Posted: February 26th, 2023
Week 7
Week 7: System Level Interventions, Legislation, & Policy & Environmental Health
Legislation Discussion:
1. Identify a bill in your state House or State. Give the bill number and the chief author of the bill.
2. Brief description of the bill.
3. Identify the personal or professional interest that you have in this bill and state the reason why you would or would not encourage your representative to support this bill.
4. What could you do to advocate for this position?
Local Environmental Health Issue Discussion:
1. Using one of the following resources, identify a public health issue in your community. I encourage you to use one of the first 3 resources but if you need to you can use online resources.
- Interview with local official
- Local newspaper article
- Contact the local environmental group
- Online resources or others you may find.
2. Identify the county and state in which you live.
3. What are current local efforts being undertaken to address this issue?
4. Citing course resources, what is the significance of the role of public health nursing in environmental issues? Identify a public health nursing intervention that could be taken locally to address this particular concern (refer to MDH Intervention Wheel).
5. What Healthy People 2030 objective/goal would be addressed with this intervention?
When responding to your peers, compare your community with their community and give a suggestion of another public health nursing intervention that could be taken or identify an agency (other than public health) that could assist the community in addressing the issue.
Climate Change:
1. Identify a recent (within the past 5 years) national or global environmental health outcome that occurred due to climate change.
2. What were the potential/actual causes of climate change that contributed to this environmental health outcome?
3. What were the consequences of climate change on health, the environment, and/or the way we live? Give specific/actual examples related to your specific environmental health outcome.
4. What role may public health nurses take to address the needs of individuals and families at the time of your specified environmental health concern?
5. What are 2 specific actions/roles public health nurses can take to mitigate the long-term impact of climate change on health, healthcare, and/or the environment? What organizations may public health nurses join or collaborate with to address future environmental concerns related to climate change?
Public/Community Health
and Nursing Practice
CARING FOR POPULATIONS
SECOND EDITION
7711_FM_i-xviii 21/08/19 11:08 AM Page i
Public/Community Health
and Nursing Practice
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
F. A. Davis Company
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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
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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
xi
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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.
xv
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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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1
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
7711_Ch01_001-022 23/08/19 10:19 AM Page 6
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)
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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)
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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.
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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
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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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22 U N I T I n Basis for Public Health Nursing Knowledge and Skills
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23
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
30 U N I T I n Basis for Public Health Nursing Knowledge and Skills
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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
7711_Ch02_023-054 23/08/19 10:21 AM Page 31
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
io
n
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
7711_Ch02_023-054 23/08/19 10:21 AM Page 38
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
3
1
2
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.
7711_Ch02_023-054 23/08/19 10:21 AM Page 40
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.
7711_Ch02_023-054 23/08/19 10:21 AM Page 41
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
7711_Ch02_023-054 23/08/19 10:21 AM Page 43
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
7711_Ch02_023-054 23/08/19 10:21 AM Page 44
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
40
A
Yes 15 55
Disease (+ = BP �140/90)
B
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
7711_Ch02_023-054 23/08/19 10:21 AM Page 49
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
7711_Ch02_023-054 23/08/19 10:21 AM Page 50
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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7. Bauer, G., Davies, J.K., Pelikan, J., Noack, H., Broesskamp,
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public health and health promotion indicator development:
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8. Institute of Medicine. (2003). The future of the public’s
health in the twenty-first century. Washington, DC: National
Academies Press.
9. Golden, S.D., McLeroy, K.R., Green, L.W., Earp, J.A.L.,
& Lieberman, L.D. (2015). Upending the social
ecological model to guide health promotion efforts toward
policy and environmental change. Health Education &
Behavior, 42(1 suppl), 8S-14S. https://doi.org/10.1177/
1090198115575098.
10. World Health Organization. (2018). Health promotion.
Retrieved from http://www.who.int/topics/health_
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promotion: What do you think? American Journal of Health
Promotion, 23(2), iv. doi: 10.4278/ajhp.23.1.iv.
12. Li, A.M. (2017). Ecological determinants of health: food
and environment on human health. Environment Science
and Pollution Research International, 24, 9002-9015.
doi: 10.1007/s11356-015-5707-9.
13. World Health Organization. (2018). Social determinants
of health. Retrieved from http://www.who.int/social_
determinants/sdh_definition/en/.
14. Braveman, P., Egerter, S., & Williams, D.R. (2011). The social
determinants of health: coming of age. Annual Review of
Public Health, 32, 381-398.
15. Martins, D.C., & Burbank, P.M. (2011). Critical interaction-
ism: an upstream-downstream approach to health care
reform. Advances In Nursing Science, 34(4), 315-329.
doi:10.1097/ANS.0b013e3182356c19.
16. U.S. Department of Agriculture. (2018). National school
lunch program. Retrieved from https://www.fns.usda.gov/
nslp/national-school-lunch-program-nslp.
17. U.S. Department of Agriculture. (2018). Interim final rule:
child nutrition program flexibilities for milk, whole grains,
and sodium requirements. Retrieved from https://
www.fns.usda.gov/school-meals/fr-113017.
18. Morgan I.S., & Marsh, G.W. (1998). Historic and future
health promotion contexts for nursing. Journal of Nursing
Scholarship, 30(4), 379-383.
19. Pender, N., Murdaugh, C.L., & Poarsons, M.A. (2014).
Health promotion in nursing practice (7th ed.). Upper Saddle
River, NJ: Prentice Hall.
20. Dicker, R., Coronado, F., Koo, D., & Parish, G. (2012).
Principles of epidemiology in public health practice (3rd ed.).
Atlanta, GA, Centers for Disease Control and Prevention.
21. Centers for Disease Control and Prevention. (1992). A
framework for assessing the effectiveness of disease and
injury prevention. Morbidity and Mortality Weekly Report,
41(RR-3).
22. Centers for Disease Control and Prevention. (2009).
Novel H1N1 flu facts and figures. Retrieved from http://
www.cdc.gov/h1n1flu/surveillanceqa.htm.
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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31. Centers for Disease Control and Prevention. (2017).
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32. National Center for Health Statistics. (2017). Health,
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33. Institute of Medicine and National Research Council.
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37. World Health Organization. (2018). Health education.
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38. Shunk, D.H. (2012). Learning theories: An educational per-
spective (6th ed.). Boston: Pearson.
39. Bandura, A. (1977). Social learning theory. New York:
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40. Hughes, N., & Schwab, I. (2010). Teaching adult health
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41. Knowles, M.S. (1990). The adult learner: A neglected species
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42. The Institute of Medicine, Committee on Health Literacy,
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43. U.S .Department of Education, National Center for
Education Statistics. (2016). Skills of U.S. unemployed,
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46. Hersh, L., Salzman, B., & Snyderman, D. (2015). Health
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and-African-Americans_UCM_301832_Article.jsp#.
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adults: Evaluation of a short form of the CES-D (Center for
Epidemiologic Studies Depression Scale). American Journal
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tal cancer statistics. Retrieved from https://www.cdc.gov/
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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
55
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
40
35
30
25
20
15
10
5
0
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
0
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
7711_Ch03_055-076 21/08/19 11:06 AM Page 68
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., 100,000
e.g., 1,000
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
7711_Ch03_055-076 21/08/19 11:06 AM Page 70
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
7711_Ch03_055-076 21/08/19 11:06 AM Page 71
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
7711_Ch03_055-076 21/08/19 11:06 AM Page 72
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
C H A P T E R 3 n Epidemiology and Nursing Practice 73
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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
7711_Ch03_055-076 21/08/19 11:06 AM Page 74
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
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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
77
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)
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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
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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
s
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
s
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.)
A
B
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96 U N I T I n Basis for Public Health Nursing Knowledge and Skills
10
20
30
40
50
60
70
80
90
100
105
0
0
United States Virgin Islands: 2050
5 5
10
20
30
40
50
60
70
80
90
100
105
0
0
United States Virgin Islands: 2100
5 5
(Thousands)
10
20
30
40
50
60
70
80
90
100
105
0
0
United States Virgin Islands: 1950
5
FemalesMales
10
20
30
40
50
60
70
80
90
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
10
20
30
40
50
60
70
80
90
100
105
0
0
Somalia: 2050
4 2 2 4
10
20
30
40
50
60
70
80
90
100
105
0
0
Somalia: 2100
4 2 2 4
(Millions)
10
20
30
40
50
60
70
80
90
100
105
0
0
Somalia: 1950
4 2
Males Females
2 4
10
20
30
40
50
60
70
80
90
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
77
29
60
98
124
195
213
6,056
4,974
848
29.5
$43,750.00
171
10,164
5,039
5,125
9,018
122
33
45
101
152
693
189
6,591
6%
6%
6%
–2%
58%
14%
–25%
3%
23%
255%
–11%
9%
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.)
7711_Ch04_077-106 22/08/19 11:35 AM Page 102
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
2
3
4
5
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
E
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
7711_Ch05_107-127 21/08/19 11:04 AM Page 120
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.
7711_Ch05_107-127 21/08/19 11:04 AM Page 121
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
122 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 122
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.
C H A P T E R 5 n Health Program Planning 123
7711_Ch05_107-127 21/08/19 11:04 AM Page 123
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).
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4. Fawcett, S.B. (2018). Section 3. Our model of practice: Build-
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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.
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(2004). Population-based public health interventions: Practice-
based and evidence-supported. Part I. Public Health Nursing,
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11. U.S. Department of Health and Human Services. (2018).
Program planning. Retrieved from https://www.healthypeople.
gov/2020/tools-and-resources/Program-Planning.
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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
7711_Ch06_128-156 21/08/19 11:03 AM Page 129
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
7711_Ch06_128-156 21/08/19 11:03 AM Page 134
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
ed
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
0
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
7711_Ch06_128-156 21/08/19 11:03 AM Page 136
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
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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.)
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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
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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
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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
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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)
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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
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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
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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
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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)
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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
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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
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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?
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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
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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.
C H A P T E R 7 n Health Disparities and Vulnerable Populations 185
7711_Ch07_157-190 23/08/19 10:23 AM Page 185
• Health disparities disproportionately affect
members of racial, ethnic, minority, underserved,
and vulnerable groups and affect the overall health
of the United States.
• Social determinants of health including poverty,
access to care, cultural barriers, and education play
a role in increasing the vulnerability of certain
populations.
• Nurses are uniquely positioned to provide care for
vulnerable populations, functioning in a variety of
roles through which they enhance health and reduce
vulnerability.
• Certain populations like the homeless, migrant
workers, immigrants, refugees, the incarcerated, and
LGBTQ+ people are more likely to be vulnerable
and benefit from specific interventions and changes
in policy.
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t CASE STUDY
Vulnerability extends from the cellular to the global
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98. U.S. Department of Health and Human Services, Office of
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99. U.S. Department of Justice Bureau of Justice Statistics (n.d.).
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100. Gramlich, J. (2018, May 2). America's incarceration rate
is at a two-decade low. Pew Research Center. Retrieved
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low/.
101. Centers for Disease Control and Prevention. (2014).
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102. Kaeble, D., & Cowhig, M. (2018). Correctional populations
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cpus16 .
103. Zeng, Z., (2018, Feb 22). Jail inmates in 2016. Office of
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104. Love, D. (2018, Feb 12). Black incarceration rates are drop-
ping while white rates rise, but what’s really behind this sur-
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surprising-trend/.
105. Wagner, P., & Sawyer, W. (2018). States of Incarceration:
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106. Estelle v. Gambelle, 429 U.S. 97. (1976). Retrieved from
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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.
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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
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mxx020.
109. Turney, K., & Goodsell, R. (2018). Parental incarceration
and children’s wellbeing. Future of Children, 28(1),
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129524480&site=ehost-live&scope=site.
110. World Health Organization. (2018). Gender equity and
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gender-equity-rights/understanding/gender-definition/en/.
111. Human Rights Campaign. (2018). Glossary of terms.
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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.
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113. Bonvicini, K.A. (2017). LGBT healthcare disparities: What
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114. Healthy People 2020. (2018). Lesbian, gay, bisexual, and trans-
gender health. Retrieved from https://www.healthypeople.
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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.
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116. Newport, F. (2018, May 22). In U.S., estimate of LGBT
population rises to 4.5%. Gallup: Politics. Retrieved from
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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
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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
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0886260514556767.
121. Heina, L.C., Stokes, F., Smith-Greenberg, C., Saewycd, E.M.
(2018). Policy brief: Protecting vulnerable LGBTQ youth
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122. Clay, R. (2014). Double-whammy discrimination. American
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123. Perez-Brumer, A., Nunn, A., Hsiang, E., Oldenburg, C.,
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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
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125. United States Department of Justice. (2015). Matthew
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126. American Psychiatric Association. (2015). Guidelines
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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
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129. Centers for Disease Control and Prevention. (2016).
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html.
190 U N I T I I n Community Health Across Populations: Public Health Issues
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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
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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
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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
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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).
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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.
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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).
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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-
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39. Centers for Disease Control and Prevention. (2013).
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40. Healthy People 2020. (2018). Immunization and communica-
ble diseases. Retrieved from http://www.healthypeople.gov/
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41. Healthy People 2020. (2017). Healthy People 2020 Midcourse
Review Chapter 23: Immunization and communicable
diseases. Retrieved from https://www.cdc.gov/nchs/data/
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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://
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46. Centers for Disease Control and Prevention. (2018).
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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.
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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/
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49. Centers for Disease Control and Prevention. (2017). 2016
sexually transmitted disease surveillance. Retrieved from
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50. Centers for Disease Control and Prevention. (2016). Sexually
transmitted disease surveillance: Chlamydia 2016. Atlanta, GA:
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from https://www.cdc.gov/std/stats16/chlamydia.htm.
51. Centers for Disease Control and Prevention. (2016). Sexually
transmitted disease surveillance: Gonorrhea 2016. Atlanta,
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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:
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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
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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,
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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-
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59. Martin P.M.V., & Martin-Granel, E. (2006). 2,500-year
evolution of the term epidemic. Emerging Infectious Diseases,
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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
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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-
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63. Praditporn, P., & Wilawan, M. (2016). Challenges in the
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64. Koster, O. (2007). Flesh-eating bug killed top economist in
24 hours. Mail Online. Retrieved from http://www.dailymail.
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24hours.html.
65. Isabel. (2018). Isabel’s story. Retrieved from https://
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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
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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,
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73. Centers for Disease Control and Prevention. (2018). Measles
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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
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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.
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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)
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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)
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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)
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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
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C H A P T E R 1 0 n Mental Health 253
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To complete this case study, do the following:
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2. Determine which stakeholders should be involved in
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5. Complete a draft plan.
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short-form health survey (SF-36). I. Conceptual framework
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69. Institute of Medicine. (2005). Improving the quality of
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70. Substance Abuse and Mental Health Services Administra-
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71. Kroenke, K., & Unutzer, J. (2017). Closing the false divide:
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C H A P T E R 1 0 n Mental Health 255
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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
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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
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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
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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
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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
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86. Centers for Disease Control and Prevention. (2014). Best
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89. Meier, A., Moore, S.K., Saunders, E.C., Metcalf, S.A.,
McLeman, B., Auty, S., & Marsch, L.A. (2017). HotSpot
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90. Green, S. (August 16, 2017). Geisel students confront
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(2015). Toward cultural safety: Nurse and patient perceptions
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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
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20
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20
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14
20
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20
16
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99
0
2
4
6
8
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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
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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
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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
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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.
Choose one to implement.
3. Determine the level of intervention based on
whether it is primary, secondary, or tertiary as well
as whether it is universal, selective, or indicated.
4. Develop a draft plan of the program. Be sure to ad-
dress possible cultural concerns, key stakeholders,
and access to care.
5. Compare plans between teams. If you could
only implement one program, which would you
chose? Support your choice using a public health
perspective.
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308 U N I T I I n Community Health Across Populations: Public Health Issues
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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
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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
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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
(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
E
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%
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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7711_Ch13_313-342 21/08/19 11:13 AM Page 327
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
7711_Ch13_313-342 21/08/19 11:13 AM Page 331
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
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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
7711_Ch13_313-342 21/08/19 11:13 AM Page 338
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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
7711_Ch14_343-371 22/08/19 11:36 AM Page 344
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
7711_Ch14_343-371 22/08/19 11:36 AM Page 345
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
6
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
1
2
3
4
5
6
7
8
9
10
1
2
4
3
5
6
7
8
11
9
10
1
2
4
3
5
6
12
7
9
8
15
1
4
3
2
5
6
8
9
7
10
12
4
6
2
3
5
10
1
14
7
8
9
(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
7711_Ch14_343-371 22/08/19 11:36 AM Page 346
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
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
7711_Ch14_343-371 22/08/19 11:36 AM Page 355
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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68. McGill, F., Griffiths, M.J., & Solomon, T. (2017). Viral
meningitis: Current issues in diagnosis and treatment.
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0000000000000355.
69. Centers for Disease Control and Prevention. (2012). Surgical
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hai/ssi/ssi.html.
70. National Institute for Health and Care Excellence. (2017).
Surgical site infections: Prevention and treatment. Clinical
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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
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Epidemiology, 35, 605-627. DOI: 10.1086/676022.
72. Preas, M.A., O’Hara, L., & Thom, K. (2017). 2017 HICPAC-
CDC guideline for prevention of surgical site infection:
What the infection preventionist needs to know. Prevention
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tinymcefilemanager/periodical_images/api-q0414_l_ssi_
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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associated pneumonia: 2016 clinical practice guidelines by
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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
(UTI). Medscape. Retrieved from https://emedicine.
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
[UTI]) and other urinary system infection [USI]) events.
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7psccauticurrent .
82. Gould, C.V., Umscheid, C.A., Agarwal, R.K., Kuntz, G., &
Pegues, D.A. (2010). Guideline for prevention of catheter-
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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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85. Kagan, E., Salgado, C.D., Banks, A.L., Marculescu, C.E., &
Cantey, J.R. (2018). Peripherally inserted central catheter-
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86. Tobar, S., Olmsted, R., & Kast, R. (2018). Intersection
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89. Centers for Disease Control and Prevention. (2018).
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gov/drugresistance/protecting_patients.html.
C H A P T E R 1 4 n Health Planning for Acute Care Settings 371
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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
7711_Ch15_372-397 21/08/19 11:12 AM Page 379
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
7711_Ch15_372-397 21/08/19 11:12 AM Page 382
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
7711_Ch15_372-397 21/08/19 11:12 AM Page 383
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
7711_Ch15_372-397 21/08/19 11:12 AM Page 384
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
7711_Ch15_372-397 21/08/19 11:12 AM Page 385
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
7711_Ch15_372-397 21/08/19 11:12 AM Page 386
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
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
Month
Month
2 Months
Month
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.
7711_Ch15_372-397 21/08/19 11:12 AM Page 388
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-
gram for the parents and children who attend your
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
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• 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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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.
Retrieved from http://www.nachc.org/wp-content/uploads/
2018/08/AmericasHealthCenters_FINAL .
60. Vogt, H.B., Tinguely, J., Franken, J., Ten Napel, S. (2018).
Community health centers in the Dakotas, 2018. South
Dakota Medicine, 8, 355-360. doi:10.1056/NEJp1003729.
61. Patient-Centered Primary Care Collaborative. (2018).
Defining the medical home. Retrieved from https://www.
pcpcc.org/about/medical-home.
62. Patient-Centered Primary Care Collaborative. (2018). PCMH
success. Retrieved from https://www.pcpcc.org/news-tags/
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
1
2
3
4
5
6
7
8
9
10
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
WA
OR
CA
HI
ID
NV
UT
AZ
AK
MT
WY
CO
NM
ND
SD
NE
KS
OK
TX
LA
AR
MO
IA
MN
WI
IL
MI
IN
OH
KY
TN
MS
AL
GA
FL
PR
SC
NC
WV
VA
MD DE
DC
PA
NY
NJ
CT
RI
MA
VT
NH
ME
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
43
36
34
31
29
27
27
25
25
24
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
37
26
23
21
21
19
19
19
19
18
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
34
19
17
17
16
14
12
12
12
12
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
410 U N I T I I I ■ Public Health Planning
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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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education, transportation, food, and other necessities.
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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-
nizations and well-child care once a month at the local
library. All other health department services were pro-
vided in the county seat 26 miles away. The residents of
the community of 4,000 people started talking about
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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
3. Who can provide the primary care?
Reimagining Rural Health Care:
https://www.commonwealthfund.org/publications/
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rural-health-care
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https://www.forbes.com/sites/brucejapsen/2018/06/
05/nurse-practitioners-boost-presence-by-43-
in-rural-america/#5452017a648b
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C H A P T E R 1 6 ■ Health Planning with Rural and Urban Communities 419
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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
7711_Ch17_420-446 28/08/19 9:16 AM Page 420
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%
1%
8%
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
12
10
8
6
4
2
0
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
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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
7711_Ch17_420-446 28/08/19 9:16 AM Page 434
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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23. The American College of Obstetricians and Gynecologists,
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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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29. Potter, P. (2001). About the cover: Ignaz Philipp Semmelweis
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factors for sudden infant death syndrome following the
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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
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36. Parks, S.E., Erck Lambert, A.B., Shapiro-Mendoza, C.K.
(2017). Racial and ethnic trends in sudden unexpected
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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
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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
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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).
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71. SDHEC. (2011). At a Glance: 2009 Infant Mortality Statistics.
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72. South Carolina Healthy Connections. (2015). Centering
pregnancy: A successful model for group prenatal care.
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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
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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
60
50
40
30
20
10
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)
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.
7711_Ch18_447-478 21/08/19 11:11 AM Page 462
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
464 U N I T I I I n Public Health Planning
7711_Ch18_447-478 21/08/19 11:11 AM Page 464
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.
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• 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?
7711_Ch18_447-478 21/08/19 11:11 AM Page 473
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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
(%
)
70
60
50
40
30
20
10
0
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
15
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
15
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
15
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
486 U N I T I I I n Public Health Planning
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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
C H A P T E R 1 9 n Health Planning for Older Adults 487
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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
7711_Ch19_479-508 21/08/19 11:10 AM Page 489
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,
7711_Ch19_479-508 21/08/19 11:10 AM Page 490
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
7711_Ch19_479-508 21/08/19 11:10 AM Page 491
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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a. Assessment needs
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suited to meet the objective
c. Health-planning steps needed specific to the
chosen intervention(s)
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74. Savage, C.L., & Finnell, D. (2015). Screening for at-risk
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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
C H A P T E R 2 0 n Health Planning for Occupational and Environmental Health 513
7711_Ch20_509-536 21/08/19 11:09 AM Page 513
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
7711_Ch20_509-536 21/08/19 11:09 AM Page 517
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
518 U N I T I I I n Public Health Planning
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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
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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• 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
7711_Ch21_537-568 21/08/19 11:09 AM Page 537
(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.
538 U N I T I I I n Public Health Planning
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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
540 U N I T I I I n Public Health Planning
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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
542 U N I T I I I n Public Health Planning
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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)
Recommended
(Sufficient Evidence)
Insufficient Evidence
Insufficient Evidence
Recommended
(Strong Evidence)
Insufficient Evidence
Insufficient Evidence
Insufficient Evidence
Recommended
(Strong 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
7711_Ch21_537-568 21/08/19 11:09 AM Page 550
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
(Strong Evidence)
Recommended
(Strong Evidence)
Recommended
(Strong Evidence)
Recommended
(Strong Evidence)
Recommended
(Strong Evidence)
Recommended
(Strong Evidence)
Recommended
(Sufficient Evidence)
Recommended
(Sufficient Evidence)
Insufficient Evidence
Recommended
(Strong Evidence)
Recommended
(Strong Evidence)
Recommended
(Strong Evidence)
Recommended
(Sufficient Evidence)
Insufficient Evidence
Insufficient Evidence
Insufficient Evidence
Recommended
(Sufficient 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
7711_Ch21_537-568 21/08/19 11:09 AM Page 552
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
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
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
7711_Ch21_537-568 21/08/19 11:09 AM Page 555
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
7711_Ch21_537-568 21/08/19 11:09 AM Page 558
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
7711_Ch21_537-568 21/08/19 11:09 AM Page 559
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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As a public health nurse in a small rural community
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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
7711_Ch22_569-606 22/08/19 11:13 AM Page 569
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
7711_Ch22_569-606 22/08/19 11:13 AM Page 571
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
7711_Ch22_569-606 22/08/19 11:13 AM Page 572
(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
7711_Ch22_569-606 22/08/19 11:13 AM Page 573
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
7711_Ch22_569-606 22/08/19 11:13 AM Page 574
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.
7711_Ch22_569-606 22/08/19 11:13 AM Page 575
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
7711_Ch22_569-606 22/08/19 11:13 AM Page 576
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
C H A P T E R 2 2 n Health Planning for Emergency Preparedness and Disaster Management 579
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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.
Any body part may be
affected.
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
C H A P T E R 2 2 n Health Planning for Emergency Preparedness and Disaster Management 591
7711_Ch22_569-606 22/08/19 11:13 AM Page 591
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
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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
7711_Ch22_569-606 22/08/19 11:13 AM Page 599
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
7711_Ch22_569-606 22/08/19 11:13 AM Page 600
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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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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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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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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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
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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
Copyright
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
127
‘‘
’’
CHAPTER
6COMPETENCY #4
Practices Within the Auspices
of the Nurse Practice Act
n Marjorie A. Schaffer
with Jill Timm
Jennifer, a public health nurse (PHN), has worked for the Weaver County Health Department for 10 years.
Jennifer’s first nursing position, after completing her bachelor of science in nursing (BSN) and passing
nursing boards, was on a medical-surgical unit in a large metropolitan hospital. Since her public health
experience in nursing school, she has been anxious to find a PHN position. She now works at a small local
health department in the town of Aurora, the county seat of Weaver County.
Aurora is surrounded by an agricultural community. Corn, soybeans, and sugar beets are the major
crops. Cattle are also raised in this area. The town of Aurora has a population of 15,000. German immi-
grants settled Aurora in the 1850s. Today, Aurora is a multicultural community. The racial makeup is 91%
Caucasian, 2% African-American, 2% Hispanic or Latino, 1% Native American, 1% Asian, 1% Pacific
Islander, and 1% other. The median income is $33,000.
Weaver County has a significant population of migrant workers from Mexico who provide a large
portion of the workforce for many farms in the area and also provide the labor for a poultry-processing
company located on the northern edge of the county. This processing company opened 10 years ago. The
town has needed to learn to adapt to a new cultural group.
Sarah, a public health nursing student, has been assigned to work with Jennifer to complete her public
health nursing field experience. She is excited to start this experience. Sarah is completing her undergrad-
uate BSN degree at a university about 45 miles from Weaver County. She is familiar with Weaver County
only through media reports regarding the difficult racial issues in the county over the past years. Sarah
grew up in an urban area, where a variety of cultures and races were represented. She is Korean and was
adopted into an American family as an infant. Sarah is eager to learn not only about the role of the PHN
but also how the community environment affects the work of the Weaver County Public Health Depart-
ment and its PHNs.
As Sarah has been reflecting on her public health nursing class, she remembers the three core functions
of public health—assessment, policy development, and assurance. Along with this underlying framework,
Sarah knows the importance of the Cornerstones of Public Health Nursing. She is particularly interested
in learning about how independent nursing practice is carried out and how PHNs use the Public Health
Intervention Wheel in Weaver County. Sarah will spend 5 weeks with Jennifer, learning as much as possi-
ble about public health nursing.
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128 PART II n Entry-Level Population-Based Public Health Nursing Competencies
SARAH’S NOTEBOOK
COMPETENCY #4 Practices Within the Auspices of the Nurse Practice Act
A. Understands the scope of nursing practice (independent nursing functions and delegated medical functions)
B. Establishes appropriate professional boundaries
C. Maintains confidentiality
D. Demonstrates ethical, legal, and professional accountability
E. Delegates and supervises other personnel
F. Understands the role of a public health nurse as described under public health nursing registration
G. Considers how to practice public health nursing in a variety of public and private healthcare settings
Source: Henry Street Consortium, 2017
USEFUL DEFINITIONS
Accountability: “To be answerable to oneself and others for one’s own choices, decisions and actions as
measured against a standard” (American Nurses Association [ANA], 2015, p. 41).
Assignment: “Designating nursing activities or tasks to be performed by another nurse or unlicensed assistive
person” (Minnesota Nurses Association, 2013, p. 10).
Confidentiality: Nondisclosure of health information that is considered to be private.
Delegation: “Transferring to a competent individual the authority to perform a selected nursing task in a selected
situation” (Minnesota Nurses Association, 2013, p. 10).
Independent Practice: Professional decision-making guided by professional standards of the profession; scope
of practice that includes independent functions might also be defined legally.
Nurse Practice Act: State statute that describes the practice of nursing; describes scope of professional nursing
practice.
Professional Boundaries: “The spaces between the nurse’s power and the patient’s vulnerability. The power of
the nurse comes from the nurse’s professional position and access to sensitive personal information” (National
Council of State Boards of Nursing, 2014).
Public Health Nursing Registration: Requirements for practicing public health nursing, which are not universal
across all states.
Reflective Supervision: A supervisor-supervisee relationship that pays attention to the influence of relation-
ships on other relationships, the parallel process, and empowers the supervisee to discover solutions/concepts
through consciously using strategies that include active listening and waiting. The goal of reflective super-
vision is to support staff who then support families and create a more effective working relationship (Zero to
Three, 2017).
Supervision: Guidance by an RN “consisting of the activities included in monitoring as well as establishing the
initial direction, delegating, setting expectations, directing activities and courses of action, critical watching,
overseeing, evaluating, and changing a course of action” (Minnesota Nurses Association, 2013, p. 10).
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129CHAPTER 6 n Competency #4
settings differs from the experience of nurses in hospitals
and other structured settings, in which medical orders
are required for many nursing tasks. On some occasions
in public health settings, a physician’s order is needed for
reimbursement from insurance, Medicare, or Medicaid for
public health nursing services. Standing orders for vaccina-
tions or condition- specific protocols also require physician
oversight and review.
Understanding Public Health
Nursing Roles Ethically, Legally,
and Professionally
This chapter discusses the Nurse Practice Act and how state
legislation guides independent practice in public health
nursing. Every state has its own Nurse Practice Act that
lays out legal specifications for definitions, titles, licensing,
and other parameters for the practice of nursing. Because
much of public health nursing involves independent
decision-making on the part of nurses and in collabora-
tion with others, PHNs need to be aware of how the Nurse
Practice Act for their state guides their professional role and
defines professional accountability. Nurse Practice Acts also
address the scope of practice for advanced practice regis-
tered nurses.
Each state has a board of nursing that develops guide-
lines through rules and regulations that go through a public
review before they are enacted. The board of nursing also
sets standards for prelicensure nursing education and clini-
cal learning experiences, reviews complaints of misconduct,
and follows up with any needed disciplinary action. Amber
Zupancic-Albin, a nurse and lawyer, describes each state’s
Nurse Practice Act as “your nursing rulebook,” which speci-
fies rules for ethical and professional conduct for nurses. She
represents nurses who are being investigated by the nursing
board for a violation of the act. Zupancic-Albin identified
five categories of common violations: failure to promote
patient safety, dishonesty, controlled substances, improper
supervision or delegation, and poor documentation and
communication (Zupancic-Albin, 2017).
Although Nurse Practice Acts vary somewhat among
states, they all include the following components (Russell,
2012, p. 37):
n Definitions
n Authority, power, and composition of the board of
nursing
n Educational program standards
n Types of titles and licenses
n Protection of titles
n Requirements for licensure
n Grounds for disciplinary action, other violations, and
possible remedies
States may revise their Nurse Practice Act based on new
roles and expertise in the nursing profession. For example,
Evidence Example 6.2 addresses the addition of holistic,
complementary, and integrative therapies into the scope
of practice.
When PHNs practice independently, they make deci-
sions based on their own expert knowledge and skills,
professional standards, and the best evidence that guides
nursing practice. Independent practice in public health
TABLE 6.1 Nurse Practice Act Themes
Theme
Percentage of
Occurrence
Care in the context of nursing 98%
Nursing process
88%
Supervision or delegation of nursing 82%
Executing the medical regimen
73%
Health maintenance and prevention 65%
Teaching nursing 65%
Source: Jarrin, 2010, p. 170
EVIDENCE EXAMPLE 6.1
Core Elements of U.S. Nurse Practice Acts
Jarrin (2010) conducted an analysis of the core elements
of Nurse Practice Acts in the United States for all 50 states
and the District of Columbia. The researcher used quali-
tative analysis software to identify the major themes and
frequency of occurrence in the Nurse Practice Acts (see
Table 6.1).
EVIDENCE EXAMPLE 6.2
American Holistic Nurses Association
Nurse Practice Act Summary
The American Holistic Nurses Association is conducting
a yearly analysis of Nurse Practice Acts about language
changes that address holistic, complementary, or integra-
tive therapies in the RN scope of practice. Four states (Illi-
nois, Nevada, Oregon, and Texas) recognize holistic nursing
as a specialty. Seventeen states include references and/or
identify separate position statements on holistic or com-
plementary health approaches (American Holistic Nurses
Association, 2016).
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130 PART II n Entry-Level Population-Based Public Health Nursing Competencies
What Is the Scope of Public Health
Nursing Practice?
Chapter 1 explains that the scope of practice includes the
boundaries of safe and ethical practice. The Public Health
Intervention Wheel (see Chapter 2) describes what PHNs
do and further explains activities that fall within the scope
of public health nursing practice. In public health nursing,
PHNs often collaborate with staff from different disciplines.
It is important to clarify job descriptions and professional
roles so that representatives from each discipline make the
best use of their specific expertise as they work together on
reaching a common goal.
TABLE 6.2 Task Analysis of PHN Interventions
Task/Intervention Frequency
Emergency preparedness
100%
Health teaching to individuals
and families
100%
Receive and make referrals 100%
Immunization clinics 93%
Health promotion/prevention programs
in the community
88%
Case management 88%
Facilitate vulnerable individuals’ access
to services
87%
Work with groups related to public
health issues
87%
Home visits 83%
Health teaching to groups 82%
Work with vulnerable children
and/or adults
81%
Investigate disease and other health
threats
78%
Health screening 78%
Educational classes, meetings,
workshops for providers
73%
Advocate for increased healthcare
availability and access
70%
Community organizing activities 60%
Lead groups related to public health
issues
47%
Source: Schaffer et al., 2015
In addition to PHNs, examples of other occupations in
the public health workforce are clerical staff, health educa-
tors, nutritionists, epidemiologists, emergency preparedness
staff, environmental health workers, information special-
ists, and public health physicians (Beck & Boulton, 2015).
The Institute of Medicine (IOM) released a progress report
on its 2010 seminal report on The Future of Nursing: Leading
Change, Advancing Health that delineated the competencies
and skills needed by nurses in order to be fully instrumental
in influencing delivery of care in a rapidly changing health-
care environment. For PHNs, the development of skills and
competencies in interprofessional collaboration and lead-
ership is necessary for working with others to accomplish
health system redesign that aims to provide quality, accessi-
ble, and affordable care (IOM, 2015).
A study on the work of PHNs (Schaffer, Keller, & Reck-
inger, 2015) demonstrated the breadth and consistency of
public health nursing practice. Sixty PHNs, representing
28 states, completed two online surveys about their pro-
fessional activities. Many of the activities implemented by
the PHNs were consistent with the interventions from the
Public Health Intervention Wheel and represent the scope
of public health nursing practice. See Table 6.2 to find out
which interventions PHNs in the study used most often.
In this same study, the PHNs were asked which activities
they thought had the greatest impact on the health of the
community. The activities they perceived to have the greatest
impact were: “(1) childhood immunizations, (2) communi-
cable disease (including tuberculosis and sexually transmit-
ted infections), surveillance, education, and investigation,
(3) maternal and child health-focused activities (early inter-
vention and school readiness activities, prenatal and parent-
ing education, case management of high-risk families, and
growth and development follow-up), and (4) linking peo-
ple to resources” (Schaffer et al., 2015, p. 716). When asked
about how the lack of public health nursing services would
affect the health of the community, they identified the fol-
lowing potential negative effects: (1) an increase in disease
and health problems, (2) worse health related to no focus on
prevention, 3) loss of services for vulnerable populations, (4)
a negative impact on the public health system, and (5) nega-
tive effects for local health departments.
Study participants observed that PHNs are viewed as
trustworthy, approachable, and holistic, which contrib-
utes to the public’s confidence in recommendations made
by PHNs. A PHN captured the important contribution of
PHNs to the health of communities:
While all aspects of public health are important, it
is the nurse who pulls all the little pieces together.
It is the nurse who looks at the big picture to ensure
services are being received (p. 118).
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131CHAPTER 6 n Competency #4
‘‘
’’
EVIDENCE EXAMPLE 6.3
Independent Practice
A national sample of school nurses completed an electronic
survey on their use of the public health interventions as defined
in the Public Health Intervention Wheel. Screening, referral
and follow-up, case management, and health teaching were
the most frequently performed interventions. School nurses
reported that they spent 65% of their time on individual-level
interventions, 22% on community-level interventions, and
14% on systems-level interventions. Participants reported con-
ducting activities consistent with the Public Health Interven-
tion Wheel, although 67% of the participants were not familiar
with the Wheel. The Public Health Intervention Wheel can be
used by school nurses to guide their practice and explain to
the school community what school nurses do. Understanding
Wheel interventions at the three levels of practice will assist
school nurses in improving the health status of a greater num-
ber of students at the population level (Schaffer, Anderson, &
Rising, 2016).
In Hennepin County, Minnesota, the Perinatal Hepatitis B
PHN serves a growing population of refugees and immigrants.
The program provides case management, contact investiga-
tion of household members, monitoring of immunizations and
titers (test for presence of antibodies) for exposed infants,
and education to address cultural myths about Hepatitis B for
pregnant women who are antigen-positive. The PHN collabo-
rates with the medical provider, social worker, mental health
worker, and family members at clinic visits and, through case
management, makes any needed referrals. Program effective-
ness is measured by improved outcomes in vaccine and serol-
ogy completion for infants (from 92% to 100%), increases in
the number of women referred to liver specialists for follow-up,
and increases in the number of referrals of sexual partners
and household members for follow-up (Przybilla, Johnson, &
Hooker, 2009).
Sarah’s first day of her public health nursing clinical expe-
rience with Jennifer begins right away on Monday morn-
ing. Sarah meets Jennifer at the Public Health Office at 7:30
a.m. She met Jennifer briefly a week earlier, but this is the
first time that Sarah will have the opportunity to observe
nursing through the eyes of a PHN.
Sarah rides with Jennifer. Jennifer has three home visits
scheduled for the morning, followed by two home visits in
the afternoon. Jennifer briefly describes the three morning
home visits, which are to families whom she knows from
previous visits: (1) a 93-year-old woman with congestive
heart failure who lives alone, (2) a toddler with an elevated
lead level whose parents had emigrated from Mexico last
year, and (3) a 17-year-old with a 3-month-old girl. After
the morning visits, Jennifer plans to return to the office for
a short time to make any follow-up phone calls and review
plans for the afternoon home visits.
See Table 6.3 on the next page for Jennifer’s schedule.
Expanded Description of Activities
Asthma Coalition: One of the school nurses in Aurora
noticed that more and more children with asthma were com-
ing to her office every year. She mentioned this concern to a
local physician, who had also noticed an increase in pediat-
ric patients needing asthma-related care. The school nurse
contacted the public health department to find out whether
it was aware of an increase in asthma rates in the county or
state. The timing of that call was good—the public health
nursing director had just learned of funds that were avail-
able for starting a coalition related to asthma in children.
The state and county statistics were showing an increase in
asthma cases over the past five years. Based on these conver-
sations, a coalition was formed. Currently one of the PHNs
is the chairperson of this coalition, which meets monthly to
identify ways to increase public and provider awareness of
methods to manage asthma. This coalition includes school
nurses, nurse practitioners, physicians, PHNs, coaches, and
parents of children with asthma.
Diversity Coalition: This is a group of community part-
ners (educators, healthcare providers, local business own-
ers) who are interested in supporting the various groups
represented in Aurora. The overall goal of this group is to
make Aurora a welcoming community for everyone. One of
the elementary school teachers in town initiated this group,
as he was observing segmentation of racial groups that led
to tension not only in the elementary school but also in the
community at large.
Foot Care Clinic: Twice a month, the PHNs hold a
clinic to provide foot care for senior citizens at the commu-
nity senior center. The PHNs worked with a podiatrist in
the community and the public health medical director to
develop a foot-clinic protocol and referral system. Because
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132 PART II n Entry-Level Population-Based Public Health Nursing Competencies
TABLE 6.3 Jennifer’s Schedule
Time Monday Tuesday Wednesday Thursday Friday
8am–9am Home visit: Hanson Staff meeting Prep for immuniza-
tion clinic
Women, Infants,
and Children Clinic
Intake, referrals,
and nursing
documentation
9am–10am Home visit: Garcia Diversity Coalition
meeting
Immunization clinic Women, Infants,
and Children Clinic
Weekly reflective
supervision
10am–11am Home visit: Loften Diversity Coalition:
Collect county data
for grant application
Immunization clinic Women, Infants,
and Children Clinic
Intake, referrals,
and nursing
documentation
11am–12pm Office: Follow
up on calls, new
referrals, nursing
documentation
Intake, referrals,
and nursing
documentation
Meet with program
manager to deter-
mine funding for
Asthma Coalition
Women, Infants,
and Children Clinic
Intake, referrals,
and nursing
documentation
12pm–1pm Lunch Lunch Lunch Lunch Lunch
1pm–2pm New Referral Home visit:
Ahmed
Prep for foot clinic
at community center
Office: Follow up
on phone calls and
referrals, prep for
afternoon home
visits
Prep for
immunization
clinic
2pm–3pm New Referral Home visit: Johnson Foot care clinic Home visit:
Wallis
Immunization
clinic
3pm–4pm
Nursing
documentation
Nursing
documentation
Foot care clinic Home visit:
Froeland
Immunization
clinic
an identified need existed in the community to provide basic
skin and nail care and assessment for elderly citizens, this
has been a very popular clinic. Two PHNs staff the clinic.
Immunization Clinic: Each week, the public health office
holds an immunization clinic where people can receive low-
cost vaccinations for children or adults in their families.
The clinic is held at the local health department, which is
centrally located. It is a walk-in clinic, so no appointments
are required. Each PHN takes a turn staffing the clinic. One
PHN oversees the clinic by ordering vaccines, following
current protocols for administration, and informing the
PHNs of updated information.
Phone Triage and Intake: The PHNs all take turns pro-
viding intake services. During this time, the PHN works on
documentation or projects at his or her desk and answers
calls that come to the agency that require a PHN to assess
and provide feedback. Examples of the types of calls include
referrals for home visiting services, questions about where
to get a car seat inspection, parents asking where to get vac-
cinations, or daycare providers worried about head lice.
Reflective Supervision: Each week PHNs in the agency
meet with their supervisor for reflective supervision. This
time is set aside for the nurse and supervisor to thoughtfully
consider the families receiving home visiting services. The
time allows the PHN to consider ethical or other challenges
in providing services, and it allows the nurse to consider his
or her own thoughts and reactions to each family.
WIC Clinic: Women, Infants, and Children (WIC) is a
federally funded food program administered by states and
counties that provides screening, nutrition counseling, and
health referrals for pregnant and breastfeeding women
and their children from birth to 5 years of age. In Aurora,
PHNs and nutritionists from the Health and Human Ser-
vices department staff this clinic twice a month at the pub-
lic health nursing office. Jennifer’s role is to provide height,
weight, and hemoglobin checks for the children and preg-
nant women in the program.
Sarah’s assignment for the day was to observe Jennifer’s
communication and actions. Sarah planned to take notes
about her observations and communication between the
PHN and her clients. See Sarah’s notes.
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133CHAPTER 6 n Competency #4
SARAH’S NOTEBOOK
Activity Sarah’s Observations
Visit 1: Lily Hanson, a
93-year-old woman with
congestive heart failure.
Lives alone.
Arrived at a four-plex apartment building. The yard and building were maintained
well, with big shade trees, grass, and flower beds surrounding the building. Lily’s
apartment was on the first floor (no steps). Jennifer knocked on the door and
opened it slightly; Lily called to Jennifer to come in. Lily was sitting at the dining
room table and using her portable oxygen, neatly dressed, with her pill bottles
lined up. The apartment was well kept, with many photos on the walls.
A fan was running quietly in the corner of the living room. Jennifer completed a
heart and lung assessment and asked Lily about her activity level. Lily reported
that even in the hot, humid weather, if she stayed indoors with the fans running,
she felt comfortable. Jennifer filled Lily’s pillbox for the week. Jennifer also asked
Lily about alternate plans if her apartment became too hot for her to tolerate. Lily
reported that she did have a window air conditioner, but it broke, and she did not
have enough money to buy a new one. Jennifer suggested that Lily call the County
Senior Support Network (SSN). The SSN has funds for elders in need of basic
housing supplies. In this heat wave, Jennifer has learned that the SSN will provide
air conditioners.
Jennifer talked to Lily so naturally. Jennifer explained that she had known Lily for
three years. The first year she came to visit, Lily was not friendly at all. She thought
Jennifer was visiting to get information that would cause her to go to a long-term
care facility. After that first year and many short conversations, Lily accepted
that Jennifer was trying to help her maintain her independence so that she could
continue to live in her apartment. Jennifer hypothesized that her persistence and
nonjudgmental attitude helped Lily realize she was there to support her.
Visit 2: Toddler with
an elevated lead
level whose parents
emigrated from Mexico
last year
Drove to an older part of town with many single-family homes. Much of the paint
had worn off or was peeling. In most of the yards, the grass was worn away, and
there were many children’s toys. Jennifer rang the doorbell, knocked, and called in
the front window, but there was no response. There was no response to a phone
call either. Jennifer explained that sometimes families might not be home even
though an appointment had been made for the visit. Persons living in poverty
experience more crises, and with fewer resources they might live from day to day,
with less emphasis on future planning. I thought about how persons living with
poverty might more often choose to meet survival needs and how these choices
are consistent with Maslow’s Hierarchy of Needs theory.
Visit 3: First-time
17-year-old mom,
Jewel, who has a
3-month-old girl
Stopped at an old apartment building that had broken glass on the front steps.
Entry security system was working. Jewel lives on the third floor. No elevator.
Smelled musty. Jewel had the door open for us and responded cheerfully to
Jennifer. It was 90 degrees out at 10 a.m. Jewel had the shades pulled to keep the
sun out, but there were no air conditioners or fans in the efficiency apartment.
Jennifer focused this visit on baby Kayla’s development. She used the Ages and
Stages Questionnaire that has questions specific to development expected for the
age of the child. I noticed Jennifer also gave some suggestions to Jewel about what
she could expect to happen in Kayla’s development over the next few months.
Jennifer gave information to Jewel about an organization that would help her get
a fan and discussed how to prevent dehydration with the hot weather. During the
visit, Jennifer coached Jewel in making a phone call to the apartment manager to
report the glass on the front steps.
(continues)
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134 PART II n Entry-Level Population-Based Public Health Nursing Competencies
SARAH’S NOTEBOOK (continued)
Activity Sarah’s Observations
Office (and lunch) Jennifer checked for messages and had one from the Garcia family—they will not
be home today. Completed some charting. Checked for new referrals. Made calls
to these families.
New Referral:
Active case of
tuberculosis (TB)
Met Mr. Adams at his house. Mr. Adams was diagnosed with pulmonary TB
(tuberculosis) about 4 months ago. He likely acquired TB working overseas in a
disaster relief effort. He recently moved to Aurora to be near his aging parents.
Jennifer will be providing Direct Observed Therapy (DOT) for Mr. Adams. In
DOT, Jennifer will observe Mr. Adams to make sure he takes his medication cor-
rectly. When TB medication is taken inconsistently, the TB bacteria can become
resistant to medication.
In comparison to Jennifer’s interaction with Lily earlier today, this was a very
formal meeting. Jennifer asked questions to get the intake information. She also
inquired about Mr. Adams’s preferences for DOT. After the discussion and a brief
health history, Jennifer observed Mr. Adams taking the medication and left.
New Referral:
Postpartum visit
We met Amy Chan. She is 2 weeks postpartum. Her baby boy is doing well.
However, Amy is anxious and nervous about her son, as her first child died of
Sudden Unexpected Infant Death (SUID) three years ago. Jennifer assessed the
home environment for infant sleep practices, reviewed guidelines for safe infant
sleep, and provided positive feedback regarding Amy’s care for her son. Jennifer
used the Edinburgh Postnatal Depression Scale (EPDS) to screen Amy for post-
partum depression. Short messages and positive feedback seemed to help Amy.
Jennifer suggested a support group for Amy.
‘‘
’’
Sarah speaks with Jennifer after the first day of her clinical
experience. Jennifer explains that her planning for home
visits needed to be flexible. Sometimes her plan needed to
change because a client might have an unexpected health
problem or family crisis. Sarah comments, “I don’t know
how I will ever become independent in my decision-making
about what to do.”
Jennifer suggests, “Let’s review the day. Then we can
analyze what we did today and which independent pub-
lic health nursing interventions were accomplished. Also, I
will have you look at my schedule for the rest of the week.
You can begin to think about which interventions you
would consider to be independent practice and how you
might collaborate with others. We can discuss the skills and
knowledge a PHN needs for these interventions.”
Activity
Review Jennifer’s schedule for the week (Table 6.3) and answer
the following questions:
n Which public health interventions from the Public Health
Intervention Wheel did Jennifer use?
n Which interventions were independent, and which were
delegated functions?
n What skills and knowledge enabled Jennifer to practice
independently?
n How did Jennifer collaborate with other individuals, groups,
professionals, or organizations?
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135CHAPTER 6 n Competency #4
‘‘
’’
healthypeople.gov
Healthy
People
On the Healthy People 2020 website, go to
“Topics & Objectives” and under “M” click
“Maternal, Infant, and Child Health.” Read
about factors that affect pregnancy and childbirth. Go back
to the Topics & Objectives page and under “S” click “Social
Determinants of Health.” Scroll to review examples of social and
physical determinants of health. Refer to the 17-year-old mother
described in Sarah’s journal. Which determinants of health
are important to consider and address for this young mother?
Return to the “Maternal, Infant, and Child Health” page and
click “Interventions and Resources” at the top of the page. Find
one intervention among the suggestions that you could use to
address the needs of this young family.
How to Establish Professional
Boundaries in Public Health Nursing
Understanding professional boundaries is essential for all
nurses. PHNs practice in environments that are sometimes
more challenging for maintaining professional boundaries,
such as in homes, schools, and other community settings
that have different norms of behavior in contrast to the hos-
pital setting. In the hospital setting, professional and client
roles are more clearly defined. In community and home set-
tings, relationships and the norms of interaction need to be
differentiated from more casual social relationships. Some-
times students and PHNs find it difficult to keep from mov-
ing into a social friendship with the client as the relationship
progresses over time. PHNs must clarify their role and the
purpose of the relationship with clients to maintain profes-
sional boundaries. PHNs can also use dedicated reflective
supervision time with their nursing supervisor to consider
challenges around client relationships and boundaries.
On Tuesday, Jennifer has a visit scheduled with a client
being seen in the targeted home visit program, Mindy, who
is 16 and lives with her mother. Mindy has a 6-month-old
baby girl. Mindy’s former boyfriend, the baby’s father, had
been physically abusive to Mindy during her pregnancy.
Mindy has developmental delays and struggles with school
and fitting in. Mindy was referred to public health nursing
after her first prenatal clinic visit when she was six months
pregnant. Mindy and Jennifer have developed a trusting
relationship. Mindy has worked hard to follow through with
good parenting practices and has been receptive to Jennifer.
Jennifer checked her Facebook account last night and saw
that Mindy had made a friend request to her. Jennifer feels
torn between the professional, therapeutic, and supportive
roles she provides for Mindy.
A Nurse’s Guide to Professional Boundaries, published by
the National Council of State Boards of Nursing, provides
guidelines for managing boundaries in nursing practice.
See Table 6.4 for specific guidelines and their application to
managing boundaries in public health nursing practice.
PHNs need to be aware of the potential for boundary vio-
lations in their interactions with individuals, families, and
communities. Consider the following potential red flags
that could lead to crossing boundaries (National Council of
State Boards of Nursing, 2014, p. 5):
n Discussing intimate or personal issues with a patient
n Engaging in behaviors that could reasonably be inter-
preted as flirting
n Keeping secrets with a patient or for a patient
n Believing that you are the only one who truly under-
stands or can help the patient
Scope of Nursing Practice in New Zealand
GOAL 17 New Zealand’s new health strategy emphasizes prevention and early interventions aimed at
ensuring that New Zealanders “live well, stay well, get well.” Jane O’Malley, chief nursing officer, is
leading the way toward using the health workforce to the maximum potential (full scope of practice for
nurses). To improve health and access to care: 1) the Nursing Council of New Zealand can now deter-
mine the education, experience, competence, and supervision requirements to allow RNs to prescribe,
and 2) a legislative change replaces the term medical practitioner with health practitioner in relevant laws.
This increases the scope of practice for nurse practitioners in New Zealand (International Council of
Nurses, 2017).
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136 PART II n Entry-Level Population-Based Public Health Nursing Competencies
TABLE 6.4 Boundaries and the Continuum of Professional Nursing Behavior
Management of Boundaries Examples of Nursing Actions
The nurse’s responsibility is to delineate and maintain
boundaries.
Sarah introduces herself as a nursing student working with
Weaver County PH, shadowing Jennifer.
The nurse should work within the therapeutic relationship. Jennifer has an open conversation with Mindy about why she
cannot accept Facebook requests from clients.
The nurse should examine any boundary crossing, be aware of its
potential implications, and avoid repeated crossings.
Sarah considers what it would mean for a nurse to have a non-
work relationship on Facebook with a current or former client.
Variables such as the care setting, community influences, patient
needs, and nature of therapy affect the delineation of boundaries.
Jennifer encourages Mindy to continue to share her personal
experiences when Jennifer comes for visits and shows interest in
Mindy’s life as a parent.
The nurse should avoid situations where he or she has a personal,
professional, or business relationship with the patient.
Jennifer declines Mindy’s Facebook request and also discusses
the agency policy with her supervisor.
Post-termination relationships are complex because the patient
may need additional services. It may be difficult to determine
when the nurse–patient relationship is completely terminated.
Jennifer works collaboratively with Mindy to ensure she feels
competent as a parent. Jennifer helps Mindy understand when
and why the home visiting services are no longer needed.
Be careful about personal relationships with patients who might
continue to need nursing services.
Upon case closure, Jennifer takes time to celebrate Mindy’s suc-
cesses on a home visit and provides encouragement to Mindy
to reach out to the agency with future needs. She does not use
Facebook to stay in contact with former clients.
Source: National Council of State Boards of Nursing, 2014, p. 3
n Spending more time than is necessary with a particular
patient
n Speaking poorly about colleagues or your employment
setting with the patient or family
n Showing favoritism
n Meeting a patient in settings besides those used to pro-
vide direct patient care or when you are not at work
Confusion about the nurse’s role may occur when clients
want to give gifts or offer money. Although PHNs do not
wear uniforms, they need to choose professional-appearing
attire that is comfortable. Individuals from some cultures
might frown on clothing that they consider too revealing
and might be reluctant to believe what the PHN is saying is
important if the PHN is not professionally dressed. How-
ever, PHNs may also dress more casually in some settings,
such as homeless shelters or schools, which may help clients
feel more comfortable when talking to them. PHNs need to
be alert for any situation or conversations that might result
in self-disclosure. They need to ask themselves whether what
they are doing is what a nurse would typically do. PHNs
can use touch as a comfort measure but need to consider
the meaning of any physical contact to the nurse and client.
Touch and eye contact are not considered accepted practices
in some cultures.
On some occasions, physical assessment is required,
and although it is a norm for adults and children to remove
clothes for physical exams in the hospital and clinic settings,
removing clothes is not a norm in a community setting.
If infants and children require a physical examination, the
PHN should ask the parent or the child, if old enough, to
remove the child’s clothes.
Maintaining professional boundaries does not mean
being detached from clients. At the same time, the PHN
does not fulfill the role of being a friend to a client. In inter-
actions with clients, PHNs need to balance how they develop
a trusting relationship with clients while maintaining their
own separate professional identity.
EVIDENCE EXAMPLE 6.4
Defining Boundaries in Public Health Nursing
Five PHNs who participated in a qualitative study described
the challenge of defining boundaries as they worked with
clients. They described situations of being persuaded to do
something and then feeling regret that they had not said
“no.” The authors of the study suggested that one’s pro-
fessional ethical responsibility does not mean doing what
others demand. Closer relationships that develop over
a long-term time period with clients can lead to a sense
of duty, which can result in over-involvement and possi-
ble development of a friendship, a potential professional
boundary violation. “Each nurse has to make decisions that
are not only based on quality standards, but also on their
professional intuition and personal involvement” (Clancy &
Svensson, 2007, p. 163).
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137CHAPTER 6 n Competency #4
‘‘
’’
Activity
Discuss the following questions:
n When is it helpful to share something personal about
yourself with a client? When is it not helpful?
n What are some red flags indicating that you might not
be maintaining professional boundaries with clients?
n Is it a boundary violation to attend a patient’s baby
shower? A funeral for a client? Why or why not?
n How do you think Jennifer should handle Mindy’s
Facebook request?
How Do Public Health Nurses Establish
and Maintain Confidentiality?
Confidentiality in public health nursing often goes hand
in hand with professional boundaries. Maintaining profes-
sional boundaries requires that PHNs keep health informa-
tion private. PHNs must consider whom they speak to about
clients and the confidentiality of their documentation pro-
cesses. The Health Insurance Portability and Accountability
Act (HIPAA), which specifies how health information may
be communicated, is discussed in Chapter 7. Respecting
patient confidentiality is a professional and legal duty. How-
ever, PHNs must also balance this duty against the need to
disclose information to protect someone from harm, such as
in situations of suicidal ideation. When children or vulner-
able adults are involved, the duty to protect outweighs the
duty to keep health information in confidence. Competing
interests can exist, which means disclosure can be justified
for the public good, such as child protection (Griffith, 2015).
Jennifer is well known at one of the apartment buildings in
Aurora where many elderly adults live. Jennifer has made
many visits to residents in this complex over the years. The
residents, although not related, have become like family to
each other and welcome Jennifer. They have an informal
system of checking on each other daily and helping each
other with trips to the grocery store or pharmacy. Often
as Jennifer exits a client’s apartment after a visit, several
residents stop Jennifer to ask how her client is doing. The
neighbors are genuinely concerned and want to be help-
ful in any way possible. Sarah notes that Jennifer does not
offer any specific information, and after the visit she asks
Jennifer how she usually responds to questions about the
well-being of residents in the complex.
What Does Ethical, Legal, and
Professional Accountability Mean
in Public Health Nursing?
Ethical and professional standards and legal guidelines
drive accountability in public health nursing practice. Public
Health Nursing: Scope and Standards of Practice (ANA, 2013)
specifies areas of accountability for PHNs (see Chapter 1).
PHNs have more accountability to populations compared
to nurses in other practice settings. The PHN is account-
able for improving population health. Legal accountability
is discussed in Chapter 7. See Chapter 1 for an explanation of
ethical theory and a framework for analyzing ethical prob-
lems in public health nursing practice.
Public health ethics is driven by social justice. The aim is
to create a flourishing community for all rather than satisfy-
ing individual self-interests. A bioethics perspective focuses
more on autonomy and individual rights (Easley & Allen,
2007). Ethical challenges in public health nursing can result
from the conflict between protecting the community and
respecting individual autonomy. For example, individuals
might be required to take medication to treat tuberculosis
EVIDENCE EXAMPLE 6.5
Maintaining Boundaries and Confidentiality
in Working With Families With Intimate
Partner Violence
Evanson (2006) investigated the role of PHNs who con-
ducted home visits with families who had experienced
intimate partner violence. The PHNs who worked in rural
settings had more challenges in keeping confidentiality,
helping women find resources, getting their own sup-
port, and keeping professional and personal boundaries.
Although all the PHNs viewed setting boundaries as an
essential part of their work with families who were expe-
riencing intimate partner violence, Evanson concluded that
the boundaries between personal and professional lives for
rural PHNs are less clear than those for nonrural nurses.
The rural PHNs had learned to be flexible with boundar-
ies because they were highly visible in the community and
often knew their clients personally through attending the
same church, having children who were friends, or know-
ing mutual acquaintances. Personal ties were perceived as
a barrier to disclosure of the interpersonal violence. Rural
PHNs needed to be vigilant about maintaining confidenti-
ality and at times needed to withhold the truth from others
within a client’s family or community. Evanson recom-
mends that rural agencies provide support opportunities
through staff meetings and case conferences to help nurses
who work with families experiencing intimate partner vio-
lence cope with the emotional labor of their jobs.
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138 PART II n Entry-Level Population-Based Public Health Nursing Competencies
(even when they would prefer to choose otherwise) to pro-
tect others’ health. Protecting individual rights to privacy
might conflict with the need to share information to bene-
fit the public’s health, such as in the case of reporting cases
of communicable diseases to the health department so that
disease incidence can be monitored (Racher, 2007).
In the study by Clancy and Svensson (2007), PHNs
expressed that they thought they had a greater sense of
responsibility than hospital nurses, because the PHNs pri-
marily worked on their own. They expressed that they felt
alone with their worries and their uncertainties about what
to do. Ethical decision-making does not occur in a vacuum.
Resolutions are better with input from other experts in the
field. PHNs need to seek out collegial and organizational
support for their decision-making to ensure ethical, legal,
and professional accountability.
Activity
Consider the attributes of nursing professionalism found in
Table 6.5. Which attributes did Ellen Johnsen demonstrate in
her quest to achieve a safe and legal medication policy in her
school district?
EVIDENCE EXAMPLE 6.6
Ethics of Caring and Social Justice in
Public Health Nursing Practice
Falk-Rafael and Betker (2012) interviewed ten expert
public health nurses in Canada about how ethics guided
their practice. Participants provided descriptions of situa-
tions that were consistent with caring, social justice, and
social activism in their professional practice. The analysis
revealed three themes: the moral imperative, the pursuit
of social justice, and barriers to moral agency. Participants
identified important values for interactions with clients
(respect, autonomy, honesty, fairness, social justice, pro-
tection of human dignity) as imperative in their practice.
They provided examples of addressing social determinants
of health and advocating for health equity in social policy.
Examples of barriers to moral agency identified by the
PHNs included: 1) financial and administrative constraints,
2) feeling powerless to make changes, and 3) a shift to
relying on electronic data for priority-setting that resulted
in less involvement of the PHN with the community and a
lack of priority-setting based on needs expressed by com-
munity members. Falk-Rafael and Betker proclaim that eth-
ical practice for PHNs and their professional organizations
requires caring through advocacy for social justice as vitally
important to both the nursing profession and society (see
Chapter 13).
EVIDENCE EXAMPLE 6.7
A School Nurse’s Heroic Journey
Ellen Johnsen worked as a school nurse in Broken Arrow,
Oklahoma, in the 1980s. Johnsen brought her concerns
about a proposed unsafe and illegal medication administra-
tion policy to the school superintendent. A committee was
formed to review the policy; however, school nurses were
not included on the committee. They were invited to submit
input by phone or mail. The committee proposed a revised
policy that was consistent with the Oklahoma Nurse Prac-
tice Act. All medications, prescribed and over the counter
(OTC), required physician orders. However, the superinten-
dent rejected the committee’s recommendation and pro-
posed a policy draft that required parental permission but
not a physician’s order for OTC medications. The nurses
were told if they did not agree with this policy, they would
be replaced with school aides. Johnsen demonstrated a
commitment to professionalism and standards of practice
through her continued quest for a safe and legal policy. An
analysis of her journey identified the following actions that
demonstrate a commitment to professionalism and stan-
dards of practice in her leadership and change agent roles:
She gathered information about professional standards;
sought expert opinion on relevant laws, regulations, and
policies; shared her knowledge with colleagues; collabo-
rated on policy development; advocated for change in the
face of barriers; and accepted the consequences of being
a change agent. Although her contract was not renewed,
Johnsen continued her quest for a safe and legal medica-
tion administration policy (Johnsen & Pohlman, 2017).
TABLE 6.5 Attributes of Nursing Professionalism
n Sense of nursing as a
calling
n Self-regulating
behaviors
n Presentation of self
(image, attire, and
expression)
n Personal integrity
n Autonomy
n Knowledge and
specialization
n Critical thinking
n Intellectual and individual
responsibility
n Respect for human dignity
n Protection of patients and
the vulnerable
n Well-developed group
consciousness
n Belief and participation in
public service
n Belonging to professional
organization
Sources: Akhtar-Danesh et al., 2013; Wynd, 2003
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139CHAPTER 6 n Competency #4
What Should I Know About
Delegation and Supervision in
Public Health Nursing?
PHNs practice within their professional scope and stan-
dards of practice as well as within the guidelines of state
Nurse Practice Acts, which define the legal parameters
of nursing practice. Delegation is based on requirements
addressed in each state’s Nurse Practice Act. PHNs may be
in the role of accepting delegated activities, such as carry-
ing out provider orders for administering immunizations or
monitoring respiratory status, and they also may be in the
role of delegating specific functions to unlicensed assistive
personnel (UAP) or licensed practical nurses (LPNs). UAPs
include nurses’ aides, certified nursing assistants, health
aides, or other nonlicensed positions (ANA, 2012). Practice
environments often include multiple services and interven-
tions to promote the health of individuals, communities,
and populations. The ability to work interprofessionally and
to clearly identify the components of the delegation process
is crucial to successful PHN practice. Weydt (2010) states:
RNs are required to understand what patients and
families need and then engage the appropriate care
givers in the plan of care in order to achieve desired
patient outcomes while maximizing the available
resources on the patient’s behalf. Delegation is an
important skill that influences clinical and financial
outcomes (para. 2).
Effective delegation is an essential nursing skill and
is guided by three concepts the PHN must understand:
responsibility, accountability, and authority (Weydt, 2010).
The PHN has the authority to delegate specific tasks to indi-
viduals or groups, and these individuals or groups accept
the responsibility for the tasks. However, at all times, the
PHN retains accountability for the safety and quality of the
outcome (Stanhope & Lancaster, 2012). Delegation is most
effective when it is based on effective communication and
mutual trust (Kaernested & Bragadottir, 2012).
The PHN must determine when and whether delegation
is appropriate. The process for determination follows the
steps of the nursing process (ANA, 2012). Some tasks should
not be delegated because they fall in the realm of profes-
sional nursing—for example, counseling; health teaching;
and activities that require nursing knowledge, skill, and
judgment based on evidence or data (ANA, 2007). Tasks
that can be delegated are more often repetitive and support-
ive in caregiving (Williams & Cooksey, 2004). It is import-
ant to note the emphasis on individuals or communities as
partners in the plan of care and the importance of commu-
nication at all phases among healthcare consumers, UAPs,
and PHNs. To determine whether delegation is appropriate,
the American Nurses Association (2012) has identified six
care provisions (see Table 6.6).
TABLE 6.6 Care Provisions for Determining
Effective Delegation
1. Perform an assessment of the healthcare consumer’s:
n Care needs and determine whether any cultural
modifications are required.
n Condition to determine whether it is stable and
predictable.
n Environment where the care will be provided.
2. Develop a plan of care with the healthcare consumer
and his or her family, identifying the delegable task and
intended outcome as part of the overall plan of care.
Involving and educating healthcare consumers and their
families about appropriate expectations of the roles of care
providers promotes a safer environment and improved
patient outcomes. The plan of care should include:
n Baseline status of the healthcare consumer.
n Specific unchanging task performance steps.
n When and to whom the UAP needs to report if the
baseline status changes.
n Documentation of expectations as appropriate.
3. Analyze the following:
n Is the task within the delegating registered nurse’s
(RN’s) scope of practice?
n Do federal or state laws, rules, or regulations support
the delegation?
n Does the employing organization/agency of the delegat-
ing RN and the UAP permit delegation?
n Is the delegating RN competent to make the delegation
decision?
n Is the UAP competent to perform the delegated task?
n Is RN supervision of the UAP available?
4. Monitor implementation of the delegated task as appropri-
ate to the overall plan of care.
5. Evaluate the overall condition of the healthcare consumer
and the consumer’s response to the delegated task.
6. Evaluate the UAP’s skills and performance of tasks and
provide feedback for improvement, if needed.
Source: ANA, 2012
Activity
Read the case study on the next page and analyze how a PHN
could ensure that the Care Provisions of Delegation are followed
when delegating to the family health aide. Then analyze how the
Care Provisions of Delegation are represented in this case study.
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140 PART II n Entry-Level Population-Based Public Health Nursing Competencies
‘‘
’’
Do I Need to Become Registered to
Become a Public Health Nurse?
Public Health Nursing: Scope and Standards of Practice iden-
tifies the baccalaureate degree in nursing as the credential
for public health nursing practice (ANA, 2013). In addition,
the Association of Community Health Nurse Educators
(ACHNE) assumes the minimum requirement for entry-
level public health or community nursing practice is a bac-
calaureate nursing degree (ACHNE, 2009). There are several
routes to achieving this entry-level education preference.
Nurses with associate degrees may choose to enter RN-to-
BSN programs, or graduates with a baccalaureate degree or
higher in another major may choose an “accelerated” nurs-
ing program. Accelerated programs may offer a master’s
degree (check individual institutions) for this select group of
students. For students interested in advanced studies in the
area of public health nursing, the doctor of nursing prac-
tice (DNP) or the PhD are degrees that support practice and
research in the field.
You can look at your state’s Nurse Practice Act to deter-
mine whether a baccalaureate degree is required for the
practice of public health nursing in your state. Some states
require certification or registration for the title of PHN. The
baccalaureate is the preferred entry into practice degree.
Sarah is very excited about public health nursing and asks
Jennifer how she could obtain public health nursing certi-
fication. Jennifer recommends that Sarah read the Nurse
Practice Act in whichever state she practices nursing after
she graduates with her baccalaureate degree in nursing.
Sarah can also contact the board of nursing in that state
to learn more about nursing practice guidelines specific to
that area.
Examples of Legal Requirements in
Nurse Practice Acts
n California, Hawaii, Iowa, Minnesota, New York, North
Carolina, South Carolina, and Wisconsin require a
baccalaureate degree for PHN practice.
n In California, Minnesota, New York, and South Caro-
lina, licensure acts or rules have language that defines
the scope of public health nursing practice and reserves
the use of the title “public health nurse” for those profes-
sional nurses who meet specific criteria.
n In California, PHN certification requires training in
child abuse and neglect, and a PHN certificate is needed
to use the title of “public health nurse” (California
Board of Registered Nursing, 2006).
CASE STUDY
Delegation
I received a referral on a 22-year-old and her 2-month-old baby.
At my initial home visit, the baby appeared overweight and over-
fed. The young mom had started him on rice cereal in a bottle
at 2 weeks. Every time he cried, she gave him a bottle, even
though he often struggled and tried to pull away from the nipple. I
talked with her about feeding the baby and my concern about his
weight, but she responded with, “Once he starts moving around,
the weight will come off.”
By 4 months of age, the baby was 27 pounds. By now I was
very concerned and called both the nurse and the doctor at the
clinic, but no action was taken. Next, I arranged a joint home
visit with a nutritionist from WIC (Women, Infants, and Children
Supplemental Food Program). We counseled the mom to feed
the baby only when he was truly hungry.
Two weeks later, I returned to do an NCAST* feeding interac-
tion and videotaped the mom feeding the baby. We watched the
tape together and talked about hunger cues and how the baby
did not appear hungry. The young mother listened but continued
to feed the baby whenever he fussed or cried. It was as though
she had no other way to comfort him other than to feed him. I
was also becoming concerned about the baby’s development,
as he exhibited several delays in fine motor and language when I
tested him.
At this point, I started visiting every 2 weeks and placed a
family health aide in the home for 2 hours at a time 1 day a week.
The aide’s assignment was to role-model appropriate parenting
and feeding. I also arranged to get a highchair for feeding the
child through a nutrition program grant. Currently, I continue to
coordinate services from the clinic, nutritionist, and family health
aide. At the present time, the baby’s weight has stabilized, and he
has not gained any more weight.
*NCAST (Nursing Child Assessment Satellite Training) is an
objective and systematic assessment of interactions between
parent and child (30 hours of continuing education). It can alert
the nurse to areas of concern and the need for teaching. It has
been used as legal documentation in court cases of child abuse.
Source: Minnesota Department of Health [MDH], Office of Public Health
Practice, 2006
Discuss how these Care Provisions of Delegation do or could take
place in this case study:
n Perform an assessment of the healthcare consumer.
n Develop a plan of care with the healthcare consumer and his
or her family.
n Analyze delegation factors.
n Monitor implementation of the delegated task as appropriate
to the overall plan of care.
n Evaluate the overall condition of the healthcare consumer
and the consumer’s response to the delegated task.
n Evaluate the UAP’s skills and performance of tasks and
provide feedback for improvement, if needed.
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141CHAPTER 6 n Competency #4
Public Health Nursing Practice in a Variety
of Public and Private Healthcare Settings
PHNs provide care for individuals, families, and commu-
nities in many settings as well as in local and state health
departments. This section provides a description of how
nurses in home care, school, corrections, and faith commu-
nity settings use public health nursing knowledge and skills
in their practice.
n Home Care: Home visiting nurses in New York, West
Virginia, and Ohio provided a specific intervention
to facilitate chronic disease management for elderly
clients enrolled in Medicare. The nurses made monthly
visits to clients, using behavior change approaches
and empowerment strategies to work with clients on
managing chronic disease. They used handbooks to
encourage physical activity. Public health interventions
implemented by the home visiting nurses included case
finding, health teaching, counseling, and case manage-
ment. Following the intervention, the group receiving
the home visits had less difficulty bathing and experi-
enced less dependence in walking (Friedman, Li, Liebel,
& Powers, 2014).
n Schools: Five nursing students from a local college
of nursing partnered with a school district in Dakota
County, Minnesota, to carry out an aggregate assess-
ment of children with seizure disorders in five elemen-
tary schools. They identified health determinants at the
individual and systems levels of practice and identified
risk factors at the systems level of practice. They found
that lunch room, playground, and transportation staff
did not know how to respond to a student having a
seizure. In response, the students: 1) developed a hand-
out and PowerPoint presentation for school teachers
and staff with input from the Minnesota Epilepsy
Society, and 2) created a laminated business-card-size
“Seizure Action Steps” that could be attached to staff
name tag lanyards. These Seizure Action Step cards
were distributed to all teachers and staff district-wide.
The cards have increased staff comfort levels in having
access to quick guidelines about actions needed if a
child has a seizure. This systems-level health teaching
intervention—implemented in partnership with the
district Health Services Coordinator, who is a licensed
school nurse—was an independent nursing action (con-
tributed by Stacie O’Leary, health service coordinator,
and Patricia Schoon, assistant professor, Metropolitan
State University).
n Correctional Facilities: The Washington County,
Minnesota, Sheriff’s Office contracts with the local
Department of Public Health & Environment to provide
nursing services to inmates in the Washington County
jail. The Correctional Health Nursing supervisor in the
jail medical unit attends weekly Re-entry Assistance
Program (RAP) team meetings that are facilitated by
Community Corrections staff. The goal of the RAP is to
provide multidisciplinary support to inmates who are
preparing to be released from jail into the community.
The collaboration between Corrections, Jail Medical,
the Workforce Center, Community Financial Services,
and other providers allows inmates to ask questions and
get concrete assistance and guidance around barriers to
successful re-entry. The Correctional Health Nursing
supervisor provides referrals for physical and dental
healthcare and assists with facilitating overall medical
care needed upon release (contributed by Jill Timm,
senior program manager, Washington County Depart-
ment of Public Health & Environment).
n Faith Communities: Pappas-Rogich and King (2014)
conducted a survey of 247 faith community nurses
(FCNs) to identify their use of faith community nursing
functions and practice standards and how often they
implement Healthy People 2020 leading indicators in
their practice. More than 50% of FCNs in the study
used the following indicators in their practice weekly or
monthly: 1) promote daily physical activity, 2) promote
good nutrition and healthier weight, and 3) promote
emotional health and well-being. FCNs partnered with
many organizations in the community, including hos-
pitals, local public health departments (LHDs), senior
service agencies, faith-sponsored agencies, and hospices.
Also, 30% of FCNs reported participating in partner-
ships with health system–sponsored FCN programs.
Ethical Application
When working with individuals and families, PHNs often
must balance acting in the professional role with building
a trusting relationship. In the attempt to find this balance
in working with at-risk families, a PHN might encounter
tension between different ethical perspectives. If a PHN
emphasizes the expert role, the client might feel inadequate
or judged.
The client might need a “friend” and want to view the
PHN as a friend. However, framing the relationship as a
friendship implies expectations of sharing and obligation
that might fall outside the professional role. Professional
caring does not mean being a friend but carries the respon-
sibility of ethical action based on promoting good for the
client, contributing to a flourishing community, and strat-
egizing to reduce oppression for clients and families who
receive public health services.
See Table 6.7 for an application of ethical perspectives
to maintaining professional boundaries. Think about the
related scenarios in this chapter: 1) the adolescent mother
asked Jennifer to be her friend on Facebook; and 2) residents
in the apartment building where Jennifer visited several
elderly clients asked her how her clients were doing.
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142 PART II n Entry-Level Population-Based Public Health Nursing Competencies
TABLE 6.7 Ethical Action in Maintaining Professional Boundaries
Ethical Perspective Application
Rule ethics (principles) n Use expert public health nursing knowledge to promote good and prevent harm to clients
and families.
n Keep health information confidential to protect the client.
Virtue ethics (character) n Be compassionate in recognizing the hardships and health challenges encountered by clients
and families.
n Use caring interactions to communicate confidence in the client’s ability to make positive
health decisions.
n Focus on building trusting relationships as a basis for mutual goal setting.
Feminist ethics
(reducing oppression)
n Connect families to resources that reduce some of the inequities they experience because
of poverty.
n Establish a relationship with the client that communicates valuing others as equal individuals.
Activity
For either of the two scenarios discussed earlier in the chapter
(the Facebook incident and the apartment residents asking
about the well-being of clients), analyze the resolution to the
ethical problem by answering the following questions:
n Which values related to the situation do you see as import-
ant to you as a professional and as a person?
n Who do you think you should be as a PHN (important
virtues)?
n Based on your values and who you should be, what would
you do in this situation?
n Which ethical perspectives (rule ethics, virtue ethics, and
feminist ethics) support your chosen action?
n Protection of patient confidentiality can be more chal-
lenging for PHNs to ensure in rural communities, where
many residents know the PHNs.
n HIPAA provides legal standards for handling protected
health information.
n PHNs can use the six Care Provisions of Delega-
tion identified by the ANA to guide their delegation
responsibilities.
n Nurses in a variety of settings use expert public health
knowledge and skills in interventions with individuals,
families, communities, and systems.
KEY POINTS
n Nurse Practice Acts in each state and the scope and
standards of public health nursing provide expectations
for PHNs’ professional accountability.
n The Public Health Intervention Wheel defines the inde-
pendent interventions that PHNs implement in their
practice.
n Professional boundaries can be more challenging to
maintain in public health nursing, given the community
setting and long-term relationships with clients.
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143CHAPTER 6 n Competency #4
REFLECTIVE PRACTICE
Nurses who practice in healthcare organizations, such as
hospitals, are constantly reminded about rules and reg-
ulations that guide their nursing practice. They are sur-
rounded by other nursing staff and supervisors whom they
can quickly ask for guidance in any situation that might
seem confusing. In many situations, PHNs do not have the
security of having other nurses and nursing administrators
immediately available to them. School nurses are often the
only nursing professionals in the building. PHNs who make
home visits might feel isolated and unsure of which response
conforms to ethical and legal actions. PHNs must be knowl-
edgeable about the scope of professional practice and guide-
lines for ethical and legal practice. They need to provide
rationales that are based on ethical, legal, and professional
guidelines to support their choice of nursing actions.
Read the case study and write your answers to the fol-
lowing questions. Then discuss them with your classmates.
1. How does the scope of public health nursing practice
(see Chapter 1) guide the responsibilities of the PHN
in this case study?
2. What do you think are the most relevant interventions
for the PHN to implement from the Public Health
Intervention Wheel?
3. What is the PHN’s ethical and legal accountability
for the boyfriend’s domestic violence?
4. What concerns do you have about maintaining con-
fidentiality and professional boundaries in this case
study?
5. Which Cornerstones of Public Health Nursing do you
think are consistent with supporting the PHN’s inter-
ventions in working with this family?
6. How would you ensure ethical practice on your part
in working with this family?
Source: Adapted from a case study developed by the Minnesota Department of Health, n.d.
Your initial referral to the family was for the premature
birth of Adan, who had respiratory complications and spent
3 weeks in the hospital before he came home. Mariana is
estranged from her mother, reporting, “She kicked me out
when she found out I was pregnant.” She appears to have
minimal parenting skills but is receptive to your visits and
is working on developing parenting skills. She has declined
your referral to Early Childhood and Family Education (ECFE)
activities.
Adan was within normal developmental limits for the first
six months of his life but is now starting to exhibit some delays.
You suspect that his frequent illnesses are contributing to the
developmental delays. He suffers from chronic upper respi-
ratory illnesses and otitis media. Mariana smokes a half pack
of cigarettes per day and has not been receptive to discussing
smoking cessation.
Mariana’s lack of a routine lifestyle, increased levels of
stress, lack of sleep, and poor nutrition has negatively affected
both her and Adan. Mariana revealed she took a pregnancy
test last week and is pregnant again. Her smoking is putting
both Adan and the unborn child at risk.
CASE STUDY
Scope of Public Health Nursing Practice
You are a PHN with approximately 40 high-risk families in
your caseload. One of your clients is a 17-year-old adolescent,
Mariana, who has an 11-month-old baby boy, Adan, whom
she delivered at 34 weeks gestation with a birth weight of
4 pounds 1 ounce. Mariana lives in a trailer court off and on
with an unemployed boyfriend who has hit her twice in the
past month. She will not report the assaults because he is
on probation for selling drugs and would immediately go to
prison. She states, “He has promised it will never happen
again.”
Mariana’s boyfriend not only isolates her from family and
friends; he has pressured her to drop out of an alternative
school, where she had successfully secured onsite licensed
childcare and school bus transportation. She was on track to
achieve her high school diploma this year. Mariana is unable
to acquire her WIC vouchers for purchase of healthy foods
because she has no transportation to the WIC office. In addi-
tion, Mariana has missed several healthcare appointments for
Adan and herself. Her healthcare provider has requested PHN
assistance in helping this family keep medical appointments.
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144 PART II n Entry-Level Population-Based Public Health Nursing Competencies
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279
‘‘
’’
CHAPTER
14
COMPETENCY #12
Demonstrates Leadership in Public
Health Nursing With Communities,
Systems, Individuals, and Families
n Patricia M. Schoon
with Bonnie Brueshoff, Erin Karsten, and Marjorie A. Schaffer
José is with the Elders at Home Program for his public health nursing clinical. He is assigned to Mr. and
Mrs. Santos, a couple in their 70s struggling to manage their healthcare needs and stay in their home in
an older inner-city neighborhood. Mrs. Santos provides primary assistance for her husband, who has
advanced chronic obstructive pulmonary disease (COPD). After a recent hospitalization, Mr. Santos
received home care services from a home care nurse, respiratory therapist, occupational therapist, and
home health aide. These services were reimbursed by Medicare because Mr. Santos met the criteria of
potential for rehabilitation and progress toward independent living. All went well. Then a 60-day health
assessment resulted in a determination that Mr. Santos was no longer eligible for home care services. He
was referred to the county public health Elders at Home Program but has been resisting a home visit.
José wonders, “I am just a student nurse. What can I do?” He sighs, “Well, it looks like my preceptor has
handed me a challenge I can’t avoid. Isn’t there a chapter we are supposed to read on leadership in public
health nursing?”
JOSÉ’S NOTEBOOK
COMPETENCY #12 Demonstrates Leadership in Public Health Nursing with Communities,
Systems, Individuals, and Families
A. Seeks learning opportunities when working with peers, organizations, and communities
B. Demonstrates ability to be flexible, adapt to change, and tolerate ambiguity while working in an unstructured
environment
C. Seeks from and provides consultation and support to peers and community partners
D. Responds to population health needs in collaboration with systems and communities
E. Contributes to team efforts to improve the quality of care provided to client populations
F. Prioritizes and organizes workload, time, materials, and resources to maximize benefits to clients and
stakeholders
G. Participates in the political process to advocate for changes in health and social policies that affect
population health, workforce health, and public health services delivery
Source: Henry Street Consortium, 2017
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280 PART II n Entry-Level Population-Based Public Health Nursing Competencies
and community teams; and in diverse community systems,
such as government, healthcare organizations, schools,
home-care agencies, prisons, faith-based communities, and
homeless shelters. PHNs employ many strategies includ-
ing persuasion, influencing, role-modeling, networking,
and collective social action. Interventions often used are
collaboration, community organizing, coalition-building,
social marketing, surveillance, and policy development and
enforcement. PHNs who work in governmental agencies are
responsible for carrying out the core functions and essential
services of public health (see Chapter 7). Leadership skills
are essential to the success of these services.
Public health nurses practice at that intersection where
societal attitudes, government policies, and people’s
lives meet. Such privilege creates a moral imperative
not only to attend to the health needs of the public but
also, like Nightingale, to work to change the societal
conditions contributing to poor health (Falk-Rafael,
2005, p. 219).
PHNs are expected to have a passionate commitment
to advocate for the health of the clients they serve and the
health of their community.
The Leadership Journey
Nurses are presented with leadership challenges through-
out their careers. Leadership challenges are events or situa-
tions that require nurses to use critical thinking and ethical
problem-solving to arrive at equitable and effective solu-
tions. These situations propel nurses along their leadership
Leadership in Public Health
Nursing Practice
Leadership is often taught as a separate course in the nurs-
ing curriculum. So, you may be asking, why is leadership
content included in this book? Why is there a separate lead-
ership competency? Isn’t leadership the same no matter
where it is practiced?
Leadership theories are certainly applicable to all forms
of nursing practice. However, there are two aspects of pub-
lic health nursing practice that are unique. Public health
nurses (PHNs) are often alone in community settings and
required to take immediate actions independently. Some-
times PHNs are the only healthcare provider available in
a community setting. PHNs must be comfortable making
decisions and taking actions independently and know how
to access consultation and support by phone and Internet.
They need to be risk takers, able to advocate for their clients
in situations where they may be alone and in situations that
may not always be comfortable. It is important for PHNs to
be comfortable in community settings where there is min-
imal structure and maximum uncertainty. PHNs must be
comfortable providing mentorship and being mentored.
Leadership skills are essential.
PHNs spend their daily lives in the community and deal
with social determinants of health and the impact of these
determinants on health outcomes with individuals, fam-
ilies, populations, and communities. They know that they
often must go outside the healthcare system to promote and
protect their clients’ health. Effective use of leadership skills
is crucial to the success of their efforts. PHNs carry out
leadership at the individual/family, community, and sys-
tems levels; in the home; in interprofessional public health
USEFUL DEFINITIONS
Advocacy-Based Leadership: Advocacy-based leaders are motivated by the needs of others to take actions
to improve others’ health and well-being.
Authentic Leadership: Authentic leaders are reflective practitioners whose actions are consistent with their
values, ethical standards, and convictions (Murphy, 2012; Wong, Spence Laschinger, & Cummings, 2010).
Leadership: Leadership is the process and art of influencing, motivating, and leading others to achieve
shared goals.
Leadership Journey: The leadership journey is a lifelong process of self-discovery, self-efficacy, and
goal-directed actions.
Shared Leadership: Shared leadership refers to the concept of being an effective team member (Avolio,
Walumbwa, & Weber, 2009).
JOSÉ’S NOTEBOOK (continued)
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281CHAPTER 14 n Competency #12
to be a leader. Staff nurses usually work within healthcare
teams and share the workload. Knowing how to work effec-
tively within the healthcare team and with groups within
the community is referred to as shared leadership. These
three forms of leadership are consistently practiced in pub-
lic health nursing.
Authentic
Leadership
Choosing to lead is a conscious choice to take action. The
authentic leader moves from concerns about self to con-
cerns about the other. Leadership is a journey from the “I”
to the “We” (George & Sims, 2007). Leadership conscious-
ness starts with an awareness and understanding of one’s
own values, beliefs, and convictions. Self-awareness or con-
sciousness leads nurses to develop their own personal and
professional leadership competencies. This consciousness
then leads them to an awareness of the needs of others, thus
creating a moral challenge and a call to action. When nurses
respond to this call for action, they develop authentic per-
sonal and professional leadership styles and competencies.
Figure 14.1 demonstrates how you move along your leader-
ship journey throughout your nursing career as you respond
to transitional moments in your nursing practice.
journey. The leadership journey is a lifelong process of
self-discovery, self-efficacy, and goal-directed actions. Nurs-
ing students and professional nurses are on a lifelong jour-
ney as they develop their leadership potential, explore their
authentic leadership styles, and identify their personal and
professional reasons and motivations for taking leadership
actions. Students and nurses entering public health have
their own unique leadership journey.
Nursing leadership begins with the nurse-patient rela-
tionship in clinical practice. You started your leadership
journey as a nursing student the moment you identified
an unmet patient need and advocated for your patient by
working to influence other members of the care team to
take actions to meet your patient’s needs. In other words,
you began to lead when you identified an unmet client need
and took the lead in advocating for your client with oth-
ers. In doing so, you demonstrated advocacy-based nursing
leadership. The actions you took were based on your beliefs
and values and reflected your own personal and profes-
sional way of being, the beginning of authentic leadership
practice. When you move beyond the nurse-client relation-
ship and advocate within the healthcare system or commu-
nity for changes in attitudes, beliefs, knowledge, actions,
and resources that will help meet your client’s needs, you
are practicing leadership. You do not have to be in a for-
mal position of authority, such as a supervisor or manager,
FIGURE 14.1 The Leadership Journey—Ongoing Leadership Challenges
Source: Based on concepts from George & Sims, 2007
Focus on “I”
Development
of personal and
professional
self-efficacy
Ability to take
actions to meet
own personal
and professional
needs
Transition Phase
from “I” to “We”
Consciousness
of needs of others
Take actions to
meet needs of
others (advocacy)
Develop emerging
leadership
approaches,
strategies, and
competencies
(authentic
leadership)
Focus on “We”
Conscious of
and comfortable
with own
leadership style,
approaches, and
competencies
Take leadership
actions and
sometimes
leadership role
within groups,
organizations,
and community
to meet needs
of others
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282 PART II n Entry-Level Population-Based Public Health Nursing Competencies
encouragement that was given to me, I gained confidence
and was motivated to advance my knowledge and skills.
For example, I received the support to apply to serve on
the MDH Maternal and Child Health (MCH) State Advi-
sory Task Force. I was appointed to be a member of this task
force, which gave me leadership experience in dealing with
statewide policy and programs and expanded my profes-
sional network. I was given support to pursue the Robert
Wood Johnson (RWJ) Executive Nurse Fellowship program
that I completed.
What inspires you and keeps you fresh in your leadership
vision and strategies?
Both my practice experiences and professional development
activities have kept me inspired including (1) experiencing
the impact that public health has in helping us all be healthy,
because the focus of public health is on prevention; (2) being
able to be innovative in trying new approaches and using
evidence-based practice; (3) reading leadership literature
and articles; (4) networking with my colleagues; (5) mentor-
ing new PHN staff; and (6) working to influence policies and
decision-making on all levels—local, state, and national.
What are your three most important “lessons learned” about
leadership in your public health nursing practice?
n To lead, you have to be willing to take risks and know
it is OK to fail and learn from your mistakes—to learn
how to “fail forward.”
n Networking and lifelong learning are key. You can do
more with others than by being solo. Join professional
organizations and stretch yourself. Get involved. Never
stop. Learning self-awareness is very important and
will help you immensely! Ask for honest feedback from
others so you can build on your strengths.
n Become politically savvy. Learn about policies and pro-
cesses that affect public health. The ability to influence
policy has a far-reaching influence on nursing!
–Bonnie Brueshoff, DNP, RN, PHN, Public Health Director and Robert
Wood Johnson Executive Nurse Fellow (2006–2009), Dakota County
Public Health
Leading Through Relationships
PHNs work with their clients, team members, interprofes-
sional colleagues, and various members of the community
in striving to meet their goals of improving population
health. Public health nursing leadership requires influenc-
ing others to achieve public health goals (Morrison, Jones,
& Fuller, 1997). You are starting your public health nursing
leadership journey at the individual/family level of practice,
which is where entry-level PHNs often begin to develop
their skills and understanding of their role. Table 14.1 out-
lines leadership styles that are often used in public health
nursing practice and provides examples of how students
may develop skill in using these styles.
You have already developed some beginning leadership
skills and practices in your previous nursing clinicals. These
skills and practices are consistent with the situational chal-
lenges you have faced and your authentic sense of self. You
may further develop your leadership style and skills as you
progress through your public health clinical. This chapter
provides guidance to help you consider the public health
nursing leadership styles and skills that fit your authentic
self. Which transitional moments in your leadership jour-
ney do you think you might encounter during your public
health nursing clinical experiences?
The Leadership Journey:
Reflections of a Public Health Nurse Leader
As you progress along your leadership journey, you may
want to reflect on the situations, personal decisions, and
role models or supporters who helped you develop your
authentic leadership style and skills. In the following
interview, a PHN leader describes her leadership journey
and what she learned along the way (Brueshoff, personal
communication, 2013):
Tell a story about how your early experiences in public health
nursing and the leadership challenges you confronted helped
you along your leadership journey.
My first job as a nurse was working in a PHN position in
northern Minnesota. I had a generalized caseload of young
families and elderly clients. One of my specific roles in the
department was to provide follow-up for the Sudden Infant
Death Syndrome (SIDS) cases in the county. As a novice
PHN, I found my knowledge base about SIDS to be inad-
equate, which led me to request additional training avail-
able at the state level. Through the training, I made valuable
connections with the Minnesota SIDS Center and accessed
expertise from SIDS Center staff that provided me with
resources for families and much-needed emotional support.
Needless to say, I became better prepared to provide the
support and assistance that benefited SIDS families during
subsequent home visits. This experience early on in my
career reinforced the importance of ongoing education and
reaching out to access resources and expertise from other
professionals. Later in my career, my experience working
with SIDS families helped me mentor other PHNs who were
working with SIDS cases and was a factor in my leadership
journey as I was hired in a position as an apnea home mon-
itoring coordinator.
Who were your role models and guides along the way?
I was extremely fortunate to have the support and guidance
from two public health directors who offered me opportu-
nities for growth and challenged me to take on leadership
roles. I consider both directors to be my role models and
mentors. I also looked to the Minnesota Department of
Health (MDH) PHN nurse consultants for guidance with
my PHN practice and took every opportunity I could to vol-
unteer for state work groups and committees. Through the
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283CHAPTER 14 n Competency #12
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’’
Advocacy-Based Leadership
Advocacy-based leadership is foundational to public health
nursing. Advocating for clients—whether those clients are
individuals, families, populations, or communities—is
part of the social justice mission of public health nursing.
Although all nurses advocate for the unmet needs of their
individual clients, PHNs have a responsibility to advocate
for the health of the public, to care about what is causing the
health disparities in their communities, and to take action
to improve the health status of the affected individuals,
families, populations, and communities. This means that
PHNs need to be aware of emerging health needs and con-
nect the patterns of health disparities they observe among
their individual clients. Sometimes advocacy-based lead-
ership is an unconscious response to an unmet healthcare
need. Sometimes it is a conscious choice triggered by an
ethical or moral call to action. Evidence Example 14.1 illus-
trates advocacy-based leadership taken by a public health
nursing student from a school of nursing in the Henry Street
Consortium.
Think about the leadership journey you have been on
since starting your public health nursing clinical. Are you
able to identify when you began to focus more on your cli-
ents and the community than yourself? Can you identify
a transformative moment when you realized that it was
morally necessary for you to advocate for the unmet health
needs of a vulnerable population by enlisting the help of
others?
José has just completed his first visit to Mr. and Mrs. Santos.
Mrs. Santos is experiencing caregiver stress, and Mr. Santos
is becoming less and less active. He loves to smoke even
though he has a portable oxygen tank in his bedroom. Mr.
and Mrs. Santos do not want nurses and social workers
coming in and telling them what to do. They are afraid of
strangers. José tells them he will make a joint visit with the
social worker and introduce them to her. He is going to take
the initiative to find the resources Mr. and Mrs. Santos need
to live independently in their own home.
Which public health nursing leadership competencies
has José demonstrated? Which leadership styles is he using
in working with Mr. and Mrs. Santo?
TABLE 14.1 Nursing Leadership Styles in Public Health Nursing
Leadership Style Student Leadership Learning Examples
Advocacy-based leadership: Advocacy-based leaders are moti-
vated by the needs of others to take actions to improve their
health and well-being. Advocacy-based leadership is based on
the ethical principles of social justice. Advocacy-based leaders
are risk takers who act with moral purpose and demonstrate
moral courage when faced with perceived or actual opposi-
tion. (Refer to a discussion of advocacy and moral courage in
Chapter 13.)
n Students meet with county commissioners to advocate for
additional funding for low-cost or free dental services to
Medicaid clients.
n Students work with local grocery stores to form a coalition to
provide food items to stock a school-based backpack program
where students take home backpacks filled with food on
Fridays so that they have food over the weekend.
Authentic leadership: Authentic leaders are reflective practi-
tioners whose actions are consistent with their values, ethical
standards, and convictions. They are true to themselves and
know why they do what they do. Authentic leaders objectively
consider all available information and the opinions of others,
clearly and openly share their perspectives, are open and honest
in their communication, and have an awareness of their own
strengths and weaknesses. They are considered trustworthy and
reliable (Murphy, 2012; Wong et al., 2010).
n Students visit a community center hosted by a recent
immigrant group to learn how to communicate and develop
respectful, trusting relationships in a culturally sensitive
manner.
n Students have a post-clinical debrief with their PHN precep-
tors to reflect on the communication strategies they used in
working with developmentally delayed adults in a sheltered
living setting.
Shared leadership: Shared leadership refers to the concept of
being an effective team member: sharing responsibilities, mutu-
ally organizing the team’s work, maintaining team communi-
cation, taking the initiative to try a new approach if something
is not working, supporting team members, providing positive
feedback, and allocating resources equitably (Avolio et al., 2009).
When leadership is shared, PHNs have more time and energy to
care for their clients.
n Students plan for and staff a hearing and vision screening
program at a local elementary school. Each group of students
has a lead student who is the primary liaison with the school
nurse and takes the lead in organizing a team of fellow stu-
dents to provide the screening.
n Students work with a PHN team to reach out to families who
are eligible for PHN services but have not accessed them.
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284 PART II n Entry-Level Population-Based Public Health Nursing Competencies
Using Public Health Interventions as
Part of the Leadership Journey
You might have noticed that José is practicing many of the
public health nursing interventions described in Chapter 2
in his role as Mr. and Mrs. Santos’s PHN. Leadership is
integrated into many of the activities that PHNs and stu-
dent nurses carry out. Table 14.2 has examples of leadership
activities utilizing the Public Health Intervention Wheel
(Minnesota Department of Health [MDH], 2001). The inter-
vention examples are suggested student learning activities.
What Are Leadership Expectations for
Entry-Level Public Health Nurses?
The expectation of what leadership roles and responsibilities
PHNs take on are dependent of the needs of specific orga-
nizations and the community. Individual nurses also bring
different leadership abilities to their work. Diverse styles of
leadership are necessary to accomplish the work of public
health nursing. PHNs select leadership strategies and inter-
ventions based on what is most effective. Characteristics
such as flexibility, a willingness and openness to develop
new leadership skills, and the courage to practice them in
the public arena are the key to successful PHN leader ship.
Consider what a public health nursing director has to say
about leadership and PHNs who are just starting out:
EVIDENCE EXAMPLE 14.1
PHN Student Initiative Demonstrates Leadership
and Improves Population Health
A student nurse completed her leadership clinical in an
inner-city school with a 95% poverty rate among its stu-
dents. She developed a dental screening program for
third-graders as her leadership project. After screening all
the children, she found that almost all of them had dental
disease, such as decay, bleeding gums, abscesses, and
missing or broken teeth. Almost none of them had received
dental care in the last year, and few owned a toothbrush.
Each child was given a toothbrush and toothpaste and
taught how to brush his or her teeth. The PHN student
then attempted to screen all the children in the elementary
school, managing to screen about 90%. She prepared a
report showing the need for dental care in almost all the
children screened, sent home referrals to all the parents,
and included information on local dental clinics that pro-
vided care for low-income patients. The principal used the
report to obtain a grant to put a dental clinic in the school.
Within a few years, dental clinics were established in ele-
mentary schools located in high-poverty neighborhoods
throughout the school district.
—Senior Student Nurse
‘‘
’’
José returns to visit with Mr. and Mrs. Santos. Mrs. Santos
is crying and wringing her hands. José asks Mrs. Santos
whether she would be willing to see a mental health case
worker. She refuses. He remembers that the local Latino
Catholic church has a pastoral ministry home visiting pro-
gram. He wonders whether Mrs. Santos would allow the
pastoral minister to visit her. Mrs. Santos agrees to let José
contact the church. José is pleased that he is developing his
advocacy-based leadership skills. He is really stretching
himself to try to find ways to help Mr. and Mrs. Santos and
be an effective advocate.
Margaret, José’s public health nursing preceptor, says to
him, “I hope you like a challenge, because this couple has
lots of them. You are going to have to think outside the box
to keep Mr. and Mrs. Santos in their own home. You really
are going to have to use all your communication, advocacy,
and leadership skills to work successfully with this family.”
José wonders and then reflects, “Do I have any leadership
skills? I thought those came later, after 5 to 10 years of prac-
tice. Hmm. Well, maybe I was practicing advocacy-based
leadership.”
Margaret agrees, “Yes, you certainly took the lead in
advocating for Mr. and Mrs. Santos.”
THEORY APPLICATION
Caring Leadership Model
The McDowell-Williams Caring Leadership Model com-
bines Watson’s Human Caring Theory (2008) and Kouzes
and Posner leadership theory (2007). This model was
developed for and implemented in an acute care setting.
However, it is applicable to any clinical setting. The model
is based on six core values (Williams, McDowell, & Kautz,
2011, p. 33):
n Always lead with kindness, compassion, and equality.
n Generate hope and faith through co-creation.
n Actively innovate with insight, reflection, and wisdom.
n Purposely create protected space founded upon mutual
respect and caring.
n Embody an environment of caring-helping-trusting for
self and others.
The acronym AGAPE is defined historically as brotherly
love and charity, which fits with the social justice and equity
precepts of public health nursing.
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285CHAPTER 14 n Competency #12
Based on the PHN population-based practice focus
in public health, a new PHN needs to demonstrate
clinical leadership for the work with individuals and
families as well as at the community level. This lead-
ership role might be as a participant or a lead posi-
tion on various committees such as an interagency
collaborative, an early childhood intervention, or a
school health team. The PHN must also be a leader in
engaging community members in efforts to improve
health and address health inequities. The PHN needs
to utilize communication and collaboration skills to
lead groups, coalitions, and committees to achieve the
goals of improving the health of the population.
–Bonnie Brueshoff, DNP, RN, PHN, Public Health Director and Robert
Wood Johnson Executive Nurse Fellow (2006–2009), Dakota County
Public Health, 2017
TABLE 14.2 Taking the Lead in Using Public Health Interventions
PHN Intervention Example
Advocacy n Observing/participating in a town meeting designed to address or change a determinant of health
n Advocating for parenting classes at a conference center in an apartment complex (community level)
Policy development n Working with schools/work sites to change vending and fundraiser policies to include healthy food
choices
(systems level)
Policy enforcement n Responding to concerns/complaints about smoking in restricted areas based on the Freedom to
Breathe Act (community level)
Surveillance n Attending or participating in immunization registry meetings (systems level)
n Locating unlicensed daycare providers and providing teaching on home safety (individual level)
Coalition building n Recruiting and inviting family daycare providers to join the childhood-obesity prevention
committee (community level)
Community organizing n Participating in/helping plan youth programs, such as smoking or alcohol-use prevention
( community level)
n Helping/coordinating a bioterrorism tabletop exercise (systems level)
Disease and health
event investigation
n Following up on reports of pertussis cases; communicating with the state health department,
clinics, and area schools about the outbreak and doing case investigation (individual and
systems levels)
n Meeting with clinics and hospitals regarding prenatal hepatitis B program (systems level)
n Working with veterinarians, meat packers, and hunting associations on chronic wasting disease
(systems level)
Case management n Participating in a Student Attendance Review Board (SARB) meeting within a school
(systems level)
Collaboration n Participating in meetings to observe the collaborative process, decision-making, and problem-
solving in groups (e.g., children’s mental health, early childhood family education) (systems level)
Consultation n Working with child daycare centers, adult daycare centers, and battered women’s shelters to
establish standards and criteria for prevention of infectious disease (systems level)
Social marketing n Designing messages and materials on “how to make a healthy home” that PHNs can use on home
visits to help families deal with asthma (systems level)
Sources: Dakota County Public Health, 2004; Henry Street Consortium, 2004; MDH, 2001
What Are Essential Leadership
Skills for Becoming a Public Health
Nursing Leader?
PHNs are often confronted with the need to use their lead-
ership skills in advocating for their clients. As someone new
to public health nursing, you might find thinking about the
skills needed for leadership in this field daunting. Remem-
ber that all good nursing leaders start at the beginning by
becoming competent in their practice specialties; as they
develop confidence as expert practitioners, they build a rep-
ertoire of leadership skills.
Nursing leadership can be formal or informal. PHNs
demonstrate leadership at all levels of nursing practice
from novice to expert and as staff nurses, clinical experts,
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286 PART II n Entry-Level Population-Based Public Health Nursing Competencies
nursing specialists, supervisors, managers, educators, or
administrators. Leadership is a process, not a role. Much
of the research on leadership in the literature looks at the
leadership roles of managers; however, all nurses can utilize
leadership styles and strategies. Leadership is an expected
competency for PHNs, regardless of their position (Ameri-
can Nurses Association [ANA], 2013; Quad Council of Pub-
lic Health Nursing Organizations, 2011).
New PHNs need to be able to carry out entry-level lead-
ership competencies. Initially, their leadership opportuni-
ties are tied to their daily clinical practice with individuals
and families. However, depending on the size and nature of
the agency, they might soon become involved in leadership
activities at the community and systems levels of practice.
Some public health agencies include leadership develop-
ment in their annual performance appraisals (Kalb et al.,
2006). You might be expected to demonstrate the leader-
ship skills you have developed after you have been in public
health nursing for a year or so. The Henry Street Consor-
tium has generated a set of leadership skills that beginning
PHNs need to develop and strengthen to practice effective
PHN leadership (see Table 14.3).
TABLE 14.3 Essential Leadership Skills for Public Health Nurses
Skill Strategies and Considerations Your Leadership Action
Seeks learning
opportunities
n Determine goals for professional development.
n Strive to see the “big picture” by attending to
community and systems processes.
Match your interests and goals to learning
opportunities.
Works independently; is
autonomous in practice
n PHNs make many independent decisions based
on established programs or protocols.
n PHNs make decisions based on their own
expertise within the framework of ethical and
professional standards or practices.
Attend a PHN team meeting to observe how
PHNs share experiences. Seek suggestions about
evidence-based practice and tools to use for com-
plex family situations.
Willing to work in
an unstructured
environment; tolerates
ambiguity
n PHNs practice in settings where people live,
learn, and work—the priorities in these set-
tings are often not health or healthcare.
n Sometimes the goals of others are not clear or
consistent with the goals of PHNs.
n PHNs learn to be in ambiguous situations
while working to determine individual, family,
and community goals.
n PHNs suggest health-oriented goals but
ultimately work within the structure of each
setting to accomplish goals that are mutually
determined or sometimes rejected.
Talk with your preceptors about the challenges
they have confronted.
Seeks consultation
and support
n It is essential to seek consultation and support
in a practice area where role models are often
not physically present.
n PHNs use technology to access resources
and expertise when additional information
is needed.
By reflecting on your experiences with expert
practitioners, you can validate your thinking and
actions and learn about more effective approaches
to your work.
Takes initiative;
is a self-starter
n PHNs are responsible for organizing their
own schedules.
n Many activities in public health nursing
involve long-term planning, especially when
building partnerships and coalitions that focus
on community and systems changes.
As you are learning the skills needed for public
health nursing practice, you can be proactive in
identifying ways to prepare for clinical experi-
ences. Do you need to do background reading? Do
you need to identify specific objectives to guide
your preparation? Which questions do you need
to ask?
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287CHAPTER 14 n Competency #12
The day-to-day work of the public health or community
health agency needs to be accomplished. This means two
things: carrying out the organization’s mission and goals,
and carrying out the organization’s priority work. For staff
nurses, that means managing their caseload of clients on a
daily basis, setting priorities based on the changing needs
of their clients, and being willing to take on tasks that need
to be done. As you work with preceptors and expert nurses
in the community, notice their leadership approaches and
styles that meet the health needs of their clients as well as
the needs of the organization.
Skill Strategies and Considerations Your Leadership Action
Adapts to change n The settings where people live, work, and learn
undergo constant changes.
n Adapting to change is a constant in public
health nursing practice.
As someone new to public health nursing, you
need to change your frame of thinking to a public
health model in contrast to the medical model
(see Chapter 7).
Is willing and able to
respond to population
needs
n Healthy People 2020 priorities are based on the
most recently identified health goals for the
United States (U.S. Department of Health and
Human Services [U.S. DHHS], n.d.).
n PHNs and local health departments must
adapt to these changes if they are to be relevant
in the interventions selected to improve popu-
lation health.
Review the health data and health disparities data
for your community. Ask your preceptor how the
public health or community agency is responding
to those needs. Identify a priority that you would
like to work on as a student or volunteer in your
community.
Demonstrates flexibility n Flexibility is required in situations where fami-
lies or coworkers oppose change.
n Sometimes being flexible means being patient
and waiting while encouraging others to make
a change.
Compare your plan for the day and reflect on
what actually occurred. Analyze how you were
flexible in adapting to changes in your plan.
Contributes to
team efforts
n PHNs need to cultivate skills that make them
effective team leaders and team players.
n Listening, being open, valuing the contribu-
tions of others, and identifying a common
vision and goals are important when bringing
others together to improve public health.
Many public health learning experiences include
collaborating with your peers on a health
promotion project for the community. Use this
experience to work on your team-building skills.
Take time to learn more about team members and
different styles of working together.
Prioritizes and organizes
workload, time, materi-
als, and resources
n Public health nursing can be overwhelming
because so many areas exist in which nurses
could spend time and energy for improving
population health.
n PHNs use technology (e.g., cellphones, digital
calendars) to organize their workloads and
manage their time.
Learning time-management skills at the begin-
ning of your public health nursing experience can
serve you well. Make a plan for what you need
to do, gather the information you need, work on
prioritization, and seek needed resources. You
can always modify your plan as you evaluate how
well it is working. You can also share your plan
with your preceptor or mentor, who can help you
reflect on your organization and preparation for
your learning experiences.
Activity
Review the activities, strategies, and actions in Table 14.3.
n What skills do you consider your strengths? Choose two
strengths and decide what strategies you might use to help
you succeed in your public health nursing clinical.
n Consider which nursing skills and strategies you might use
to help achieve the mission and work of the public health/
community health agency in which you are working.
n What skills do you think you could strengthen during your
clinical? Choose one skill to strengthen. What strategies
might you use to help you do this?
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288 PART II n Entry-Level Population-Based Public Health Nursing Competencies
‘‘
’’
level of public health practice. The aims of this work are
to ensure a high level of care, to create supportive practice
environments for nurses, and to build strong partnerships
that achieve community health outcomes (Giddens, 2013).
Staff nurses use their leadership skills as part of the team to
achieve the work of the organization.
Organizational Culture and Leadership
The leadership and culture of the organization in which the
PHN works determine the support available for effective
PHN practice. The culture of support for achieving pub-
lic health nursing practice goals must permeate the entire
organization, as demonstrated in Figure 14.2. Nurses at all
levels within the organization must take responsibility for
carrying out the work of public health nursing practice. Fig-
ure 14.2 illustrates who needs to provide leadership to shape
and maintain a supportive organizational culture at all lev-
els within a public health nursing agency. Evidence Exam-
ple 14.2 identifies the organizational attributes that support
public health nursing leadership and practice.
José makes a joint visit to Mr. and Mrs. Santos with the
social worker. Margaret, his PHN preceptor, tells him
that the directors of Public Health Nursing and Human
Resources have made a renewed commitment for public
health nursing and social work staff to work together in
the Elders at Home Program. Joint visiting is encouraged.
In preparation for that shared visit, José reviews the job
description of the social worker and considers how his role
as a public health nursing student is both similar to and
different from the role of the social worker. He phones the
social worker in advance of the visit to discuss how they
might work together. During the visit, José and the social
worker spend time evaluating the home environment of Mr.
and Mrs. Santos and talking with the couple about their
goals to live in place. Mr. and Mrs. Santos are committed
to living in this home that they have worked so hard to pur-
chase and maintain. It is obvious that home maintenance is
poor. Stacks of old papers litter the house, they lack working
smoke detectors, and they have minimal food stored in the
cupboards or refrigerator. The kitchen sink is not draining
properly, and the washer and dryer are not working. The
social worker offers to help the couple apply for assistance
for home repairs and for Meals on Wheels. José is glad he
can share the care needs with the social worker. He believes
they will be more effective in helping Mr. and Mrs. Santos
by working as a team. After the visit, he asks his preceptor
for feedback about the leadership skills he demonstrated as
a member of the care team.
Challenges of Working
in the Community
Working in the community is challenging because of the
diversity, uncertainty, and constant change you experience
in an environment that is not within your control. As one
student said, “The patients aren’t lined up nicely in their
beds all in a row down the hall.” In home settings, children
are running around, animals abound, and the sounds of
the television and people coming and going are often dis-
concerting. Older or disabled adults might like their slip-
pery throw rugs on the floor and might want to have their
favorite snacks available even though they are not on their
prescribed diets. You might find homes without heat in the
winter and homes without refrigerators in the summer.
Some people live alone, and others live with myriad rela-
tives and friends. You never know what to expect when you
knock on the door. But you need to be ready for both the
expected and the unexpected. The following student exam-
ple demonstrates several leadership skills:
During a home visit, a student was in the process of
changing a catheter for a paraplegic man when the
man’s cat jumped on the bed. What was the student
to do? Her sterile field was about to be compromised.
She was wearing her only pair of sterile gloves, and
her equipment was laid out on the bed. She thought
for a moment. Then, very calmly, she asked the man
whether he would hold his cat while she changed his
catheter.
Activity
n What leadership skills did this student nurse demonstrate?
n If you were the student in this situation, what might you do?
n What leadership skills would you use in this situation?
As you develop the ability to practice nursing in the
community, whether in a home, school, clinic, faith-based
organization, or other type of community agency, you are
developing your leadership skill set.
Achieving the Work of the
Organization—Systems Level of Practice
The primary work of a public health organization is to
improve the health status of the population. PHNs in for-
mal leadership roles (e.g., team leaders, supervisors, manag-
ers, administrators) are responsible for achieving the work
of the organization. Much of this work is done at a systems
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289CHAPTER 14 n Competency #12
‘‘
’’
Students can take the initiative to create their own lead-
ership opportunities and share leadership with their peers.
Evidence Example 14.3 on the next page demonstrates that
when students worked together to plan and organize their
nursing care, their shared leadership actions enhanced their
ability to provide patient-centered care.
José makes another joint visit with the social worker. They
talk with Mr. and Mrs. Santos about their healthcare needs.
Mr. Santos is on oxygen therapy. Mrs. Santos states that
she knows her husband should stop smoking and that she
turns off his oxygen when he does smoke. Mr. Santos can-
not care for his personal needs. Mrs. Santos says that she
is uncomfortable assisting him with hygiene and that he
has not had a good bath or shower for several weeks. Mrs.
Santos is becoming stressed and showing signs of depres-
sion. No one has contacted Mr. and Mrs. Santos about
home maintenance. José decides he needs to prioritize their
health needs. The social worker starts the application pro-
cess for a home health aide to assist Mrs. Santos with Mr.
Santos’s personal needs. José is going to follow up on the
home-maintenance referral and work with Mr. Santos on a
safe smoking program. He will focus on Mrs. Santos’s stress
and possible depression on the next visit. José is excited to
share with his fellow students what he has learned about
his own leadership abilities and how he has been able to
work with Mr. and Mrs. Santos and the social worker to
help the Santoses stay independent in their own home.
EVIDENCE EXAMPLE 14.2
Organizational Attributes That Support Public
Health Nursing Practice
A Canadian study (Meagher-Stewart et al., 2010; Under-
wood et al., 2009) identified effective leadership as an
organizational attribute that supports public health nursing
practice. The study analyzed survey data from more than
13,000 community nurses across Canada and data from 23
focus groups of PHNs and policymakers. The organizational
factors that were identified as requisite for effective public
health nursing practice included government policy that
supports public health, supportive organizational culture,
and good management practices. Visionary and empower-
ing leadership that permeated the organization facilitated
the PHNs’ ability to practice their full scope of competen-
cies. These organizational attributes and leadership quali-
ties empowered and motivated staff to be effective in their
roles. Researchers concluded that it was essential for lead-
ership to respect, trust, and value public health for PHNs to
be effective.
FIGURE 14.2 Organizational Culture of Support for Public Health Nursing Practice
Administrative-
Level
Leadership
Program- and
Management-
Level
Leadership
Staff-, Team-,
Supervisory-Level
Leadership
Entry-Level
PHN
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290 PART II n Entry-Level Population-Based Public Health Nursing Competencies
Workload and Resource Management
To move the organization toward its vision, a PHN leader
must effectively manage workloads and resources. Public
health organizations rely on formal leaders to manage bud-
gets, supplies, and performance. In a business sense, public
health organizations require a variety of management activ-
ities to operate effectively (Baker & Baker, 2014). Because the
business of a public health organization is service to its pop-
ulation, public health nursing leaders must make thought-
ful, responsible decisions as they plan and direct various
aspects of the organization’s work. Figure 14.3 illustrates
how the day-to-day work of formal PHN leaders impacts
quality and ensures efficiency.
Although their duties differ from those of a formal leader,
informal PHN leaders are just as vital to an organization’s
success. Staff and entry-level PHNs can use their leadership
skills to effectively manage their workload and achieve the
goals of the team. PHN leaders set the standard and role
model for their peers of what it looks like to take initiative
and to be proactive. They understand how their daily work
impacts the mission of the organization and the overall
health of the community that they serve. PHN leaders are
skilled at time management, problem solving, communica-
tion, and relationship building. They regularly share their
ideas and volunteer for collaborative projects outside of their
regular job duties. These leaders bring a positive energy to
the team, which contributes to a high level of morale.
Each of us has a spark of life inside us and our high-
est endeavor ought to be to set off that spark in one
another.
–Florence Nightingale
EVIDENCE EXAMPLE 14.3
Shared Leadership Enhances Nursing Care in a Homeless Center
An example of how nursing students effectively practiced
leadership occurred during a clinical at a homeless shelter.
Public health nursing students conducted a monthly foot-care
clinic from September through May. During a 3-hour clinic, six
to eight students provided foot care to 20 to 45 clients. The
instructor and homeless shelter staff oriented the students to
the shelter and the foot-care clinic. Then the instructor turned
the clinic over to the students to manage. The students deter-
mined how to arrange the clinic space, how to allocate the
foot-care supplies, and who would carry out the different clinic
roles (recruitment and registration of the clients; assigning the
clients to students for their foot care; keeping each workspace
stocked with supplies; providing hospitality; documenting cli-
ent assessments and services provided; and following up with
clients after they received care to make sure all their priority
health needs were met). The instructor noticed that when she
turned over the management of the clinic to the students, they
were much more engaged and took more responsibility for the
clinic and their clients. Every group of students organized its
clinic a little differently. Each month, the shared responsibility,
freedom to be creative and practice autonomously, and mutual
contributions to team efforts led to a successful clinic. Because
of their ability to prioritize what needed to be done and orga-
nize their workload effectively, students managed to take the
time to provide a therapeutic encounter with each client who
visited the clinic. As one man said, after he spent an hour with
one of the students who listened patiently to his story, “This
has been the best day of my life.”
Measuring Outcomes of
Population-Based Practice
The core public health function of assurance requires those
working in governmental public health to evaluate the out-
comes of programs and interventions (see Chapter 7). PHN
leaders rely on meaningful data to demonstrate the posi-
tive outcomes of their interventions for individuals/fami-
lies and communities. The Omaha System is a valuable tool
FIGURE 14.3 Workload and Resource Management
Responsibilities
Monitor workflow
and develop new
efficiencies
Develop budget
recommendations
Provide clinical
and administrative
supervision
Analyze
program-related
reports
Monitor input
and output data
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291CHAPTER 14 n Competency #12
for public health nursing practice to capture the correla-
tion between PHN interventions and client outcomes (see
Chapter 3). The Omaha System helps to create meaningful
concepts for public health practice. Public health nurs-
ing leaders use knowledge-behavior-status (KBS) ratings
to evaluate client and program outcomes. This is evidence
that the PHN leader can use to leverage population health
data (U.S. DHHS, 2016). By evaluating which interventions
and targets caused the most effective changes for certain
EVIDENCE EXAMPLE 14.4
Health Literacy Outcomes
A study of health literacy outcomes (Monsen et al., 2012)
used Omaha System data to examine knowledge scores
across problems over time. Monsen’s team collected
pre- intervention and post-intervention KBS (knowledge-
behavior-status) scores by traditional racial categories.
Their findings showed significant inequities across race
categories in pre-intervention knowledge ratings. How-
ever, the post-intervention KBS ratings improved for all race
categories and, in fact, their ratings began to parallel one
another. Racial disparities decreased post-intervention, and
all races saw a marked increase in their KBS outcomes. The
targeted intervention worked to increase KBS outcomes
and promoted health equity.
EVIDENCE EXAMPLE 14.5
Dakota County Family Health Practice Advisory Committee
The Family Health Practice Advisory Committee is a quality
assurance committee for the family health unit at the Dakota
County Public Health Department. The committee is composed
of PHNs with varying levels of experience and is facilitated by
the unit coordinator. The main responsibility of the committee
is to ensure the implementation of evidence-based practice in
family home visiting. The committee utilizes the nursing pro-
cess and a continuous quality improvement approach for proj-
ects, literature reviews, case consultation, chart audits, and
continuing education for PHNs. PHNs on this committee act
as evidence champions when changes to practice are imple-
mented. This advisory committee ensures that the unit is in
compliance with targeted state and federal benchmarks for
family home visiting programs. The work of this committee has
resulted in improved quality in PHN interventions.
One project this committee worked on was the implemen-
tation of a Sexually Transmitted Infection (STI) assessment
for the Family Home Visiting program. For this project, the
identified problem was that the PHNs did not currently have a
standardized STI assessment form, although they were work-
ing with a population known to be at-risk for STIs. The commit-
tee used evidence from the Minnesota Department of Health
and the Centers for Disease Control and Prevention to develop
and implement a standardized assessment and teaching kit.
The assessment included basic screening questions to ask cli-
ents as a part of the nursing assessment, and the kit included
information on low-cost testing clinics, a laminated sexual
health exposure chart, educational pamphlets, and STI testing
recommendations. The committee held an in-person training
for all staff prior to implementation, which included presenta-
tions by a local epidemiologist and a nurse practitioner. Each
PHN received an assessment kit at the training. The initial eval-
uation of this project showed that 90% of the clients who were
screened using the new assessment form had at least one risk
factor, indicating that they were at-risk and required follow-up
testing for STIs. The Family Home Visiting program continues
to use the assessment and evaluate the data.
Source: Karsten, 2017
problems, PHN leaders can decide how to adjust practice to
meet the anticipated outcomes. Use of the data also supports
leveraging funding and policy support.
Reports that demonstrate the effectiveness of public
health nursing interventions provide a rationale for contin-
ued or increased funding for public health nursing services.
Strategies for Improving Quality
in PHN Interventions
Ongoing evaluation and improvement of services provided
by public health and other community agencies is carried
out as part of the core public health function of assurance.
Public health nursing staff and managers use the qual-
ity improvement process to meet this challenge. Qual-
ity improvement is defined as “the use of a deliberate and
defined improvement process and the continuous ongoing
effort to achieve measurable improvement in the efficiency,
effectiveness, performance, accountability, outcomes, and
other indicators of quality that improve the health of the
community” (MDH, 2017a, para. 1).
Along with continuous program assessment and staff
supervision, public health nursing leaders use this process
to improve quality in PHN interventions. Evidence Exam-
ple 14.5 describes how a local public health nursing agency
utilizes the quality improvement processes.
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292 PART II n Entry-Level Population-Based Public Health Nursing Competencies
‘‘
’’
(see Chapter 8) to achieve the goals of public health (Com-
mittee on Assuring the Health of the Public, 2003; Institute
of Medicine, 1988). Creative, cost-saving solutions to popu-
lation health concerns can result from interprofessional col-
laboration (Giddens, 2013). This collaboration is especially
important in public health nursing practice. PHNs work
regularly with their clients, team members, interprofes-
sional colleagues, and various members of the community.
This collaborative practice is a form of shared leadership.
Collaboration also occurs between the PHN and the
client at the individual/family level of practice. This form
of collaboration is part of case management, in which the
PHN works to optimize the self-care capacities of the client
and empower the client to make positive, healthy decisions
(MDH, 2001). The PHN must be flexible and comfortable
working in the unstructured environment of the client’s
home to share leadership and collaborate with the client in
making decisions.
José makes another visit to Mr. and Mrs. Santos. He notices
that Mr. Santos is still smoking in the same room as his oxy-
gen tank. José is concerned about the safety issues and the
possible neglect of a vulnerable adult. He wants to honor
the couple’s independence and wishes but understands
that his professional responsibility requires him to report
the potential for harm to this vulnerable adult. José con-
sults with Margaret, his preceptor. She says she will make
a joint visit with José the next day to determine whether
there is anything else they can do. During the visit the next
day, José observes Margaret’s approach to Mr. Santos. Mar-
garet and Mr. and Mrs. Santos set up a smoking schedule
for Mr. Santos that allows him to smoke while on the front
porch. Mr. Santos will use his oxygen before and after each
smoking session but not during it. José is impressed with
Margaret’s skill in working with Mr. Santos. He is going to
use her technique during his next visit.
Collaboration at the systems and community levels of
practice occurs through strategic partnerships between
two or more parties that use a structured approach to pur-
sue agreed-upon goals. As PHNs work with the commu-
nity both as client and partner, they share data collection,
problem solving, planning, and evaluation in carrying out
community assessment, setting priorities, and developing
programs (see Chapters 3 and 8). The ability to develop and
work in strategic partnerships has become more important
in public health nursing practice. A growing expectation of
public health practice and PHN leadership is the ability to
influence others to achieve the public health goal of health
equity (see Chapter 13). A 2016 Public Health 3.0 initiative
speaks to this expectation (U.S. DHHS, 2016).
Maximizing Benefits to Clients
and Stakeholders
Public health organizations are the guardians of avail-
able community health resources. Both fiscal and human
resources are finite. It is important to manage resources in
a way that benefits the public as a whole while not disad-
vantaging those who are most in need of assistance. Pub-
lic health organizations rely on nursing leaders to develop
and implement creative approaches that maximize benefits
to clients and stakeholders and ensure health equity for all
(U.S. DHHS, 2016). Recipients, or customers, of PHN inter-
ventions include direct clients, as well as stakeholders in the
community. Public health organizations are continually
challenged to respond to the question, what do our custom-
ers need from us? Population health models suggest that
investments in prevention efforts are highly likely to have
a substantial impact on improving a community’s health.
Increased spending on traditional medical services does not
appear to have the same level of impact on overall popula-
tion health. Rather, interventions that have a broad reach
across populations have the potential to improve quality
of life for community residents (National Home Visiting
Resource Center [NHVRC], 2017).
Shared Leadership
Through Collaboration
Today’s healthcare system requires nurses to work with oth-
ers to meet the goal of improving population health. The defi-
nition of public health, what nurses do together as a society
to ensure the conditions in which everyone can be healthy,
reinforces the importance of PHNs working collaboratively
EVIDENCE EXAMPLE 14.6
Family Home Visiting Return on Investment
Public health programs such as home visiting have yielded
a strong return on investment over the years. Numerous
studies have shown that the cost-effectiveness of home
visiting yields $3.75 on average for every dollar invested
(NHVRC, 2017). Outcomes of home visiting programs
include a reduction in the number of childhood emergency
room visits, early identification of developmental and
social-emotional delays in children, higher employment
rates and tax revenues, and reduced dependence on wel-
fare programs. These improvements in child health and
well-being and parental self-sufficiency demonstrate how
public health services maximize benefits not only to indi-
viduals, but to entire communities.
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293CHAPTER 14 n Competency #12
EVIDENCE EXAMPLE 14.7
Public Health 3.0
Public Health 3.0 (PH 3.0) refers to “a new era of enhanced
and broadened public health practice that goes beyond tradi-
tional public department functions and programs” (U.S. DHHS,
2016, p. 11). Led by the U.S. Department of Health and Human
Services, PH 3.0 emphasizes collaboration across public and
private sectors in an effort to advance health equity. This initia-
tive requires businesses, lawmakers, community leaders, and
federal policymakers to incorporate health into all areas within
their span of control. Collaboration with community partners
and the involvement of multiple sectors is essential to the
vision of PH 3.0, which is aimed at improving the social deter-
minants of health. Strong public health leadership is necessary
to develop and maintain cross-sector relationships because
this interprofessional collaboration is the foundation for policy
approaches that have the potential to affect large populations
(U.S. DHHS, 2016). Throughout 2016, a series of regional lis-
tening sessions brought community leaders from the private
and public sectors together to learn more about opportunities
to improve and modernize public health. In October 2016, the
Office of the Assistant Secretary for Health (OASH) issued a
white paper titled Public Health 3.0: A Call to Action to Create a
21st Century Public Health Infrastructure. This white paper pro-
vides recommendations for advancing Public Health 3.0 (see
Table 14.4).
TABLE 14.4 Five Critical Leadership Dimensions in Enhanced Scope of Public Health Practice
Dimension Scope
Strong leadership and
workforce
n Think outside of the box to leverage data in communications within and outside the
traditional health sector
n Partner with educational institutions to build a strong public health workforce pipeline
n Create opportunities for growth within the organization to maintain strong public health
professionals already working in the field
Strategic partnerships n Cultivate relationships and identify collective goals
n Develop sustainable partnerships
Flexible and sustainable
funding
n Advocate for flexible funding models that allow leaders to respond more rapidly to emerging
community needs
n Capture and document cost-savings attributable to public health efforts
n Engage funders in shared goals and values
Timely and locally relevant
data, metrics, and analytics
n Explore new types of data, including healthcare utilization trends, that paint a more complete
picture of the community’s strengths and challenges
n Address data gaps and challenges by advocating for timely, sub-county, de-identified data that
will quickly move evidence into action
Foundational infrastructure n Develop a clear mission and values statement that guides the organization’s strategic plan
n Document processes for decision-making
n Build interdisciplinary teams within the organization
n Focus on equity and cultural competence
Source: Based on U.S. DHHS, 2016
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294 PART II n Entry-Level Population-Based Public Health Nursing Competencies
of populations (Falk-Rafael, 2005). PHNs need to move
from behind the scenes to put forward strategies that can
make a difference for the health of populations. This means
increasing their knowledge and skills to transform the envi-
ronments where they live, learn, work, and play into settings
that foster good health through public health interventions
and public policy (French, 2009).
Taking the initiative to improve health by reducing risk
factors that contribute to chronic disease demonstrates
nursing leadership. Evidence Example 14.8 in the school
environment outlines leadership interventions that PHNs
can use to create good health by decreasing obesity rates and
reducing tobacco use and exposure, both major contribut-
ing factors to chronic diseases and rising healthcare costs
(MDH, 2017b).
PHNs can bring about change through initiating pub-
lic discussion and building awareness of proven strategies
to promote healthy eating and physical activity. Actions
include putting chronic disease prevention on the agenda of
professional organizations and using the media to increase
awareness. PHNs can use the data from their monitoring
activities to inform other professionals, organizations, and
the public about how the lack of access to healthy food and
physical activity contributes to health disparities and ineq-
uities. Partnership skills for collective action (see Chapter 8)
are essential in bringing about change through advocacy
action.
Although PHNs can identify and study the impact of
health determinants, they cannot solve such problems as
poverty, housing, unemployment, and unsafe environ-
ments. PHNs can, however, call attention to these problems
and get them on the policy agenda and into the public dis-
course. PHNs can also study the causes and results of these
health determinants and examine the effectiveness of social
and collective responses to these problems. They can help
mobilize public will and coordinate actions of the public
and private healthcare, education, and business sectors.
Leading successful change in communities involves many
different strategies (Hill, 2008; Nissen, Merrigan, & Kraft,
2005). Examples of such strategies are outlined in Table 14.5.
healthypeople.gov
Healthy
People
Immunization rates across the life span are
highlighted in Healthy People 2020 Topics
and Objectives (https://www.healthypeople.
gov/2020/topics-objectives). Click the National Snapshots tab
under the topic “Immunization and Infectious Diseases” to find
the proportion of children in your state who have been immu-
nized for measles, mumps, rubella, hepatitis B, and pneumonia.
Which vaccination rate is of most concern to you? Click the
Interventions & Resources tab to find evidence-based informa-
tion and recommendations for best practices for immunizations.
Which intervention would you like to see implemented in your
community to increase immunization rates? Which leadership
strategies might you use to convince elected officials to fund
this intervention to increase the immunization rate in your
community?
Leadership at the
Community Level of Practice
As leaders, PHNs aim to be change agents to reduce the
social conditions that contribute to poor health (health dis-
parities and inequity). Power to influence key stakeholders
and decision-makers is gained through developing alliances
(coalition building) with individuals and groups who have
influential power. The PHN’s ability to engage with com-
munities and develop effective partnerships to address the
priorities in the community is critical. Nurses have a long
history of advocacy and coalition-building to improve the
health of populations. Florence Nightingale made alliances
with politicians, journalists, philosophers, scientists, and
influential thinkers and writers who contributed to her
understanding of the public health issues of her time, but
also helped her bring about change for improving the health
EVIDENCE EXAMPLE 14.8
Statewide Health Improvement Partnership (SHIP)
in Action Working to Create Good Health
The SHIP program uses evidence-based strategies based
on the latest science, compiled by the Minnesota Depart-
ment of Health (MDH) in collaboration with local public
health (MDH, 2017b). Local public health staff, including
PHNs, are involved in working with communities to choose
strategies that address local needs. The community-led
improvements have resulted in healthy eating, physical
activity, and reduced commercial tobacco use. One suc-
cessful component of SHIP in Dakota County, Minnesota,
has been working with schools to create healthier food
environments (Dakota County Public Health, 2017). This
partnership, called Smart Choices, has engaged schools
with the highest rates of students receiving free and
reduced-price lunch (a measure of poverty). Currently, 32
schools across 6 districts are involved in Smart Choices.
Public health provided startup funds to schools to support
projects that are sustainable and impact school policies or
practices. Changes to systems or policies are important to
reach all children regardless of race, income, or other fac-
tors. Partner school districts have made multiple success-
ful changes to their food environments. For example, during
a visit to a school, public health staff observed that most
students in the lunch room had water bottles. A senior at
the school commented that they could remember when
the food and drink options weren’t nearly as healthy, and
they were glad that incoming freshman would never know
a time when the water wasn’t the norm. Other successes
include establishing district-wide farm-to-school infra-
structure, including salad bars, water-only vending options,
and district-wide treat-free classroom birthday celebration
policies (MDH, 2017b).
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295CHAPTER 14 n Competency #12
The leadership skill of being willing and able to respond
to population needs is extremely important. PHNs often
refer to this as having a passion for public health. Taking the
initiative to advocate for and to participate in the process
of social change to improve the health status of vulnerable
populations requires a passionate commitment to the health
of the public. Evidence Example 14.9 illustrates the complex
mix of leadership skills required to improve the health sta-
tus of vulnerable populations.
PHNs can bring about social change through initiating
public discussion on the effects of poverty and the contribu-
tion of policy decisions to reduce poverty. Actions include
TABLE 14.5 Leadership Strategies for
Successful Community Change
n Define the roles and responsibilities for stakeholders
involved in leading the change.
n Seek input from all who will experience the change.
n Be present “at the table.” As Hill says, “Interpersonal and
political skills and personal presence are essential during
periods of change” (Hill, 2008, p. 460).
n Look for traditional as well as nontraditional partners,
including funding sources.
n Consider the big picture.
n Collaborate with others to create a positive vision of the
future, and choose strategies to work toward that vision.
n Remember that leadership is about relationships every day.
n Engage in self-examination and self-correction.
n Consistently integrate evidence-based approaches.
n Be hopeful but realistic when planning change.
Sources: Hill, 2008; Nissen et al., 2005
Public-Private Partnership in the Health Sector
GOAL 11 At the global level, private public partnerships (PPP) have been encouraged to achieve specific
national healthcare goals in countries where there is a mismatch between demand for and supply of
healthcare services. The Chiranjeevi Yojana Scheme in Gujarat, India, was initiated in 2005 when the
government realized it did not have the resources to provide necessary emergency and routine obstetri-
cal care to its population due to lack of medical providers and emergency hospital care. Its goals were to:
reduce the maternal mortality ratio from 389/100,000 to 100/100,000 live births, reduce total fertility
rate from 3.0 to 2.1, and reduce the infant mortality rate from 53/1,000 to 30/1,000 live births by 2010.
The assumption for the PPP is that the private sector has experience and resources to provide quality
and cost-effective services. The government operationalized this scheme to provide obstetrical care to nontaxpaying families,
families below the poverty line, and tribal families. The District Health Service enrolled trust hospitals and private gynecologists
and obstetricians to provide maternity services. The Maternal Mortality Rate in 2010 was 200/100,000 live births, so although
that goal was not achieved, significant progress was made. Problems identified were lack of enrolled physicians providing care,
high cost of care provided by private providers and hospitals, poor quality of care with some providers, and tendency to refer
complex cases to the public hospitals. Several PPP models currently in use are working to balance existing resources, skills, and
expertise and to reduce disparities between rich and poor by expanding access.
Source: Thadani, 2014
EVIDENCE EXAMPLE 14.9
Bringing About Social Change to Reduce
Child Poverty
Cohen and Reutter (2007) reviewed literature from Canada,
the United States, and the United Kingdom as well as the
professional standards and competencies for nursing prac-
tice in Canada. Based on their review, the authors recom-
mend using Blackburn’s (1992) framework for working with
families living in poverty. Blackburn conceptualizes three
broad roles, which can be carried out at all levels of practice:
n Monitoring: Collecting and analyzing information to
determine the impact of poverty on families
n Alleviating and preventing: Helping families avoid,
reduce, and counteract the impact of poverty
n Bringing about social change: Working with organiza-
tions and the government to create policies that reduce
or eliminate poverty.
putting poverty on the agenda of professional organizations
and using the media to increase awareness. Working with
the community as your client, just as working with individ-
uals and families, requires a mutual egalitarian approach as
you share data collection, problem solving, planning, and
evaluation with community members. See Chapter 8 for
examples of PHNs collaborating with communities, and
note in Chapter 3 how they work with community members
in carrying out a community assessment. Taking leadership
in working toward social change involves skills in shared
leadership strategies.
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296 PART II n Entry-Level Population-Based Public Health Nursing Competencies
‘‘
’’
José has almost completed his public health nursing clini-
cal. He is feeling like he has taken on leadership in working
with Mr. and Mrs. Santos. He has a meeting with Marga-
ret, his PHN preceptor, to review his leadership journey
throughout the clinical experience. Margaret tells him that
in her evaluation of his leadership competencies, he has
shown initiative in taking on challenges and responsibilities
and has become more flexible in accepting Mr. and Mrs.
Santos’s independence in deciding on their own healthcare
and lifestyle. She tells him that he has demonstrated col-
laborative leadership in working with her and the social
worker. Margaret asks José if he wants to go to a community
meeting where a group of PHNs, social workers, faith com-
munity leaders, and members of the business community
are considering forming a coalition to influence legislators
to fund more living-in-place programs for older adults. She
would like him to support Mr. and Mrs. Santos in telling
their story at the meeting. Margaret believes that storytell-
ing will help the different members of the group find the
common ground needed to form the coalition. José agrees.
He is ready to work on strengthening his advocacy-based
leadership.
Coalition Formation as Community
and Civic Engagement
PHNs work in community and interprofessional coali-
tions to build capacity to meet the health and social needs
of diverse community groups. These coalitions are part of
community engagement. When public health nursing lead-
ers work in coalitions to influence elected and appointed
officials and key community decision-makers, they are par-
ticipating in civic engagement or the political process. See
Chapter 13 for a discussion of civic engagement. Evidence
Example 14.10 demonstrates the long-term commitment of
a public health department and collaborative leadership to
work with partners at a state-wide level to influence policy
development, a core function of public health.
Ethical Considerations
In addition to considering the impact of decisions on the
health of individuals, families, communities, and systems,
public health nursing leaders must consider how decisions
affect PHNs and other public health staff. Nursing leaders
can apply ethical perspectives to guide decisions that affect
their teamwork and leadership activities (see Table 14.6).
Collaborative Leadership at the
Community Level of Practice
Public health nurses are skilled at adapting to change and
responding with flexibility and creativity when working
with groups in the community. PHNs work collaboratively
as leaders in two different ways (Work Group for Commu-
nity Health and Development, University of Kansas, 2016):
n Collaborative leadership: Leadership of a collaborative
effort, such as a coalition or inter-agency task force,
in which the leader guides and coordinates the group
to solve a problem, create something new, or lead an
initiative
n Leading collaboratively: Leadership as a collaborative
effort within a community organization in which
leadership shifts to take advantage of different talents
or abilities, or leadership is permanently shared by the
entire group or members of the group
Finding Common Ground
One of the most difficult challenges public health profes-
sionals experience is to build consensus in a community
with groups who have diverse histories, values, and beliefs.
A barrier to consensus-building or finding common ground
is dissensus, which is demonstrated by community con-
troversy, disagreement, and conflict. However, enduring
change seldom occurs without the consensus of disparate
groups. So PHNs take on the challenge by working within
communities to form coalitions to achieve a common pur-
pose. The process of consensus-building takes both com-
mitment and persistence, as illustrated in Figure 14.4.
FIGURE 14.4 Consensus-Building to Achieve a Common Goal
Find
Common
Ground
Form a
Coalition
Act
as One
to Achieve
Common
Goal
Meet the
Opposition
Know the
Opposition
Select an
Issue
Take a
Position
Study the
Issue
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297CHAPTER 14 n Competency #12
EVIDENCE EXAMPLE 14.10
Tobacco Prevention Program
Haley Thorson, the PHN Tobacco Prevention Coordinator,
recounted the activities of the Grand Forks Public Health
Department in Grand Forks, North Dakota, as a statewide
leader in tobacco prevention since the early 1990s.
The public health nurses have led the tobacco prevention
efforts in Grand Forks for nearly three decades. The nurses
working in the Tobacco Prevention Program have focused pri-
marily on evidence-based policy changes recommended by
the Centers for Disease Control (CDC, 2014) to shift the social
and cultural norms related to tobacco use. When this norm
changes, it is realized in reductions of tobacco use rates among
youth and adults within the community. Specifically, in 2010,
the tobacco prevention nursing staff led a local coalition who
collaborated with key partners in the community to strengthen
the local smoke-free law, removing exemptions that left sev-
eral pockets of the workforce unprotected from exposure to
secondhand smoke. In the months prior, the nurses utilized
relationship-building skills to cultivate both a champion on the
city council and a well-known champion within the medical
community. With past tobacco-related policy initiatives taking
controversial tones, the nurses decided that a community-wide
assessment of attitudes, awareness, and perceptions sur-
rounding the policy change would be important.
A collaboration with the University of North Dakota’s
research department led to the conduction of the Grand
Forks Secondhand Smoke Study (Social Science Research
Institute-University of North Dakota, 2010), which validated
the community support for a secondhand smoke policy. The
nurses’ connectedness and respect in the community led to
relationships with unconventional partners such as the Con-
vention and Visitor’s Bureau and the Chamber of Commerce.
These connections were instrumental in sharing messages
to calm unsubstantiated financial fears related to the policy
change within the business community. These newfound part-
nerships in combination with focused, on-point health mes-
saging led to the successful passage of the proposed changes
to the local smoke-free law. In an effort to evaluate the effec-
tiveness of the new law, the public health nurses collabo-
rated on several key pieces of research, including an indoor
air quality study (Travers & Vogl, 2011), a community impact
study (Social Science Research Institute- University of North
Dakota, 2012), and a study on the economic impact of the pol-
icy change (Goenner, 2013). These data were instrumental in
building the evidence base to assist additional communities
across the state in passing similar policies and eventually a
comprehensive statewide law in 2012.
Source: Thorson, 2017
TABLE 14.6 Ethical Action in Public Health Nursing Leadership
Ethical Perspective Application
Rule ethics (principles) n Make leadership decisions that promote good and prevent harm to families, communities, organiza-
tions, and public health workers.
n Consider which leadership actions promote social justice in the community and among public health
staff members.
n Use advocacy-based leadership to improve population health at the individual/family and community
levels of practice.
Virtue ethics
(character)
n Be conscious of the needs of others, moving from the “I” to the “we” perspective.
n Use your authentic leadership styles based on your beliefs, values, ethical standards, and convictions.
n Be a leader who establishes caring relationships as a foundation for leadership actions.
n Be a leader who values both the success of the organization and the well-being of public health staff
members.
n Value the contributions of all team members.
Feminist ethics
(reducing oppression)
n Identify the moral and ethical leadership challenges related to population health and health
disparities.
n Be inclusive in the decision-making process within the community. Include all population groups that
will receive services.
n Use a team approach versus a hierarchical approach to prioritizing public health strategies.
n Use a shared leadership approach to be an effective team member within the interprofessional public
health team and within the community.
n Use an advocacy-based leadership approach to empower communities to take charge of and manage
their own healthcare needs.
Table based on work by Racher, 2007 and Volbrecht, 2002
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298 PART II n Entry-Level Population-Based Public Health Nursing Competencies
organize, and complete assigned workloads; seek con-
sultation and support; take initiative and be self-starters;
be flexible and adapt to change; and respond to popula-
tion needs.
n PHNs use many of the interventions from the Public
Health Intervention Wheel (see Chapter 2) to carry out
leadership activities.
n PHNs are able to be effective leaders when they are sup-
ported by a shared leadership culture that permeates all
levels of the organization.
n PHNs are expected to advocate for improvement in
population health and to reduce health disparities by
working collaboratively with interprofessional and
community groups.
KEY POINTS
n Providing leadership at all three levels of public health
nursing practice—individual/family, community, and
system—is a professional expectation of nurses who
work in public health.
n Students and professional nurses are on leadership
journeys that will continue throughout their nursing
careers. Leadership approaches that are particularly
relevant to public health nursing practice include
advocacy-based leadership, authentic leadership, and
shared leadership.
n Students and new graduates demonstrate entry-level
leadership skills in public health by their ability to
seek learning opportunities; work independently and
autonomously; work in unstructured environments and
tolerate ambiguity; contribute to team efforts; prioritize,
REFLECTIVE PRACTICE
Think about the imperative that PHNs are expected to pro-
vide leadership to improve the health status of individuals,
families, and communities. Think about how you might
respond to an unexpected situation that might prompt you
to take the lead in resolving a healthcare concern in the
community. How might you respond to the leadership chal-
lenge in the following scenario?
During a staff meeting, several PHNs in a health
department shared their concerns about new moms
dealing with postpartum depression and the lack of a
postpartum depression support group in the county.
Working with their supervisor, the PHNs discovered
that a hospital bordering the county did have an active
postpartum support group/program. Through several
meetings and discussion of the needs that could be met
and roles that each could provide, a partnership was
established. The hospital agreed to provide staff with
the expertise to facilitate the support group at no cost,
and the PHNs were able to make space and childcare
available at no cost, as well as do outreach and adver-
tise this new program. Through these PHNs’ leader-
ship, the postpartum support group was established
and continues to be successful in reaching many new
moms who benefit from the encouragement and sup-
port provided during the group meetings.
Consider the following questions:
n What was the leadership challenge in this situation?
n Which ethical principles might be used to resolve this
leadership challenge?
n How did the PHNs demonstrate advocacy-based and
authentic leadership?
n Which leadership skills did the PHNs demonstrate?
n Which levels of practice did PHNs use in planning and
implementing nursing interventions?
APPLICATION OF EVIDENCE
1. Which examples of public health nursing leadership
have you observed at the individual, community, and
systems levels when working with PHNs during your
clinical experience?
2. Identify three leadership skills you have read about in
this chapter that you have observed during your public
health clinical.
3. Give an example of how a PHN has used advocacy-
based leadership to improve the health of an
individual/family or community during your
public health nursing clinical.
4. Give an example of a PHN who has used authentic
leadership to carry out the mission and the work of
the public health agency.
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299CHAPTER 14 n Competency #12
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147
‘‘
’’
CHAPTER
7
COMPETENCY #5
Works Within the Responsibility
and Authority of the Governmental
Public Health System
n Marjorie A. Schaffer
with Bonnie Brueshoff and Raney Linck
Dan was recently employed as a public health nurse (PHN) by a county health department. After two
months on the job, he is asked to assist other PHNs in responding to a recent outbreak of measles. All con-
firmed cases to date are in the Somali population. Unfortunately, the Somali communities have been tar-
geted with misinformation about vaccine risks and have subsequently struggled with low rates of MMR
immunization.
Dan has never worked for the government. Through the orientation process, he begins to wonder
whether he will ever understand how the different levels of government work together. He refers to his ori-
entation materials for Population-Based Public Health Nursing Competency #5, which focuses on work-
ing with governmental systems. He comments to his supervisor, Carol, “This competency has so many
parts. How will I ever understand what all these terms mean for the work I am doing?”
DAN’S NOTEBOOK
COMPETENCY #5 Works Within the Responsibility and Authority of the Governmental Public Health System
A. Describes the relationship among the federal, state, and local levels of public health system
B. Identifies the individual’s and organization’s responsibilities within the context of the Essential Public
Health Services and Core Functions
C. Understands practice implications for laws, regulations, and rules relevant to public health
D. Adheres to legal mandates such as data privacy and mandated reporting
E. Differentiates the public health model from the medical model
F. Understands the independent public health nursing role as described in the Scope and Standards of
Public Health Nursing
G. Describes the role of government in the delivery of community health services
H. Identifies components of the healthcare system:
1) Funding streams such as Medicare, Medicaid, Prepaid Medical Assistance Plan (PMAP), categorical
grants
2) Programs utilized by state and local health departments, such as Women, Infants, and Children (WIC)
program, home visiting, and school health
3) Community resources
Source: Henry Street Consortium, 2017
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for Nurses
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148 PART II n Entry-Level Population-Based Public Health Nursing Competencies
USEFUL DEFINITIONS
Funding Stream: Source of revenue for public health programs and services.
Local Public Health Department: An “administrative or service unit of local or state government concerned
with health, and carrying some responsibility for the health of a jurisdiction smaller than the state” (National
Association of County and City Health Officials [NACCHO], 2016, p. 12).
Medical Model: Focuses on the individual; concerned with restoring health for individuals who seek care.
Public Health Infrastructure: The underlying framework for the public health system, which includes: 1) a quali-
fied workforce, 2) up-to-date data and information systems, and 3) capable agencies for assessing and respond-
ing to public health needs (Healthy People 2020, 2017b).
Public Health Model: Focuses on the health of populations; concerned with promoting, protecting, and
maintaining the health of every citizen.
Statutory Authority: A set of rules or a statute that gives an agency authority to determine rules to carry out
assigned duties (Minnesota Department of Health [MDH], 2016).
DAN’S NOTEBOOK (continued)
Taking Responsibility for
Improving Population Health
PHNs work in all levels of government; in urban, suburban,
and rural settings; and in a variety of community agencies
and organizations. Federal, state, and local governments all
provide essential resources for contributing to the public’s
health. This chapter discusses how levels of government
work together to promote public health and how PHNs
deliver population-based public health services in these set-
tings, agencies, and organizations.
How Are the Federal, State, and Local
Levels of Public Health Connected?
At the federal level, the U.S. Department of Health and
Human Services (DHHS) oversees many other agencies that
focus on the health and well-being of U.S. citizens. One of
these agencies is the Centers for Disease Control and Preven-
tion (CDC). The CDC keeps track of disease outbreaks and
health statistics and protects the health and quality of life
for U.S. populations. The CDC website is a good source for
statistics and other information you need for public health
interventions. For example, a PHN could use the CDC web-
site to find updated statistics on state and national obesity
trends and evidence-based strategies for obesity prevention.
Other agencies that come under the DHHS umbrella
oversee Medicare and Medicaid Services; research and
healthcare quality; substance abuse and mental health ser-
vices; and the safety of food, cosmetics, medications, bio-
logical products, and medical devices. For example, a PHN
could access information on food-safety alerts, such as the
contamination of ground beef (salmonella, typhimurium)
and salad bars (norovirus).
State health departments often work with both federal
and local levels of government. State health departments
regulate facilities and organizations that influence health
and health services. Examples of healthcare facilities reg-
ulated by the state include hospitals, clinics, and nursing
homes. State functions include financing and administering
programs (Stanhope & Lancaster, 2016) and offering tech-
nical assistance to local health departments for program
development and services. The organization and functions
of state healthcare departments can differ greatly among the
states. Regardless of the organizational structure, a strong
partnership between state and local health departments is
essential to promote and protect the health of populations.
Local public health departments (LHDs) include both
city and county health departments. They get directives
from the state and federal levels and report to their local
elected board members. Local agencies display consider-
able variability in the populations they serve and how they
accomplish their work. Table 7.1 identifies characteristics of
LHDs found in the 2016 National Profile of Local Health
Departments report (NACCHO, 2016).
LHDs often take actions to comply with state health
department regulations and federal guidelines. In Dakota
County in Minnesota, when a PHN received a report on a
suspected case of measles, the PHN (local level) documented
information from the Minnesota Department of Health
(state level) and followed up on the measles contacts. The
PHN reached all contacts and recommended contacts be in
quarantine for the incubation period for showing symptoms
of measles. In addition, relevant surveillance activities were
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149CHAPTER 7 n Competency #5
conducted by the PHN per MDH (state) and CDC (federal)
guidelines.
healthypeople.gov
Healthy
People
On the Healthy People 2020 website, go to
“Topics and Objectives,” and under “P” click
“Preparedness.” Government agencies,
nongovernmental organizations, the private sector, communi-
ties, and individuals work together to “strengthen and sustain
communities’ abilities to prevent, protect against, mitigate the
effects of, respond to, and recover from incidents with negative
health effects” (Healthy People 2020, 2017a, para. 1). What are
some ways that PHNs can use the information in this section to
contribute to accomplishing this goal? Think about actions that
will address the needs of individuals, families, and communities
during a major health incident. Which levels of government will
be involved in PHN responses? See Table 7.2 in this chapter.
How Do the Essential Public Health Services
and Core Functions Guide the Public Health
Department and Your Work as a Public
Health Nurse?
In the United States, PHNs and other public health profes-
sionals who work for governmental public health agencies
have a scope of practice based on core public health functions
and the essential services of public health (Institute of Med-
icine [IOM], 1988).
TABLE 7.1 Characteristics of Local Health Departments
LHD Characteristic Data
Populations served n Fewer than 50,000 persons: 61% of LHDs
n 500,000 or more: 6% of LHDs
Per capita expenditures n 2008: $63 per person
n 2016: $48 per person
Examples of partners n Emergency responders (98% of LHDs)
n K–12 schools (98% of LHDs)
n Hospitals (95% of LHDs)
n Media (95% of LHDs)
Registered nurses n 94% of LHDs employ registered nurses
n Median number of nurses ranged from 1 in LHDs serving populations under 10,000 to 542
for LHDs serving populations greater than 1 million
n Registered nurses comprise 18% of the LHD workforce (not all are PHNs)
n Overall percentage of nurses decreased by 28% between 2008 and 2016, related to health
department budget cuts for programs and staffing
Other public health staff
in LHDs
n 91% of LHDs employ office and administrative support staff
n Larger LHDs also often employ epidemiologists, statisticians, information systems specialists,
public information professionals, health educators, and public health physicians
Source: NACCHO, 2016
EVIDENCE EXAMPLE 7.1
Three Levels of Government Working Together in
Emergency Preparedness
LHDs work with the state and federal levels of govern-
ment to provide emergency preparedness services. At
the local level, 45% of LHDs reported they responded to
an all-hazards event in the past year and 90% participated
in an emergency preparedness exercise (NACCHO, 2016).
PHNs have specific skills for preparing for and respond-
ing to disasters. In addition to acting as first responders in
disaster events, PHNs use a population approach to col-
laborate on policy development, disaster response plans,
and disaster drills and training (Jakeway, LaRosa, Cary, &
Schoenfisch (2008). PHNs contribute to the following four
disaster phases (Jakeway et al., 2008, p. 355):
n Mitigation: Prevent a disaster or emergency; minimize
vulnerability to effects of an event
n Preparedness: Ensure capacity to effectively respond
to disasters and emergencies
n Response: Provide support to people and communities
affected by disasters and emergencies
n Recovery: Restore systems to functional level
See Table 7.2 for an example of how the three levels of gov-
ernment work together in emergency preparedness.
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150 PART II n Entry-Level Population-Based Public Health Nursing Competencies
TABLE 7.2 Emergency Preparedness Example
Local State Federal
Planning LHDs write all-hazards plans to
direct local emergency responses,
including staffing of Open Points
of Dispensing (PODs), communi-
cations with the public and other
partners, and Department Opera-
tions Center (DOC) on setup and
procedures.
LHDs conduct exercises to test
plans in order to practice skills and
identify areas for improvement.
The state health department
consults with LHD on plans and
writes grant requests regard-
ing required plan elements and
required exercises that need to be
completed in order to receive grant
funding.
The Centers for Disease Control
and Prevention (CDC) is the
funding source for both state and
local health departments. The CDC
creates and conducts a biannual
assessment, the Operational
Readiness Review, to measure the
overall status of both state and local
preparedness around the 15 Public
Health Preparedness Capabilities.
Prevention and
Risk Mitigation
LHDs complete a Hazard and
Vulnerability Assessment with
Emergency Management to evalu-
ate greatest risks in the jurisdiction
(geographical area). Based on those
risks, the LHD can do community
outreach and provide trainings to
mitigate some of the adverse effects
of different emergencies.
The state health department
regularly communicates and meets
with LHD staff to provide training
and consultation and interpret
CDC guidance. The state employs
regional consultants to individ-
ually work with the LHDs and
coordinate risk and prevention
activities across the region.
The CDC stockpiles medications
and supplies based on assessed
public health risks such as a future
influenza pandemic, bioterrorism,
or emerging infectious agents.
These are called Strategic National
Stockpiles (SNS). The CDC also
funds development of vaccines and
other prophylactic pharmaceuticals
to prepare for future needs.
Response The LHD sets up a Department
Operations Center from which
the Incident Command will run
the response to a Public Health
Emergency. This response could
be staffing a hotline, communicat-
ing with the public, setting up a
shelter, or dispensing prophylactic
medication or vaccine through a
Point of Dispensing (POD).
The state public health agency
provides situational updates,
subject matter experts, and emer-
gency messaging to the public.
The state can request emergency
medications, vaccines, equipment,
and supplies from the Strategic
National Stockpile and push that
out to the LHD to dispense to the
public.
The CDC interacts with interna-
tional partners to coordinate inter-
national public health emergency
responses, such as the 2015 Ebola
outbreak. The CDC also can help
deploy staff to state and local part-
ners for assistance. This is called
the Epidemic Intelligence Service
(EIS). They have medical response
teams available to assist state and
local partners when local resources
are depleted.
PHN Role PHNs working in LHDs hold lead-
ership roles in incident command
and can provide subject matter
expertise regarding the health
implications of an emergency. At
a Point of Dispensing, nurses staff
the roles of screening (assessing
for contraindications, allergies, or
drug interactions), dispensing, and
education.
PHNs working at the state help
provide subject matter expertise
around infectious pathogens, mass
dispensing guidelines, and public
health interventions. The majority
of emergency preparedness work
at the state level falls under the
population-based section of the
Public Health Intervention Wheel.
Many emergency preparedness
interventions are consistent with
the PHN role.
PHNs at the CDC are involved in
many preparedness roles, including
serving as experts in vaccine guide-
line development. PHNs are part of
the disease response teams at the
national level that are deployed to
local responses as needed. Nurses
serve in leadership roles in emer-
gency preparedness and planning
as well.
Contributed by Christine Lees, MPH, BSN, PHN, Dakota County Public Health and Amalia Roberts DNP, RN, PHN, Dakota County Public Health
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151CHAPTER 7 n Competency #5
Figure 7.1 demonstrates the relationship between the core
functions and the essential services that government agen-
cies and their staff must carry out (Source: CDC, 2014).
The three core functions are:
n Assessment: Community assessment of population
health needs by monitoring and investigating levels of
population health and illness
n Policy Development: Development of health policies,
goals, plans, and interventions to meet priority commu-
nity health needs
n Assurance: Measurement of outcomes of health poli-
cies, goals, plans, and interventions and the competency
and adequacy of public health professionals to deter-
mine whether a community’s priority health needs have
been met in an efficient, effective, and timely manner
The Ten Essential Services of Public Health (CDC, 2014)
in Figure 7.1 need to be carried out by PHNs and other public
health professionals to maintain the health of a community
and its diverse populations. Table 7.3 outlines these essential
services and provides examples of each.
TABLE 7.3 Ten Essential Services of Public Health, With Examples
Essential Service Example
1. Monitor Health n Carry out community assessment to determine levels of health and illness in community and
populations.
2. Diagnose and Investigate n Check lead levels of preschool children, infants, and toddlers at risk for lead poisoning.
n Offer diabetes screening in the Native American community.
3. Inform, Educate, and
Empower
n Teach first-time parents how to care for their new baby.
n Provide car seat education to new parents.
4. Mobilize Community
Partnerships
n Develop a network of community services for elderly people within the community.
5. Develop Policies n Work with county board members to develop a policy for playground safety in local
communities.
6. Enforce Laws n Report suspected child abuse or neglect.
n Monitor compliance with immunization laws for school children.
7. Link to/Provide Care n PHNs and emergency department staff develop a referral and follow-up system for homebound
elderly who visit the emergency department and then return home.
8. Assure Competent
Workforce
n Update public health nursing staff on the influenza virus.
n Teach rural PHNs how to do well-water testing.
n Precept nursing students.
9. Evaluate n Carry out evaluation studies to determine the effectiveness of public health nursing programs,
such as home visiting to new families.
n Evaluate programs that LHDs contract with for service provision.
10. System Management and
Research
n Determine needs for public health services and service gaps in the community.
n Provide data to justify claims that tax dollars improve the public’s health and demonstrate a
return on investment.
Source: CDC, 2014
FIGURE 7.1 Essential Public Health Services and Core Functions
Source: CDC, 2014
A
SS
U
R
A
N
CE
ASSESSM
ENT
PO
LICY
DEVELOPMENT
Sy
ste
m Management
Research
Assure
Competent
Workforce
Link to/
Provide Care
Enforce
Laws
Develop
Policies
Mobilize
Community
Partnerships
Inform,
Educate,
Empower
Diagnose
& Investigate
Evaluate Monitor
Health
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152 PART II n Entry-Level Population-Based Public Health Nursing Competencies
‘‘
’’
The following section shows how PHNs accomplish the
work that is outlined in the essential services and core func-
tions and contribute to the well-being of populations. In a
survey of 57 PHNs working in local and state governments
and representing 28 states, they identified the amount of
time spent providing each of the essential services. The per-
centage of time spent on each essential service ranged from
7% to 14% (Keller & Litt, 2008). See Figure 7.2.
Dan remembers seeing the Public Health Core Functions in
his orientation manual—assessment, policy development,
and assurance. He says to Carol, “Let’s see if I understand
how this works.”
“For the measles outbreak, I can see assessment hap-
pening when we are identifying how many children in the
targeted age group live in our county. For policy develop-
ment, we are following the directives given by the CDC and
the state department of health for vaccine administration.
I can see how we are working with and through others to
ensure that as many children as possible have access to the
vaccine. Assurance occurs when we make sure the vaccine
is accessible to the population groups that need to be vacci-
nated and that the vaccine has been administered to them.”
Carol affirms Dan’s analysis of how the core functions
were represented in the response efforts to the measles out-
break. Dan then says, “I am not sure about all those essen-
tial services. Do PHNs conduct all ten in response to the
measles outbreak?”
Carol answers, “Let’s analyze how each of the essential
services occurs when our health department responds to the
measles outbreak. Let’s develop a handout to put into the
orientation manual to help everyone understand how we
are providing the essential services.”
See Table 7.4 for the handout that Dan and Carol developed.
Application of Ten Essential Services to
Measles Outbreak Response
A measles outbreak occurred in Minnesota in late March
of 2017. This was the worst measles outbreak in Minnesota
since 1990. A total of 79 cases were reported, which primar-
ily affected the Minnesota Somali community. All local
health departments in Minnesota had a role in prevent-
ing the spread of this infectious disease, involving activi-
ties such as active awareness and risk communication with
medical providers.
How Do Public Health Nurses
Use Statutory Authority?
Statutory authority refers to the statutes (laws) and rules
through which the government gives authority to agencies
to carry out specific duties. In the public health arena, PHNs
are responsible for adhering to public health laws that have
been enacted to protect and promote the health of commu-
nities. Public health laws may be federal, state, or local, but
many are implemented at the local level.
Public health law is often established in response to crit-
ical public health problems that affect populations. Mello
and colleagues (2013) identified three criteria for determin-
ing opportunities for establishing public health law: 1) the
EVIDENCE EXAMPLE 7.2
National Public Health Accreditation
In 2011, a national voluntary accreditation program for
local, state, territorial, and tribal leaders was established to
ensure accomplishment of the Core Functions and the Ten
Essential Services. The Public Health Accreditation Board
(PHAB) oversees the accreditation process. Participation
in the accreditation process helps health departments to
identify their strengths and weaknesses; establish quality
improvement strategies; communicate their accountability
to community members, stakeholders, and policymakers;
and be competitive in funding opportunities (CDC, 2017b).
FIGURE 7.2 Percentage of PHNs’ Time Dedicated to Essential
Services (n = 57)
14%
Inform, educate,
& empower
7%
Research
8%
Develop
policies &
plans
8%
Mobilize
11%
Evaluate
11%
Diagnose &
investigate
11%
Assess health
status
11%
Assure
12%
Link
7%
Enforce laws
& regulations
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153CHAPTER 7 n Competency #5
TABLE 7.4 Ten Essential Services: Measles Outbreak Response by Local Public Health
Essential Service Application Example
1. Monitor health Monitored data on those at risk due to being unvaccinated, and monitored clinic and hospital data
of reported cases provided by Minnesota Department of Health
2. Diagnose and Investigate Communicated with summer camps and daycares on symptoms to watch for and resources
available
3. Inform, Educate,
and Empower
Worked with local media outlets and sent a Health Advisory to medical providers on the outbreak,
including what to watch for and report
4. Mobilize Community
Partnerships
Worked with Somali community leaders and organizations to reach the at-risk population
5. Develop Policies Adopted policies from CDC and state department of health on vaccine recommendations
6. Enforce Laws Activated response by utilizing the Health Department Emergency Response Plan
7. Link to/Provide Care Coordinated with the Department of Human Services regarding childcare licensing regulations
and potential changes needed due to outbreak
8. Ensure Competent
Workforce
Provided training for staff to assist with contact investigation and follow-up to ensure competence
for roles and responsibilities
9. Evaluate Once outbreak was over, a “hot wash” was conducted to document the response work and lessons
learned
10. System Management
and Research
CDC vaccine information posted on website, which included basic information and vaccination
guidance
law targets a significant public health problem, 2) factors
contributing to the public health problem are understood
well enough to change behavior through law, and 3) a feasi-
ble intervention can be implemented.
Public health law is potentially an effective tool for
improving population health outcomes. However, compet-
ing interests and values about laws may affect individual
choice. This adds complexity to enacting laws that address
threats to individual and population health. It is important
to provide objective and timely evidence to support legal
policy that contributes to improving population health.
Major trends in public health law and practice include the
following focus areas (Hodge et al., 2013):
n The Affordable Care Act
n Emergency legal preparedness
n Health information privacy and data sharing
n Tobacco control
n Drug overdose protection
n Food policy
n Vaccination requirements and exemptions
n Sports injury law and policy
n Public health accreditation
n Maternal and child health
Public health laws influence funding for public health
programs. For example, emergency preparedness programs
received major funding following bioterrorism events and
threats. Funding increases the number of public health prac-
titioners employed in emergency preparedness programs.
Public health laws also protect the health of the public.
PHNs need to understand public health law and how it pro-
tects individual, family, and community safety. Laws con-
cerned with public health include public health nuisance;
quarantine; mandated reporting of communicable disease;
mandated reporting of suspected abuse and neglect of chil-
dren, the disabled, and the elderly; and commitment. See
examples of local public health laws in Table 7.5.
For PHNs who practice in school settings, a federal
law titled the Family Educational Rights and Privacy Act
(FERPA) protects the privacy of student educational records
(U.S. Department of Education, 2015; U.S. DHHS and the
U.S. DoE, 2008). When the school contracts for school nurs-
ing services from a community agency, the school nurse is
obligated to follow the school data privacy policy for educa-
tional records (Association of State and Territorial Health
Officers [ASTHO], 2015).
The Network for Public Health Law (https://www.
networkforphl.org/) compiles information and resources
about public health law at all levels of government. It iden-
tifies primary legal issues and offers technical assistance for
a variety of topics.
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154 PART II n Entry-Level Population-Based Public Health Nursing Competencies
TABLE 7.5 Public Health Law Examples
Type of Law Key Features Example
Civil commitment Protects mentally ill individuals from danger to
themselves or others; addresses process of obtain-
ing a court order to obtain treatment for mental
illness when individuals are unable or unwilling
to seek treatment voluntarily and need protection
from harming themselves or others due to illness.
Civil commitment laws vary across states.
PHNs collaborate with family members, other
health professionals, community agencies, and
the government in the civil commitment process
by providing information about the process and
referring to resources.
Data privacy The federal government administers the Health
Insurance Portability and Accountability Act
(HIPAA) of 1996. PHNs are accountable for ensur-
ing the data-privacy aspect of HIPAA. In some
states, laws specify that information important for
ensuring public health can be disclosed.
Minnesota’s Data Sharing Law allows the sharing
of immunization data with schools and childcare
providers without parental permission. Healthcare
providers can share information about commu-
nicable diseases with the state health department
without patients’ permission. Otherwise, the
sharing of individual and family healthcare infor-
mation requires that clients sign a release of infor-
mation form authorizing sharing of information.
Mandated reporting of
suspected child abuse
or neglect
Professionals in relevant disciplines who have
a reason to believe a child is being neglected or
abused are obligated to report the information to
the local welfare agency. Many states also offer
civil immunity for people who make reports, and
penalties if suspected child abuse is not reported
(Pozgar, 2005).
PHNs are mandated reporters for suspected child
abuse and neglect.
Mandated reporting of
communicable disease
Mandates reporting of communicable diseases so
that occurrence of the disease can be monitored.
During the H1N1 epidemic in 2009, surveillance
of incidence of H1N1 cases helped determine the
number of flu clinics to be offered and whether
schools needed to close.
Public health
nuisances
Include conditions that threaten the health of the
public and require response or action from the
local health department. Examples are: garbage
accumulation, sewage, noise, junked cars, aban-
doned swimming pools, rodent infestation, and
faulty electrical wiring or plumbing.
Top three complaints were mold, garbage
houses, and accumulation of rubbish or junk
(MDH, 2017c).
Quarantine Provides for isolating individuals or groups to pre-
vent the spread of communicable disease; restricts
activities or travel of an otherwise healthy person
with possible exposure to a communicable disease
to prevent disease transmission.
Can be used to reduce the effects of bioterrorism
or pandemic events, such as the spread of avian
influenza or Ebola.
School-entry laws Mandate evidence of vaccination for specific com-
municable diseases or a legal exemption signed by
a parent.
School-entry laws, in place since the 1960s, have led
to increased vaccination rates and decreased rates
of childhood communicable diseases (Horlich,
Shaw, Gorji, & Fishbein, 2008). Some parents
might object to compulsory vaccinations for their
children because of medical reasons or religious/
cultural beliefs.
Sources: Minnesota Department of Health, 2003, 2005, 2015, 2016, 2017a, 2017b; Minnesota Department of Health State Community Health Services
Advisory Committee, 1992; National Alliance on Mental Illness, 2016; Office of the Reviser of Statutes, 2016
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155CHAPTER 7 n Competency #5
TABLE 7.6 Differences Between the Public Health and Medical Models
Public Health Model Medical Model
Mission is to promote, protect, and maintain the health of
every citizen.
Mission is to restore health to those who seek care (i.e., treatment
and cure).
Focus is on the primary health needs of communities and
populations.
Focus is on the primary health needs of individuals.
Health seen as a birthright of every citizen. Healthcare seen as a service to be sought.
Goal is client/family and population self-sufficiency. Goal is providing quality service to meet immediate medical
care needs.
Focus is on prevention. Focus is on treatment.
Seeks to protect the public’s health before problems arise. Seeks to meet the needs of patients who present for care of an
existing problem.
Reaches out to identify individuals, families, and populations
with service needs (case-finding).
Addresses the needs of patients who present for care.
Focus is on populations, the community, and the family. Focus is on the individual.
Provides services that others cannot or will not provide. Generally provides services that are reimbursable.
Seeks social change to improve the health status of
populations.
Seeks change to improve health status of an individual.
Provides services primarily in community settings. Provides services primarily in healthcare facilities.
Provides health-promotion services in the home and might
provide services to meet medical needs or refer those individ-
uals with medical needs to a home care agency.
Provides home care services for medical needs related to disease
and disability.
THEORY APPLICATION
Comparison of the Public Health and Medical Models
As you think about how government organizations guide
and deliver public health services, and the responsibilities of
the government and PHNs for improving the health status of
individuals and populations, consider how PHNs use a public
health model in contrast to a medical model. One difference is
that the public health model focuses on populations, whereas
the medical model focuses on individuals. Another differ-
ence is the public health focus on prevention of disease as
opposed to the medical model focus on treatment of disease.
In the public health model, healthcare is viewed as a right,
whereas in the medical model, healthcare is a service. PHNs
can use the public health model to help frame their practice
as prevention-oriented and population-based. See Table 7.6.
Consider how the public health model differs from the tradi-
tional medical model when planning interventions to improve
health status among populations to ensure that interventions
are consistent with the mission of public health.
Some services are provided in both public health and med-
ical settings, but their approaches to healthcare differ. For
example, childhood screening is provided in public health
programs to improve the well-being of the population of chil-
dren in the community. From the perspective of the medical
model, an individual child is screened on routine visits in a
clinic to evaluate that child’s health status.
In 2008, the Minnesota state legislature signed into law the
Statewide Health Improvement Program, changed to State-
wide Health Improvement Partnership in 2017 (SHIP). SHIP
is designed to reduce risk factors for chronic disease; reduc-
ing these risk factors ultimately decreases healthcare costs.
Partnership strategies engage communities in implementing
evidence-based interventions to reduce obesity and tobacco
use. SHIP awards community-level grants to support public
health solutions in Minnesota counties. Since SHIP strategies
have been implemented, the adult obesity rate in Minnesota
has decreased in comparison to obesity rates in surround-
ing states from 27.6% in 2014 to 26.1% in 2015 (Minnesota
Department of Health, 2017d). Many partners work together
to improve health, including schools, businesses, apartment
owners and managers, farmers, hospital, clinics, faith commu-
nities, and local government.
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156 PART II n Entry-Level Population-Based Public Health Nursing Competencies
‘‘
’’
How Do the Scope and Standards of
Public Health Nursing Guide the Public
Health Nurse in Independent Practice?
The great majority of interventions implemented by PHNs
represent independent nursing practice and are consistent
with interventions delineated by the Public Health Inter-
vention Wheel. Public Health Nursing: Scope and Standards
of Practice, published in 2013 by the American Nurses Asso-
ciation, is also important for guiding the professional role
expectations and actions of PHNs (see Chapter 1). The docu-
ment has two sections—standards of practice and standards
of professional performance. The standards of practice
detail how the nursing process is applied in public health
nursing. Table 7.7 analyzes how each of these role expecta-
tions occurred in the response to the measles outbreak.
How Is the Government Involved in the
Delivery of Community Health Services?
Often, governmental organizations collaborate with private
and nonprofit organizations to deliver community health
services. Governmental organizations may provide funding,
oversight, consultation, and other resources to support the
public health work of private and nonprofit organizations.
How do the core functions of assessment, policy develop-
ment, and assurance take place in the following evidence
examples?
After the flurry of responses to the measles outbreak had
subsided, Dan reflects on how his work differs from that of
his previous position as a nurse for a pediatric clinic. Dan
comments to his supervisor, Carol, “I never realized how
the government is responsible for public health. I now think
about people who need the MMR vaccine not as individu-
als, but as populations. We prioritized which populations
were at risk. We also made sure that the vaccine was avail-
able to everyone, regardless of whether they could pay for
the vaccine. In the clinic, we followed a medical model that
approached clients as individuals.”
Carol adds, “Yes, the public health model is oriented to
finding people who need health services rather than always
waiting for people to identify their needs. In addition, pub-
lic health is oriented toward changing health and social
systems to create environments that encourage improve-
ment in health status. By reaching out to those populations
most in need of the vaccination, we have actually created
an environment that will help keep people healthy in the
communities served by our agency.”
EVIDENCE EXAMPLE 7.3
Childhood Obesity Prevention
A program in School District 197 in Dakota County, Minnesota,
is consistent with the public health model approach. SHIP fund-
ing was awarded to the school district to encourage students
to eat a variety of fruits and vegetables. The program is based
on the following premises: 1) obesity contributes to diseases
that affect a population (heart disease, diabetes, and other
chronic diseases); 2) disease and health problems result from
individual vulnerability and environmental factors, and 3 of 5
Minnesotans are overweight or obese due to insufficient phys-
ical activity and unhealthy eating (Minnesota Department of
Health, 2017d); and 3) interventions should be targeted toward
changing environmental factors. Interventions include:
n During lunch each week, students have an opportunity to
taste a less common fruit or vegetable.
n After tasting, students fill out a survey on their interest in
having the new food on the lunch menu.
n Foods with favorable ratings among the students are
included in school lunch menus, when feasible.
n Parents are encouraged to send lunches or snacks that
include vegetables and fruits instead of less healthy alter-
natives such as chips and candy.
n In addition, sugary drinks were banned from school
vending machines, which was a policy developed by the
state Department of Education in collaboration with the
Department of Agriculture.
School nurses and parents reported children were willing to try
new foods. Stacie O’Leary, the health service coordinator for
the school district, observed the project goal led to making an
environmental change in the school district.
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157CHAPTER 7 n Competency #5
TABLE 7.7 Standards of Professional Performance—Application to Measles Outbreak in Minnesota
Standard Example
Ethics Recognized that the outbreak is about unvaccinated children versus specific communities or ethnic
groups
Education Provided education materials to childcare centers and summer camps on signs and symptoms of
measles and where to refer to for any concerns
Evidence-Based Practice
and Research
Accessed information from the CDC for vaccine safety and adverse reactions
Quality of Practice Adhered to CDC vaccination recommendations, including the exceptions to be made for providing
earlier vaccinations per CDC
Communication Held meetings in communities with populations at risk to dispel the misinformation about vaccine
risks, including the Somali community where key Somali leaders were involved
Leadership Activated Incident Command Structure to coordinate the response and work with local
organizations
Collaboration Worked with MDH and other LHDs to provide outreach and surveillance to the population at risk
Professional Practice
Evaluation
Completed After Action/Improvement Plan that follows guidelines from the Homeland Security
Exercise and Evaluation Program
Resource Utilization Worked with the Minnesota Vaccines for Children Program that provides free or low-cost vaccines
for eligible children through age 18
Environmental Health Promoted practices that reduced exposure to those most at risk within the community
Advocacy Provided outreach throughout the county to promote and encourage measles vaccination and
communicate clinic schedules
EVIDENCE EXAMPLE 7.4
Government Collaboration With Communities
n The Minnesota Health Department adopted a statewide
Breastfeeding-Friendly Health Department (BFHD) pro-
gram to support initiating and maintaining breastfeeding
for 12 months and beyond. One of the ten steps for being
a BFHD is collaborating with community partners. For
example, the BFHD initiative recommends collaborating
with community partners to ensure access to breastfeed-
ing classes, educating the community on breastfeeding
support, encouraging local public places to provide a
breastfeeding-friendly environment, and providing work-
place lactation support training to local businesses. The
initiative aims to establish breastfeeding as a community
norm (MDH, 2017e).
n The Orange County Health Department California created
a coalition called Waste Not Orange County. The coalition
advocates for food security screening in primary health-
care settings and food donation sites. They educate the
community about food donations, identify individuals and
families experiencing food insecurity, and connect them to
sources of food. They partner with Food Finders, which is a
nonprofit organization that picks up excess food from hos-
pitals, restaurants, and supermarkets and distributes it to
food shelves. The coalition implemented a health inspec-
tion protocol, using volunteers to educate businesses
about food donations and market the coalition’s activities
to the business community. To incentivize food dona-
tions, the coalition awarded window seals to participating
businesses and featured a photo of the business on their
coalition website (Garcia-Silva, Handler, & Wolfe, 2017).
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158 PART II n Entry-Level Population-Based Public Health Nursing Competencies
What Should the Public Health Nurse
Know About the Healthcare System?
The United States healthcare system is financed by a com-
bination of public and private entities that provide services
to insured, underinsured, and uninsured populations.
Private healthcare organizations may be for-profit or non-
profit. Many government programs provide services using a
combination of federal, state, and local funds. Local health
departments often provide services to low-income residents.
PHNs can assist community residents with referrals to clin-
ics that are free or have sliding fee scales and connect them
with insurance navigators for accessing healthcare coverage.
Table 7.8 identifies major programs and funding sources
in the U.S. Healthcare System.
The ACA included provisions for health promotion ini-
tiatives to contribute to better health outcomes and reduce
costs. As part of the ACA, the National Prevention Strategy:
America’s Plan for Better Health and Wellness (National
Prevention Council, 2011) has four major strategies:
1. Building healthy and safe community environments
2. Expanding quality preventive services in clinical and
community settings
3. Empowering people to make healthy choices
4. Eliminating health disparities
The seven priority areas are: (1) tobacco-free living, (2)
preventing drug abuse and excessive alcohol use, (3) healthy
eating, (4), active living, (5) injury and violence-free living,
(6) reproductive and sexual health, and (7) mental health
and emotional well-being. The National Prevention Strategy
identifies evidence-based recommendations for reducing
the incidence of preventable death and major illness.
Several other federal agencies are responsible for oversee-
ing health research, dissemination of health information, and
Mobile Outreach Nurse-Led Clinic USA
GOAL 9 Nurses are firsthand witnesses to client needs and healthcare system challenges, which posi-
tions them to create innovative solutions. Elisabeth Knight, a nurse practitioner, brings health services
to rural and low-income areas of southern Arizona, where many lack access to healthcare and insur-
ance. Along with a medical assistant and a driver, Elisabeth provides health clinics in a truck equipped
with exam rooms and a lab. Services include preventative care, basic wellness advice, management of
chronic conditions, and prenatal and birth care to expectant mothers. The Arizona legislature provided
funding for the mobile clinic. The College of Medicine at the University of Arizona, Tucson, oversees the
program. The mobile clinic serves 2,400 people yearly; everyone is accepted, regardless of their income
and ability to pay. Elisabeth observed, “Part of what we’re able to do is teach people to manage their chronic conditions by provid-
ing the tools, information and knowledge they need to take care of themselves, which helps us keep them out of the emergency
room” (International Council of Nurses, 2017).
health regulations to protect public health and safety. These
include (Mossialos, Djordjevic, Osborn, & Sarnak, 2017):
n Centers for Disease Control and Prevention:
Conducts research and programs to protect public
health and safety
n National Institutes of Health: Oversees biomedical
and health-related research
n Health Resources and Services Administration:
Supports strategies to improve healthcare access
n Agency for Healthcare Research and Quality:
Conducts evidence-based research
n Food and Drug Administration: Regulates food,
tobacco products, pharmaceutical drugs, medical
devices, and vaccines
Because of the high cost of healthcare, service delivery
is changing. New ways of structuring healthcare aim to
improve health outcomes and reduce costs. Recent initia-
tives include (Mossialos et al., 2017):
n Healthcare or Medical Home: A patient-centered
model that emphasizes care coordination and continuity
of care.
n Accountable Care Organization (ACO): Provider
networks that take on contractual responsibility for
providing quality care for a defined population.
n Bundled payments: Organizations providing care are
reimbursed with a single payment for all services deliv-
ered by multiple providers for a single episode of care,
such as surgical or chronic illness care.
In addition, the U.S. healthcare system has implemented
special Information Technology infrastructures to maintain
public health in four areas. See Table 7.9. A program called
Electronic Health Record (EHR) Meaningful Use is creating
a secure electronic reporting infrastructure for real-time
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159CHAPTER 7 n Competency #5
TABLE 7.8 Major U.S. Healthcare System Programs and Funding
Component Description
Centers for Medicare and Medicaid
Services (CMS)
Established by Congress in 1965 fol-
lowed by many incremental legislative
changes
Federal agency administers Medicare, a federal program for adults 65 and older and
some people with disabilities.
Works in partnership with state governments to administer Medicaid.
The Affordable Care Act (ACA)
Established by Congress in 2010
“…established ‘shared responsibility’ between the government, employers, and individ-
uals for ensuring that all Americans have access to affordable and good-quality health
insurance. However, health coverage remains fragmented, with numerous private and
public sources, as well as wide gaps in insured rates across the U.S. population” (p. 173).
The ACA gives states the option of expanding Medicaid through subsidies from the
federal government.
Private insurance—individual
or employer
Regulated at state level.
“In 2014, state and federally administered health insurance marketplaces were estab-
lished to provide additional access to private insurance coverage, with income-based
premium subsidies for low- and middle-income people” (p. 173).
Medicare beneficiaries have the option of purchasing private supplemental insurance to
cover additional health services and cost-sharing.
Source: Mossialos et al., 2017
TABLE 7.9 Public Health IT Structures
Public Health Reporting System Description
Syndromic Surveillance (SS) SS examples include monitoring for injury trends, such as bicycle accident–related inju-
ries; tracking the burden of disaster-related conditions in hospitals following a natural
disaster, such as a tornado; and tracking the severity of asthma and upper respiratory
tract infections during allergy season.
79% of local health departments (LHDs) have implemented in 2016, with 3% in process.
Immunization Information
Systems (IIS)
Creates a centralized repository of all immunization data with two-way electronic record
exchanges that include sending and receiving immunization histories for individuals
and related demographic information, as well as observations about an immunization
event, such as reactions or eligibility for a funding program.
85% of local health departments (LHDs) have implemented in 2016, with 3% in process.
Electronic Laboratory Reporting (ELR) State and local laws require the reporting of particular lab results to public health agen-
cies regarding communicable diseases such as anthrax, botulism, smallpox, and more.
Through reporting, these agencies can act quickly to control the spread of the disease
(e.g., vaccinating or treating close contacts of a patient, identifying contaminated foods,
or uncovering industrial practices that cause toxic exposures).
49% of local health departments (LHD) have implemented in 2016, with 8% in process.
Cancer Registry Population-based cancer surveillance is essential for coordination of care, activities, and
resource allocation to decrease the mortality and morbidity of this disease, which is the
second-leading cause of death in the United States.
Cancer registries exist in all 50 states, Washington D.C., Puerto Rico, and the U.S.
Pacific islands.
Sources: CDC, 2013, 2017a; Georgia Department of Health, 2017; International Society for Disease Surveillance, 2012; NACCHO, 2016; Savage, 2011
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160 PART II n Entry-Level Population-Based Public Health Nursing Competencies
analysis. The goal is that whenever a provider charts health-
care data in a hospital or clinic EHR, the data is automati-
cally submitted to public health agencies. This provides an
early warning system for bioterrorism, communicable dis-
ease outbreaks, as well as insights in how to prepare for and
provide better care during extreme weather events and mass
gatherings like major sporting events (Yoon, Ising, & Gunn,
2017).
The Institute for Healthcare Improvement (IHI) devel-
oped the Triple Aim Initiative as a framework for improv-
ing health system performance. The three dimensions that
healthcare policymakers need to pursue are: 1) improving
the patient experience, 2) improving the health of popula-
tions, and 3) reducing the per capita cost of healthcare (IHI,
2017). See Figure 7.3.
EVIDENCE EXAMPLE 7.5
ACA Outcomes
Since implementation of the ACA, access to healthcare
has increased in the United States. The groups with the
greatest gains in access include young adult, Hispanic,
black, and low-income populations, which demonstrates
some progress in reducing health disparities. In addition,
cost control measures have reduced some expenses.
Incentives to reduce avoidable hospital readmissions
for Medicare patients have decreased the 30-day read-
mission rate nationally. Since Medicare payments to
the lowest-performing hospitals were reduced in 2012,
hospital-acquired conditions decreased by 17% over a
3-year period. Although healthcare spending following
ACA implementation has slowed, data through July 2016
showed that national healthcare spending had increased
4.9% in the previous year (Mossialos et al., 2017).
EVIDENCE EXAMPLE 7.6
Impact of ACA on PHN Daily Work
Edmonds, Campbell, and Guilder (2016) surveyed 1,143
PHNs across the United States on their knowledge, percep-
tions, and practices under the ACA. Forty-five percent of
PHNs reported their work changed due to the ACA. PHN
activities related to ACA provisions included: integration
of primary care and public health, provision of clinical
preventive services, care coordination, client navigation,
establishing private-public partnerships, implementation
of population health strategies and population health data
assessment and analysis, community health assessment,
involvement with medical homes and Accountable Care
Organizations, and maternal and child health home visiting
services.
EVIDENCE EXAMPLE 7.7
Comparison of U.S. Healthcare System With Other
High-Income Countries
The United States has worse health outcomes and higher
care costs in comparison with ten other high-income coun-
tries ( Australia, Canada, France, Germany, Netherlands,
New Zealand, Norway, Sweden, Switzerland, and the
United Kingdom). The U.S.:
n Ranks last in overall healthcare system performance
n Ranks last in access, equity, and healthcare outcomes
n Ranks next to last in administrative efficiency
n Ranks fifth in care process (prevention, safe care,
coordination, patient engagement)
n Has worse population health outcomes in infant
mortality and life expectancy at age 60
Out of the 11 countries in the study, the U.S. was the only
country that did not have universal access to healthcare.
Access to primary care in the U.S. is poor, which means
there is “inadequate prevention and management of
chronic diseases, delayed diagnoses, incomplete adher-
ence to treatments, wasteful overuse of drugs and technol-
ogies, and coordination and safety problems” (Schneider,
Sarnak, Squires, Shah, & Doty, 2017).
IHI emphasizes that all three dimensions need to be
addressed simultaneously:
IHI believes that to do this work effectively, it’s
important to harness a range of community determi-
nants of health, empower individuals and families,
substantially broaden the role and impact of primary
care and other community based services, and assure
a seamless journey through the whole system of care
throughout a person’s life (IHI, 2017, para. 5).
FIGURE 7.3 Triple Aim Initiative
Health of a
Population
Per Capita
Cost
Experience
of Care
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161CHAPTER 7 n Competency #5
through presenting data about public health needs and col-
laborating with other public health professionals and orga-
nizations to make a case for funds needed to implement
effective public health programs.
Programs of Local Public Health Departments
In larger health departments, you might become more
specialized with skills and knowledge for a specific public
health program, such as follow-up for clients with tuber-
culosis or family-planning clinics. In rural health depart-
ments, your skill set and knowledge may have to be broader,
because you might work in a variety of programs and set-
tings. Although variation exists among programs that
LHDs provide, some public health services are provided
more frequently, such as immunizations and surveillance
and epidemiology for communicable/infectious diseases. In
addition, population-focused home visiting programs can
be offered that target specific vulnerable or high-risk popu-
lations, such as parenting adolescents.
LHDs have numerous responsibilities and activities;
percentages of the occurrence of specific activities in local
health departments are the following (NACCHO, 2016):
n Communicable disease surveillance (93%)
n Adult immunization provision (90%)
n Child immunization provision (88%)
n Environmental health (85%)
n Tuberculosis screening (84%)
n Tuberculosis treatment (79%)
n Food service establishment inspection (78%)
n Food-safety education (77%)
n Schools/daycare centers (74%)
n Population-based nutrition services (74%)
n Maternal and child health (69%)
n Women, Infants, and Children (WIC) (66%)
n Home visits (60%)
n Family planning (53%)
The NACCHO 2016 report showed that emergency pre-
paredness has become an important responsibility of public
health, with 81% of health departments providing emer-
gency preparedness training to staff. Data from this report
noted that LHDs provided screening for a number of dis-
eases and conditions in addition to tuberculosis, includ-
ing high blood pressure, blood lead, diabetes, cancer, and
cardiovascular conditions. Additional health services that
may be provided by LHDs are prenatal care, well child clin-
ics, oral health, home healthcare, primary care, and mental
health and substance abuse services.
Increasingly, LHDs are employing informatics special-
ists, given the growth in the use of information technology
(IT). Information technology use by LHDs has increased in
all categories since the 2008 NACCHO report, particularly
Some health policy experts recommend adding a fourth
aim (Quadruple Aim), which addresses the goal of improv-
ing the work environments for healthcare providers, clini-
cians, and staff (Bodenheimer & Sinksy, 2014).
The ACA does address Triple Aim dimensions to some
degree. However, given the U.S. political climate, the future
of the ACA is uncertain. Differing values and beliefs about
the right to healthcare and partisan politics have contrib-
uted to the inability of the 2017 Congress to move forward
with a clear healthcare agenda.
Understanding Funding Streams in
Local Public Health Departments
In your PHN role, you might be called on to contribute to
planning and writing grant applications for funds for spe-
cific public health programs. Funding for local public health
comes from a mix of local, state, and federal funds, fees,
and reimbursements. Because there are multiple sources
of funding for public health, budgets are complex and vary
each fiscal year. Sources of funding include local taxes,
Medicaid, Medicare, client fees, Local Public Health Act
state funds, federal Temporary Assistance for Needy Fami-
lies (TANF), and private insurance (Riley, Gearin, Parrotta,
Briggs, & Gyllstrom, 2013).
Public health programs and funding sources vary across
states. For example, in Minnesota, for clients receiving Med-
icaid (low-income adults, children, pregnant women, and
individuals with disabilities), state law authorizes the Pre-
paid Medical Assistance Program (PMAP). This program
provides managed care, which includes regular preventive
services and illness care, and may include dental care, free
car seats, disease management programs for members with
chronic conditions, and smoking cessation programs.
Categorical grants are a potential source of funding for
local public health programs. Categorical grants, awarded
by federal and state governments, are competitive, may have
specific eligibility criteria, and are often project-oriented.
An example is the Maternal and Child Health Block Grant
Program (Title V), the nation’s oldest federal-state partner-
ship, which aims to improve the health and well-being of
women and children. Funds are distributed to states (who
distribute to local health departments) based on a formula
and require a match; every 4 dollars of federal Title V money
received must be matched by at least 3 dollars of state or
local money.
Funding sources often respond to current crises, such as
bioterrorism and opioid overdosing. Public health funding
is dependent on a flourishing economy; a downturn in the
economy means that public health resources might be more
limited. Research studies show that there is strong relation-
ship between local public health spending and performance
of public health departments (MDH, 2012). PHNs have an
important role to play in advocating for population health
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162 PART II n Entry-Level Population-Based Public Health Nursing Competencies
‘‘
’’
that assist in working on and achieving public health goals.
Nonprofit organizations provide services that contribute to
the well-being of persons, communities, or society and do
not aim to make a profit. They might be funded by grants or
donations and sometimes receive funds from governmental
organizations.
Dan notes that nurses from the Medical Reserve Corps are
volunteering to help staff some of the immunization clinics.
He asks one of the nurses, Grace, how she became involved
in the Medical Reserve Corps. Grace comments, “I have a
regular job at the hospital in my community, but when I
heard about the Medical Reserve Corps, I decided I wanted
to help my community if a disaster occurred. I am a volun-
teer. I found out about this organization when some of my
friends went to New Orleans to help with health needs after
Hurricane Katrina.”
Dan later speaks with his supervisor, Carol, about the
Medical Reserve Corps.* Carol says, “Since Hurricane
Katrina, many healthcare workers in our state have signed
up to be in the program, and now it includes more than
7,000 volunteers. This program strengthens the public
health response, which we call public health infrastructure,
when a disaster occurs. Local coordinators oversee the pro-
gram and provide training and support so that volunteers
are ready to respond to the disaster. Our health commis-
sioner can mobilize volunteers when they are needed.”
Dan responds, “The Medical Reserve Corps is a great
community resource. I am going to tell my friends from
my last job at the hospital about this wonderful volunteer
opportunity.”
*NACCHO, 2017
Ethical Application
PHNs might encounter an ethical problem regarding
immunizations for children if parents are concerned that
immunizations can cause their children harm (for example,
the worry about the measles vaccination causing autism).
An important role for PHNs is to know about evidence on
the effects of immunizations to communicate to parents.
(See Table 7.10 for the application of ethical perspectives to
immunization.)
for the use of electronic records. The NACCHO 2016
report identified the following uses of IT in local health
departments:
n Have electronic immunization registries (85%)
n Electronic disease reporting systems (79%)
n LHD website 78%
n Use Facebook (65%)
n Have electronic health records (EHRs) or plan to
implement EHRs (37%)
n Use Twitter (25%)
Community Resources
PHNs are expected to have knowledge about the many
resources that are available to individuals, families, and
communities and the referral process needed to receive ser-
vices from those resources. LHDs cannot carry out their
mission without community partnerships and resources.
PHNs build cooperative partnerships with community
agencies, organizations, other professionals, and commu-
nity groups to respond to community health concerns. (See
Chapter 8.) Many nonprofit organizations are vital partners
EVIDENCE EXAMPLE 7.8
Community Resources
n The Minnesota Visiting Nurse Agency (MVNA) is a
nonprofit organization that provides family-centered
and community-based public health nursing services to
clients from diverse racial, ethnic, and socioeconomic
backgrounds. PHNs coordinate care with healthcare
providers and local community agencies. In their family
health program, PHNs support family self-sufficiency
and use of community resources, such as WIC, Min-
nesota Family Investment Program (MFIP), schools,
Early Childhood Family Education, Follow Along, Child
and Teen Checkups, Help Us Grow, and Way to Grow
(MVNA, 2017).
n In a qualitative study that explored public health inter-
ventions used in school nursing practice, the school
nurses (SNs) in the study referred students and fami-
lies to many community resources, including vision and
hearing assessment and care, insurance, free or low-
cost medical care, teen pregnancy, clothing, shelter,
dental, mental health, and child protection. SNs who
practiced in rural schools described barriers to finding
needed community resources due to fewer resources,
lack of transportation, parents’ work schedules, and a
lack of healthcare organizations willing to provide care
for children receiving Medicaid (Anderson et al., 2017).
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163CHAPTER 7 n Competency #5
TABLE 7.10 Ethical Action in Providing Immunizations to Children
Ethical Perspective Application
Rule ethics (principles) n Promote justice by providing access to immunizations for families with children, which is
consistent with school-entry laws.
n Prevent harm to the children by promoting immunization for this population.
n Use evidence about the effectiveness of immunizations and debunk misinformation to provide
education about benefits.
Virtue ethics (character) n Respect individual parental rights to refuse immunization for their children per the law, which
allows parental exemption based on religious or other values.
Feminist ethics ( reducing
oppression)
n Be aware of using authority in a manner that oppresses parents.
n Encourage parents’ voices and perspectives in making decisions about what to do.
n The U.S. healthcare system has poorer healthcare out-
comes in comparison to other high-income countries.
n The Triple Aim Framework—which focuses on improv-
ing the patient care experience, improving population
health, and reducing healthcare costs—is an innovative
approach for guiding strategies to improve health sys-
tem performance.
n Funding for public health comes from public and pri-
vate sources and determines the programs and services
that local public health departments can provide.
n Local public health departments work with non-
profit organizations to improve the health status of
populations.
KEY POINTS
n All levels of government (local, state, and federal) have
responsibility for promoting public health and often
work together.
n Three core functions of public health and ten essen-
tial services determine the goals of public health
departments.
n PHNs who are employed by governmental agencies are
responsible for upholding specific laws that protect the
public health.
n The public health model focuses on populations and
prevention, in contrast to the medical model, which
focuses on individuals and provides healthcare services
in response to illness and injury.
REFLECTIVE PRACTICE
Governmental organizations develop and enforce laws and
regulations to prevent disease and promote the health of pop-
ulations. They also provide the resources needed to improve
public health. These resources include staff members with
expert knowledge and funds to support public health pro-
grams and services. As a PHN working for a governmental
organization, it is both a responsibility and an honor to con-
tribute to improved population health through one’s expert
knowledge and skills. Consider how PHNs use their expert
knowledge and skills in governmental responses to natural
disasters and severe weather.
Locate your state health department web page on emer-
gency preparedness for natural disasters. Select a natural
disaster that may potentially impact the health of the popu-
lation. Consider how PHNs are involved in helping commu-
nities respond to a natural disaster.
n What are the responsibilities of the local, state, and fed-
eral levels of government in responding to the disaster?
n How could community resources be involved in
responding to the consequences of the disaster (disease
prevention and health promotion)?
n How would PHN actions in response to the disaster
be consistent with the Cornerstones of Public Health
Nursing? (See Chapter 1.)
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164 PART II n Entry-Level Population-Based Public Health Nursing Competencies
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APPLICATION OF EVIDENCE
1. Which essential services would be most relevant in
responding to the natural disaster of flooding in a
community?
2. Give a practice example that illustrates each of the
three core functions for responding to a flood in a
community.
3. Refer to Table 7.7, which identifies the ANA Standards
of Professional Performance for Public Health Nursing.
How do the following standards apply to the example of
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4. Which public health laws and legal issues do PHNs
need to keep in mind when responding to a flood
disaster?
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