas in the context of the

subjectivities and inter-subjectivities of clinical care. The

phenomenological traditions within continental philosophy are

poised to articulate the peculiar dilemmas of illness and embodi-

ment – how individuals find themselves within the world through

the sensations and affordances of the physical body and how one

embodied person is recognized and called into being by the fact of

another embodied person.48 The body is the avenue through which

the self lives in the world. Without our bodies, we are not in the

world. Through our perception, sensation, and motility, we are able

to not just address but to come into contact and to confront the

real, whatever the real might mean. Without the body, we would be

left only with our own imaginary representations of what we might

intimate is out there.

Situations of health care, especially the hospital during a time of

plague, poignantly enact the dramas of the body and the self that Hei-

degger, Husserl, Merleau-Ponty, and their followers so deeply investi-

gated. Such contemporary phenomenologists as Drew Leder and Havi

Carel continue the work of phenomenology by examining questions

of social justice – imprisonment and maltreatment of animals – and

the plight of individual patients whose serious and sudden illnesses

derail their ongoing lives.4950

When I discuss the body of the patient, I do not invoke the Carte-

sian assertion that one can think of one’s body as if disengaged from

or outside of it but, in Gadamer’s words, of “the absolute inseparabil-

ity of the living body and life itself” (45; p. 71). And so it is that I partic-

ularly appreciate Ms. Madé’s comments on dignity, coming from the

perspective of the nurse, that the body of the clinician as well as the

body of the patient is involved in these clinical questions. More than

medicine, nursing has been influenced by and has been the source of

care ethics and feminist ethics formulations that bear on our question.

The ethics of care, as proposed by Carol Gilligan in the 1980s and

continued by Nel Noddings and Joan Tronto, among many others

since then, focus on the relationship aspects of care.515253 From the

perspectives of care ethics, clinicians must be present themselves in

order for care to be ethically and clinically effective – present not just

in their cognitive and diagnostic capacities but in their moral, values-

based, and even physical incarnations in the orbit of the patient. Such

an ethics is a highly “costly” personal one, shifting the notions of duty

from disengagement to engagement. I believe this ethical perspective

clarifies some aspects of the dilemma we are faced with here. As one

follows the literature in the ethics of care and feminist bioethics, one

sees expansion beyond its initial focus on the perspectives of women

in health care towards non-gendered formulations of relational moral

visions, spreading from health care and education to inter-sectional,

global, political, and economic issues.54

At their cores, the feminist approaches in bioethics and care

ethics formulations seat the personal commitment of the caregiver –

family, teacher, health care provider, legislative representative, policy

maker – to address both the impersonal and personal dimensions of

the situation and its ethical calculus. The “address” is one-to-one, with

the one who is cared for – in whatever situation – and the one giving

the care as partners in the outcome. In our COVID setting, the

patient’s body is in the clinician’s hands. The patient’s body has been

entrusted to this clinician who is present in her own body, however

BUSTAN ET AL. 727

protected or unprotected from the physical and existential contact

she may be.

I conclude this essay by thinking back to our opening case, that

of the cameras in the ICU taking images from the bed of a dying

patient to broadcast those images into the public media. However

protected such photojournalism might be by France’s equivalent of

the US freedom of speech laws and however allowed such

photographing may be by the consent of surrogates, it seems to me

like a greedy gesture on the part of the media to take and display

what they think will be most shocking and the most potentially

“viral” of images. I wish the photographers were more skilled than

that. I wish they could capture perhaps less violent and intrusive but

perhaps more telling images. We all probably remember the Holo-

caust photographs of the pile of children’s shoes that most spoke to

the horror of that genocide. So my closing request is a request for

nuance instead of flamboyance, depth instead of shock. What we

have to endure in the pandemic requires our capacity to see in great,

great detail and delicacy all that unfolds, to not be catapulted to fac-

ile and false conclusions but to take the measure of the complexity

of the time and the need for our utmost discretion in learning and

teaching its lessons.

5 | FOURTH ETHICAL MEDICAL DILEMMA:
HONOURING DEATH

Does public interest in social distancing outweigh the patient’s right

not to die alone and the family’s right to be with their dying relative?

5.1 | Honouring death: Meinhard Kritzinger,
Clinician

Meinhard Kritzinger, MD ICU-Anaesthesia (Italy), is a specialist in anaes-

thesia and intensive care with diploma in tropical medicine and public

health. He has trained in Austria, South Africa, Italy, America, and in sev-

eral war zones working for MSF-Italy.

I am a consultant in Intensive Care Medicine and Anaesthesia

working and living in South Tyrol, the northern most Italian province

bordering Austria. We serve a population of 500 000 people with one

large and four smaller hospitals, all with ICU facilities. The experiences

I will recount are based partly on my own experiences and experi-

ences of fellow doctors working in the wards.

The 1990s was the last time that a special Italian law for infec-

tious diseases was applied for the then new “AIDS epidemic.” When

HIV patients were admitted to hospital, they had to stay in a newly

constructed unit, which had negative pressure isolation rooms and

closed doors. The rooms had glass panels facing balconies and the vis-

itors could see their relatives through the glass window.55

Since there were no real therapeutic options at this time, those

patients did not have any contact with relatives or the outside world.

Their families could only see them from the balconies through a

closed and locked glass window. As knowledge about this disease

improved, this inhumane practice was abandoned. Little did we know

that 30 years later, this practice was to be reintroduced.

On 31 January 2020, a state of emergency was declared and a

COVID task force, introduced by the Italian Ministry of Health, was

created to handle the health emergency crisis and to govern all clinical

decisions.56 End of February 2020 saw the beginning of a widespread

lockdown following the disastrous spreading of the disease in the

Province of Bergamo, situated 2 hours south of our hospital. There

were dramatic pictures from the overflowing emergency departments

and ICUs. The first cases in South Tyrol were diagnosed at the begin-

ning of March with the peak around middle of April.57

In the subsequent weeks, the number of ICU beds was

increased from 25 to 60. This was achieved by converting operation

theatres to ICUs, and normal wards were converted to COVID only

wards. Triage units were created and doctors from other depart-

ments such as dermatology, urology or ophthalmology found them-

selves in charge of newly admitted patients with almost daily

differing case definitions and treatment protocols. Diagnostic path-

ways and responsibilities changed throughout the emergency, and

doctors who never had seen a patient die under their care, had to

face dying patients every day.

By the beginning of April, at the peak of the epidemic, sick

patients were flown out to Germany and Austria. The daily death

count reached 10 patients a day with 234 patients admitted to differ-

ent hospitals in the region.58

When caring for terminal patients in ICU we would normally

invite family members to spend the last hours with their loved ones.

Despite strict visitor regulations of only one close family member per

patient and only close family, in such situations, makeshift rooms were

created with privacy screens, so that family could accompany their

loved one.

In the normal wards, family would be given ample space and

possibility to talk to nurses and doctors while staying with the

dying patient. Once the death had occurred, the corpse would be

brought to the hospital chapel, where the deceased would be

dressed and rested for 24 hours. This allows friends and family

spend some time in prayer with the deceased since it is not cus-

tomary to display the deceased in an open cask at the funeral in

our region. The next day, the mortician would remove the body

for the funeral, which takes place after a couple of days. Crema-

tion is the exception since people like to see a coffin at the funeral

and not an urn.

During the COVID epidemic, a “no visitor” policy was strictly

enforced by the task force for COVID but also non-COVID patients.

Doctors shifts were adjusted on daily basis as the workload dramati-

cally increased. Changing diagnostic pathways and triage options left

patients on the ward with a different doctor being responsible for

them almost daily. Dermatologists and ophthalmologists, who had

never cared for dying patients, let alone discuss terminal care faced

difficult situations, as they were never trained in this area. Daily

increasing patient numbers, uncertainty and fear to get infected

decreased the time, that staff interacted with family and patients to

the absolute minimum. Personal protection equipment with mask,

728 BUSTAN ET AL.

gown and a triple layer of gloves did contribute to reduce any per-

sonal contact.

The majority of the COVID patients were elderly and they had

to stay in an isolation room, deprived of human contact during

their final hours. In contrast to people dying of other diseases,

patients with COVID sometimes were lucid until the very end.

They were well aware that they were suffering from a disease

where no cure was known and they were about to die from

it. Nursing staff even at the deathbed was reduced to a minimum

for fear of contagion.

Not only did the patient have to die alone, sadly even family

members were also left on their own. They could not leave their

house as lockdown prohibited all movements so they could not even

meet to mourn.

In addition, frequently an elderly spouse was left alone at home

confused and startled by having to stay in quarantine, with their part-

ner taken in an ambulance with people dressed in gowns and masks,

only to have him or her back as ashes in an urn a week later.

Once the death had occurred, the corpses were undressed and

soaked with disinfectant and zipped into a plastic body bag. There

was no way any relative could see the deceased, nor was it possible

to dress the body with clothing sent from the family.

Once the ashes were returned to the household, funerals were

limited to 10 people attending and lasted for a couple of

minutes only.

To alleviate their patients’ final hours, the nursing staff would

sometimes stick printouts of photos of the family onto the surround-

ing walls, so that the patient could picture the presence of their loved

ones in the room. In one case, a little dog was smuggled into the isola-

tion unit for a quick farewell as this was the patient’s last wish. In

other cases, the relatives could see their loved ones through a glass

window standing on the balcony of the isolation unit. Even though

the regulations were uniform in the whole province, they were only

strictly adhered to in the main hospital. In the smaller hospitals, one

family member with protective clothing could sit with their dying

relative.

The provincial ethical committee was aware of this problem and

on the 1st of April, they wrote an urgent letter (attached in Appendix)

to the task force regarding the increasing loneliness of the patients,

the lack of patient’s involvement in therapeutic decisions and access

to terminal care (Irmgard Spiess RN, Alessandro Felici MD, e-mail

communication, April 2020). Unfortunately, this letter was never pub-

lished nor did the task force respond to this letter.

It was as if regarding the dilemma of honouring death, the epi-

demic had abolished patient’s rights.

5.2 | Honouring death: Jeremy R. Simon,
Philosopher and Clinician

Jeremy Rosenbaum Simon, MD, PhD (USA), is an emergency physician,

medical ethicist and philosopher of medicine on the faculty of Columbia

University. He is a member of several local and national ethics

committees and chair of the International Philosophy of Medicine Round-

table, the leading organization of philosophers of medicine.

The question at hand is Honouring Death: Does the public’s inter-

est in social distancing outweigh the patient’s right not to die alone

and the family’s right to be with their dying relative? The issues raised

by the situation Dr Kritzinger describes in this regard need to be ethi-

cally analysed on two levels. The first is the question of the nature of

the rights under consideration, and the second is the question of the

nature of rights in general at this time of public health crisis.

The dilemma as posed presupposes two different but related

rights. That of the patient not to die alone, bereft of their family, and

that of the family members not to be separated from their dying loved

one. Of course it would be difficult to honour one of these rights

without honouring the other, but with two rights in play, there are

more arguments to be made in favour of respecting them.

One might think that right of the dying person is the more power-

ful right here. The dying are often given special consideration due to

their status, even those being executed (last meal, cigarette, blindfold).

The right to have comfort in dying, which ordinarily is not problematic,

would seem to be something patients are entitled to. And certainly on

some level they are. Being alone in a stressful time is frightening, and

patients have a right not to be subject to undue fear. But if we focus

on the right to visitors particularly of the dying, and not all patients,

this right may seem to be somewhat reduced, especially in the current

situation. First, patients can only be considered dying for a brief part

of their hospitalization, when it becomes clear that they cannot be

kept alive much longer, or when life support is being removed. Thus,

any harm that may be caused by violating this right is mitigated by the

relatively short time during which the right is being violated and the

patients are exposed to unnecessary stress. Second, and this is rele-

vant particularly to COVID, a large percentage of the patients who die

are intubated and sedated at that point. Even to the extent that

patients in general may have a right not to die alone, it is not clear that

this right extents to unconscious patients. This is not to say that it

does not. It may be an intrinsic matter of human dignity not to be

abandoned at the time of death. But, even given that, hospitalized

patients are not abandoned; they are not even without those who

care for them. They are just without those with whom they have

long-term bonds of affection. Note that the second point is of limited

applicability, since many patients also die without being intubated. In

those cases, the other arguments presented here will have to suffice.

What then of the family? They are conscious, and the harm done

to them could potentially reverberate for years to come. And familial

rights are certainly recognized in medical ethics, at least when it

comes to surrogate decision-making. Perhaps it is their right that is

stronger. But, whether or not it is stronger, it cannot be absolute. For,

there is a very simple case where a hospital may, and must, keep out

such a visitor – at the patient’s request. Likewise, if the family member

has behaved badly, even to the staff, during prior visits. This is of

course not what is happening here. However, it does show that the

family’s right to visit is defeasible.

These, then, are the rights in question. What I have shown thus

far is not that they do not exist here, just that they may not be as solid

BUSTAN ET AL. 729

as they at first appear. The next question is, how should we approach

rights during the time of a pandemic. Traditionally, ethical analyses

can be broken into two types, consequentialist, or outcomes-based,

and deontological, or rules-based. A consequentialist, or utilitarian,

decides whether an action is right based on the outcome that results

– did the action create more good in the world than the alternative? A

rules-based ethicist sees whether an action follows certain ethical

rules – thou shall and thou shalt not – without looking to see what

the impact is of following the rules in a given case. But that dichotomy

is a bit misplaced here. Even a deontologist, a rules-based ethicist,

may have rules that take into account outside impacts. So to have a

specifically rules-based argument that visits to the dying is a right at

this time, one would have to have a rule that implied that not only

was it a right, but that it was a more or less absolute, first-tier right

that no amount of bad consequences could override. I have trouble

seeing this in general, and certainly in light of the arguments made

earlier.

That was a bit quick I am afraid. The main point was just to argue

that we need to analyse the ethics of our dilemma, as to whether the

public’s interest in social distancing outweighs the patient’s right not

to die alone and the family’s right to be with their dying relative, based

on the real world consequences of taking one side or the other, and

not based on abstract, timeless rules. Therefore, we are left consider-

ing the consequences of allowing or not allowing visits to dying

patients during the COVID pandemic.

Ultimately, answering this question requires objective data, or at

least assumptions about such data, about the risk to visitors of acquir-

ing COVID (and then also perhaps spreading it to others) and the risk

of their already having COVID and spreading it within the hospital.

This is information that I do not have. It also depends on the organiza-

tion of the ICUs and the potential for disruption visitors could create.

I know that at our hospital at Columbia, operating rooms have been

converted to ICUs, so that in addition to the MICU, or medical ICU,

and SICU, or surgical intensive care unit, etc., we also now have an

new beast called the ORICU, for operating room intensive care unit.

These do not necessarily have the same space and barriers that nor-

mal intensive care units have, and may have less room for extra peo-

ple in them.

How could one use this information to make decisions here? Cer-

tainly, if wearing a simple mask is enough to prevent getting or

spreading infection, then the danger to the visitor, the other patients,

and to society at large is not a real issue, and is not a reason to forbid

visitors. Of course, we do not know this to be the case, and so this

danger must be considered. Given the degree of disruption to every-

thing else that our assessment of the risk from COVID is causing, it is

not unreasonable (though not necessary) to take a conservative

approach here too. Note that the risk to the visitor is only part of the

issue here, and so we cannot simply leave it up to them to take on the

risk or not.

But even if the risk of virus transmission is small, the disrup-

tion to the intensive care units, and especially the makeshift ones,

could be real. And I think that there is an argument to be made

that if some intensive care units cannot have visitors, none should.

At the very least having different policies for different units would

lead to arbitrary distinctions between patients, and at the worst it

could lead to placing patients in preferred intensive care units for

non-medical VIP (“Very Important Person”) reasons, which is cer-

tainly unjust.

Thus, I think that while keeping visitors away from dying patients

is certainly a bad thing, it is not an absolute wrong, and may indeed be

justified at times, perhaps even now. We broadly restrict rights during

public health emergencies, and the right to visits is not stronger than

many of these, and is perhaps weaker than some of the even more

fundamental rights, such as engaging in religious worship and com-

merce, that life under COVID has, of necessity, interfered with. None-

theless, if it is possible to have a safe, nuanced policy, with small

numbers of visitors to those patients who would benefit from it, this

is certainly desirable.

Any philosophical analysis of difficult human issues is in danger

of losing the human, even when the analysis is rooted in the real

world. Without pulling back from the somewhat difficult conclusions

I have presented, I would like to pair them with a quotation from

Rodrigo Marquez. Marquez is the son of the novelist Gabriel Garcia

Marquez, author of Love in the Time of Cholera, and the quotations

comes from a column he wrote as a “letter” to his late father,

describing the pandemic to him. He says: “It’s not just death that fri-

ghtens us, but the circumstances. A final exit without goodbyes,

attended by strangers dressed as extraterrestrials, machines beeping

heartlessly, surrounded by others in similar situations, but far from

our people.”59

CONFLICT OF INTEREST

All authors declare no potential conflict of interest.

ORCID

Smadar Bustan https://orcid.org/0000-0002-9574-9289

ENDNOTE
1 I refer here to “superhomism,” as interpreted by Gramsci, depicting the

tendency to conceive of the individual affirmation as an “expansion of

the personality without moral constraints.”60 Originally, superhomism is

the concept of the Superman by Gabriele D’Annunzio and which has

been historically read through the lens of an autobiographical and intel-

lectual superhomism, whereby female characters fade into the back-

ground, often considered minor figures, either passive-ethereal helpers

or more active but negative antagonists, always bound to the male

protagonists.61

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SUPPORTING INFORMATION

Additional supporting information may be found online in the

Supporting Information section at the end of this article.

How to cite this article: Bustan S, Nacoti M, Botbol-Baum M,

et al. COVID 19: Ethical dilemmas in human lives. J Eval Clin

Pract. 2021;27:716–732. https://doi.org/10.1111/jep.13453

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http://www.provincia.bz.it/news/it/news.asp?news_action=4%26news_article_id=637469

https://doi.org/10.1111/jep.13453

1 GENERAL INTRODUCTION

1.1 The four ethical dilemmas

2 FIRST ETHICAL MEDICAL DILEMMA: RESPONSIBILITY

2.1 Responsibility: Mirco Nacoti, Clinician

2.1.1 Acknowledgements

2.2 Responsibility: Smadar Bustan, Philosopher

2.2.1 Acknowledgements

3 SECOND ETHICAL MEDICAL DILEMMA: FAIRNESS

3.1 Fairness: Katherine Fischkoff, Clinician

3.2 Fairness: Triage in the name of quality of life? Mylène Botbol-Baum, Philosopher

3.2.1 Rationality and consistency

3.2.2 Rationing policies and the limit of their rationality

4 THIRD ETHICAL MEDICAL DILEMMA: DIGNITY

4.1 Dignity: Laure Madé, Nurse

4.2 Dignity: Rita Charon, Ethicist, Narrative Medicine

5 FOURTH ETHICAL MEDICAL DILEMMA: HONOURING DEATH

5.1 Honouring death: Meinhard Kritzinger, Clinician

5.2 Honouring death: Jeremy R. Simon, Philosopher and Clinician

CONFLICT OF INTEREST

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