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7thnewCommunityPublicHealthNursingPromotingtheHealthofPopulationsbyMaryA.NiesMelanieMcEwenz-lib.org1.pdf
Community/Public Health Nursing
Promoting the Health of Populations
SEVENTH EDITION
Mary A. Nies, PhD, RN, FAAN, FAAHB Director of Nursing Research and Professor College of Nursing, Joint Appointment MPH Program, Kasiska Division of Health Sciences, Idaho State University, Pocatello, Idaho
Melanie McEwen, PhD, RN, CNE, ANEF Professor, University of Texas Health Science Center at Houston, Cizik School of Nursing, Houston, Texas
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Table of Contents
Cover image
Title page
Copyright
Dedication
About the Author
Acknowledgments
Contributors
Preface Unit 1. Introduction to Community Health Nursing
1. Health: A Community View
Definitions of Health and Community
Determinants of Health and Disease
Indicators of Health and Illness
Definition and Focus of Public Health and Community Health
Preventive Approach to Health
Definition and Focus of Public Health Nursing, Community Health Nursing, and Community- Based Nursing
Population-Focused Practice and Community/Public Health Nursing Interventions
Public Health Nursing, Managed Care, and Health Reform
Summary
Evolve Website
2. Historical Factors: Public Health Nursing in Context
Evolution of Health in Western Populations
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Advent of Modern Health Care
Consequences for The Health of Populations
Social Challenges and Public Health Nursing
Challenges for Public Health Nursing
Summary
Evolve Website
3. Thinking Upstream: Nursing Theories and Population-Focused Nursing Practice
Thinking Upstream: Examining the Root Causes of Poor Health
Historical Perspectives on Nursing Theory
How Theory Provides Direction to Nursing
Microscopic Versus Macroscopic Approaches to the Conceptualization of Community Health Problems
Assessing a Theory’s Scope in Relation to Community Health Nursing
Review of Theoretical Approaches
Healthy People 2020
Summary
Evolve Website
4. Health Promotion and Risk Reduction
Health Promotion and Community Health Nursing
Determinants of Health
Theories in Health Promotion
Risk and Health
The Relationship of Risk to Health and Health Promotion Activities
Summary
Evolve Website
Unit 2. The Art and Science of Community Health Nursing
5. Epidemiology
Use of Epidemiology in Disease Control and Prevention
Calculation of Rates
Concept of Risk
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Use of Epidemiology in Disease Prevention
Use of Epidemiology in Health Services
Epidemiological Methods
Summary
Learning Activities
6. Community Assessment
The Nature of Community
Healthy Communities
Assessing the Community: Sources Of Data
Needs Assessment
Diagnosing Health Problems
Summary
Evolve Website
7. Community Health Planning, Implementation, and Evaluation
Overview of Health Planning
Health Planning Model
Health Planning Projects
Health Planning Models in Public Health
Health Planning Federal Legislation
Nursing Implications
Summary
Evolve Website
8. Community Health Education
Connecting With Everyday Realities
Health Education in the Community
Learning Theories, Principles, and Health Education Models
The Nurse’s Role in Health Education
Enhancing Communication
Framework for Developing Health Communications
Health Education Resources
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Social Media
Summary
Evolve Website
9. Case Management
Overview of Case Management
Origins of Case Management
Purpose of Case Management
Trends that Influence Case Management
Education and Preparation for Case Managers
Case Manager Services
Case Manager Roles and Characteristics
Case Identification
The Referral Process
Application of Case Management in Community Health
Research in Case Management
Summary
Evolve Website
Unit 3. Factors That Influence the Health of the Community
10. Policy, Politics, Legislation, and Community Health Nursing
Overview: Nurses’ Historical and Current Activity in Health Care Policy
Definitions
A Major Paradigm Shift
Structure of the Government of the United States
Overview of Health Policy
Public Policy: Blueprint for Governance
The Effective Use of Nurses: a Policy Issue
Nurses’ Roles in Political Activities
Health Care Reform and Restructuring of the Health Care Industry
Nurses and Leadership in Health Policy Development
Summary
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Evolve Website
11. The Health Care System
Overview: The Health Care System
Components of the Health Care System
Critical Issues in Health Care Delivery
Future of Public Health and the Health Care System
Summary
Evolve Website
12. Economics of Health Care
Factors Influencing Health Care Costs
Public Financing of Health Care
Philanthropic Financing of Health Care
Private Health Care Insurance
Cost Containment
Trends in Health Financing
Health Care Financing Reform
Roles of the Public Health Nurse in the Economics of Health Care
Best Care at Lower Cost
Summary
Evolve Website
13. Cultural Diversity and Community Health Nursing
Cultural Diversity
Transcultural Perspectives on Community Health Nursing
Population Trends
Cultural Perspectives and Healthy People 2020
Transcultural Nursing
Overview of Culture
Culture and Socioeconomic Factors
Culture and Nutrition
Culture and Religion
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Culture and Aging
Cross-Cultural Communication
Health-Related Beliefs and Practices
Management of Health Problems: A Cultural Perspective
Management of Health Problems in Culturally Diverse Populations
Role of the Community Health Nurse in Improving Health for Culturally Diverse People
Resources for Minority Health
Summary
Evolve Website
14. Environmental Health
A Critical Theory Approach to Environmental Health
Areas of Environmental Health
Effects of Environmental Hazards
Efforts to Control Environmental Health Problems
Emerging Issues in Environmental Health
Approaching Environmental Health at the Population Level
Critical Environmental Health Nursing Practice
Summary
Evolve Website
15. Health in the Global Community
Population Characteristics
Environmental Factors
Patterns of Health and Disease
International Agencies and Organizations
International Health Care Delivery Systems
Research in International Health
Summary
Evolve Website
Unit 4. Aggregates in the Community
16. Child and Adolescent Health
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Issues of Pregnancy and Infancy
Childhood Health Issues
Adolescent Health Issues
Factors Affecting Child and Adolescent Health
Strategies to Improve Child and Adolescent Health
Public Health Programs Targeted to Children and Adolescents
Sharing Responsibility for Improving Child and Adolescent Health
Legal and Ethical Issues in Child and Adolescent Health
Summary
Evolve Website
17. Women’s Health
Major Indicators of Health
Life Expectancy
Social Factors Affecting Women’s Health
Working Women and Home Life
Health Promotion Strategies for Women
Major Legislation Affecting Women’s Health
Health and Social Services to Promote the Health of Women
Levels of Prevention and Women’s Health
Roles of the Community Health Nurse
Research in Women’s Health
Summary
Evolve Website
18. Men’s Health
Men’s Health Status
Use of Medical Care
Theories that Explain Men’s Health
Factors that Impede Men’s Health
Men’s Health Care Needs
Community Health Nursing Services for Men
New Concepts of Community Care
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Summary
Evolve Website
19. Senior Health
Concept of Aging
Theories of Aging
Demographic Characteristics
Psychosocial Issues
Physiological Changes
Wellness and Health Promotion
Common Health Concerns
Additional Health Concerns
Elder Safety and Security Needs
Psychosocial Disorders
Spirituality
End-of-Life Issues
Summary
Evolve Website
20. Family Health
Challenges Facing U.S. Families
Understanding Family Nursing
The Changing Family
Approaches to Meeting the Health Needs of Families
Approaches to Family Health
Assessment Tools
Family Health Assessment
Extending Family Health Intervention to Larger Aggregates and Social Action
Applying the Nursing Process
Summary
Evolve Website
Unit 5. Vulnerable Populations
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21. Populations Affected by Disabilities
Self-Assessment: Perception of Disability
Definitions and Models for Disability
A Historical Context for Disability
Prevalence of Disability
Disability and Public Policy
The Experience of Disability
Health Promotion and Disease Prevention for Pwd
Ethical Issues for People Affected by Disabilities
Summary
Evolve Website
22. Veterans’ Health
Overview of the American Uniformed Services
Veteran Health Risks
Veterans Health Assessment
Interventions for Veteran Health Problems
Summary
Evolve Website
23. Homeless Populations
Definitions, Prevalence, and Demographic Characteristics of Homelessness
Factors that Contribute to Homelessness
Health and Homeless Populations
Health Status of the Homeless Population
Community Public Health Nursing: Care of Homeless Populations
Summary
Evolve Website
24. Rural and Migrant Health
Rural United States
Rural Health
Rural Health Disparities: Context and Composition
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Specific Rural Aggregates
Rural Health Care Delivery System
Community-Based Care
Legislation and Programs Affecting Rural Public Health
Rural Community Health Nursing
New Models Of Health Care Delivery for Rural Areas
Evolve Website
25. Populations Affected by Mental Illness
Overview and History of Community Mental Health: 1960 to the Present Day
Healthy People 2020: Mental Health and Mental Disorders
Factors Influencing Mental Health
Mental Disorders Encountered in Community Settings
Identification and Management of Mental Disorders
Community-Based Mental Health Care
Role of the Community Mental Health Nurse
Summary
Evolve Website
Unit 6. Population Health Problems
26. Communicable Disease
Communicable Disease and Healthy People 2020
Principles of Infection and Infectious Disease Occurrence
Chain of Transmission
Breaking the Chain of Transmission
Public Health Control of Infectious Diseases
Vaccines and Infectious Disease Prevention
Vaccine Needs for Special Groups
Healthy People 2020 Focus on Immunization and Infectious Diseases
Healthy People 2020 Focus on Sexually Transmitted Diseases
Healthy People 2020 Focus on Hiv/Aids
Prevention of Communicable Diseases
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Summary
Evolve Website
27. Substance Abuse
Etiology of Substance Abuse
Historical Overview of Alcohol and Illicit Drug Use
Prevalence, Incidence, and Trends
Adolescent Substance Abuse
Conceptualizations of Substance Abuse
Sociocultural and Political Aspects of Substance Abuse
Course of Substance-Related Problems
Legal and Ethical Concerns Related to Substance Abuse
Modes of Intervention
Social Network Involvement
Vulnerable Aggregates
Nursing Perspective on Substance Abuse
Summary
Evolve Website
28. Violence
Overview of Violence
History of Violence
Interpersonal Violence
Community Violence
Factors Influencing Violence
Violence from a Public Health Perspective
Prevention of Violence
Summary
Evolve Website
29. Natural and Manmade Disasters
Disaster Definitions
Types of Disasters
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Characteristics of Disasters
Disaster Management
Disaster Management Stages
Recovery Stage
Summary
Evolve Website
Unit 7. Community Health Settings
30. School Health
History of School Health
School Health Services
School Nursing Practice
School-Based Health Centers
Future Issues Affecting the School Nurse
Summary
Evolve Website
31. Occupational Health
Evolution of Occupational Health Nursing
Demographic Trends and Access Issues Related to Occupational Health Care
Occupational Health Nursing Practice and Professionalism
Occupational Health and Prevention Strategies
Skills and Competencies of the Occupational Health Nurse
Impact of Federal Legislation on Occupational Health
Legal Issues in Occupational Health
Multidisciplinary Teamwork
Summary
Evolve Website
32. Forensic and Correctional Nursing
Subspecialties of Forensic Nursing
Correctional Nursing
Health Issues in Prison Populations
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Mental Health Issues in Correctional Settings
Education and Forensic Nursing
Summary
Evolve Website
33. Faith Community Nursing
Faith Communities: Role in Health and Wellness
Foundations of Faith Community Nursing
Roles or Functions of the Faith Community Nurse
Education of the Faith Community Nurse
The Faith Community Nurse and Spirituality
Issues in Faith Community Nurse Practice
Summary
Evolve Website
34. Home Health and Hospice
Types of Home Health Agencies
Certified and Noncertified Agencies
Special Home Health Programs
Reimbursement for Home Care
OASIS
Nursing Standards and Educational Preparation of Home Health Nurses
Conducting a Home Visit
Documentation of Home Care
Application of the Nursing Process
Hospice Home Care
Summary
Evolve Website
Index
IBC
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Copyright
3251 Riverport Lane St. Louis, Missouri 63043
COMMUNITY/PUBLIC HEALTH NURSING: PROMOTING THE HEALTH OF POPULATIONS,
SEVENTH EDITION ISBN: 978-0-323-52894-8 Copyright © 2019 by Elsevier, Inc. All rights reserved.
Chapter 22: Veteran’s Health—Contributions made by Alison C. Sweeney, Angelic Denise Chaison, and Joanna Lamkin are in public domain.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
Previous editions copyrighted 2015, 2011, 2007, 2001, 1997, and 1993.
Library of Congress Cataloging-in-Publication Control Number: 2018944741
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Content Strategist: Jamie Blum Senior Content Development Manager: Ellen Wurm-Cutter Content Development Specialist: John Tomedi Publishing Services Manager: Julie Eddy Senior Project Manager: Rachel E. McMullen Design Direction: Renee Duenow
Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
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Dedication
To Phil Yankovich, my husband, companion, and best friend, whose love, caring, and true support are always there for me. He provides me with the energy I need to pursue my dreams.
To Kara Nies Yankovich, my daughter, for whom I wish a happy and healthy life. Her energy, joy, and enthusiasm for life give so much to me.
To Earl (who passed away October 15, 2017, at the age of 92) and Lois Nies, my parents, for their never-ending encouragement and lifelong support. They helped me develop a foundation for
creative thinking, new ideas, and spirited debate.
Mary A. Nies
To my husband, Scott McEwen, whose love, support, inspiration, and encouragement have been my foundation for more than 40 years. I can’t wait to see what happens next!
Melanie McEwen
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About the Author
Mary A. Nies Mary A. Nies, PhD, RN, FAAN, FAAHB, is the Director of Nursing Research and Professor
College of Nursing, Joint Appointment MPH Program, Kasiska Division of Health Sciences, Idaho State University. Dr. Nies received her diploma from the Bellin School of Nursing in Green Bay, Wisconsin; her BSN from the University of Wisconsin, Madison; her MSN from Loyola University, Chicago; and her PhD in Public Health Nursing, Health Services, and Health Promotion Research at
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the University of Illinois, Chicago. She completed a postdoctoral research fellowship in health promotion and community health at the University of Michigan, Ann Arbor. She is a fellow of the American Academy of Nursing and a fellow of the American Academy of Health Behavior. Dr. Nies co-edited Community Health Nursing: Promoting the Health of Aggregates, which received the 1993 Book of the Year award from the American Journal of Nursing. Her program of research focuses on the outcomes of health promotion interventions for minority and nonminority populations in the community. Her research is involved with physical activity and obesity prevention for vulnerable community populations.
Melanie McEwen Melanie McEwen, PhD, RN, CNE, ANEF, is a Professor at the University of Texas Health Science
Center at Houston’s Cizik School of Nursing. Dr. McEwen received her BSN from the University of Texas School of Nursing in Austin; her Master’s in Community and Public Health Nursing from Louisiana State University Medical Center in New Orleans; and her PhD in Nursing from Texas
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Woman’s University. Dr. McEwen has been a nursing educator for 30 years and is also the co- author of Community–Based Nursing: An Introduction (Elsevier, 2009) and co-author/editor of Theoretical Basis for Nursing (Wolters Kluwer, 2018).
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Acknowledgments
Community/Public Health Nursing: Promoting the Health of Populations could not have been written without sharing the experiences, thoughtful critique, and support of many people: individuals, families, groups, and communities. We give special thanks to everyone who made significant contributions to this book.
We are indebted to our contributing authors whose inspiration, untiring hours of work, and persistence have continued to build a new era of community health nursing practice with a focus on the population level. We thank the community health nursing faculty and students who welcomed the previous editions of the text and responded to our inquiries with comments and suggestions for the seventh edition. These people have challenged us to stretch, adapt, and continue to learn throughout our years of work. We also thank our colleagues in our respective work settings for their understanding and support during the writing and editing of this edition.
Finally, an enormous “thank you” to John Tomedi of Spring Hollow Press, Elsevier editors Ellen Wurm-Cutter and Jamie Blum, and project manager Rachel E. McMullen. Their energy, enthusiasm, encouragement, direction, and patience were essential to this project.
Mary A. Nies, PhD, RN, FAAN, FAAHB Melanie McEwen, PhD, RN, CNE, ANEF
I would like to express appreciation for the chapter authors who have been with me since the very first edition of the textbook in 1993, namely:
• Patricia Burbank, Chapter 7: Community Health Planning, Implementation, and Evaluation • Holly Cassells, Chapter 5: Epidemiology; Chapter 6: Community Assessment • Susan Givens, Chapter 16: Child and Adolescent Health • Jean Cozad Lyon, Chapter 9: Case Management
Mary A. Nies, PhD, RN, FAAN, FAAHB
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Contributors
Cathy R. Arvidson, PhD, FNP-BC, Associate Professor, School of Nursing, Idaho State University, Pocatello, Idaho
Chapter 10: Policy, Politics, Legislation, and Community Health Nursing Tonya Bragg-Underwood, DNP, FNP-BC, CNE, Associate Professor, School of Nursing, Western Kentucky University, Bowling Green, Kentucky
Chapter 20: Family Health Carrie L. Buch, PhD, BSN, MS, Associate Professor, School of Nursing, Oakland University, Rochester, Michigan
Chapter 34: Home Health and Hospice Patricia M. Burbank, DNSc, BS, MS, Associate Dean and Professor, College of Nursing, The University of Rhode Island, Kingston, Rhode Island
Chapter 7: Community Health Planning, Implementation, and Evaluation Sarah G. Candler, MD, MPH, Assistant Professor, Baylor College of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
Chapter 22: Veterans’ Health Holly B. Cassells, PhD, MPH, MN, Professor, School of Nursing and Health Professions, University of the Incarnate Word, San Antonio, Texas
Chapter 5: Epidemiology Chapter 6: Community Assessment
Angelic Denise Chaison, PhD, Psychologist, Michael E. DeBakey Veterans Affairs Medical Center, Assistant Professor, Baylor College of Medicine, Houston, Texas
Chapter 22: Veterans’ Health Christina N. DesOrmeaux, BSN, MSN, PhD, Community Division Head, Community Nursing, The University of Texas at Houston Health Science Center, School of Nursing, Houston, Texas
Chapter 13: Cultural Diversity and Community Health Nursing Chapter 30: School Health
Tina Doyle-Hines, LPC, NCC, U.S. Air Force, Retired, Former Veteran Counselor, UTH Cizik School of Nursing, Houston, Texas
Chapter 22: Veterans’ Health Stacy A. Drake, MSN, MPH, RN, Assistant Professor, Nursing Systems, The University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas
Chapter 32: Forensic and Correctional Nursing
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Allison P. Edwards, DrPH, MS, RN, CNE Assistant Professor, Nursing Systems, The University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas Board Member, Texas Board of Nursing, Austin, Texas
Chapter 21: Populations Affected by Disabilities Rola El-Serag, MD, Medical Director Women Veteran’s Program, Michael E. DeBakey Veterans Affairs Medical Center, Assistant Professor of Medicine, Baylor College of Medicine, Houston, Texas
Chapter 22: Veterans’ Health Melissa Domingeaux Ethington, BSN, MSN, PhD, Assistant Professor, Family Health, The University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas
Chapter 16: Child and Adolescent Health Ginette G. Ferszt, PhD, RN, PMHCNS-BC, Professor, College of Nursing, University of Rhode Island, Kingston, Rhode Island
Chapter 28: Violence Lori A. Glenn, DNP, MS, CNM, RN Clinical Associate Professor, McAuley School of Nursing, University of Detroit Mercy, Detroit, Michigan Nurse Midwife, Mid-Michigan Midwifery, Hurley Medical Center, Flint, Michigan
Chapter 17: Women’s Health Deanna E. Grimes, DrPH, RN, MSN, FAAN, Suzie Conway Endowed Professor in Nursing, Nursing Systems, The University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas
Chapter 26: Communicable Diseases Karyn Leavitt Grow, MS, BSN, RN Director of Care Coordination Training, Clinical Development, Caravan Health, Berkeley, California Chief Nursing Officer, Manager, Case Management/Preadmission Screening, Sierra Surgery Hospital, Carson City, Nevada, Reno, Nevada
Chapter 9: Case Management Jené M. Hurlbut, BSN, MSN, MS, PhD, Professor, Nursing, Roseman University of Health Sciences, Henderson, Nevada
Chapter 18: Men’s Health Joanna Lamkin, PhD, Postdoctoral Fellow, Veterans Affairs Health Services Research & Development, Houston Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Houston, Texas
Chapter 22: Veterans’ Health Jean Cozad Lyon, PhD, MSN, Clinical Care Practitioner, ATOP2, HealthInsight, Reno, Nevada
Chapter 9: Case Management
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Rex Marsau, U.S. Navy, Retired, Former Program Director, U.S. Vets, Houston, Texas
Chapter 22: Veterans’ Health Diane Cocozza Martins, MEd, MA, PhD, Professor, College of Nursing, University of Rhode Island, Kingston, Rhode Island
Chapter 3: Thinking Upstream: Nursing Theories and Population-Focused Nursing Practice Chapter 7: Community Health Planning, Implementation, and Evaluation
Mary E. McBee, DNP, MSN, BSN, RN, Assistant Professor, Nursing Systems, The University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas
Chapter 11: The Health Care System Chapter 12: Economics of Health Care
Melanie McEwen, PhD, RN, CNE, ANEF, Professor, University of Texas Health Science Center at Houston, Cizik School of Nursing, Houston, Texas
Chapter 1: Health: A Community View Chapter 2: Historical Factors: Public Health Nursing in Context Chapter 11: The Health Care System Chapter 12: Economics of Health Care
Cathy D. Meade, PhD, RN, FAAN Senior Member, Population Science, Health Outcomes & Behavior, Moffitt Cancer Center Professor, Oncologic Sciences, University of South Florida, Tampa, Florida
Chapter 8: Community Health Education Mary A. Nies, PhD, RN, FAAN, FAAHB, Director of Nursing Research and Professor College of Nursing, Joint Appointment MPH Program, Kasiska Division of Health Sciences, Idaho State University, Pocatello, Idaho
Chapter 1: Health: A Community View Chapter 4: Health Promotion and Risk Reduction Chapter 34: Home Health and Hospice
Julie Cowan Novak, DNSc, RN, CPNP Executive Director, Neuro Developmental NICU Follow up Clinic, Sharp Mary Birch Hospital for Women and Newborns, San Diego, California Professor Emerita, Purdue University, West Lafayette, Indiana
Chapter 15: Health in the Global Community Bridgette Crotwell Pullis, BSN, MS, PhD, Assistant Professor of Nursing, Director, The Veterans’ Bachelor of Science in Nursing Program, Nursing Systems, The University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas
Chapter 4: Health Promotion and Risk Reduction Chapter 22: Veterans’ Health
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Robert Pullis, Houston, Texas
Chapter 22: Veterans’ Health Elda G. Ramirez, PhD, RN, FNP-BC, Professor of Clinical Nursing, Acute and Clinical Care, The University of Texas Health Science Center at Houston, School of Nursing, Houston, Texas
Chapter 29: Natural and Manmade Disasters Bonnie Rogers, DrPH, COHN-S, LNCC, Director, NC Occupational Safety and Health and Education and Research Center, OHN Program, University of North Carolina, School of Public Health, Chapel Hill, North Carolina
Chapter 31: Occupational Health Tamara Rose, BSN, MPH, PhD, Associate Dean, Nursing, Oregon Health and Science University, Klamath Falls, Oregon
Chapter 14: Environmental Health Mary Ellen Trail Ross, DrPH, MSN, RN, GCNS-BC, Associate Professor of Clinical Nursing, Department of Nursing Systems, The University of Texas Health Science Center at Houston, Houston, Texas
Chapter 19: Senior Health Beverly Cook Siegrist, EdD, MS, BSN, CNE, Professor, School of Nursing, Western Kentucky University, Bowling Green, Kentucky
Chapter 20: Family Health Chapter 33: Faith Community Nursing
Alison C. Sweeney, PsyD, Clinical Psychologist, Michael E. DeBakey Veterans Affairs Medical Center, Assistant Professor, Menninger Department of Psychiatry and Behavioral Science, Baylor College of Medicine, Houston, Texas
Chapter 22: Veterans’ Health Lisa W. Thomas, DNP, MS, BSN, Assistant Professor, Clinical, Acute and Continuing Care, University of Texas Health Science Center;, Houston Research Nurse Consultant, Nursing Administration, TIRR Memorial Herman, Houston, Texas
Chapter 21: Populations Affected by Disabilities Patricia L. Thomas, PhD, MS, BSN, ADN, Assistant Dean for Practice, Cook DeVos Health Science Center-Kirkhof, College of Nursing, Grand Valley State University, Grand Rapids, Michigan
Chapter 24: Rural and Migrant Health Meredith Troutman-Jordan, PhD, MSN, Associate Professor, School of Nursing, University of North Carolina, Charlotte, North Carolina
Chapter 21: Populations Affected by Disabilities Chapter 23: Homeless Populations Chapter 25: Populations Affected by Mental Illness Chapter 27: Substance Abuse
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Lori Wightman, BSN, MSN, DNP, Chief Nursing Officer, System Administration, Regional Health, Rapid City, Michigan
Chapter 24: Rural and Migrant Health ANCILLARY AUTHORS
Joanna E. Cain, BSN, BA, RN, President and Founder, Auctorial Pursuits, Inc., Atlanta, Georgia
NCLEX Review Questions
Case Studies
Dulce Santacroce, DNP, RN, CCM, RN-BSN Coordinator, Touro University Nevada, Henderson, Nevada
PowerPoint Slides
Anna K. Wehling Weepie, DNP, RN, CNE, COI, Assistant Dean, Undergraduate Nursing and Professor, Allen College, Waterloo, Iowa
Test Bank
REVIEWERS
Lisa L. Capps, PhD, APN, FNP-BC, Assistant Professor, School of Nursing, Saint Xavier University, Chicago, Illinois
Michelle L. Gerrety, EdD, MSN, RN, Administrative Director, Academic Services, Director, St. Elizabeth School of Nursing, Division Coordinator, Nursing, Saint Joseph’s College, Lafayette, Indiana
Jean Brewer Grantham, MSN, APRN, WHNP-BC, Instructor, Robert E. Smith School of Nursing, Delta State University, Cleveland, Mississippi
Meryle Gurmankin, PhD, RN, CSN, AHN-BC, Adjunct Faculty, School of Nursing and Health Sciences, LaSalle University, Philadelphia, Pennsylvania
Karen A. Ivantic, DNP, APRN-BC, APNP, Professor and Family Nurse Practitioner, Columbia College of Nursing, Milwaukee, Wisconsin
Susan K. Lee, PhD, MSN, RN, Nursing Consultant, Department of Education, Texas Board of Nursing, Austin, Texas
Sherry R. Lovan, PhD, MSN, RN, BSN Program Coordinator and Associate Professor, School of Nursing, Western Kentucky University, Bowling Green, Kentucky
Patricia S. Martin, MSN, RN, Assistant Professor, School of Nursing, University of Louisville, Louisville, Kentucky
Jill M. Nocella, PhD, APRN-BC, Associate Professor of Nursing, Department of Nursing, William Paterson University of New Jersey, Wayne, New Jersey
Dulce Anne Santacroce, DNP, RN, CCM, Assistant Professor, School of Nursing, Touro University Nevada, Henderson, Nevada
Marcia R. Scanlon, RN, DNP, Assistant Professor of Nursing, Department Chair of Nursing and Allied Health, Westfield State University, Westfield, Massachusetts
Terri Stone, MSN, MBA, RN, Assistant Professor of Nursing, Department of Nursing, Pennsylvania College of Technology, Williamsport, Pennsylvania
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Deborah Lynn Sweeney, DNSc, RN, Associate Professor of Nursing, Division of Nursing, Baptist College of Health Sciences, Memphis, Tennessee
Dokagari Woods, PhD, RN, Assistant Professor and Undergraduate Program Director, Department of Nursing, Tarleton State University, Stephenville, Texas
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Preface
More money is spent per capita for health care in the United States than in any other country ($9990 in 2015). The United States spent 17.8% of its gross domestic product on health care expenditures in 2015, reaching a record high of $3.2 trillion. It is one of the few industrialized countries in the world that lacks a program of national health services or national health insurance, so despite this spending, 8.8% of the nation lacks health insurance. In addition, many countries have far better indices of health, including traditional indicators such as infant mortality rates and longevity for both men and women, than does the United States.
Over the years, the most significant improvements in the health of the population have been achieved through advances in public health using organized community efforts, such as improvements in sanitation, immunizations, and food quality and quantity. Although access to health care services and individual behavioral changes are important, they are only components of the larger determinants of health, such as social and physical environments. The greatest determinants of health are still equated with factors in the community, such as education, employment, housing, and nutrition. The more money put into health care expenditures in the United States, the less money there is to improve these community factors.
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Upstream Focus The traditional focus of many health care professionals, known as a downstream focus, has been to deliver health care services to ill people and to encourage needed behavioral change at the individual level. The focus of public/community health nursing has traditionally been on health promotion and illness prevention by working with individuals and families within the community. A shift is needed to an upstream focus, which includes working with aggregates and communities in activities such as organizing and setting health policy. This focus will help aggregates and communities work to create options for healthier environments with essential components of health, including adequate education, housing, employment, and nutrition, and will provide choices that allow people to make behavioral changes, live and work in safe environments, and access equitable and comprehensive health care.
Grounded in the tenets of public health nursing and the practice of public health nurses such as Lillian Wald, this seventh edition of Community/Public Health Nursing: Promoting the Health of Populations builds on the earlier works by highlighting an aggregate focus in addition to the traditional areas of family and community health, and thus promotes upstream thinking. The primary focus is on the promotion of the health of aggregates. This approach includes the family as a population and addresses the needs of other aggregates or population subgroups. It conceptualizes the individual as a member of the family and as a member of other aggregates, including organizations and institutions. Furthermore, individuals and families are viewed as a part of a population within an environment (i.e., within a community).
An aggregate is made up of a collective of individuals, be it a family or another group that, with others, makes up a community. This text emphasizes the aggregate as a unit of focus and how aggregates that make up communities promote their own health. The aggregate is presented within the social context of the community, and students are given the opportunity to define and analyze environmental, economic, political, and legal constraints to the health of these populations.
Community/public health nursing has been determined to be a synthesis of nursing and public health practice with goals to promote and preserve the health of populations. Diagnosis and treatment of human responses to actual or potential health problems comprise the nursing component. The ability to prevent disease, prolong life, and promote health through organized community effort is from the public health component. Community/public health nursing practice is responsible to the population as a whole. Nursing efforts to promote health and prevent disease are applied to the public, which includes all units in the community, be they individual or collective (e.g., person, family, other aggregate, community, or population).
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Purpose of the Text In this text, the reader is encouraged to become a student of the community, learn from families and other aggregates in the community how they define and promote their own health, and learn how to become an advocate of the community by working with it to initiate change. The student is exposed to the complexity and rich diversity of the community and is shown evidence of how the community organizes to meet change.
The use of language or terminology by clients and agencies varies in different parts of the United States, and it may vary from that used by government officials. The contributors to this text are a diverse group from various parts of the United States. Their terms vary from chapter to chapter and from those in use in local communities. For example, some authors refer to African Americans, some to blacks, some to European Americans, and some to whites. The student must be familiar with a range of terms and, most important, know what is used in his or her local community.
Outstanding features of this seventh edition include its provocative nature as it raises consciousness regarding the social inequalities that exist in the United States and how the market- driven health care system contributes to prevention of the realization of health as a right for all. With a focus on social justice, this text emphasizes society’s responsibility for the protection of all human life to ensure that all people have their basic needs met, such as adequate health protection and income. Attention to the merits of population-focused care, or care that covers all people residing within geographic boundaries rather than only those populations enrolled in insurance plans, highlights the need for further reform of the systems of health reimbursement. Working toward providing health promotion and population-focused care to all requires a dramatic shift in thinking from individual-focused care for the practitioners of the future. The future paradigm for health care is demanding that the focus of nursing move toward population-based interventions if we are to forge toward the goals established in Healthy People 2020.
This text is designed to stimulate critical thinking and challenge students to question and debate issues. Complex problems demand complex answers; therefore the student is expected to synthesize prior biophysical, psychosocial, cultural, and ethical arenas of knowledge. However, experiential knowledge is also necessary, and the student is challenged to enter new environments within the community and gain new sensory, cognitive, and affective experiences. The authors of this text have integrated the concept of upstream thinking, introduced in the first edition, throughout this seventh edition as an important conceptual basis for nursing practice of aggregates and the community. The student is introduced to the individual and aggregate roles of community health nurses as they are engaged in a collective and interdisciplinary manner, working upstream, to facilitate the community’s promotion of its own health. Students using this text will be better prepared to work with aggregates and communities in health promotion and with individuals and families in illness. Students using this text will also be better prepared to see the need to take responsibility for participation in organized community action targeting inequalities in arenas such as education, jobs, and housing and to participate in targeting individual health-behavioral change. These are important shifts in thinking for future practitioners who must be prepared to function in a population-focused health care system.
The text is also designed to increase the cultural awareness and competency of future community health nurses as they prepare to address the needs of culturally diverse populations. Students must be prepared to work with these growing populations as participation in the nursing workforce by ethnically and racially diverse people continues to lag. Various models are introduced to help students understand the growing link between social problems and health status, experienced disproportionately by diverse populations in the United States, and understand the methods of assessment and intervention used to meet the special needs of these populations.
The goals of the text are to provide the student with the ability to assess the complex factors in the community that affect individual, family, and other aggregate responses to health states and actual or potential health problems and to help students use this ability to plan, implement, and evaluate community/public health nursing interventions to increase contributions to the promotion of the health of populations.
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Major Themes Related to Promoting the Health of Populations This text is built on the following major themes:
• A social justice ethic of health care in contrast to a market justice ethic of health care in keeping with the philosophy of public health as “health for all”
• Integration of the concept of upstream thinking throughout the text and other appropriate theoretical frameworks related to chapter topics
• The use of population-focused and other community data to develop an assessment, or profile of health, and potential and actual health needs and capabilities of aggregates
• The application of all steps in the nursing process at the individual, family, and aggregate levels
• A focus on identification of needs of the aggregate from common interactions with individuals, families, and communities in traditional environments
• An orientation toward the application of all three levels of prevention at the individual, family, and aggregate levels
• The experience of the underserved aggregate, particularly the economically disenfranchised, including cultural and ethnic groups disproportionately at risk of developing health problems.
Themes are developed and related to promoting the health of populations in the following ways:
• The commitment of community/public health nursing is to an equity model; therefore community health nurses work toward the provision of the unmet health needs of populations.
• The development of a population-focused model is necessary to close the gap between unmet health care needs and health resources on a geographic basis to the entire population. The contributions of intervention at the aggregate level work toward the realization of such a model.
• Contemporary theories provide frameworks for holistic community health nursing practice that help students conceptualize the reciprocal influence of various components within the community on the health of aggregates and the population.
• The ability to gather population-focused and other community data in developing an assessment of health is a crucial initial step that precedes the identification of nursing diagnoses and plans to meet aggregate responses to potential and actual health problems.
• The nursing process includes, in each step, a focus on the aggregate, assessment of the aggregate, nursing diagnosis of the aggregate, planning for the aggregate, and intervention and evaluation at the aggregate level.
• The text discusses development of the ability to gather clues about the needs of aggregates from complex environments, such as during a home visit, with parents in a waiting room of a well-baby clinic, or with elders receiving hypertension screening, and to promote individual, collective, and political action that addresses the health of aggregates.
• Primary, secondary, and tertiary prevention strategies include a major focus at the population level.
• In addition to offering a chapter on cultural influences in the community, the text includes data on and the experience of underserved aggregates at high risk of developing health problems and who are most often in need of community health nursing services (i.e., low and marginal income, cultural, and ethnic groups) throughout.
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Organization The text is divided into seven units. Unit 1, Introduction to Community Health Nursing, presents an overview of the concept of health, a perspective of health as evolving and as defined by the community, and the concept of community health nursing as the nursing of aggregates from both historical and contemporary mandates. Health is viewed as an individual and collective right, brought about through individual and collective/political action. The definitions of public health and community health nursing and their foci are presented. Current crises in public health and the health care system and consequences for the health of the public frame implications for community health nursing. The historical evolution of public health, the health care system, and community health nursing is presented, as well as the evolution of humans from wanderers and food gatherers to those who live in larger groups. The text also discusses the influence of the group on health, which contrasts with the evolution of a health care system built around the individual person, increasingly fractured into many parts. Community health nurses bring to their practice awareness of the social context; economic, political, and legal constraints from the larger community; and knowledge of the current health care system and its structural constraints and limitations on the care of populations. The theoretical foundations for the text, with a focus on the concept of upstream thinking, and the rationale for a population approach to community health nursing are presented. Recognizing the importance of health promotion and risk reduction when striving to improve the health of individuals, families, groups, and communities, this unit concludes with a chapter elaborating on those concepts. Strategies for assessment and analysis of risk factors and interventions to improve health are described.
Unit 2, The Art and Science of Community Health Nursing, describes application of the nursing process—assessment, planning, intervention, and evaluation—to aggregates in the community using selected theory bases. The unit addresses the need for a population focus that includes the public health sciences of biostatistics and epidemiology as key in community assessment and the application of the nursing process to aggregates to promote the health of populations. Application of the art and science of community health nursing to meeting the needs of aggregates is evident in chapters that focus on community health planning and evaluation, community health education, and case management.
Unit 3, Factors That Influence the Health of the Community, examines factors and issues that can both positively and negatively affect health. Beginning with an overview of health policy and legislation, the opening chapter in this unit focuses on how policy is developed and the effect of past and future legislative changes on how health care is delivered in the United States. This unit examines the health care delivery system and the importance of economics and health care financing on the health of individuals, families, and populations. Cultural diversity and associated issues are described in detail, showing the importance of consideration of culture when developing health interventions in the community. The influence of the environment on the health of populations is considered, and the reader is led to recognize the multitude of external factors that influence health. This unit concludes with an examination of various aspects of global health and describes features of the health care systems and patterns of health and illness in developing and developed countries.
Unit 4, Aggregates in the Community, presents the application of the nursing process to address potential health problems identified in large groups, including children and adolescents, women, men, families, and seniors. The focus is on the major indicators of health (e.g., longevity, mortality, and morbidity), types of common health problems, use of health services, pertinent legislation, health services and resources, selected applications of the community health nursing process to a case study, application of the levels of prevention, selected roles of the community health nurse, and relevant research.
Unit 5, Vulnerable Populations, focuses on those aggregates in the community considered vulnerable: persons with disabilities, veterans of the armed forces, the homeless, those living in rural areas including migrant workers, and persons with mental illness. Chapters address the application of the community health nursing process to the special service needs in each of these areas. Basic community health nursing strategies are applied to promoting the health of these vulnerable high-risk aggregates.
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Unit 6, Population Health Problems, focuses on health problems that affect large aggregates and their service needs as applied in community health nursing. These problems include communicable disease, violence and associated issues, substance abuse, and a chapter describing nursing care during disasters.
Unit 7, Community Health Settings, focuses on selected sites or specialties for community health: school health, occupational health, faith community health, and home health and hospice. Finally, forensic nursing, one of the more recently added subspecialty areas of community health nursing, is presented in this unit, combined with correctional nursing content.
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Special Features The following features are presented to enhance student learning:
• Learning objectives. Learning objectives set the framework for the content of each chapter. • Key terms. A list of key terms for each chapter is provided at the beginning of the chapter.
The terms are highlighted in blue within the chapter. The definitions of these terms are found in the glossary located on the book’s Evolve website.
• Chapter outline. The major headings of each chapter are provided at the beginning of each chapter to help locate important content.
• Theoretical frameworks. The use of theoretical frameworks common to nursing and public health will aid the student in applying familiar and new theory bases to problems and challenges in the community.
• Healthy People 2020. Goals and objectives of Healthy People 2020 are presented in a special box throughout the text. (The updated Healthy People 2020 information is new to this edition and based on the proposed objectives.)
• Upstream thinking. This theoretical construct is integrated into chapters throughout the text.
• Case studies and application of the nursing process at individual, family, and aggregate levels. The use of case studies and clinical examples throughout the text is designed to ground the theory, concepts, and application of the nursing process in practical and manageable examples for the student.
• Research highlights. The introduction of students to the growing bodies of community health nursing and public health research literature is enhanced by special boxes devoted to specific research studies.
• Active learning exercises. Selected learning activities are interspersed throughout the chapter to test students’ knowledge of the content they’ve just read, helping provide clinical application and knowledge retention.
• Photo novellas. Numerous stories in photograph form depicting public health care in a variety of settings and with different population groups.
• Ethical insights boxes. These boxes present situations of ethical dilemmas or considerations pertinent to particular chapters.
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New Content in this Edition • An increased focus on genomics—found in new Genetics in Public Health boxes—reflects
growing scientific evidence supporting the health benefits of using genetic tests and family health history to guide public health interventions.
• A new chapter dedicated to the care of veterans has been added, reflecting the need for enhanced education and information related to the specific needs and issues for this special population.
• Most chapters contain new or updated Research Highlights boxes highlighting timely, relevant examples of the topics from recent nursing literature and Ethical Insights boxes that emphasize specific ethical issues.
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Teaching and Learning Package Evolve website: The website at http://evolve.elsevier.com/Nies/community is devoted exclusively to this text. It provides materials for both instructors and students.
• For Instructors: PowerPoint lecture slides, image collection, and more than 900 test bank questions with alternative item questions, as well as TEACH for Nurses, which contains detailed chapter Lesson Plans, including references to curriculum standards such as QSEN, BSN Essentials and Concepts, BSN Essentials for Public Health, and new and unique Case Studies.
• For Students: NCLEX-style multiple-choice review questions with correct answer rationales, and Case Studies with questions and answers.
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UNIT 1 Introduction to Community Health Nursing
OUTLINE
1. Health: A Community View
2. Historical Factors: Public Health Nursing in Context
3. Thinking Upstream: Nursing Theories and Population-Focused Nursing Practice
4. Health Promotion and Risk Reduction
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Health
A Community View
Melanie McEwen, and Mary A. Nies
OUTLINE
Definitions of Health and Community Health Community
Determinants of Health and Disease Indicators of Health and Illness Definition and Focus of Public Health and Community Health Preventive Approach to Health
Health Promotion and Levels of Prevention Thinking Upstream Prevention versus Cure Healthy People 2020
Definition and Focus of Public Health Nursing, Community Health Nursing, and Community- Based Nursing
Public and Community Health Nursing Community-Based Nursing Community and Public Health Nursing Practice
Population-Focused Practice and Community/Public Health Nursing Interventions Public Health Interventions The Public Health Intervention Wheel
Public Health Nursing, Managed Care, and Health Reform
OBJECTIVES
Upon completion of this chapter, the reader will be able to do the following: 1. Compare and contrast definitions of health from a public health nursing perspective. 2. Define and discuss the focus of public health. 3. Discuss determinates of health and indicators of health and illness from a population
perspective. 4. List the three levels of prevention, and give examples of each. 5. Explain the difference between public/community health nursing practice and community-
based nursing practice. 6. Describe the purpose of Healthy People 2020 and give examples of the topic areas that
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encompass the national health objectives. 7. Discuss public/community health nursing practice in terms of public health’s core functions and
essential services. 8. Discuss public/community health nursing interventions as explained by the Intervention Wheel.
KEY TERMS aggregates community community health community health nursing disease prevention health health promotion health-related quality-of-life (HRQOL) population population-focused nursing primary prevention public health public health nursing secondary prevention tertiary prevention As a result of recent and anticipated changes related to health care reform, community/public health nurses are in a position to assist the U.S. health care system in the transition from a disease- oriented system to a health-oriented system. Costs of caring for the sick account for the majority of escalating health care dollars, which increased from 5.7% of the gross domestic product in 1965 to 17.8% in 2015 (National Center for Health Statistics [NCHS], 2017). Alarmingly, national annual health care expenditures reached $2.7 trillion in 2015, or an astonishing $8500 per person.
Healthy People 2020
Topic Areas
• Access to health services • Adolescent health • Arthritis, osteoporosis, and chronic back conditions • Blood disorders and blood safety • Cancer • Chronic kidney disease • Dementias, including Alzheimer • Diabetes • Disability and health • Early and middle childhood • Educational and community-based programs • Environmental health • Family planning
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• Food safety • Genomics • Global health • Health communication and health information technology • Health care–associated infections • Health-related quality of life and well-being • Hearing and other sensory or communication disorders • Heart disease and stroke • HIV • Immunization and infectious diseases • Injury and violence prevention • Lesbian, gay, bisexual, and transgender health • Maternal, infant, and child health • Medical product safety • Mental health and mental disorders • Nutrition and weight status • Occupational safety and health • Older adults • Oral health • Physical activity • Preparedness • Public health infrastructure • Respiratory diseases • Sexually transmitted diseases • Social determinants of health • Substance abuse • Tobacco use • Vision
From U.S. Department of Health and Human Services. Healthy People 2020 topics & objectives— objectives A-Z. Retrieved from <http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx>.
Health expenditures in the U.S. reflect a focus on the care of the sick. In 2015, $0.38 of each health care dollar supported hospital care, $0.23 supported physician/professional services, and $0.12 was spent on prescription drugs (more than double the proportion since 1980). The vast majority of these funds were spent providing care for the sick, and less than $0.03 of every health care dollar was directed toward preventive public health activities (NCHS, 2017). Despite high hospital and physician expenditures, U.S. health indicators such as life expectancy and infant mortality rate remain considerably below the health indicators of many other countries. This situation reflects a relatively severe disproportion of funding for preventive services and social and economic opportunities. Furthermore, the health status of the population within the United States varies markedly across areas of the country and among groups. For example, the economically disadvantaged and many cultural and ethnic groups have poorer overall health status compared with middle-class Caucasians.
Nurses constitute the largest segment of health care workers; therefore they are instrumental in creating a health care delivery system that will meet the health-oriented needs of the people. According to a survey of registered nurses (RNs) conducted by the National Council of State Boards of Nursing (NCSBN, 2016), about 54.4% of approximately 2.5 million RNs employed full-time in the United States worked in hospitals during 2015 (down from about 66.5% in 1992). This survey also found that about 16%, or approximately 470,000, of all RNs worked in home, school, public/community health, or occupational health settings; 11% worked in ambulatory care settings; and 5.5% worked in nursing homes or other extended care facilities (NCSBN, 2016).
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Between 1980 and 2015, the number of nurses employed in community, health, and ambulatory care settings more than doubled (NCSBN, 2016; USDHHS, HRSA, BHP, 2010). The decline in the percentage of nurses employed in hospitals and the subsequent increase in nurses employed in community settings suggests a shift in focus from illness and institutional-based care to health promotion and preventive care. This shift will likely continue into the future as alternative delivery systems, such as ambulatory and home care, employ more nurses (ANA, 2016; IOM, 2011; Rosenfeld & Russell, 2012).
Community/public health nursing is the synthesis of nursing practice and public health practice. The major goal of community/public health nursing is to preserve the health of the community and surrounding populations by focusing on health promotion and health maintenance of individuals, families, and groups within the community. Thus community/public health nursing is associated with health and the identification of populations at risk rather than with an episodic response to patient demand.
Public Health is often described as the art and science of preventing disease, prolonging life and promoting health through organized community efforts to benefit each citizen (Winslow, 1920). The mission of public health is social justice, which entitles all people to basic necessities such as adequate income and health protection and accepts collective burdens to make it possible. Public health, with its egalitarian tradition and vision, often conflicts with the predominant U.S. model of market justice that largely entitles people to what they have gained through individual efforts. Although market justice respects individual rights, collective action and obligations are minimal. An emphasis on technology and curative medical services within the market justice system has limited the evolution of a health system designed to protect and preserve the health of the population. Public health assumes that it is society’s responsibility to meet the basic needs of the people. Thus there is a greater need for public funding of prevention efforts to enhance the health of our population.
Current U.S. health policies advocate changes in personal behaviors that might predispose individuals to chronic disease or accidents. These policies promote exercise, healthy eating, tobacco use cessation, and moderate consumption of alcohol. However, simply encouraging the individual to overcome the effects of unhealthy activities lessens focus on collective behaviors necessary to change the determinants of health stemming from such factors as poor air and water quality, workplace hazards, unsafe neighborhoods, and unequal access to health care. Because living arrangements, work/school environment, and other sociocultural constraints affect health and well- being, public policy must address societal and environmental changes, in addition to lifestyle changes, that will positively influence the health of the entire population.
With ongoing and very significant changes in the health care system and increased employment in community settings, there will be greater demands on community and public health nurses to broaden their population health perspective. The Code of Ethics of the American Nurses Association (ANA) (2015) promotes social reform by focusing on health policy and legislation to positively affect accessibility, quality, and cost of health care. Community and public health nurses therefore must align themselves with public health programs that promote and preserve the health of populations by influencing sociocultural issues such as human rights, homelessness, violence, disability, and stigma of illness. This principle allows nurses to be positioned to promote the health, welfare, and safety of all individuals.
This chapter examines health from a population-focused, community-based perspective. Therefore it requires understanding of how people identify, define, and describe related concepts. The following section explores six major ideas:
1. Definitions of “health” and “community” 2. Determinants of health and disease 3. Indicators of health and disease 4. Definition and focus of public and community health 5. Description of a preventive approach to health 6. Definition and focus of “public health nursing,” “community health nursing,” and
“community-based nursing”
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Definitions of Health and Community Health The definition of health is evolving. The early, classic definition of health by the World Health Organization (WHO) set a trend toward describing health in social terms rather than in medical terms. Indeed, the WHO (1958, p. 1) defined health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”
Social means “of or relating to living together in organized groups or similar close aggregates” (American Heritage College Dictionary, 1997, p. 1291) and refers to units of people in communities who interact with one another. “Social health” connotes community vitality and is a result of positive interaction among groups within the community, with an emphasis on health promotion and illness prevention. For example, community groups may sponsor food banks in churches and civic organizations to help alleviate problems of hunger and nutrition. Other community groups may form to address problems of violence and lack of opportunity, which can negatively affect social health.
In the mid-1980s, the WHO expanded the definition of health to emphasize recognition of the social implications of health. Thus health is:
the extent to which an individual or group is able, on the one hand, to realize aspirations and satisfy needs; and, on the other hand, to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living; it is a positive concept emphasizing social and personal resources, and physical capacities.
(WHO, 1986, p. 73)
Saylor (2004) pointed out that the WHO definition considers several dimensions of health. These include physical (structure/function), social, role, mental (emotional and intellectual), and general perceptions of health status. It also conceptualizes health from a macro perspective, as a resource to be used rather than a goal in and of itself.
The nursing literature contains many varied definitions of health. For example, health has been defined as “a state of well-being in which the person is able to use purposeful, adaptive responses and processes physically, mentally, emotionally, spiritually, and socially” (Murray, Zentner, & Yakimo, 2009, p. 53); “The individual’s total well-being. the regular patterns of people and their environments that result in maintaining wholeness and human integrity” (Roy, 2009, p. 3); “realization of human potential through goal-directed behavior, competent self-care, and satisfying relationships with others” (Pender, Murdaugh, & Parsons, 2011, p. 22); and a “state of physical, mental, spiritual and social functioning that realizes a person’s potential and is experienced within a developmental context” (Greiner, 2014, p. 3).
The variety of characterizations of the word illustrates the difficulty in standardizing the conceptualization of health. Commonalities involve description of “goal-directed” or “purposeful” actions, processes, responses, functioning, or behaviors and the possession of “integrity,” “wholeness,” and/or “well-being.” Problems can arise when the definition involves a unit of analysis. For example, some writers use the individual or “person” as the unit of analysis and exclude the community. Others may include additional concepts, such as adaptation and environment, in health definitions, and then present the environment as static and requiring human adaptation rather than as changing and enabling human modification.
For many years, community and public health nurses have favored Dunn’s (1961) classic concept of wellness, in which family, community, society, and environment are interrelated and have an impact on health. From his viewpoint, illness, health, and peak wellness are on a continuum; health is fluid and changing. Consequently, within a social context or environment, the state of health depends on the goals, potentials, and performance of individuals, families, communities, and societies.
Active Learning Exercise
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Interview several community/public health nurses and several clients regarding their definitions of health. Share the results with your classmates. Do you agree with their definitions? Why or why not?
Community The definitions of community are also numerous and variable. Baldwin and colleagues (1998) outlined the evolution of the definition of community by examining community health nursing textbooks. They determined that, before 1996, definitions of community focused on geographic boundaries combined with social attributes of people. Citing several sources from the later part of the decade, the authors observed that geographic location became a secondary characteristic in the discussion of what defines a community.
In recent nursing literature, community has been defined as “a collection of people who interact with one another and whose common interests or characteristics form the basis for a sense of unity or belonging” (Rector, 2017, p. 6); “a group of people who share something in common and interact with one another, who may exhibit a commitment with one another and may share a geographic boundary” (Lundy & Janes, 2016, p. 13); and “a locality-based entity, composed of systems of formal organizations reflecting society’s institutions, informal groups and aggregates” (Shuster, 2012, p. 398).
Maurer and Smith (2013) further addressed the concept of community and identified three defining attributes: people; place; and social interaction or common characteristics, interests, or goals. Combining ideas and concepts, in this text, community is seen as a group or collection of individuals interacting in social units and sharing common interests, characteristics, values, and goals.
Maurer and Smith (2013) noted that there are two main types of communities: geopolitical communities and phenomenological communities. Geopolitical communities are those most traditionally recognized or imagined when the term community is considered. Geopolitical communities are defined or formed by natural and/or man-made boundaries and include cities, counties, states, and nations. Other commonly recognized geopolitical communities are school districts, census tracts, zip codes, and neighborhoods. Phenomenological communities, on the other hand, refer to relational, interactive groups. In phenomenological communities, the place or setting is more abstract, and people share a group perspective or identity based on culture, values, history, interests, and goals. Examples of phenomenological communities are schools, colleges, and universities; churches, synagogues, and mosques; and various groups and organizations, such as social networks.
A community of solution is a type of phenomenological community. A community of solution is a collection of people who form a group specifically to address a common need or concern. The Sierra Club, whose members lobby for the preservation of natural resource lands, and a group of disabled people who challenge the owners of an office building to obtain equal access to public buildings, education, jobs, and transportation are examples. These groups or social units work together to promote optimal “health” and to address identified actual and potential health threats and health needs.
Population and aggregate are related terms that are often used in public health and community health nursing. Population is typically used to denote a group of people with common personal or environmental characteristics. It can also refer to all of the people in a defined community (Williams, 2016). Aggregates are subgroups or subpopulations that have some common characteristics or concerns (Gibson & Thatcher, 2016). Depending on the situation, needs, and practice parameters, community health nursing interventions may be directed toward a community (e.g., residents of a small town), a population (e.g., all elders in a rural region), or an aggregate (e.g., pregnant teens within a school district).
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Determinants of Health and Disease The health status of a community is associated with a number of factors, such as health care access, economic conditions, social and environmental issues, and cultural practices, and it is essential for the community health nurse to understand the determinants of health and recognize the interaction of the factors that lead to disease, death, and disability. It has been estimated that individual behaviors are responsible for about 50% of all premature deaths in the United States (Cassidy, Trujillo, & Orleans, 2015). Indeed, individual biology and behaviors influence health through their interaction with each other and with the individual’s social and physical environments. Thus policies and interventions can improve health by targeting detrimental or harmful factors related to individuals and their environment. Fig. 1.1 shows the model of Healthy People 2020, which depicts the interaction of these determinants and shows how they influence health.
In a seminal work, McGinnis and Foege (1993) described what they termed “actual causes of death” in the United States, explaining how lifestyle choices contribute markedly to early deaths. Their work was updated a decade later (Mokdad et al., 2004). Leading the list of “actual causes of death” was tobacco, which was implicated in almost 20% of the annual deaths in the United States —approximately 435,000 individuals. Poor diet and physical inactivity were deemed to account for about 16.6% of deaths (about 400,000 per year), and alcohol consumption was implicated in about 85,000 deaths because of its association with accidents, suicides, homicides, and cirrhosis and chronic liver disease. Other leading causes of death were microbial agents (75,000), toxic agents (55,000), motor vehicle crashes (43,000), firearms (29,000), sexual behaviors (20,000), and illicit use of drugs (17,000).
Although all of these causes of mortality are related to individual lifestyle choices, they can also be strongly influenced by population-focused policy efforts and education. For example, the prevalence of smoking has fallen dramatically during the past two decades, largely because of legal efforts (e.g., laws prohibiting sale of tobacco to minors and much higher taxes), organizational policy (e.g., smoke-free workplaces), and education. Likewise, concerns about the widespread increase in incidence of overweight and obesity have led to population-based measures to address the issue (e.g., removal of soft drink and candy machines from schools, regulations prohibiting the use of certain types of fats in processed foods).
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FIG. 1.1 Model: Healthy People 2020. From U.S. Department of Health and Human Services Office of Disease Prevention and Health
Promotion: Federal interagency workgroup: the vision, mission, and goals of healthy people 2020, n.d., Retrieved from: https://www.healthypeople.gov/sites/default/files/HP2020Framework.pdf
Public health experts have observed that health has improved over the past 100 years largely because people become ill less often (McKeown, 2003; Russo, 2015). Indeed, at the population level, better health can be attributed to higher standards of living, good nutrition, a healthier environment, and having fewer children. Furthermore, public health efforts, such as immunization and clean air and water, and medical care, including management of acute episodic illnesses (e.g., pneumonia, tuberculosis) and chronic disease (e.g., cancer, heart disease), have also contributed significantly to the increase in life expectancy.
Community and public health nurses should understand these concepts and appreciate that health and illness are influenced by a web of factors, some that can be changed (e.g., individual behaviors such as tobacco use, diet, physical activity) and some that cannot (e.g., genetics, age, gender). Other factors (e.g., physical and social environment) may require changes that will need to be accomplished from a policy perspective. Public health nurses must work with policy makers and community leaders to identify patterns of disease and death and to advocate for activities and policies that promote health at the individual, family, aggregate, and population levels.
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Indicators of Health and Illness A variety of health indicators are used by health providers, policy makers, and community health nurses to measure the health of the community. Local or state health departments, the Centers for Disease Control and Prevention (CDC), and the National Center for Health Statistics (NCHS) provide morbidity, mortality, and other health status–related data. State and local health departments are responsible for collecting morbidity and mortality data and forwarding the information to the appropriate federal-level agency, which is often the CDC. Some of the more commonly reported indicators are life expectancy, infant mortality, age-adjusted death rates, and cancer incidence rates.
Indicators of mortality in particular illustrate the health status of a community and/or population because changes in mortality reflect a number of social, economic, health service, and related trends (Shi & Singh, 2016). These data may be useful in analyzing health patterns over time, comparing communities from different geographic regions, or comparing different aggregates within a community.
When the national health objectives for Healthy People 2020 were being developed, a total of 12 leading health indicators were identified that reflected the major public health concerns in the United States (see Healthy People 2020 box). They are individual behaviors (e.g., tobacco use, nutrition, physical activity, and obesity), physical and social environmental factors (e.g., environmental quality, injury, and violence), and health systems issues (e.g., access to health services). Each of these indicators can affect the health of individuals and communities and can be correlated with leading causes of morbidity and mortality. For example, tobacco use is linked to heart disease, stroke, and cancer; substance abuse is linked to accidents, injuries, and violence; irresponsible sexual behaviors can lead to unwanted pregnancy as well as sexually transmitted diseases, including human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS); and lack of access to health care can contribute to poor pregnancy outcomes, untreated illness, and disability.
Healthy People 2020
Leading Health Indicator Topics
• Access to Health Services • Clinical Preventive Services • Environmental Quality • Injury and Violence • Maternal, Infant, and Child Health • Mental Health • Nutrition, Physical Activity, and Obesity • Oral Health • Reproductive and Sexual Health • Social Determinants • Substance Abuse • Tobacco
From U.S. Department of Health and Human Services. Healthy People 2020 leading health indicator topics. Retrieved from https://www.healthypeople.gov/2020/Leading-Health-Indicators
Public health nurses should be aware of health patterns and health indicators within their practice. Each nurse should ask relevant questions, including the following: What are the leading causes of death and disease among various groups served? How do infant mortality rates and teenage pregnancy rates in my community compare with regional, state, and national rates? What
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are the most serious communicable disease threats in my neighborhood? What are the most serious environmental risks in my city?
The public health nurse may identify areas for further investigation and intervention through an understanding of health, disease, and mortality patterns. For example, if a school nurse learns that the teenage pregnancy rate in their community is higher than regional and state averages, the nurse should address the problem with school officials, parents, and students. Likewise, if an occupational health nurse discovers an apparent high rate of chronic lung disease in an industrial facility, the nurse should work with company management, employees, and state and federal officials to identify potential harmful sources. Finally, if a public health nurse works in a state- sponsored AIDS clinic and recognizes an increase in the number of women testing positive for HIV, the nurse should report all findings to the designated agencies. The nurse should then participate in investigative efforts to determine what is precipitating the increase and work to remedy the identified threats or risks.
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Definition and Focus of Public Health and Community Health C. E. Winslow is known for the following classic definition of public health:
Public health is the Science and Art of (1) preventing disease, (2) prolonging life, and (3) promoting health and efficiency through organized community effort for:
(a) sanitation of the environment, (b) control of communicable infections, (c) education of the individual in personal hygiene, (d) organization of medical and nursing services for the early diagnosis and preventive
treatment of disease, and
BOX 1.1 Core Public Health Functions
Assessment: Regular collection, analysis, and information sharing about health conditions, risks, and resources in a community.
Policy development: Use of information gathered during assessment to develop local and state health policies and to direct resources toward those policies.
Assurance: Focuses on the availability of necessary health services throughout the community. It includes maintaining the ability of both public health agencies and private providers to manage day-to-day operations and the capacity to respond to critical situations and emergencies.
From Institute of Medicine: The future of public health, Washington, DC, 1988, National Academy Press.
(e) development of the social machinery to ensure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity.
(Hanlon, 1960, p. 23)
A key phrase in this definition of public health is “through organized community effort.” The term public health connotes organized, legislated, and tax-supported efforts that serve all people through health departments or related governmental agencies.
The public health nursing tradition, begun in the late 1800s by Lillian Wald and her associates, clearly illustrates this phenomenon (Wald, 1971; see Chapter 2). After moving into the immigrant community in New York City to provide care for individuals and families, these early public health nurses saw that neither administering bedside clinical nursing nor teaching family members to deliver care in the home adequately addressed the true determinants of health and disease. They resolved that collective political activity should focus on advancing the health of aggregates and improving social and environmental conditions by addressing the social and environmental determinants of health, such as child labor, pollution, and poverty. Wald and her colleagues
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affected the health of the community by organizing the community, establishing school nursing, and taking impoverished mothers to testify in Washington, DC (Wald, 1971).
In a key action, the National Academy of Medicine (NAM), formerly called the Institute of Medicine (IOM) (1988) identified the following three primary functions of public health: assessment, assurance, and policy development. Box 1.1 lists each of the three primary functions and describes them briefly. All nurses working in community settings should develop knowledge and skills related to each of these primary functions.
The term community health extends the realm of public health to include organized health efforts at the community level through both government and private efforts. Participants include privately funded agencies such as the American Heart Association and the American Red Cross. A variety of private and public structures serves community health efforts.
Public health efforts focus on prevention and promotion of population health at the federal, state, and local levels. These efforts at the federal and state levels concentrate on providing support and advisory services to public health structures at the local level. The local-level structures provide direct services to communities through two avenues:
BOX 1.2 Essential Public Health Services
• Monitor health status to identify and solve community health problems • Diagnose and investigate health problems and health hazards in the community • Inform, educate, and empower people about health issues • Mobilize community partnerships and actions to identify and solve health problems • Develop policies and plans that support individual and community health efforts • Enforce laws and regulations that protect health and ensure safety • Link people to needed personal health services and assure the provision of health care when
otherwise unavailable • Assure a competent public health and personal health care workforce • Evaluate effectiveness, accessibility, and quality of personal and population-based health
services • Research for new insights and innovative solutions to health problems
From Centers for Disease Control and Prevention, Office of the Director, Office of the Chief of Public Health Practice, National Public Health Performance Standards Program: 10 essential public health services, 2014. Retrieved from: https://www.cdc.gov/nphpsp/essentialservices.html.
• Community health services, which protect the public from hazards such as polluted water and air, tainted food, and unsafe housing
• Personal health care services, such as immunization and family planning services, well- infant care, and sexually transmitted disease (STD) treatment
Personal health services may be part of the public health effort and often target the populations most at risk and in need of services. Public health efforts are multidisciplinary because they require people with many different skills. Community health nurses work with a diverse team of public health professionals, including epidemiologists, local health officers, and health educators. Public health science methods that assess biostatistics, epidemiology, and population needs provide a method of measuring characteristics and health indicators and disease patterns within a community. In 1994 the American Public Health Association drafted a list of 10 essential public health services, which the U.S. Department of Health and Human Services later adopted. The updated list of essential services (CDC, 2014) appears in Box 1.2.
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Preventive Approach to Health Health Promotion and Levels of Prevention Contrasting with “medical care,” which focuses on disease management and “cure,” public health efforts focus on health promotion and disease prevention. Health promotion activities enhance resources directed at improving well-being, whereas disease prevention activities protect people from disease and the effects of disease. Leavell and Clark (1958) identified three levels of prevention commonly described in nursing practice: primary prevention, secondary prevention, and tertiary prevention (Fig. 1.2 and Table 1.1).
Primary prevention relates to activities directed at preventing a problem before it occurs by altering susceptibility or reducing exposure for susceptible individuals. Primary prevention consists of two elements: general health promotion and specific protection. Health promotion efforts enhance resiliency and protective factors and target essentially well populations. Examples include promotion of good nutrition, provision of adequate shelter, and encouraging regular exercise. Specific protection efforts reduce or eliminate risk factors and include such measures as immunization, seat belt use, and water purification.
FIG. 1.2 The three levels of prevention.
Secondary prevention refers to early detection and prompt intervention during the period of early disease pathogenesis. Secondary prevention is implemented after a problem has begun, but before signs and symptoms appear, and targets those populations that have risk factors. Mammography, blood pressure screening, scoliosis screening, and Papanicolaou tests are examples of secondary prevention.
Tertiary prevention targets populations that have experienced disease or injury and focuses on limitation of disability and rehabilitation. Aims of tertiary prevention are to keep health problems
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from getting worse, to reduce the effects of disease and injury, and to restore individuals to their optimal level of functioning. Examples include teaching how to perform insulin injections and disease management to a patient with diabetes, referral of a patient with spinal cord injury for occupational and physical therapy, and leading a support group for grieving parents.
Much of public health nursing practice is directed toward preventing the progression of disease at the earliest period or phase feasible using the appropriate level(s) of prevention. For example, when applying “levels of prevention” to a client with HIV/AIDS, a nurse might perform the following interventions:
• Educate students on the practice of sexual abstinence or “safer sex” by using barrier methods (primary prevention)
• Encourage testing and counseling for clients with known exposure or who are in high-risk groups; provide referrals for follow-up for clients who test positive for HIV (secondary prevention)
• Provide education on management of HIV infection, advocacy, case management, and other interventions for those who are HIV positive (tertiary prevention)
TABLE 1.1
Examples of Levels of Prevention and Clients Served in the Community
AIDS, Acquired immunodeficiency syndrome; HIV, human immunodeficiency virus; STI, sexually transmitted infection. ∗ Note that terms are used differently in literature of various disciplines. There are not any clear-cut definitions; for example, families may be referred to as an aggregate, and a population and subpopulations may exist within a community.
Thinking Upstream The concepts of prevention and population-focused care figure prominently in a conceptual
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orientation to nursing practice referred to as thinking upstream. This orientation is derived from an analogy of patients falling into a river upstream and being rescued downstream by health providers overwhelmed with the struggle of responding to disease and illness. The river as an analogy for the natural history of illness was first coined by McKinlay (1979), with a charge to health providers to refocus their efforts toward preventive and “upstream” activities. In a description of the daily challenges of providers to address health from a preventive versus curative focus, McKinlay differentiates the consequences of illness (downstream endeavors) from its precursors (upstream endeavors). The author then charges health providers to critically examine the relative weights of their activities toward illness response versus the prevention of illness.
A population-based perspective on health and health determinants is critical to understanding and formulating nursing actions to prevent disease. By examining the origins of disease, nurses identify social, political, environmental, and economic factors that often lead to poor health options for both individuals and populations. The call to refocus the efforts of nurses “upstream, where the real problems lie” (McKinlay, 1979) has been welcomed by community health nurses in a variety of practice settings. For these nurses, this theme provides affirmation of their daily efforts to prevent disease in populations at risk in schools, work sites, and clinics throughout their local communities and in the larger world.
Ethical Insights Inequities: Distribution of Resources In the United States, inequities in the distribution of resources pose a threat to the common good and a challenge for community and public health nurses. Factors that contribute to wide variations in health disparities include education, income, and occupation. Lack of health insurance is a key factor in this issue and a major rationale for health care reform efforts. Lack of insurance is damaging to population health, as low-income, uninsured individuals are much less likely than insured individuals to receive timely primary health care and preventive dental care.
Public health nurses are regularly confronted with the consequences of the fragmented health care delivery system. They diligently work to improve the circumstances for populations who have not had adequate access to resources largely because of who they are and where they live.
Ethical questions commonly encountered in community and public health nursing practice include the following: Should resources (e.g., free or low-cost immunizations) be offered to all, even those who have insurance that will pay for the care? Should public health nurses serve anyone who meets financial need guidelines, regardless of medical need? Should the health department provide flu shots to persons of all ages or just those most likely to be affected by the disease? Should nonresidents in the United States illegally or persons working on “green cards” receive the same level of health care services that are available to citizens? Who should have free or reduced-cost access to extremely expensive drugs such as those that treat hepatitis C, multiple sclerosis, or many forms of cancer, and who should bear the financial burden?
Access to health care is a goal for all. To this end, community and public health nurses must face the challenges and dilemmas related to these and other questions as they assist individuals, families, and communities dealing with the uneven distribution of health resources and the associated costs of health care.
Prevention versus Cure Spending additional dollars for cure in the form of health care services does little to improve the health of a population, whereas spending money on prevention does a great deal to improve health. Getzen (2013) and others (Russo, 2015; Shi & Singh, 2016) note that there is an absence of convincing evidence that the amount of money expended for health care improves the health of a population. The real determinants of health, as mentioned, are prevention efforts that provide education, housing, food, a decent minimal income, and safe social and physical environments, as well as encouraging positive lifestyle choices. The United States spends more than one sixth of its wealth on health care or “cure” for individuals, likely diverting money away from the needed resources and services that would make a greater impact on health (NCHS, 2017 Shi & Singh, 2016).
U.S. policy makers must become committed to achieving improved health outcomes for the poor
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and vulnerable populations. With a limited health workforce and monetary resources, the United States cannot continue to spend vast amounts on health care services when the investment fails to improve health outcomes. In industrialized countries, life expectancy at birth is not related to the level of health care expenditures; in developing countries, longevity is closely related to the level of economic development and the education of the population (Russo, 2015; Shi & Singh, 2016).
The current health care system is currently in a flux following implementation of the Affordable Care Act (ACA) and subsequent efforts to “repeal and replace” it. These endeavors could actually be detrimental to the health of the population, as the focus on obtaining health insurance for more people may defer a large investment of the country’s wealth from education and other developmental efforts that would positively affect the health of the population as a whole. Managed care organizations (MCOs) focus on prevention and have determined that the rate of health care cost increases have slowed among employees of large firms (Kongstvedt, 2013). Prevention programs may help reduce costs for those enrolled in MCOs, but it remains unclear who will provide services for those who are required to purchase insurance, those who are currently uninsured and may remain so, the poor, and other vulnerable populations. In addition, still to be determined is who will provide adequate schooling, housing, meals, wages, and a safe environment for the disadvantaged. Increasing health care spending may negatively affect efforts to address economic disparities by reducing investments in sufficient housing, employment, education, nutrition, and safe environments.
Healthy People 2020 In 1979, the U.S. Department of Health and Human Services published a national prevention initiative titled Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention. The 1979 version established goals that would reduce mortality among infants, children, adolescents and young adults, and adults and increase independence among older adults. In 1990, the mortality of infants, children, and adults declined sufficiently to meet the goal. Adolescent mortality did not reach the 1990 target, and data systems were unable to adequately track the target for older adults (USDHHS, 2000).
Published in 1989, Healthy People 2000 built on the first surgeon general’s report. Healthy People 2000 contained the following broad goals (USDHHS, 1989):
1. Increase the span of healthy life for Americans. 2. Reduce health disparities among Americans. 3. Achieve access to preventive services for all Americans.
The purpose of Healthy People 2000 was to provide direction for individuals wanting to change personal behaviors and to improve health in communities through health promotion policies. The report assimilated the broad approaches of health promotion, health protection, and preventive services and contained more than 300 objectives organized into 22 priority areas. Although many of the objectives fell short, the initiative was extremely successful in raising providers’ awareness of health behaviors and health promotional activities. States, local health departments, and private- sector health workers used the objectives to determine the relative health of their communities and to set goals for the future.
Healthy People 2010 emerged in January 2000. It expanded on the objectives from Healthy People 2000 through a broadened prevention science base, an improved surveillance and data system, and a heightened awareness of and demand for preventive health services. This reflects changes in demographics, science, technology, and disease. Healthy People 2010 listed two broad goals:
Goal 1: Increase quality and years of healthy life. Goal 2: Eliminate health disparities.
The first goal moved beyond the idea of increasing life expectancy to incorporate the concept of health-related quality of life (HRQOL). This concept of health includes aspects of physical and mental health and their determinants and measures functional status, participation, and well-being. HRQOL expands the definition of health—beyond simply opposing the negative concepts of disease and death—by integrating mental and physical health concepts (USDHHS, 2000).
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The final review and analysis of the Healthy People 2010 objectives showed decidedly mixed progress for the nation. Some 23% of the objectives were met or exceeded, and another 48% “moved toward target.” Conversely, 24% of the objectives “moved away from target” (i.e., the indicators were worse than in the previous decade), and another 5% showed no change. Particularly concerning were the poor responses in two of the focus areas: Arthritis, Osteoporosis and Chronic Back conditions (Focus Area 2) and Nutrition and Overweight (Focus Area 19) “moved toward” or “achieved” less than 25% of their targets (USDHHS, 2012).
The fourth version of the nation’s health objectives, Healthy People 2020, was published in 2010. Healthy People 2020 is divided into 42 topic areas and contains numerous new objectives and updates for hundreds of objectives from the previous editions. The topic areas are listed in the “Healthy People 2020” box. The objectives and related information and materials can help guide health promotion activities and can be used to aid in community-wide initiatives (USDHHS, 2017). All health care practitioners, particularly those working in the community, should review the Healthy People 2020 objectives and focus on the relevant areas in their practice. Practitioners should incorporate these objectives into programs, events, and publications whenever possible and should use them as a framework to promote healthy cities and communities. Selected relevant objectives are presented throughout this book to acquaint future community health nurses with the scope of the Healthy People 2020 initiative and to enhance awareness of current health indicators and national goals (see www.healthypeople.gov for more information).
Active Learning Exercise
Become familiar with Healthy People 2020 (www.healthypeople.gov). Review objectives from several of the topic areas covered. How does your community compare with the groups, aggregates, and populations described? What objectives should be targeted for your community?
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Definition and Focus of Public Health Nursing, Community Health Nursing, and Community-Based Nursing The terms community health nursing and public health nursing are often used synonymously or interchangeably. Like the practice of community/public health nursing, the terms are evolving. In past debates and discussions, definitions of “community health nursing” and “public health nursing” have indicated similar yet distinctive ideologies, visions, or philosophies of nursing. These concepts and a third related term—community-based nursing—are discussed in this section.
Public and Community Health Nursing Public health nursing has frequently been described as the synthesis of public health and nursing practice. Freeman (1963) provided a classic definition of public health nursing:
Public health nursing may be defined as a field of professional practice in nursing and in public health in which technical nursing, interpersonal, analytical, and organizational skills are applied to problems of health as they affect the community. These skills are applied in concert with those of other persons engaged in health care, through comprehensive nursing care of families and other groups and through measures for evaluation or control of threats to health, for health education of the public, and for mobilization of the public for health action. (p. 34)
Through the 1980s and 1990s, most nurses were taught that there was a distinction between “community health nursing” and “public health nursing.” Indeed, “public health nursing” was seen as a subspecialty nursing practice generally delivered within “official” or governmental agencies. In contrast, “community health nursing” was considered to be a broader and more general specialty area that encompassed many additional subspecialties (e.g., school nursing, occupational health nursing, forensic nursing, home health). In 1980, the American Nurses Association (ANA) defined community health nursing as “the synthesis of nursing practice and public health practice applied to promoting and preserving the health of populations” (ANA, 1980, p. 2). This viewpoint noted that a community health nurse directs care to individuals, families, or groups; this care, in turn, contributes to the health of the total population.
The ANA has revised the standards of practice for this specialty area (ANA, 2013). In the updated standards, the designation was again “public health nursing,” and the ANA used the definition presented by the American Public Health Association (APHA) Committee on Public Health Nursing (1996). Thus, public health nursing is defined as “the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences” (APHA, 1996, p. 5). The ANA (2013) elaborated by explaining that public health nursing practice “is population-focused, with the goals of promoting health and preventing disease and disability for all people through the creation of conditions in which people can be healthy” (p. 5).
Some nursing writers will continue to use community health nursing as a global or umbrella term and public health nursing as a component or subset. Others, as stated, use the terms interchangeably. This book uses the terms interchangeably.
Active Learning Exercise
Ask several neighbors or consumers of health care about their views of the role of public health and community health nursing. Share your results with your classmates.
Research Highlights
Public Health Nursing Research Agenda
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In 2010, a national conference was held to set a research agenda that would advance the science of public health nursing (PHN). The conference employed a multistage, multimethod, participatory developmental approach, involving many influential PHN leaders. Following numerous meetings and discussions, an agenda was proposed. The agenda was structured around four “High Priority Themes”: (1) public health nursing interventions models, (2) quality of population-focused practice, (3) metrics of/for public health nursing, and (4) comparative effectiveness and public health nursing outcomes. The aim of the agenda is to help PHN scholars contribute to an understanding of how to improve health and reduce population health disparities by advancing the evidence base regarding the outcomes of practice and by influencing related health policy. The group encouraged the agenda’s use to guide and inform programs of research, to influence funding priorities, and to be incorporated into doctoral PHN education through course and curriculum development. Ultimately, it is anticipated that PHN research will proactively contribute to the effectiveness of the public health system and create healthier communities. Data from Issel, L. M., Bekemeier, B., & Kneipp, S. (2012). A public health nursing research agenda, Public Health Nursing 29, 330–342.
Community-Based Nursing The term community-based nursing has been identified and defined in recent years to differentiate it from what has traditionally been seen as community and public health nursing practice. Community-based nursing practice refers to “application of the nursing process in caring for individuals, families and groups where they live, work or go to school or as they move through the health care system” (McEwen & Pullis, 2009, p. 6). Community-based nursing is setting specific, and the emphasis is on acute and chronic care and includes such practice areas as home health nursing and nursing in outpatient or ambulatory settings.
BOX 1.3 The Scope and Standards of Practice for Public Health Nursing The Scope and Standards of Practice for Public Health Nursing is the result of the collaborative effort between the American Nurses Association and the Quad Council of Public Health Nursing Organizations. The standards were originally developed in 1999 and were updated in 2013. The Scope and Standards of Practice, which are divided into Standards of Practice and Standards of Professional Performance, describe specific competencies relevant to the public health nurse and the public health nurse in advanced practice.
The Standards of Practice include six standards that are based on the critical thinking model of the nursing process, with competencies addressing each nursing process step. The implementation step is further broken down into specific public health areas, including coordination of services, health education and health promotion, consultation, and regulatory activities. The Standards of Professional Performance include the leadership competencies necessary in the professional practice of all registered nurses, but with additional standards specific to the public health nurse and advanced public health nurse roles. These standards include evidence-based practice and research, collaboration, resource utilization, and advocacy, with competencies specific to public health, such as building coalitions and achieving consensus in public health issues, assessing available health resources within a population, and advocating for equitable access to care and services. Data from American Nurses Association: Public health nursing: scope and standards of practice, ed 2, Silver Spring, MD, 2013, Author. The standards can be purchased at: http://www.nursesbooks.org/Homepage/Hot-off-the-Press/Public-Health-Nursing-2nd.aspx
Zotti, Brown, and Stotts (1996) compared community-based nursing and community health nursing and explained that the goals of the two are different. Community health nursing emphasizes preservation and protection of health, and community-based nursing emphasizes managing acute or chronic conditions. In community health nursing, the primary client is the community; in community-based nursing, the primary clients are the individual and the family. Finally, services in community-based nursing are largely direct, but in community health nursing,
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services are both direct and indirect (Williams, 2016).
Community and Public Health Nursing Practice Community and public health nurses practice disease prevention and health promotion. It is important to note that public health nursing practice is collaborative and is based in research and theory. It applies the nursing process to the care of individuals, families, aggregates, and the community. Box 1.3 provides an overview of the Standards for Public Health Nursing (ANA, 2013).
As discussed, the core functions of public health are assessment, policy development, and assurance. In 2003, the Quad Council of Public Health Nursing Organizations (Quad Council) closely examined the core functions and used them to develop a set of public health nursing competencies. These competencies were updated in 2011 and are summarized in Table 1.2 (Quad Council, 2011). Current and future community health nurses should study these competencies to understand the practice parameters and skills required for public health nursing practice.
Active Learning Exercise
Interview several community/public health nurses regarding their opinions on the focus of community/public health nursing. Do you agree?
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Population-Focused Practice and Community/Public Health Nursing Interventions Community/public health nurses must use a population-focused approach to move beyond providing direct care to individuals and families. Population-focused nursing concentrates on specific groups of people and focuses on health promotion and disease prevention, regardless of geographic location (Baldwin et al., 1998). The goal of population-focused nursing is “provision of evidence-based care to targeted groups of people with similar needs in order to improve outcomes” (Curley, 2016, p. 4). In short, population-focused practice (Minnesota Department of Health, 2003):
• Focuses on the entire population • Is based on assessment of the population’s health status • Considers the broad determinants of health • Emphasizes all levels of prevention • Intervenes with communities, systems, individuals, and families
Whereas community and public health nurses may be responsible for a specific subpopulation in the community (e.g., a school nurse may be responsible for the school’s pregnant teenagers), population-focused practice is concerned with many distinct and overlapping community subpopulations. The goal of population-focused nursing is to promote healthy communities.
Population-focused public health nurses would not have exclusive interest in one or two subpopulations, but instead would focus on the many subpopulations that make up the entire community. A population focus involves concern for those who do, and for those who do not, receive health services. A population focus also involves a scientific approach to community health nursing. Thus a thorough, systematic assessment of the community or population is necessary and basic to planning, intervention, and evaluation for the individual, family, aggregate, and population levels.
Public health nursing practice requires the following types of data for scientific approach and population focus: (1) the epidemiology, or body of knowledge, of a particular problem and its solution and (2) information about the community. Each type of knowledge and its source appear in Table 1.3. To determine the overall patterns of health in a population, data collection for assessment and management decisions within a community should be ongoing, not episodic.
Public Health Interventions Public health nurses focus on the care of individuals, groups, aggregates, and populations in many settings, including homes, clinics, worksites, and schools. In addition to interviewing clients and assessing individual and family health, public health nurses must be able to assess a population’s health needs and resources and identify its values. Public health nurses must also work with the community to identify and implement programs that meet health needs and to evaluate the effectiveness of programs after implementation. For example, school nurses were once responsible only for running first-aid stations and monitoring immunization compliance. Now they are actively involved in assessing the needs of their population and defining programs to meet those needs through activities such as health screening and group health education and promotion. The activities of school nurses may be as varied as designing health curricula with a school and community advisory group, leading support groups for elementary school children with chronic illness, advocating for emergency equipment (e.g., automatic external defibrillators) in gyms and athletic fields, and monitoring the health status of teenage mothers.
TABLE 1.2
Summary of Tier 1 Public Health Nursing (PHN) Competencies (Generalist Public Health Nurses)
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Modified from Quad Council of Public Health Nursing Organizations: Public health nursing competencies, Washington, DC, 2011, Author.
TABLE 1.3
Information Useful for Population Focus
Type of Information Examples Sources
Demographic data Age, gender, race/ethnicity, socioeconomic status, education level Vital statistic data (national, state, county, local); census
Groups at high risk
Health status and health indicators of various subpopulations in the community (e.g., children, elders, those with disabilities)
Health statistics (morbidity, mortality, natality); disease statistics (incidence and prevalence)
Services/providers available
Official (public) health departments; health care providers for low- income individuals and families; community service agencies and organizations (e.g., Red Cross, Meals on Wheels)
City directories; phone books; local or regional social workers; low-income providers’ lists; local community health nurses (e.g., school nurses)
Similarly, occupational health nurses are no longer required to simply maintain an office or dispensary. They are involved in many different types of activities. These activities might include maintaining records of workers exposed to physical or chemical risks, monitoring compliance with Occupational Safety and Health Administration standards, teaching classes on health issues, acting as case managers for workers with chronic health conditions, and leading support group discussions for workers with health-related problems.
Private associations, such as the American Diabetes Association or the Red Cross, employ public health nurses for their organizational ability and health-related skills. Other public health nurses work with multidisciplinary groups of professionals, serve on boards of voluntary health associations such as the American Heart Association, work as case managers for insurance companies, and are members of health planning agencies and councils.
Genetics in Public Health
Community-Based Research for the Prevention of Cardiovascular Disease Cardiovascular disease (CVD) is the leading cause of death among Americans, and prevention of CVD should be a priority for all nurses. It has been established that CVD results from a complex interaction among modifiable factors including lifestyle choices and environmental influences, and non-modifiable factors such as age and race/ethnicity or genetics. A group of nurse researchers led by Fletcher (2011) presented a “call to action for nursing” to promote community-based research
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that focuses on the genetic factors that contribute to CVD. The team described the need to build capacity for participation in genetics research within communities through community engagement, particularly among vulnerable ethnic minority groups. The importance of identifying the genetic-environmental interactions that may led to clinical manifestation of CVD was stressed and a number of community-based interventions to prevent CVD were described. Fletcher BJ, Himmelfarb CD, Lira MT, Meininger JC, Pradhan SR, Sikkema J: Global cardiovascular disease prevention: A call to action for nursing. Journal of Cardiovascular Nursing, 26, 45, 535-545.
The Public Health Intervention Wheel The Public Health Intervention Model was initially proposed in the late 1990s by nurses from the Minnesota Department of Health to describe the breadth and scope of public health nursing practice (Keller et al., 1998). This model was later revised and termed the Intervention Wheel (Fig. 1.3) (Keller et al., 2004a; Keller et al., 2004b), and it has become increasingly recognized as a framework for community and public health nursing practice.
The Intervention Wheel contains three important elements: (1) it is population based; (2) it contains three levels of practice (community, systems, and individual/family); and (3) it identifies and defines 17 public health interventions. The levels of practice and interventions are directed at improving population health (Keller et al., 2004a). Within the Intervention Wheel, the 17 health interventions are grouped into five “wedges.” These interventions are actions taken on behalf of communities, systems, individuals, and families to improve or protect health status. Table 1.4 provides definitions.
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FIG. 1.3 Public Health Intervention Wheel. Modified from Section of Public Health Nursing, Minnesota Department of Health: Public health
interventions, 2001. Retrieved from: http://www.health.state.mn.us/divs/opi/cd/phn/docs/0301wheel_manual.pdf,
The Intervention Wheel is further dissected into levels of practice, in which the interventions may be directed at an entire population within a community, a system that would affect the health of a population, and/or the individuals and families within the population. Thus each intervention can and should be applied at each level. For example, a systems-level intervention within “disease investigation” might be the community health nurse working with the state health department and federal vaccine program to coordinate a response to an outbreak of measles in a migrant population. An example of a population- or community-level intervention for “screening” would be public health nurses working with area high schools to give each student a profile of his or her health to promote nutritional and physical activity lifestyle changes to improve the student’s health.
Finally, an individual-level implementation of the intervention “referral and follow-up” would occur when a nurse receives a referral to care for an individual with a diagnosed mental illness who would require regular monitoring of his or her medication compliance to prevent rehospitalization (Keller et al., 2004b).
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Public Health Nursing, Managed Care, and Health Reform Shifts in reimbursement, the growth of managed care, and implementation and revision of the ACA have revitalized the notion of population-based care. Health insurance companies, governmental financing entities (e.g., Medicare, Medicaid), and MCOs use financial incentives and organizational structures in an attempt to increase efficiency and decrease health care costs. The foundation for managed care is management of health care for an enrolled group of individuals. This group of enrollees is the population covered by the plan who receive health services from managed care plan providers (Kongstvedt, 2013).
An understanding of enrolled populations and health care patterns is essential for managing health care services and resources effectively. Most MCOs have become sophisticated in identifying key subgroups within the population of enrollees at risk for health problems. Typically, managed care systems target subgroups according to characteristics associated with risk or use of expensive services, such as selected clinical conditions, functional status, and past service use patterns.
TABLE 1.4
Public Health Interventions and Definitions
Public Health Intervention Definition
Surveillance Describes and monitors health events through ongoing and systematic collection, analysis, and interpretation of health data for the purpose of planning, implementing, and evaluating public health interventions
Disease and other health event investigation
Systematically gathers and analyzes data regarding threats to the health of populations, ascertains the source of the threat, identifies cases and others at risk, and determines control measures
Outreach Locates populations of interest or populations at risk and provides information about the nature of the concern, what can be done about it, and how services can be obtained
Screening Identifies individuals with unrecognized health risk factors or asymptomatic disease conditions Case finding Locates individuals and families with identified risk factors and connects them with resources Referral and follow-up
Assists individuals, families, groups, organizations, and/or communities to identify and access necessary resources to prevent or resolve problems or concerns
Case management Optimizes self-care capabilities of individuals and families and the capacity of systems and communities to coordinate and provide services
Delegated functions
Carries out direct care tasks under the authority of a health care practitioner as allowed by law
Health teaching Communicates facts, ideas, and skills that change knowledge, attitudes, values, beliefs, behaviors, and practices of individuals, families, systems, and/or communities
Counseling Establishes an interpersonal relationship with a community, a system, and a family or individual, with the intention of increasing or enhancing their capacity for self-care and coping
Consultation Seeks information and generates optional solutions to perceived problems or issues through interactive problem solving with a community system and family or individual
Collaboration Commits two or more persons or organizations to achieve a common goal by enhancing the capacity of one or more of the members to promote and protect health
Coalition building Promotes and develops alliances among organizations or constituencies for a common purpose Community organizing
Helps community groups to identify common problems or goals, mobilize resources, and develop and implement strategies for realizing the goals they collectively have set
Advocacy Pleads someone’s cause or acts on someone’s behalf, with a focus on developing the community, system, and individual or family’s capacity to plead their own cause or act on their own behalf
Social marketing Utilizes commercial marketing principles and technologies for programs designed to influence the knowledge, attitudes, values, beliefs, behaviors, and practices of the population of interest
Policy development and enforcement
Places health issues on decision makers’ agendas, acquires a plan of resolution, and determines needed resources, resulting in laws, rules, regulations, ordinances, and policies. Policy enforcement compels others to comply with laws, rules, regulations, ordinances, and policies
Modified from Keller LO, Strohschein S, Lia-Hoagberg B, Schaffer MA: Population-based public health interventions: practice-based and evidence-supported. Part I, St. Paul, MN, 2004a, Minnesota Department of Health, Center for Public Health Nursing.
In March 2010, President Obama signed the Patient Protection and Affordable Care Act (ACA) (PL 111-148) into law. The ACA served to expand insurance coverage for those uninsured and to help control health care costs. Expansion of coverage was accomplished by requiring individuals to purchase health insurance for themselves and their families, implementation of “exchanges” to increase options for individuals to purchase health insurance, and requiring more employers to
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offer health insurance to employees. Public programs (e.g., Medicaid and State Children’s Health Insurance Program) were expanded to cover health care for those who could not afford to buy their own insurance. With the change of administration in 2017, it is anticipated that there will be significant revisions of the ACA with new federal and state-sponsored initiatives. Public health nurses must stay informed of these changes and work with groups and organizations to support legislation that will promote population health, reduce disparities, and better manage the costs of care.
The purpose of public health is to improve the health of the public by promoting healthy lifestyles, preventing disease and injury, and protecting the health of communities. In the past, shrinking public health resources have supported personal health services over community health promotion. In public health practice, the community is the population of interest. With the proposed changes to health care financing, the personal health care system will be under increasing pressure to provide the services that health departments previously provided. Traditionally served by public health, the most vulnerable populations will pose tremendous challenges for private health care providers. Public health agencies and providers will be responsible for partnering with private providers to care for these populations.
Providing population-based care requires a dramatic shift in thinking from individual-based care. Some of the practical demands of population-based care are the following:
1. It must be recognized that populations are not homogeneous; therefore it is necessary to address the needs of special subpopulations within populations.
2. High-risk and vulnerable subpopulations must be identified early in the care delivery cycle. 3. Nonusers of services often become high-cost users; therefore it is essential to develop
outreach strategies. 4. Quality and cost of all health care services are linked together across the health care
continuum. (Kaiser Family Foundation, 2013)
Nurses in community and public health have an opportunity to share their expertise regarding population-based approaches to health care for groups of individuals across health care settings. Today, health care practitioners require additional skills in assessment, policy development, and assurance to provide community public health practice and population-based service. Health care professionals should focus attention on promoting healthy lifestyles, providing preventive and primary care, expanding and ensuring access to cost-effective and technologically appropriate care, participating in coordinated and interdisciplinary care, and involving patients and families in the decision-making process. Public health nurses must work in partnership with colleagues in managed care settings to improve community health. Partnerships may address information management, cultural values, health care system improvement, and the physical environment roles in health and may require complex negotiations to share data. The partners may need to develop new community assessment strategies to augment epidemiological methods that often mask the context or meaning of the human experience of vulnerable populations.
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Summary The health care system has been evolving from focusing on individuals in acute care settings to being more community based and population health directed. Nursing practice has changed in response, and today a growing proportion of nurses is working outside of hospitals. Public and community health nursing practice includes population-focused interventions that seek to improve the health and well-being of groups, aggregates, and communities.
This chapter has presented information on key concepts, including “health” and “community,” and described the vital importance of addressing societal needs in order to improve population health. With widely recognized changes in population demographics, it is necessary that nurses be attuned to the determinants and indicators of health, health-promoting activities, and changes in the health care system. This includes efforts to promote access to more individuals and to understand the need to contain costs. With this knowledge and skills, public and community health nurses can influence health practices and policies that will positively affect the future health of individuals, families, groups, and communities.
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Evolve Website http://evolve.elsevier.com/Nies/community
• NCLEX Review Questions • Case Studies
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Historical Factors
Public Health Nursing in Context
Melanie McEwen∗
OUTLINE
Evolution of Health in Western Populations Aggregate Impact on Health Evolution of Early Public Health Efforts
Advent of Modern Health Care Evolution of Modern Nursing Establishment of Modern Health Care and Public Health Practice Community Caregiver Establishment of Public Health Nursing
Consequences for the Health of Populations Twenty-First Century
Social Challenges and Public Health Nursing Challenges for Public Health Nursing
OBJECTIVES
Upon completion of this chapter, the reader will be able to do the following: 1. Describe the impact of aggregate living on population health. 2. Identify approaches to population health promotion from prerecorded historic to present times. 3. Understand historical events that have influenced population health. 4. Compare the application of public health principles to the nation’s major health problems at the
turn of the twentieth century (i.e., acute disease) with that at the beginning of the twenty-first century (i.e., chronic disease).
5. Describe two leaders in nursing who had a profound impact on addressing population health. 6. Discuss major contemporary issues facing community/public health nursing, and trace the
historical roots to the present.
KEY TERMS district nursing Edward Jenner Edwin Chadwick
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Elizabethan Poor Law endemic epidemic Flexner Report Florence Nightingale health visiting House on Henry Street John Snow Joseph Lister Lemuel Shattuck Lillian Wald Louis Pasteur pandemic Robert Koch Sanitary Revolution stages in disease history An understanding of the historical factors that have influenced the evolution of population health may help explain current health challenges. This chapter examines the health of Western populations from early historic times to recent times and describes the evolution of modern health care. The role of public health nurses and concurrent challenges for improving the health of groups, aggregates, and communities are also discussed.
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Evolution of Health in Western Populations Medical anthropologists use paleontological records and disease descriptions of primitive societies to speculate on the interrelationship of early humans, probable diseases, and their environment. Historians have also documented the existence of public health activity (i.e., an organized community effort to prevent disease, prolong life, and promote health) since before recorded historical times. This section describes how aggregate living patterns and early public health efforts have affected the health of Western populations.
Aggregate Impact on Health Polgar (1964) defined the following stages in disease history: hunting and gathering stage, settled villages stage, preindustrial cities stage, industrial cities stage, and present stage (Fig. 2.1). In these stages, growing populations, increased population density, and imbalanced human ecology resulted in changes in cultural adaptation. In each stage, humans created an ecological imbalance by altering their environment to accommodate group living. This imbalance subsequently had a significant effect on aggregate health.
FIG. 2.1 Stages in the disease history of humankind. Stages overlap, and time periods are widely debated in the field of anthropology. Some form of each stage remains evident in the world today.
Although these stages are associated with the evolution of civilization, it is important to note that the information is limited by cultural bias. The stages depict the evolution of civilization from the perspective of the Western world. They consist of overlapping historical time periods, which anthropologists widely debate. However, the stages of human disease can provide a frame of reference to aid in determining the relationship among humans, disease, and environment from early historical times to the present. Furthermore, although the stages chronicle the general evolution in the Western world, it is important to realize that each stage still exists in civilization today. For example, Australian aborigines continue to hunt and gather food, and “settled villages” can readily be found in developing countries.
Public health nurses should be aware that populations from each stage consist of a variety of people with distinct cultural traditions and a broad range of health care practices and beliefs. For example, a nurse currently practicing in an American community may need to plan care for immigrants or refugees from a settled village or a preindustrial city. Public and community health nurses must recognize that the environment, the population’s health risks, and the host culture’s strengths and challenges affect the health status of each particular group.
Hunting and Gathering Stage During the Paleolithic period, or Old Stone Age, nomadic and semi-nomadic people engaged in
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hunting and gathering, with generations of small aggregate groups wandering in search of food. Armelagos and Dewey (1978) reviewed how the size, density, and relationship to the environment of such people probably affected their health. These groups may have avoided many contagious diseases because the scattered groups were small, nomadic, and separated from other groups. Under these conditions, diseases would not spread among the groups. Evidently the disposal of human feces and waste was not a great problem; the nomadic people most likely abandoned the caves they used for shelter once waste accumulated.
Settled Village Stage Small settlements were characteristic of the Mesolithic period, or Middle Stone Age, and the Neolithic period, or New Stone Age. Wandering people became more sedentary and formed small encampments and villages. The concentration of people in these small areas caused new health problems. For example, people began to domesticate animals and live close to their herds, a practice that probably transmitted diseases such as salmonella, anthrax, Q fever, and tuberculosis (TB) (Polgar, 1964). These stationary people also domesticated plants, a change that may have reduced the range of consumable nutrients and may have led to deficiency diseases. They had to secure water and remove wastes, often leading to the cross-contamination of the water supply and the spread of waterborne diseases such as dysentery, cholera, typhoid, and hepatitis A.
Preindustrial Cities Stage In preindustrial times, large urban centers formed to support the expanding population. Populations inhabited smaller areas; therefore exposure to preexisting problems expanded. For example, the urban population had to resource increased amounts of food and water and remove increased amounts of waste products. Some cultures developed elaborate water systems. However, waste removal via the water supply led to diseases such as cholera. Further, with the development of towns, rodent infestation increased and facilitated the spread of plague. People had more frequent close contact with one another; therefore the transmission of diseases spread by direct contact increased, and diseases such as mumps, measles, influenza, and smallpox became endemic (Polgar, 1964). Of significance, a population must reach a certain size to maintain a disease in endemic proportions (Table 2.1); for example, approximately 1 million people are needed to sustain measles at an endemic level (Cockburn, 1967).
TABLE 2.1
Disease Definitions
Types of Disease Definition
Endemic Diseases that are always present in a population (e.g., colds and pneumonia) Epidemic Diseases that are not always present in a population but flare up on occasion (e.g., diphtheria and measles) Pandemic The existence of disease in a large proportion of the population: a global epidemic (e.g., human immunodeficiency virus,
acquired immunodeficiency syndrome, and annual outbreaks of influenza type A)
Industrial Cities Stage Industrialization caused urban areas to become denser and even more heavily populated. Increased industrial wastes, air and water pollution, and harsh working conditions took a toll on health. During the eighteenth and nineteenth centuries, there was an increase in respiratory diseases such as TB, pneumonia, and bronchitis and in epidemics of infectious diseases such as diphtheria, smallpox, typhoid fever, typhus, measles, malaria, and yellow fever (Armelagos and Dewey, 1978). Furthermore, exploration and imperialism spread epidemics of many diseases to susceptible populations throughout the world because settlers, traders, and soldiers moved from one location to another, introducing communicable diseases into native population groups.
Present Stage Although infectious diseases no longer account for a majority of deaths in the Western world, they continue to cause many deaths in the non-Western world. They also remain prevalent among low- income populations and some ethnic minority groups in the West. Western diseases such as cancer, heart disease, obesity, hypertension, and diabetes are less common among populations from
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nonindustrial communities. These diseases typically appear when cultures adopt Western customs and transition into urban environments. Epidemiological studies suggest that common risk factors that contribute to chronic health conditions are changes in diet (e.g., increases in refined sugar and fats and lack of fiber), environmental alterations (e.g., use of motorized transportation and climate- controlled living and work sites), and occupational hazards. A rise in population and greater population density also increase mental and behavioral disorders.
In summary, disease patterns and environmental demands changed when wandering, hunting, and gathering aggregates grew into large populations and became sedentary. Humans had to adapt to more densely populated, largely urban existence with marked consequences for health. As a result, over time, the leading causes of death changed from infectious disease to chronic illness.
Evolution of Early Public Health Efforts Traditionally, historians believed that organized public health efforts were eighteenth- and nineteenth-century activities associated with the Sanitary Revolution. However, modern historians have shown that organized community health efforts to prevent disease, prolong life, and promote health have existed since early human history.
Public health efforts developed slowly over time. The following sections briefly trace the evolution of organized public health and highlight the periods of prerecorded historical times (i.e., before 5000 BCE), classical times (i.e., 3000 to 200 BCE), the Middle Ages (i.e., 500 to 1500 CE), the Renaissance (i.e., fifteenth, sixteenth, and seventeenth centuries), the eighteenth century, the nineteenth century, and into the present day. It is important to note that, like the disease history of humankind, public health efforts exist in various stages of development throughout the world, and this brief history suggests a Western viewpoint.
Prerecorded Historic Times From the early remains of human habitation, anthropologists recognize that early nomadic humans became domesticated and tended to live in increasingly larger groups. Aggregates ranging from extended families to larger communities inevitably shared episodes of life, health, sickness, and death. Whether based on superstition or sanitation, health practices evolved to ensure the survival of many aggregates. For example, primitive societies used elements of medicine (e.g., voodoo), isolation (e.g., banishment), and fumigation (i.e., use of smoke) to manage disease and thus protect the community for thousands of years (Hanlon and Pickett, 1990).
Classical Times In the early years of the period 3000 to 1400 BCE, the Minoans devised ways to flush water and construct drainage systems. Circa 1000 BCE, the Egyptians constructed elaborate drainage systems, developed pharmaceutical preparations, and embalmed the dead. Pollution is an ancient problem. The biblical book of Exodus reported that “all the waters that were in the river stank,” and in the book of Leviticus (believed to be written around 500 BCE), the Hebrews formulated the first written hygiene code. This hygiene code protected water and food by creating laws that governed personal and community hygiene such as contagion, disinfection, and sanitation.
Greece Greek literature contains accounts of communicable diseases such as diphtheria, mumps, and malaria. The Hippocratic book On Airs, Waters and Places, a treatise on the balance between humans and their environment, may have been the only volume on this topic until the development of bacteriology in the late nineteenth century (Rosen, 2015). Diseases that were always present in a population, such as colds and pneumonia, were called endemic. When diseases such as diphtheria and measles presented fairly widespread outbreaks, the diseases were termed epidemic.
In practice, the Greeks emphasized the preservation of health, or good living, which the goddess Hygeia represented, and curative medicine, which the goddess Panacea personified. Human life had to be in balance with environmental demands; therefore the Greeks weighed the importance of exercise, rest, and nutrition according to age, sex, constitution, and climate (Rosen, 2015).
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BOX 2.1 Romans Provided Public Health Services The ancient Romans provided public health services that included the following:
• A water board to maintain the aqueducts • A supervisor of the public baths • Street cleaners • Supervision of the sale of food
Data from Rosen G: A history of public health, expanded edition, Baltimore, MD, 2015, Johns Hopkins Press.
Rome Although the Romans readily adopted Greek culture, they far surpassed Greek engineering by constructing massive aqueducts, bathhouses, and sewer systems. For example, at the height of the Roman Empire, Rome provided its 1 million inhabitants with 40 gallons of water per person per day, which is comparable to modern consumption rates (Rosen, 2015). Inhabitants of the overcrowded Roman slums, however, did not share in public health amenities such as sewer systems and latrines, and their health suffered accordingly.
The Romans also observed and addressed occupational health threats. In particular, they noted the pallor of the miners, the danger of suffocation, and the smell of caustic fumes (Rosen, 2015 ) (Box 2.1). For protection, miners devised safeguards by using masks made of bags, sacks, membranes, and bladder skins.
In the early years of the Roman Republic, priests were believed to mediate diseases and often dispensed medicine. Public physicians worked in designated towns and earned money to care for the poor. In addition, they were able to charge wealthier patients a service fee. Much as in a modern health maintenance organization or group practice, several families paid a set fee for yearly services. Hospitals, surgeries, infirmaries, and nursing homes appeared throughout Rome. In the fourth century, a Christian woman named Fabiola established a hospital for the sick poor. Others repeated this model throughout medieval times (Donahue, 2011).
Middle Ages The decline of Rome, which occurred circa 500 CE, led to the Middle Ages. Monasteries promoted collective activity to protect public health, and the population adopted protective measures such as building wells and fountains, cleaning streets, and disposing of refuse. The commonly occurring communicable diseases were measles, smallpox, diphtheria, leprosy, and bubonic plague. Physicians had little to offer in the management of diseases such as leprosy. The church took over by enforcing the hygienic codes from Leviticus and establishing isolation and leper houses, or leprosaria (Rosen, 2015).
A pandemic is the existence of disease in a large proportion of the population. One such pandemic, the bubonic plague, ravaged much of the world in the fourteenth century. This plague, or Black Death, claimed close to half the world’s population at that time (Hanlon and Pickett, 1990). For centuries, medicine and science did not recognize that fleas, which were attracted to the large number of rodents inhabiting urban areas, were the transmitters of plague. Modern public health practices such as isolation, disinfection, and ship quarantines emerged in response to the bubonic plague (Box 2.2).
BOX 2.2 Human Plague Cases in the United States Between 1900 and 2012, more than 1000 cases of human plague occurred in the United States (CDC, 2015). A recent analysis of the historical epidemiology of the disease described how it evolved over the 113 years, changing from an illness that was largely located in port cities of California and the Gulf Coast between 1900 and 1925, to being primarily found in the “four corners” regions of the American Southwest, with periodic outbreaks in the mid-1980s and mid-1990s. Although many of the very early (pre-1925) cases affected Asian immigrants and sailors and were believed to have
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been transmitted person to person, the later outbreaks (post-1965) affected a high percentage of American Indians and were most commonly associated with working with animals and known flea bites.
Recently, two cases of plague were reported to have occurred after visits to Yosemite National Park in 2015 (CDC, 2016). A comprehensive investigation indicated that the two individuals likely contracted the disease from rodent droppings, but from different locations within the park. Significant changes and interventions were undertaken by park staff and education initiatives for the public were proposed to reduce the risk for further plague transmission.
Data from Centers for Disease Control and Prevention: Epidemiology of human plague in the United States, 1900–2012, Emerg Infect Diseases 21(1):16–22, 2015. Retrieved from: https://wwwnc.cdc.gov/eid/article/21/1/pdfs/14-0564.pdf
Centers for Disease Control and Prevention: Investigation of and response to 2 plagues cases, Yosemite National Park, California, USA, 2015, Emerg Infect Diseases 22(12):2045–2053, 2016. Retrieved from: https://wwwnc.cdc.gov/eid/article/22/12/pdfs/16-0560.pdf
During the Middle Ages, clergymen often acted as physicians and treated kings and noblemen. Monks and nuns provided nursing care in small houses designated as structures similar to today’s small hospitals. Medieval writings contained information on hygiene and addressed such topics as housing, diet, personal cleanliness, and sleep (Rosen, 2015). Box 2.3 presents an account of living conditions in the sixteenth century.
The Renaissance Although the cause of infectious disease remained undiscovered, two events important to public health occurred during the Renaissance. In 1546, Girolamo Fracastoro presented a theory that infection was a cause and epidemic a consequence of the “seeds of disease.” Then, in 1676, Anton van Leeuwenhoek described microscopic organisms, although he did not associate them with disease (Rosen, 2015).
The Elizabethan Poor Law, enacted in England in 1601, held the church parishes responsible for providing relief for the poor. This law governed health care for the poor for more than two centuries and became a prototype for later U.S. laws.
BOX 2.3 Life in an English Household in the Sixteenth Century In the following account, Erasmus described how life in the sixteenth century must have affected health. Such accounts appeared in literature throughout the sixteenth century.
As to floors, they are usually made with clay, covered with rushes that grow in the fens and which are so seldom removed that the lower parts remain sometimes for twenty years and has in it a collection of spittle, vomit, urine of dogs and humans, beer, scraps of fish and other filthiness not to be named.
Quotation from Hanlon JJ, Pickett GE: Public health administration and practice, ed 9, St. Louis, MO, 1990, Mosby, p 25.
Eighteenth Century
Great Britain The eighteenth century was marked by imperialism and industrialization. Unsanitary conditions remained a huge problem. During the Industrial Revolution, a gradual change in industrial productivity occurred. The industrial boom sacrificed many lives for profit. In particular, it forced poor children into labor. Under the Elizabethan Poor Law, parishes established workhouses to employ the poor. Orphaned and poor children were wards of the parish; therefore the parish forced these young children to labor in parish workhouses for long hours (George, 1925). At 12 to 14 years of age, a child became a master’s apprentice. Those apprenticed to chimney sweeps reportedly suffered the worst fate because their masters forced them into chimneys at the risk of being burned and suffocated.
Vaccination was a major discovery of the times. In 1796, Edward Jenner observed that people
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who worked around cattle were less likely to contract smallpox. He concluded that immunity to smallpox resulted from an inoculation with the cowpox virus. Jenner’s contribution was significant because approximately 95% of the population suffered from smallpox and approximately 10% of the population died of smallpox during the eighteenth century. Frequently, the faces of those who survived the disease were scarred with pockmarks.
The Sanitary Revolution’s public health reforms were beginning to take place throughout Europe and England. In the eighteenth century, scholars used survey methods to study public health problems (Rosen, 2015). These surveys mapped “medical topographies,” which were geographic factors related to regional health and disease. A health education movement provided books and pamphlets on health to the middle and upper classes, but it neglected “economic factors” and was not concerned with the working classes.
Nineteenth Century
Europe During the nineteenth century, communicable diseases ravaged the population that lived in unsanitary conditions, and many lives were lost. For example, in the mid-1800s, typhus and typhoid fever claimed twice as many lives each year as the Battle of Waterloo (Hanlon and Pickett, 1990).
Edwin Chadwick called attention to the consequences of unsanitary conditions that resulted in health disparities that shortened life spans of the laboring class in particular. Chadwick contended that death rates were high in large industrial cities such as Liverpool, where more than half of all children born of working-class parents died by age 5. Laborers lived an average of 16 years. In contrast, tradesmen lived 22 years, and the upper classes lived 36 years (Richardson, 1887). In 1842, Chadwick published his famous Report on an Inquiry Into the Sanitary Conditions of the Labouring Population of Great Britain. The report furthered the establishment of the General Board of Health for England in 1848. Legislation for social reform followed, addressing prevailing concerns such as child welfare; factory management; education; and care for the elderly, sick, and mentally ill. Clean water, sewers, fireplugs, and sidewalks emerged as a result.
In 1849, a German pathologist named Rudolf Virchow argued for social action—bettering the lives of the people by improving economic, social, and environmental conditions—to attack the root social causes of disease. He proposed “a theory of epidemic disease as a manifestation of social and cultural maladjustment” (Rosen, 2015, p. 62). He further argued that the public was responsible for the health of the people; that social and economic conditions heavily affected health and disease; that efforts to promote health and fight disease must be social, economic, and medical; and that the study of social and economic determinants of health and disease would yield knowledge to guide appropriate action.
These principles were embodied in a public health law submitted to the Berlin Society of Physicians and Surgeons in 1849 (Rosen, 2015). According to this document, public health has as its objectives (1) the healthy mental and physical development of the citizen, (2) the prevention of all dangers to health, and (3) the control of disease.
A very critical event in the development of modern public health occurred in 1854, when an English physician, anesthetist, and epidemiologist named John Snow demonstrated that cholera was transmissible through contaminated water. In a large population afflicted with cholera, he shut down the community’s water resource by removing the pump handle from a well on Broad Street and carefully documented changes as the number of cholera cases fell dramatically (Rosen, 2015).
United States In the United States during the nineteenth century, waves of epidemics continued to spread. As in Europe, diseases such as yellow fever, smallpox, cholera, typhoid fever, and typhus particularly affected the poor. These illnesses spread because cities grew and the poor crowded into inadequate housing with unsanitary conditions.
Lemuel Shattuck, a Boston bookseller and publisher with an interest in public health, organized the American Statistical Society in 1839 and issued a Census of Boston in 1845. The census showed high overall mortality and very high infant and maternal mortality rates. Living conditions for the poor were inadequate, and communicable diseases were widely prevalent (Rosen, 2015). Shattuck’s 1850 Report of the Sanitary Commission of Massachusetts outlined the findings and recommended
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modern public health reforms that included keeping vital statistics and providing environmental, food, drug, and communicable disease control information. Shattuck called for well-infant, well- child, and school-aged–child health care; mental health care; vaccination; and health education. Unfortunately, the report fell on deaf ears, and little was done to improve population health for many years. For example, a state board of health was not formed until 19 years after the report was issued.
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Advent of Modern Health Care Early public health efforts evolved slowly throughout the mid-nineteenth century. Administrative efforts, initial legislation, and debate regarding the determinants of health and approaches to health management began to appear on a social, economic, and medical level. The advent of “modern” health care occurred around this time, and nursing made a large contribution to the progress of health care. The following sections discuss the evolution of modern nursing, the evolution of modern medical care and public health practice, the evolution of the community caregiver, and the establishment of public health nursing.
Evolution of Modern Nursing Florence Nightingale, the woman credited with establishing “modern nursing,” began her work during the mid-nineteenth century. Historians remember Florence Nightingale for contributing to the health of British soldiers during the Crimean War and establishing nursing education. However, many historians failed to recognize her remarkable use of public health principles and distinguished scientific contributions to health care reform (Cohen, 1984; Grier and Grier, 1978).
Nightingale was from a wealthy English family, was well educated, and traveled extensively. She studied with Adolphe Quetelet, a Belgian statistician who taught her the discipline of social inquiry (Goodnow, 1933). Nightingale also had a passion for hygiene and health, and in 1851, at the age of 31 years, she trained in nursing at Kaiserswerth Hospital in Germany. She later studied the organization and discipline of the Sisters of Charity in Paris. Nightingale wrote extensively and published analyses of the nursing systems she studied in France, Austria, Italy, and Germany (Dock and Stewart, 1925).
In 1854, Nightingale responded to distressing accounts of a lack of care for wounded soldiers during the Crimean War. She and 40 other nurses traveled to Scutari, which was then a part of the Ottoman Empire. Nightingale was accompanied by lay nurses, Roman Catholic sisters, and Anglican sisters. Upon their arrival, the nurses learned that the British army’s methods for treating the sick and wounded had created conditions that resulted in extraordinarily high death rates among soldiers. Indeed, one of Nightingale’s greatest achievements was improving the management of these ill and wounded soldiers (Dossey, 2010).
During the Crimean War, cholera and “contagious fever” were rampant. Equal numbers of men died of disease and battlefield injury (Cohen, 1984). Nightingale found that allocated supplies were bound in bureaucratic red tape; for example, supplies were “sent to the wrong ports or were buried under munitions and could not be got” (Goodnow, 1933, p. 86).
Nightingale encountered problems reforming the army’s methods for care of the sick because she had to work through eight military affairs departments related to her assignment. She sent reports of the appalling conditions of the hospitals to London. In response to her actions, governmental and private funds were donated to set up kitchens and a laundry and provided food, clothing, dressings, and laboratory equipment (Dock and Stewart, 1925).
Major reforms occurred during the first two months of her assignment. Aware that an interest in keeping social statistics was emerging, Nightingale realized that her most forceful argument would be statistical in nature. She reorganized the methods of keeping statistics and was the first to use shaded and colored coxcomb graphs of wedges, circles, and squares to illustrate the preventable deaths of soldiers. Nightingale compared the deaths of soldiers in hospitals during the Crimean War with the average annual mortality in Manchester and with the deaths of soldiers in military hospitals in and near London at the time (Fig. 2.2). Through her statistics she also showed that, by the end of the war, the death rate among ill soldiers during the Crimean War was no higher than that among well soldiers in Britain (Cohen, 1984). Indeed, Nightingale’s careful statistics revealed that the death rate for treated soldiers decreased from 42% to 2%. Furthermore, she established community services and activities to improve the quality of life for recovering soldiers. These included rest and recreation facilities, study opportunities, a savings fund, and a post office. She also organized care for the families of the soldiers (Dock and Stewart, 1925).
After returning to London at the close of the war in 1856, Nightingale devoted her efforts to sanitary reform. At home, she surmised that if the sanitary neglect of the soldiers existed in the battle area, it probably existed at home in London. She prepared statistical tables to support her
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suspicions (Table 2.2). In one study comparing the mortality of men aged 25 to 35 years in the army barracks of England
with that of men the same age in civilian life, Nightingale found that the mortality of the soldiers was nearly twice that of the civilians. In one of her reports, she stated that “our soldiers enlist to death in the barracks” (Kopf, 1978, p. 95). Nightingale was very political and distributed her reports to members of Parliament and to the medical and commanding officers of the army (Kopf, 1978). Prominent leaders of the time challenged her reports. Undaunted, she rewrote them in greater depth and redistributed them.
In her efforts to compare the hospital systems in European countries, Nightingale discovered that each hospital kept incomparable data and that many hospitals used various names and classifications for diseases. She noted that these differences prevented the collection of similar statistics from larger geographic areas. These statistics would create a regional health–illness profile and allow for comparison with other regions. She printed common statistical forms that some hospitals in London adopted on an experimental basis. A study of the tabulated results revealed the promise of this strategy (Kopf, 1978) (Box 2.4).
Nightingale also stressed the need to use statistics at the administrative and political levels to direct health policy. Noting the ignorance of politicians and those who set policy regarding the interpretation and use of statistics, she emphasized the need to teach national leaders to use statistical facts. Nightingale continued the development and application of statistical procedures, and she won recognition for her efforts. The Royal Statistical Society made her a fellow in 1858, and the American Statistical Association made her an honorary member in 1874 (Kopf, 1978).
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FIG. 2.2 (A) Coxcomb charts by Florence Nightingale. (B) Photographs of large, foldout charts from an original preserved at the University of Chicago Library.
A from Nightingale F: Notes on matters affecting the health, efficiency and hospitalization of the British army, London, 1858, Harrison and Sons; B, Public domain; courtesy University of Chicago Library.
It is interesting to note that the paradigm for nursing practice and nursing education that evolved through Nightingale’s work did not incorporate her emphasis on statistics and a sound research base. It
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is also curious that nursing education did not consult her writings and did not stress the importance of determining health’s social and environmental determinants until much later.
TABLE 2.2
Nightingale’s Crimean War Mortality Statistics: Nursing Research That Made a Difference∗
∗ Number of deaths of noncommissioned officers and men also shows the number of deaths that would have occurred if the mortality were 7.7 per 1000—such as it was among Englishmen of the soldiers’ age in healthy districts, in the years 1849 to 1853 —which fairly represent the average mortality. † The exact mortality in the healthy districts is 0.0077122, with use of the logarithm of 3.8871801.
From Grier B, Grier M: Contributions of the passionate statistician, Res Nurs Health 1:103–109, 1978. Copyright ©1978 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.
Active Learning Exercise
Find two recent articles about Florence Nightingale. After reading the articles, list Nightingale’s contributions to public health, public health nursing, and community health nursing.
Establishment of Modern Health Care and Public Health Practice To place Nightingale’s work in perspective, it is necessary to consider the development of health care in light of common education and practice during the late nineteenth and early twentieth centuries. Goodnow (1933) called this time a “dark age.” Health sciences were underdeveloped, and bacteriology was unknown. Few medical schools existed at the time, thus apprenticeship was the path to medical education. The majority of physicians believed in the “spontaneous generation” theory of disease causation, which stated that disease organisms grew from nothing (Najman, 1990). Typical medical treatment included bloodletting, starving, using leeches, and prescribing large doses of metals such as mercury and antimony (Goodnow, 1933).
BOX 2.4 Nightingale’s Use of Statistical Methods in Community Assessment London’s Southeastern Railway planned to remove St. Thomas’ Hospital to enlarge the railway’s
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right of way between London Bridge and Charing Cross. Nightingale applied her statistical method to the health needs of the community by conducting a community assessment. She plotted the cases served by the hospital, analyzed the proportion by distance, and calculated the probable impact on the community if the hospital were relocated to the proposed site. In her view, hospitals were a part of the wider community that served the needs of humanity. Kopf (1978) noted that this method of health planning and matching resources to the needs of the population was visionary and was not reapplied until the twentieth century.
Nightingale’s uniform classification of hospital statistics focused on the importance of tabulating the classification of diseases in hospital patients and the need to identify the diseases that patients contracted in the hospital. These diseases, such as gangrene and septicemia, were later called iatrogenic diseases (Kopf, 1978). Considering the lack of surgical sanitation in hospitals at the time, it is not surprising that iatrogenic infection was rampant. For example, Goodnow (1933) illustrates the following unsanitary operating procedures:
Before an operation the surgeon turned up the sleeves of his coat to save the coat, and would often not trouble to wash his hands, knowing how soiled they soon would be! The area of the operation would sometimes be washed with soap and water, but not always, for the inevitability of corruption made it seem useless. The silk or thread used for stitches or ligatures was hung over a button of the surgeon’s coat, and during the operation a convenient place for the knife to rest was between his lips. Instruments ... used for ... lancing abscesses were kept in the vest pocket and often only wiped with a piece of rag as the surgeon went from one patient to another. (pp. 471–472)
During the nineteenth century, the following important scientists were born: Louis Pasteur in 1822, Joseph Lister in 1827, and Robert Koch in 1843. Their research had a profound impact on health care, medicine, and nursing. Pasteur was a chemist, not a physician. While experimenting with wine production in 1854, he proposed the theory of the existence of “germs.” Although his colleagues ridiculed him at first, Koch applied his theories and developed his methods for handling and studying bacteria. Subsequently, Pasteur’s colleagues gave him acknowledgment for his work (Kalisch and Kalisch, 2004).
Lister, whose father perfected the microscope, observed the healing processes of fractures. He noted that when the bone was broken but the skin was not, recovery was uneventful. However, when both the bone and the skin were broken, fever, infection, and even death were frequent. He postulated the answer to his observation from Pasteur’s work and suggested that something outside the body entered the wound through the broken skin, causing the infection (Goodnow, 1933). Lister’s surgical successes eventually improved when he soaked the dressings and instruments in mixtures of carbolic acid (i.e., phenol) and oil.
In 1882, Koch discovered the causative agent for cholera and the tubercle bacillus. Pasteur discovered immunization in 1881 and the rabies vaccine in 1885. These discoveries were significant to the development of public health and medicine. However, physicians accepted these discoveries slowly (Rosen, 2015). For example, TB was a major cause of death in late nineteenth-century America and often afflicted its victims with chronic illness and disability. It was a highly stigmatized disease, and most physicians thought it was a hereditary, constitutional disease associated with poor environmental conditions. Hospitalization for TB was rare because the stigma caused families to hide their infected relatives. Without treatment, the communicability of the disease increased. The most common treatment was a change of climate (Rosen, 2015). Although Koch had announced the discovery of the tubercle bacillus in 1882, it was 10 years before the emergence of the first organized community campaign to stop the spread of the disease.
The case of puerperal (i.e., childbirth) fever illustrates another example of slow innovation stemming from scientific discoveries. Although Pasteur showed that Streptococcus caused puerperal fever, it was years before physicians accepted his discovery. However, medical practice eventually changed, and physicians no longer delivered infants after performing autopsies of puerperal fever cases without washing their hands (Goodnow, 1933).
Debates over the causes of disease occurred throughout the nineteenth century. Scientists discovered organisms during the latter part of the century, supporting the theory that specific contagious entities caused disease. This discovery challenged the earlier miasmic theory that environment and atmospheric conditions caused disease (Greifinger and Sidel, 1981). The new
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scientific discoveries had a major impact on the development of public health and medical practice. The emergence of the germ theory of disease focused diagnosis and treatment on the individual organism and the individual disease.
State and local governments felt increasingly responsible for controlling the spread of microorganisms. A community outcry for social reform forced state and local governments to take notice of the deplorable living conditions in the cities. In the New York City riots of 1863, the populace expressed their disgust for overcrowding; filthy streets; lack of provisions for the poor; and lack of adequate food, water, and housing. Local boards of health formed, taking responsibility for safeguarding food and water stores and managing the sewage and quarantine operation for victims of contagious diseases (Greifinger and Sidel, 1981).
The New York Metropolitan Board of Health formed in 1866, and state health departments formed shortly thereafter. States built large public hospitals that treated TB and mental disease with rest, diet, and quarantine. In 1889, the New York City Health Department recommended the surveillance of TB and TB health education, but physicians did not welcome either recommendation (Rosen, 2015). Despite their objections, in 1894 the New York City Health Department required institutions to report cases of TB and required physicians to do the same by 1897.
BOX 2.5 Scientific Theory/Single-Agent Theory The emphasis on the use of scientific theory, or single-agent theory, in medical care developed into a focus on disease and symptoms rather than a focus on the prevention of disability and care for the “whole person.” The old-fashioned family doctor viewed patients in relation to their families and communities and apparently helped people cope with problems in personal life, family, and society. American medicine adopted science with such vigor that these qualities faded away. Science allowed the physician to deal with tissues and organs, which were much easier to comprehend than the dynamics of human relationships or the complexities of disease prevention. Many physicians made efforts to integrate the various roles, but society was pushing toward academic science.
In 1883, The Johns Hopkins University Medical School in Baltimore, Maryland, formed under the German model that promoted medical education on the principles of scientific discovery. In the United States, the Carnegie Commission appointed Abraham Flexner to evaluate medical schools throughout the country on the basis of the German model. In 1910, the Flexner Report outlined the shortcomings of U.S. medical schools that did not use this model. Within a few years, the report caused philanthropic organizations such as the Rockefeller and Carnegie foundations to withdraw funding of poor-performing and scientifically “inadequate” medical schools, ensuring their closure. A “new breed” of physicians emerged who had been taught about “germ theory” and the “single agent theory” of disease causation (Greifinger and Sidel, 1981, p. 132) (Box 2.5).
Philanthropic foundations continued to influence health care efforts. For example, the Rockefeller Sanitary Commission for the Eradication of Hookworm formed in 1909. Hookworm was an occupational hazard among Southern workers. Implementation of preventive efforts to eradicate hookworm kept the workers healthy and thus proved to be a great industrial benefit. The model was so successful that the Rockefeller Foundation established the first school of public health, The Johns Hopkins School of Hygiene and Public Health, in 1916. The focus of this institution was the preservation and improvement of individual and community health and the prevention of disease through multidisciplinary activities.
Community Caregiver The traditional role of the community caregiver or the traditional healer has nearly vanished in the West. However, medical and nurse anthropologists who have studied primitive and Western cultures are familiar with the community healer and caregiver role (McFarland and Wehbe-Alamah, 2015). The traditional healer (e.g., shaman, midwife, herbalist, or priest) is common in non-Western, ancient, and underdeveloped societies. Although traditional healers have always existed, professionals and many people throughout industrialized societies may overlook or minimize their role. The role of the healer is often integrated into other institutions of society, including religion,
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medicine, and morality. The notion that one person acts alone in healing may be foreign to many cultures; healers can be individuals, kin, or entire societies (Hughes, 1978).
Societies retain folk practices because they provide some repeated successes. Most cultures have a pharmacopeia and maintain therapeutic and preventive practices, and it is estimated that one- fourth to one-half of folk medicines are empirically effective. Indeed, many modern drugs are based on the medicines of primitive cultures (e.g., eucalyptus, coca, and opium) (Hughes, 1978).
Since ancient times, folk healers and cultural practices have both positively and negatively affected health. The late nineteenth- and early twentieth-century practice of midwifery illustrates modern medicine’s arguably sometimes negative impact on traditional healing in many Western cultures (Smith, 1979). For example, traditional midwifery practices made women rise out of bed within 24 hours of delivery to help “clear” the lochia. Throughout the mid-1900s, in contrast, “modern medicine” recommended keeping women in bed after delivery, often for fairly extended periods (Smith, 1979).
Research Highlights
Historical Methodology for Nursing Research Historiography is the methodology of historical research. It involves specialized techniques, principles, and theories that pertain to historical matters. Historical research involves interpreting history and contributing to understanding through data synthesis. It relies on existing sources or data and requires the researcher to gain access to sources such as libraries, librarians, and databases.
Historical research should be descriptive. It should answer the questions of who, what, when, where, how, and the interpretive why. Historians reconstruct an era using primary sources and interpret the story from that perspective. Historical research in nursing will enhance the understanding of current nursing practice and will help prepare for the future. Adapted from Lusk B: Historical methodology for nursing research, Image J Nurs Sch 29:3555–3560, 1997.
Establishment of Public Health Nursing Public health nursing as a holistic approach to health care developed in the late nineteenth and early twentieth centuries. Public and community health nursing in its current form evolved from home nursing practice, community organizations, and political interventions on behalf of families, groups, and populations as explained in this section.
England Public health nursing developed from providing nursing care to the sick poor and furnishing information and through channels of community organization that enabled the poor to improve their own health status.
District Nursing District nursing was first established in England. Between 1854 and 1856, the Epidemiological Society of London developed a plan that trained selected poor women to provide nursing care to the disadvantaged families within a community. The society theorized that nurses belonging to their patients’ social class would be more effective caregivers and that more nurses would be available to improve the health of community residents (Rosen, 2015).
A similar plan was implemented by William Rathbone in Liverpool in 1859. After experiencing the excellent care a nurse gave his sick wife in his home, Rathbone strongly believed that nurses could offer the same care throughout the community. He developed a plan that divided the community into 18 districts and assigned a nurse and a social worker to each district. This team met the needs of their communities with respect to nursing, social work, and health education. The community widely accepted the plan. To further strengthen it, Rathbone consulted Nightingale about educating the district nurses. She assisted him by providing training for the district nurses, referring to them as “health nurses.” The model was successful, and eventually voluntary agencies
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adopted the plan on the national level (Rosen, 2015).
Health Visiting Health visiting to provide information to improve health is a parallel service based on the district nursing tradition. The Ladies Section of the Manchester and Salford Sanitary Association originated health visiting in Manchester in 1862. Prior to that time, it had been observed that providing health pamphlets alone had little effect on improving health; therefore this service enlisted home visitors to distribute health information to the poor.
In 1893, Nightingale pointed out that the district nurse should be a health teacher and a nurse for the sick in the home. She believed that teachers should educate “health missioners” for this purpose. The model charged the district nurse with providing care for the sick in the home and the health visitor with providing health information in the home. Eventually, government agencies sponsored health visitors, medical health officers supervised them, and the municipality paid them. Thus a collaborative model developed between government and voluntary agencies.
United States In the United States, public health nursing developed from the British traditions of district nursing, health visiting, and home nursing. In 1877, the Women’s Board of the New York City Mission sent a graduate nurse named Frances Root into homes to provide care for the sick. The innovation spread, and nursing associations, later called visiting nurse associations, were implemented in Buffalo in 1885 and in Boston and Philadelphia in 1886.
In 1893, nurses Lillian Wald and Mary Brewster established a district nursing service on the Lower East Side of New York City called the House on Henry Street. This was a crowded area teeming with unemployed and homeless immigrants who needed health care. The organization, later called the Visiting Nurse Association of New York City, played an important role in establishing public health nursing in the United States. Box 2.6 contains Wald’s compelling account of her early exposure to the community where she identified public health nursing needs.
Wald (1971) described a range of services that evolved from the House on Henry Street. Nurses provided home visits, and patients paid carfare or a cursory fee. Physicians were consultants to Henry Street, and families could arrange a visit by calling the nurse directly, or a physician could call the nurse on the family’s behalf. The nursing service adopted the philosophy of meeting the health needs of the population, which included the many evident social, economic, and environmental determinants of health. By necessity, this effort involved an aggregate approach that empowered people of the community.
BOX 2.6 Lillian Wald: The House On Henry Street The following highlights from The House on Henry Street, published in 1915, bring Lillian Wald’s experience to life:
A sick woman in a squalid rear tenement, so wretched and so pitiful that, in all the years since, I have not seen anything more appalling, determined me, within half an hour, to live on the East Side.
I had spent two years in a New York training-school for nurses … After graduation, I supplemented the theoretical instruction, which was casual and inconsequential in the hospital classes twenty-five years ago, by a period of study at a medical college. It was while at the college that a great opportunity came to me.
While there, the long hours “on duty” and the exhausting demands of the ward work scarcely admitted freedom for keeping informed as to what was happening in the world outside. The nurses had no time for general reading; visits to and from friends were brief; we were out of the current and saw little of life saved as it flowed into the hospital wards. It is not strange, therefore, that I should have been ignorant of the various movements which reflected the awakening of the social conscience at the time.
Remembering the families who came to visit patients in the wards, I outlined a course of
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instruction in home nursing adapted to their needs, and gave it in an old building in Henry Street, then used as a technical school and now part of the settlement. Henry Street then as now was the center of a dense industrial population.
From the schoolroom where I had been giving a lesson in bedmaking, a little girl led me one drizzling March morning. She had told me of her sick mother, and gathering from her incoherent account that a child had been born, I caught up the paraphernalia of the bedmaking lesson and carried it with me.
The child led me over broken roadways—there was no asphalt, although its use was well established in other parts of the city—over dirty mattresses and heaps of refuse—it was before Colonel Waring had shown the possibility of clean streets even in that quarter—between tall, reeking houses whose laden fire-escapes, useless for their appointed purpose, bulged with household goods of every description. The rain added to the dismal appearance of the streets and to the discomfort of the crowds which thronged them, intensifying the odors which assailed me from every side. Through Hester and Division Street[s] we went to the end of Ludlow; past odorous fishstands, for the streets were a market-place, unregulated, unsupervised, unclean; past evil-smelling, uncovered garbage-cans; and—perhaps worst of all, where so many little children played—past the trucks brought down from more fastidious quarters and stalled on these already overcrowded streets, lending themselves inevitably to many forms of indecency.
The child led me on through a tenement hallway, across a court where open and unscreened closets were promiscuously used by men and women, up into a rear tenement, by slimy steps whose accumulated dirt was augmented that day by the mud of the streets, and finally into the sickroom.
All the maladjustments of our social and economic relations seemed epitomized in this brief journey and what was found at the end of it. The family to which the child led me was neither criminal nor vicious. Although the husband was a cripple, one of those who stand on street corners exhibiting deformities to enlist compassion, and masking the begging of alms by a pretense at selling; although the family of seven shared their two rooms with boarders—who were literally boarders, since a piece of timber was placed over the floor for them to sleep on—and although the sick woman lay on a wretched, unclean bed, soiled with a hemorrhage two days old, they were not degraded human beings, judged by any measure of moral values.
In fact, it was very plain that they were sensitive to their condition, and when, at the end of my ministrations, they kissed my hands (those who have undergone similar experiences will, I am sure, understand), it would have been some solace if by any conviction of the moral unworthiness of the family I could have defended myself as a part of a society which permitted such conditions to exist. Indeed, my subsequent acquaintance with them revealed the fact that, miserable as their state was, they were not without ideals for the family life, and for society, of which they were so unloved and unlovely a part.
That morning’s experience was a baptism of fire. Deserted were the laboratory and the academic work of the college. I never returned to them. On my way from the sickroom to my comfortable student quarters my mind was intent on my own responsibility. To my inexperience it seemed certain that conditions such as these were allowed because people did not know, and for me there was a challenge to know and to tell. When early morning found me still awake, my naive conviction remained that, if people knew things—and “things” meant everything implied in the condition of this family—such horrors would cease to exist, and I rejoiced that I had had a training in the care of the sick that in itself would give me an organic relationship to the neighborhood in which this awakening had come.
To the first sympathetic friend to whom I poured forth my story, I found myself presenting a plan which had been developing almost without conscious mental direction on my part.
Within a day or two a comrade from the training-school, Mary Brewster, agreed to share in the venture. We were to live in the neighborhood as nurses, identify ourselves with it socially, and, in brief, contribute to it our citizenship.
I should like to make it clear that from the beginning we were most profoundly moved by the
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wretched industrial conditions which were constantly forced upon us … I hope to tell of the constructive programmes that the people themselves have evolved out of their own hard lives, of the ameliorative measures, ripened out of sympathetic comprehension, and finally, of the social legislation that expresses the new compunction of the community.
From Wald L: The house on Henry Street, New York, 1971, Dover Publications (original work published 1915, Henry Holt), pp 1–9.
Helen Hall, who later directed the House on Henry Street, wrote that the settlement’s role was “one of helping people to help themselves” (Wald, 1971) through the development of centers of social action aimed at meeting the needs of the community and the individual. Community organization led to the formation of a great variety of programs, including youth clubs, a juvenile program, sex education for local schoolteachers, and support programs for immigrants.
Additional programs such as school nursing were based on individual observations and interventions. Wald reported the following incident that preceded her successful trial of school nursing (1971):
I had been downtown only a short time when I met Louis. An open door in a rear tenement revealed a woman standing over a washtub, a fretting baby on her left arm, while with her right she rubbed at the butcher’s aprons which she washed for a living.
“Louis,” she explained, “was bad.” He did not “cure his head of lice and what would become of him, for they would not take him into the school because of it?” Louis said he had been to the dispensary many times. He knew it was awful for a twelve-year-old boy not to know how to read the names of the streets on the lamp-posts, but “every time I go to school Teacher tells me to go home.”
It needed only intelligent application of the dispensary ointments to cure the affected area, and in September, I had the joy of securing the boy’s admittance to school for the first time in his life. The next day, at the noon recess, he fairly rushed up our five flights of stairs in the Jefferson Street tenement to spell the elementary words he had acquired that morning. (pp. 46–47)
Overcrowded schools, an uninformed and uninterested public, and an unaware Department of Health all contributed to social health neglect. Wald and the nursing staff at the settlement kept anecdotal notes on the sick children teachers excluded from school. One nurse found a boy in school whose skin was desquamating from scarlet fever and took him to the president of the Department of Health in an attempt to place physicians in schools. A later program had physicians screen children in school for 1 hour each day.
Twentieth Century In 1902, Wald persuaded Dr. Ernest J. Lederle, Commissioner of Health in New York City, to try a school nursing experiment. Henry Street lent a public health nurse named Linda Rogers to the New York City Health Department to work in a school (Dock and Stewart, 1925). The experiment was successful, and schools adopted nursing on a widespread basis. School nurses performed physical assessments, treated minor infections, and taught health to pupils and parents.
In 1909, Wald mentioned the efficacy of home nursing to one of the officials of the Metropolitan Life Insurance Company. The company decided to provide home nursing to its industrial policyholders, and soon the United States and Canada used the program successfully (Wald, 1971).
The growing demand for public health nursing was hard to satisfy. In 1910, the Department of Nursing and Health formed at the Teachers College of Columbia University in New York City. A course in visiting nursing placed nurses at the Henry Street settlement for fieldwork. In 1912, the newly formed National Organization for Public Health Nursing elected Lillian Wald its first president. This organization was open to public health nurses and to those interested in public health nursing. In 1913, the Los Angeles Department of Health formed the first Bureau of Public Health Nursing (Rosen, 2015). That same year, the Public Health Service appointed its first public health nurse.
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Research Highlights
Example of Historical Nursing Research Thompson and Keeling (2012) presented an historical examination describing how public health nurses contributed to a significant decline in infant mortality in New England between 1884 and 1925. Analyzing archived data and documents from Providence, Rhode Island, they estimated that in the late nineteenth century, the mortality rate of children younger than 2 was between 15% and 20%. Furthermore, they reported that the health officials believed that of those infants and small children who died during those years, 40% to 50% died from digestive-related diseases (e.g., diarrhea).
The germ theory was not widely accepted until the early 1900s. Thus, in the late nineteenth century, nurses were trained to understand “elements of modern hygiene” (e.g., good nutrition, light, cleanliness). But following acceptance of the germ theory and epidemiological techniques for data analysis in the early 1900s, public health efforts shifted to consideration of factors, including biological, environmental, and economic, that contributed to the high infant mortality rate.
To address the problem of infant/child mortality, public health nurses focused on teaching low- income mothers how to care for and feed their children. The nurses worked in homes, “milk stations,” and other creative settings to meet the identified needs. They set up and participated in “milk dispensaries,” which provided pasteurized milk (rather than the widely available unrefrigerated milk—which was frequently days old). They also promoted breast-feeding and provided information on “infant hygiene” along with the milk. These and other efforts, including developing the role of a “children’s special nurse,” were effective, and the infant mortality rate dropped from 142/1000 to 102/1000 between 1907 and 1917. From Thompson ME, Keeling AA: Nurses’ role in the prevention of infant mortality in 1884–1925: health disparities then and now, J Pediatr Nurs 27:471–478, 2012.
At first, many public health nursing programs used nurses in specialized areas such as school nursing, TB nursing, maternal-child health nursing, and communicable disease nursing. In later years, more generalized programs have become acceptable. Efforts to contain health care costs include reducing the number of hospital days. With the advent of shortened hospital stays, private home health agencies provide home-based illness care across the United States.
The second half of the century saw a shift in emphasis to cost containment and the provision of health care services through managed care. Traditional models of public health nursing and visiting nursing from home health agencies became increasingly common over the next several decades, but waned toward the end of the century due to changes in health care financing.
Active Learning Exercise
1. Research the history of the health department or visiting nurse association in a particular city or county.
2. Discuss with peers how Lillian Wald’s approach to individual and community health care provides an understanding of how to facilitate the empowerment of aggregates in the community.
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Consequences for The Health of Populations An understanding of the consequences of the health care delivery system for population health is necessary to form conclusions about public health nursing from a historical perspective. Implications for the health of aggregates relate to new causes of mortality (i.e., Hygeia, or health promotion/care, vs. Panacea, or cure) and additional theories of disease causation.
Twenty-First Century New Causes of Mortality Since the middle of the twentieth century, the focus of disease in Western societies has changed from mostly infectious diseases to chronic diseases. Increased food production and better nutrition during the nineteenth and early twentieth centuries contributed to the decline in infectious disease– related deaths. Other factors were better sanitation through water purification, sewage disposal, improved food handling, and milk pasteurization. According to McKeown (2001) and Schneider (2017), the components of “modern” medicine, such as antibiotics and immunizations, had little effect on health until well into the twentieth century. Indeed, widespread vaccination programs began in the late 1950s, and antibiotics came into use after 1945.
The advent of chronic disease in Western populations puts selected groups at risk, and those groups need health education, screening, and programs to ensure occupational and environmental safety. Too often modern medicine still focuses on the single cause of disease (i.e., germ theory) and treating the acutely ill. As a result, many health providers treat the chronically ill with an acute care approach even though preventive care, health promotion, and restorative care are necessary and would likely be more effective in combating chronic disease. This expanded approach may develop under new systems of cost containment.
Hygeia versus Panacea The Grecian Hygeia (i.e., healthful living) versus Panacea (i.e., cure) dichotomy still exists today. Although the change in the nature of health “problems” is certain, the roles of individual and collective activities in the prevention of illness and premature death are slow to evolve.
In 2010, about two thirds of the active physicians in the United States were specialists (U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality [USDHHS/AHRQ], 2011). In recent years, medical education has increasingly focused on enhancing the education of primary care physicians (e.g., those specializing in internal medicine, obstetrics- gynecology, family medicine, and pediatrics) to meet the growing need for primary care. In addition to primary care, Hygeia (health promotion) requires a coordinated system that addresses health problems holistically with the use of multiple approaches and planning of outcomes for aggregates and populations. A redistribution of interest and resources to address the major determinants of health, such as food, housing, education, and a healthy social and physical environment, is critical (Shi and Singh, 2016).
Additional Theories of Disease Causation As mentioned, the germ theory of disease causation is a unicausal model that evolved in the late nineteenth century. Najman (1990) reviewed the following theories of disease causation: the multicausal view, which considers the environment multidimensionally, and the general susceptibility view, which considers stress and lifestyle factors. Najman contended that each theory accounts for some disease under some conditions, but no single theory accounts for all disease. Other factors, such as literacy and nutrition, may reduce disease morbidity and mortality to a greater extent than medical interventions alone.
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Social Challenges and Public Health Nursing Several social and political changes have occurred in the United States that have affected the development of public health nursing practice. During the twentieth century, the health of the client, nursing, health, and the environment were influenced by the development of health insurance and an emphasis on population-based focus.
The advent of and changes in health insurance dramatically altered health care delivery. The greatest health concerns at the beginning of the twentieth century were lost wages associated with sickness. The cost of health care was so low that there was little understanding of the need for health insurance. Between 1900 and 1920 there were minimal technological advances. Treatments available at the time, including surgery, were often performed in private homes.
During the 1920s and 1930s, the costs of health care rose. As the population moved from rural to urban settings, the delivery points for much of health care changed, moving from private homes to hospitals. Improved therapeutic options, more medications, the acceptance of medicine as a science, and the closure of underperforming medical schools during the 1920s increased the demand for health care and raised the associated cost (Rosenberg, 1987).
As hospitals began to expand and organize, they formed the American Hospital Association, whose leaders encouraged the development of health insurance plans. In 1929, the Committee of the Costs of Medical Care, a national group, produced a report that promoted voluntary insurance in the United States. That same year, Baylor Hospital in Dallas, Texas, joined with a local teachers’ association to provide health care for those agreeing to pay a small monthly premium. In a short time, this relationship grew to include more employers and evolved into Blue Cross (Getzen, 2013; Sparer and Thompson, 2015). Improvements in medical technology and the growing practice of employers’ offering health insurance in place of employee compensation during and after World War II further supported the expansion of private health insurance.
During the 1960s, politicians supported the development of federal and state health insurance for the poor and the elderly populations, subsequently enacting Medicare and Medicaid. As a result, since the 1970s most health care has been paid for with either public or private insurance plans. As a result of “third-party” reimbursement, costs grew steadily as much of the public paid little attention to charges because they were not directly responsible for payment. Consequently, the growth in available treatments because of improving technological advances, chronic disease associated with an aging population, and negative lifestyle choices and other factors led to a dramatic number of individuals and families who were not able to afford health care because they could not afford health insurance.
BOX 2.7 Ten Great Public Health Achievements—United States , 1900– 2010 During the twentieth century, the health and life expectancy of persons living in the United States improved dramatically. It is important for nurses to realize that of the 30 years of life expectancy gained during the century, 25 years were attributable to public health efforts. During 1999, the Centers for Disease Control and Prevention published a series of articles outlining 10 of the great public health achievements of the twentieth century. In 2011, the agency published an update of highlights from the ensuing decade. Summarized here are the “Public Health Achievements” presented:
Vaccination/vaccine-preventable diseases—Widespread vaccination programs resulted in eradication of smallpox; elimination of polio in the Americas; and control of measles, rubella, tetanus, diphtheria, and a number of other infectious diseases in the United States. In the first decade of the twenty-first century, new vaccines (e.g., rotavirus, herpes zoster, hepatitis A, and human papilloma virus) were introduced and are having a significant, positive impact on population health.
Motor vehicle safety—Improvements in motor vehicle safety contributed to large reductions in traffic deaths. Improvements included efforts to make both vehicles and highways safer and to change personal behaviors (e.g., increase use of seat belts and child safety seats, reduce driving under the influence [DUI] offenses). Between 2000 and 2009, the death rate from motor vehicle
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accidents continued to decline, largely as a result of safer vehicles, safer roads, safer road use, and related policies (e.g., graduated driver’s licenses).
Safer workplaces—Work-related health problems (e.g., coal worker’s pneumoconiosis [black lung] and silicosis) were very significantly reduced during the twentieth century, as were severe injuries and deaths related to mining, manufacturing, construction, and transportation. Following legislation in 1980, safer workplaces resulted in further reduction of 40% in the rate of fatal occupational injuries by the end of the century.
Control of infectious diseases—Since the early 1900s, control of infectious diseases has resulted from clean water and better sanitation. Cholera and typhoid were major causes of illness and death in the early twentieth century and have been virtually eliminated today. Additionally, the discovery of antimicrobial therapy has been very successful in helping efforts to control infections such as tuberculosis, sexually transmitted infections, and influenza. Much of the efforts in the last decade of the twentieth century and the first of the twenty-first century focused on prevention and treatment of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Prevention/education efforts, along with enhanced screening for HIV, early diagnosis, and effective treatment, have resulted in reduction in transmission of the virus, along with enabling access to lifesaving treatment and care for those who are HIV positive and their partners.
Decline in deaths from coronary heart disease (CHD) and stroke—Since 1972, the death rate for CHD has decreased 51%. This improvement is largely the result of risk factor modification (e.g., smoking cessation, blood pressure control) coupled with early detection and better treatment. In the last decade, CHD deaths continued to decline, going from 195/100,000 to 126/100,000. Contributing to the ongoing reduction are better control of hypertension, reduction in elevated cholesterol and smoking, and improvement in treatment and available medications.
Safer and healthier foods—Since 1900, reduction in microbial contamination and increases in nutritional content have led to safer and healthier foods. Food fortification programs and enhanced availability of nutritional options have almost eliminated major nutritional deficiency diseases in the United States.
Healthier mothers and babies—Since 1900, infant mortality in the United States has decreased 90% and maternal mortality has decreased 99%. These improvements are the result of better hygiene and nutrition, availability of antibiotics, access to better health care, and advances in maternal and neonatal medicine. During the early twenty-first century, there has been a significant reduction in the number of infants born with neural tube defects, a change attributable to mandatory folic acid fortification of cereal grain products.
Family planning—Access to family planning and contraceptives has provided women with better social and economic opportunities and health benefits, including smaller families and longer intervals between children.
Fluoridation of drinking water—Fluoridation of drinking water began in 1945, and by 1999 about half of all Americans had fluoridated water. This achievement positively and inexpensively benefited both children and adults by preventing tooth decay. Indeed, fluoridation has been credited for reducing tooth decay by 40% to 70% in children and tooth loss by 40% to 60% in adults.
Tobacco control—Recognition in 1964 that tobacco use is a health hazard resulted in behavior and policy changes that eventually led to a dramatic decline in the prevalence of smoking among adults. The rate of smoking peaked in the 1960s, and by 2009 only about 20% of adults and youths were current smokers. Health policy efforts (e.g., prohibition of smoking in worksites, restaurants, and bars), dramatic increases in cigarette taxes, and prohibition of selling to youths have contributed to much of the recent decline. Data from Centers for Disease Control and Prevention: Ten great public health achievements— United States, 1900-1999, MMWR Morb Mortal Wkly Rep 48(12):241–243, 1999; and Centers for Disease Control and Prevention: Ten great public health achievements—United States, 2001–2010, MMWR Morb Mortal Wkly Rep 60(19):619–623, 2001.
The Patient Protection and Affordable Care Act (ACA) was passed in 2010 to help reduce some of the problems associated with access to health care. After implementation, the number of uninsured dropped dramatically, but costs continued to increase and access was still problematic for some.
Changes to the ACA are anticipated, but problems with costs and access will likely persist. Indeed, considerable attention on current public health initiatives, such as the Healthy People 2020
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campaign and further health care reform, focus on ensuring elimination of disparities in health care. Box 2.7 provides a summary of some of the dramatic effects of public health activities on the health of Americans during the last 100 years. The photo novella in this chapter illustrates community health nursing in the early and mid-twentieth century.
Images of Community Health Nursing in the Early and Mid-Twentieth Century
Group Immunization. Multiracial group of women and children in a housing project mobile clinic waiting for and receiving vaccinations. Scene contains a doctor and a nurse. (1972).
Courtesy of the Centers for Disease Control and Prevention Public Health Image Library [PHIL] Image #1661. Source: CDC/ Reuel Waldrop.
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A visiting nurse outside a shack with a mother and two children. Courtesy of the U.S. National Library of Medicine, History of Medicine Division. Order No. A017986.
A public health nurse immunizes farm and migrant workers in the 1940s. Courtesy of the Library of Congress, Washington, DC.
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A public health nurse transports children to a clinic. Courtesy of MedStar Visiting Nurse Association.
A public health nurse performs health teaching. Courtesy of the Library of Congress, Washington, DC.
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A public health nurse talks to a young woman and her mother about childbirth. Courtesy of the U.S. National Library of Medicine, History of Medicine Division. Order No. A029980.
The Shanghai Mother’s Club of the Child Welfare and Maternal Health Clinic. United Nations Relief and Rehabilitation Administration (UNRRA) Public Health Nurse Irene Muir instructs Nurse S. U. Zee on child
bathing techniques. Courtesy of the U.S. National Library of Medicine, History of Medicine Division. Order No. A016681.
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Research Highlights
Example of Historical Nursing Research Fairman’s (1996) review of 150 fictional novels from 1850 to 1995 revealed how the image of nursing has changed over the past 140 years. The results showed that the image of nursing improved dramatically from the negative perception of the 1850s. Trained nurses became more common in the early 1900s, and novels began to depict strong, independent, female nurses. The positive image continued until the 1960s and 1970s, when novels presented the negative image of “bed hopping honeys.” Popular literature showed the most negative image of nurses, and classics and children’s literature showed a more positive image. Adapted from Fairman PL: Analysis of the image of nursing and nurses as portrayed in fictional literature from 1850 to 1995, San Francisco, CA, 1996, University of San Francisco Dissertation Abstracts.
Active Learning Exercise
Obtain copies of early articles from nursing journals (e.g., American Journal of Nursing dates from 1900). Discuss the health problems, medical care, and nursing practice these articles illustrated.
Collect copies of early nursing textbooks. Discuss the evolution of thoughts on pathology, illness management, and health promotion.
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Challenges for Public Health Nursing Public health nurses face the challenge of promoting the health of populations. They must accomplish this goal with a broadened understanding of the multiple causes of morbidity and mortality. The specialization of medicine and nursing has affected the delivery of nursing and health care. Well-prepared nurses must be aware of the increased technological advances that specialization has contributed to. These advances have resulted in an increase in the number of advanced practice nurses in the past several decades. It is anticipated that this growth will persist and likely expand (IOM, 2011).
The community need for a focus on prevention, health promotion, and home care may become more widespread with the changing patterns of health care cost reimbursement. Holistic care requires multiple dimensions and must have more attention in the future.
The need for education in public health nursing calls for a curriculum that prepares students to meet the needs of aggregates through population-based strategies that include an understanding of statistical data and epidemiology. Such a curriculum would move the focus from the individual to a broader population approach. Strategies would promote literacy, nutrition programs, prevention of overweight school-aged children, decent housing and income, education, and safe social and physical environments.
Health care services to individuals alone cannot solve today’s health problems. All health care workers must learn to work with and on behalf of aggregates and help them build a constituency for the consumer issues they face.
A population focus for nursing addresses the health of all in the population through the careful gathering of information and statistics. A population focus will better enable community health nurses to contribute to the ethic of social justice by emphasizing society’s responsibility for health (Beauchamp, 1986). Helping aggregates help themselves will empower people and create avenues for addressing their concerns.
Research Highlights
Example of Historical Nursing Research An in-depth examination of all of the issues from 115 years of the American Journal of Nursing was undertaken to “explore the nurse’s historical and contemporary role in promoting patient safety” (Kowalski and Anthony, 2017, p. 34). A detailed content analysis of almost 1100 articles outlined the evolution of nursing’s emphasis and interventions related to safety.
The authors described how the “safety” focus moved from asepsis and the “newly understood germ theory” in the early decades of the twentieth century to preventing medication errors in the 1930s. During and after World War II, improving patient survival rates was emphasized, and in the 1950s, attention moved to progressive patient care and various levels of care (intensive, intermediate, long-term, or home care). During the 1960s and 1970s, focus turned to the increasing complexity of care related to technology and enhanced medication regimens and the associated safety problems. Hospital-acquired infections and medication and nursing procedure safety were emphasized in the 1980s and 1990s. Since 2000, safety attention has moved to systematic factors such as communication, patient–nurse ratios, provider skill mix, and shift work.
The authors identified three major themes related to patient safety throughout the 115 years: infection prevention, medication safety, and technology response. They described the concurrent processes and procedures that were implemented to improve patient safety, but concluded that much more work is needed. Kowalski SL, Anthony M: Nursing’s evolving role in patient safety, Am J Nurs 117(2):34–50, 2017.
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Summary Western civilization evolved from the Paleolithic period to the present, and people began to live in increasingly closer proximity to one another; therefore they experienced a change in the nature of their health problems.
In the mid-nineteenth and early twentieth centuries, public health efforts and the precursors of modern and public health nursing began to improve societal health. Nursing pioneers such as Nightingale in England and Wald in the United States focused on the collection and analysis of statistical data, health care reforms, home health nursing, community empowerment, and nursing education. They established the groundwork for today’s public health nurses.
Modern public health nurses must recognize and try to understand the philosophical controversies that influence society and ultimately their practice. These controversies include different opinions about what “intervention” means—specifically in regard to “cure” vs. “care.”
Controversy also surrounds the significance of maintaining a focus on individuals, families, groups, or populations. Finally, public health nurses need to understand social determinants of health and to be part of the solution with regard to coming up with ways to address persistent health problems while addressing the critical problem of escalating health care costs.
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Evolve Website http://evolve.elsevier.com/Nies/community
• NCLEX Review Questions • Case Studies
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Centers for Disease Control and Prevention. Epidemiology of human plague in the United States, 1900-2012. Emerg Infect Dis. 2015;21(1):16–22 Available from. https://wwwnc.cdc.gov/eid/article/21/1/pdfs/14-0564.pdf.
Centers for Disease Control and Prevention. Investigation of and response to 2 plagues cases, Yosemite National Park, California, USA, 2015. Emerg Infect Dis. 2016;22(12):2045–2053 Available from. https://wwwnc.cdc.gov/eid/article/22/12/pdfs/16-0560.pdf.
Cockburn T.A. The evolution of human infectious diseases. In: Cockburn T, ed. Infectious diseases: their evolution and eradication. Springfield, IL: Charles C Thomas; 1967.
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York: Putnam; 1925. Donahue M.P. Nursing: the finest art. ed 3. St. Louis, MO: Mosby/Elsevier; 2011. Dossey B.M. Florence Nightingale: mystic, visionary, healer. Philadelphia: F.A. Davis Co; 2010. Duffus R.L. Lillian Wald: neighbor and crusader. New York: Macmillan; 1938. Fairman P.L. Analysis of the image of nursing and nurses as portrayed in fictional literature from 1850 to
1995. Dissertation Abstracts, University of San Francisco; 1996. Garn S.M. Culture and the direction of human evolution. Hum Biol. 1963;35:221–236. George M.D. London life in the XVIIIth century. New York: Knopf; 1925. Getzen T. Health economics and financing. ed 5. Hoboken, NJ: John Wiley & Sons; 2013. Goodnow M. Outlines of nursing history. Philadelphia: WB Saunders.; 1933. Greifinger R.B, Sidel V.W. American medicine: charity begins at
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MA: Jones & Bartlett; 2001. Najman J.M. Theories of disease causation and the concept of a general susceptibility: a review. Soc
Sci Med. 1990;14A:231–237. Nightingale F. Notes on matters affecting the health, efficiency and hospitalization of the British
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∗ The author would like to acknowledge the contribution of Tom H. Cook, who wrote this chapter for the previous edition.
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Thinking Upstream
Nursing Theories and Population-Focused Nursing Practice
Diane Cocozza Martins
OUTLINE
Thinking Upstream: Examining the Root Causes of Poor Health Historical Perspectives on Nursing Theory How Theory Provides Direction to Nursing Microscopic Versus Macroscopic Approaches to the Conceptualization of Community Health Problems Assessing a Theory’s Scope in Relation to Community Health Nursing Review of Theoretical Approaches
The Individual Is the Focus of Change Orem’s Self-Care Deficit Theory of Nursing The Health Belief Model
The Upstream View: Society Is the Focus of Change Milio’s Framework for Prevention Critical Theoretical Perspective
Healthy People 2020
OBJECTIVES
Upon completion of this chapter, the reader will be able to do the following: 1. Differentiate between upstream interventions, which are designed to alter the precursors of
poor health, and downstream interventions, which are characterized by efforts to modify individuals’ perceptions of health.
2. Describe different theories and their application to community/public health nursing. 3. Critique a theory with regard to its relevance to population health issues. 4. Explain how theory-based practice achieves the goals of community/public health nursing by
protecting and promoting the public’s health.
KEY TERMS conservative scope of practice
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critical interactionism critical theoretical perspective health belief model (HBM) macroscopic focus microscopic focus Milio’s framework for prevention self-care deficit theory theory upstream thinking It may seem as if many community health problems are so complex, so multifaceted, and so deep that it is impossible for a nurse to make substantial improvements in health. Although nurses see persons in whom cancer, cardiovascular disease, or pulmonary disease has just been diagnosed, we know that their diseases began years or even decades ago. In many cases, genetic risks for diseases are interwoven with social, economic, and environmental risks in ways that are difficult to understand and more difficult to change. In the face of all these challenges, how can nurses hope to affect the health of the public in a significant way? How can the actions nurses take today reduce the current burden of illness and prevent illness in the next generation of citizens?
When nurses work on a complex community health problem, they need to think strategically. They need to know where to focus their time, energy, and programmatic resources. Most likely they will be up against health problems that have existed for years, with other layers of foundational problems that may have existed for generations. If nurses use organizational resources in an unfocused manner, they will not solve the problem at hand and may create new problems along the way. If nurses do not build strong relationships with community partners (e.g., parent groups, ministers, local activists), it will be difficult to succeed. If nurses are unable to advocate for their constituencies in a scientifically responsible, logical, and persuasive manner, they may fail. In the face of these challenges and many more, how can nurses succeed in their goal to improve public health?
Fortunately, there are road maps for success. Some of those road maps can be found by reading a nursing history book or an archival work that tells the story of a nurse who succeeded in improving health by leveraging diplomacy skills or neighborhood power, such as Lillian Wald. Other road maps may be found in “success stories” that provide an overview of how a nurse approached a problem, mobilized resources, and moved strategically to promote change. This chapter addresses another road map for success: the ability to think conceptually, almost like a chess player, to formulate a plan to solve complex problems. Thinking conceptually is a subtle skill that requires you to understand the world at an abstract level, seeing the manifestations of power, oppression, justice, and access as they exist within our communities. Most of all, thinking conceptually means that you develop a “critical eye” for the community and understand how change happens at micro and macro levels.
This chapter begins with a brief overview of nursing theory, which is followed by a discussion of the scope of community health nursing in addressing population health concerns. Several theoretical approaches are compared to demonstrate how different conceptualizations can lead to different conclusions about the range of interventions available to the nurse.
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Thinking Upstream: Examining the Root Causes of Poor Health
I am standing by the shore of a swiftly flowing river and hear the cry of a drowning man. I jump into the cold waters. I fight against the strong current and force my way to the struggling man. I hold on hard and gradually pull him to shore. I lay him out on the bank and revive him with artificial respiration. Just when he begins to breathe, I hear another cry for help. I jump into the cold waters. I fight against the strong current and swim forcefully to the struggling woman. I grab hold and gradually pull her to shore. I lift her out onto the bank beside the man and work to revive her with artificial respiration. Just when she begins to breathe, I hear another cry for help. I jump into the cold waters. Fighting again against the strong current, I force my way to the struggling man. I am getting tired, so with great effort I eventually pull him to shore. I lay him out on the bank and try to revive him with artificial respiration. Just when he begins to breathe, I hear another cry for help. Near exhaustion, it occurs to me that I’m so busy jumping in, pulling them to shore, applying artificial respiration that I have no time to see who is upstream pushing them all in …(Adapted from a story told by Irving Zola as cited in McKinlay, J.B. (2012). A case for refocusing upstream: The political economy of illness. In P. Conrad & V. Leiter (Eds.), The sociology of health and illness: Critical perspectives (Ch 47, 9th ed.), New York: Worth.)
In his description of the frustrations in medical practice, McKinlay (1979) used the image of a swiftly flowing river to represent illness. In this analogy, doctors are so busy rescuing victims from the river that they fail to look upstream to see who is pushing patients into the perilous waters. Many things could cause a patient to fall (or be pushed) into the waters of illness. Refocusing upstream requires nurses to look beyond individual behavior or characteristics to what McKinlay terms the “manufacturers of illness.” McKinlay discusses factors such as tobacco products companies, companies that profit from selling products high in saturated fats, the alcoholic beverage industry, the beauty industry, exposure to environmental toxins, and occupationally induced illnesses. “Manufacturers of illness” are what push clients into the river. Cigarette companies are a good example of manufacturers of illness—their product causes a change for the worse in the health status of their consumers, and they take little to no responsibility for it. McKinlay used this analogy to illustrate the ultimate futility of “downstream endeavors,” which are characterized by short-term, individual-based interventions, and challenged health care providers to focus more of their energies “upstream, where the real problems lie” (McKinlay, 1979, p. 9). Downstream health care takes place in our emergency departments, critical care units, and many other health care settings focused on illness care. Upstream thinking actions focus on modifying economic, political, and environmental factors that are the precursors of poor health throughout the world. Although the story cites medical practice, it is equally fitting to the dilemmas of nursing practice. Nursing has a rich history of providing preventive and population-based care, but the current U.S. health system emphasizes episodic and individual-based care. Chronic diseases are responsible for 70% of American deaths each year and accounts for 86% of U.S. health care costs (Centers for Disease Control and Prevention, 2017)
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Historical Perspectives on Nursing Theory Many scholars agree that Florence Nightingale was the first nurse to formulate a conceptual foundation for nursing practice. Nightingale believed that clean water, clean linens, access to adequate sanitation, and quiet would improve health outcomes (Ali Parani, 2016). However, in the years after her leadership, nursing practice became less theoretical and was based primarily on reacting to the immediacy of patient situations and the demands of medical staff. Thus hospital and medical personnel defined the boundaries of nursing practice. Once nursing leaders saw that others were defining their profession, they became proactive in advancing the theoretical and scientific foundations of nursing practice. Some of the early nursing theories were extremely narrow and depicted health care situations that involved only one nurse and one patient. Family members and other health professionals were noticeably absent from the context of care. Historically, this characterization may have been an appropriate response to the constraints of nursing practice and the need to emphasize the medically dependent activities of the nursing profession.
Although somewhat valuable, theories that address health from a microscopic, or individual, rather than a macroscopic, or global/social, perspective have limited applicability to community/public health nursing. Such perspectives are inadequate because they do not address social, political, and environmental factors that are central to an understanding of communities. More recent advances in nursing theory development address the dynamic nature of health- sustaining and/or health-damaging environments and address the nature of a collective (e.g., school, worksite) versus an individual client.
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How Theory Provides Direction to Nursing The goal of theory is to improve nursing practice. Chinn and Kramer (2015) stated that using theories or parts of theoretical frameworks to guide practice best achieves this goal. Students often find theory intellectually burdensome and cannot see the benefits to their practice of something so seemingly obscure. Theory-based practice guides data collection and interpretation in a clear and organized manner; therefore it is easier for the nurse to diagnose and address health problems. Through the process of integrating theory and practice, the student can focus on factors that are critical to understanding the situation. The student also has an opportunity to analyze the realities of nursing practice in relation to a specific theoretical perspective, in a process of ruling in and ruling out the fit of particular concepts (Schwartz-Barcott et al., 2002). Barnum (1998) stated, “A theory is like a map of a territory as opposed to an aerial photograph. The map does not give the full terrain (i.e., the full picture); instead it picks out those parts that are important for its given purpose” (p. 1). Using a theoretical perspective to plan nursing care guides the student in assessing a nursing situation and allows the student “to plan and not get lost in the details or sidetracked in the alleys” (J. M. Swanson, personal communication to P. Butterfield, May 1992).
As with other abstract concepts, different nursing writers have defined and interpreted theory in different ways. Several writers’ definitions of theory are listed in Box 3.1. The lack of uniformity among these definitions reflects the evolution of thought and the individual differences in the understanding of relationships among theory, practice, and research. The definitions also reflect the difficult job of describing complex and diverse theories within the constraints of a single definition. Reading several definitions can foster an appreciation for the richness of theory and help the reader identify one or two particularly meaningful definitions. Within the profession, definitions of theory typically refer to a set of concepts and relational statements and the purpose of the theory. This chapter presents theoretical perspectives that are congruent with a broad interpretation of theory and correspond with the definitions proposed by Dickoff and James (1968), Torres (1986), and Chinn and Kramer (2015).
BOX 3.1 Definitions of Theory Proposed by Nursing Theorists
• “A systematic vision of reality; a set of interrelated concepts that is useful for prediction and control” (Woods and Catanzaro, 1988, p. 568).
• “A conceptual system or framework invented for some purpose; and as the purpose varies so too must the structure and complexity of the system” (Dickoff and James, 1968, p. 19).
• “A creative and rigorous structuring of ideas that projects a tentative, purposeful, and systematic view of phenomena” (Chinn & Kramer, 1999, p. 51).
• “A set of ideas, hunches, or hypotheses that provides some degree of prediction and/or explanation of the world” (Pryjmachuk, 1996, p. 679).
• “Theory organizes the relationships between the complex events that occur in a nursing situation so that we can assist human beings. Simply stated, theory provides a way of thinking about and looking at the world around us” (Torres, 1986, p. 19).
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Microscopic Versus Macroscopic Approaches to the Conceptualization of Community Health Problems Each nurse must find her or his own way of interpreting the complex forces that shape societies to understand population health. The nurse can best achieve this transformation by integrating population-based practice and theoretical perspectives to conceptualize health from a macroscopic rather than microscopic perspective. Table 3.1 differentiates between these two approaches to conceptualizing health problems.
The individual patient is the microscopic focus, whereas society or social economic factors influencing health status are the macroscopic focus. When the individual is the focus, the micro focus contains the health problem of interest (e.g., pediatric exposure to lead compounds). In this context, a microscopic approach to assessment would focus exclusively on individual children with lead poisoning. Nursing interventions would focus on the identification and treatment of the child and family. However, the nurse can broaden his or her view of this problem by addressing removal of lead sources in the home and by examining interpersonal and intercommunity factors that perpetuate lead poisoning on a national scale. A macroscopic approach to lead exposure may incorporate the following activities: examining trends in the prevalence of lead poisoning over time, estimating the percentage of older homes in a neighborhood that may contain lead pipes or lead- based paint surfaces, and locating industrial sources of lead emissions. These efforts usually involve the collaborative efforts of nurses from school, occupational, government, and community settings. Burbank and Martins (2010) discussed macro-level perspectives that provide nurses with the conceptual tools that empower clients to make health decisions on the basis of the interests of the community at large.
One common dilemma in community health practice is the tension between working on behalf of individuals and working on behalf of a population. For many nurses, this tension is exemplified by the need to reconcile and prioritize multiple daily tasks. Population-directed actions are often more global than the immediate demands of ill people; therefore they may sink to the bottom of the priority list. A community health nurse or nursing administrator may plan to spend the day on a community project directed at preventive efforts, such as screening programs, updating the surveillance program, or meeting with key community members about a specific preventive program. However, the nurse may actually end up spending the time responding to the emergency of the day. This type of reactive rather than proactive nursing practice prevents progress toward “big picture” initiatives and population-based programs. When faced with multiple demands, nurses must be vigilant in devoting a sustained effort toward population-focused projects. Daily pressures can easily distract the nurse from population-based nursing practice. Several nursing organizations focus on this population, and one organization, the Quad Council of Public Health Nursing, is composed of representatives from the following four public health/community health nursing organizations:
TABLE 3.1
Microscopic Versus Macroscopic Approaches to the Delineation of Community Health Nursing Problems
Microscopic Approach Macroscopic Approach Examines individual, and sometimes family, responses to health and illness
Examines interfamily and intercommunity themes in health and illness Delineates factors in the population that perpetuate the development of illness or foster the development of health
Often emphasizes behavioral responses to an individual’s illness or lifestyle patterns
Emphasizes social, economic, and environmental precursors of illness
Nursing interventions are often aimed at modifying an individual’s behavior by changing his or her perceptions or belief system
Nursing interventions may include modifying social or environmental variables (i.e., working to remove care barriers and improving sanitation or living conditions) May involve social or political action
• Public Health Nursing Section of the American Public Health Association (PHN-APHA) • Association of Community Health Nurse Educators (ACHNE) • Association of Public Health Nurses (APHN) • American Nurses Association Council on Nursing Practice and Economics (ANA)
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The organizations emphasize system-level thinking in practice and the importance of improving health through the design and implementation of population-based interventions (Swider, Krothe, Reyes, and Cravetz, 2013).
A theoretical focus on the individual can preclude understanding of a larger perspective. Dreher (1982) used the term conservative scope of practice in describing frameworks that focus energy exclusively on intrapatient and nurse–patient factors. She stated that such frameworks often adopt psychological explanations of patient behavior. This mode of thinking attributes low compliance, missed appointments, and reluctant participation to problems in patient motivation or attitude. Nurses are responsible for altering patient attitudes toward health rather than altering the system itself, “even though such negative attitudes may well be a realistic appraisal of health care” (Dreher, 1982, p. 505). This perspective does not entertain the possibility of altering the system or empowering patients to make changes.
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Assessing a Theory’s Scope in Relation to Community Health Nursing Theoretical scope is especially important to community health nursing because there are many levels of practice within this specialty area. For example, a home health nurse who is caring for ill people after hospitalization has a very different scope of practice from that of a nurse epidemiologist or health planner. Unless a given theory is broad enough in scope to address health and the determinants of health from a population perspective, the theory will not be very useful to community health nurses. Healthy People 2020 incorporated social determinants of health in the nation’s health objectives (U.S. Department of Health and Human Services, 2017). Robert Wood Johnson Foundation addressed the need for a Culture of Health that benefits everyone to ensure all people have equal opportunities to make healthy choices, whatever their circumstances (Robert Wood Johnson, 2017). Applying the terms microscopic and macroscopic to health situations may help nurses guide and stimulate theory development in community health nursing.
Although the concept of macroscopic is similar to the upstream analogy, the term macroscopic refers to a broad scope that incorporates many variables to aid in understanding a health problem. Upstream thinking would fall within this domain. Viewing a problem from this perspective emphasizes the variables that precede or play a role in the development of health problems. Macroscopic is the broad concept, and upstream is a more specific concept. These related concepts and their meanings can help nurses develop a critical eye in evaluating a theory’s relevance to population health.
Active Learning Exercise
Review the ANA’s definition of community health nursing practice and the APHA’s definition of public health nursing practice. What do these definitions indicate about the theoretical basis of community health nursing? How does the theoretical basis of community health nursing practice differ from that of other nursing specialty areas?
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Review of Theoretical Approaches The differences among theoretical approaches demonstrate how a nurse may draw very diverse conclusions about the reasons for client behavior and the range of available interventions. The following section uses two theories to exemplify individual microscopic approaches to community health nursing problems; one originates within nursing and one is based in social psychology. Two other theories demonstrate the examination of nursing problems from a macroscopic perspective; one originates from nursing and another has roots in phenomenology.
The format for this review is as follows:
1. The individual is the focus of change (i.e., microscopic). a. Orem’s self-care deficit theory of nursing b. The health belief model (HBM)
FIG. 3.1 Variables and relationships in the health belief model (HBM). Redrawn from Rosenstock IM: Historical origins of the health belief model. In Becker MH, editor: The health belief model and personal health behavior, Thorofare, NJ, 1974, Charles B. Slack.
2. Thinking upstream: Society is the focus of change (i.e., macroscopic). a. Milio’s framework for prevention b. Critical social theory perspective
The Individual Is the Focus of Change Orem’s Self-Care Deficit Theory of Nursing In 1958, Dorothea Orem, a staff and private duty nurse who later became a faculty member at Catholic University of America, began to formalize her insights about the purpose of nursing activities and why individuals required nursing care (Berbiglia and Banfield, 2014; Fawcett, 2001). Her theory is based on the assumption that self-care needs and activities are the primary focus of nursing practice. Orem outlined her self-care deficit theory of nursing and stated that this general theory is actually a composite of the following related constructs: the theory of self-care deficits, which provides criteria for identifying those who need nursing; the theory of self-care, which explains self-care and why it is necessary; and the theory of nursing systems, which specifies nursing’s role in the delivery of care and how nursing helps people (Orem, 2001).
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Application of Self-Care Deficit Theory During a discussion about theory-based initiatives, a British occupational health nurse lamented over her nursing supervisor’s intention to adopt Orem’s self-care deficit theory. She was frustrated and argued that much of the model’s assumptions seemed incongruous with the realities of her daily practice. Kennedy (1989) maintained that the self-care deficit theory assumes that people are able to exert purposeful control over their environments in the pursuit of health; however, people may have little control over the physical or social aspects of their work environment. On the basis of this thesis, she concluded that the self-care model is incompatible with the practice domain of occupational health nursing.
The Health Belief Model The second theory that focuses on the individual as the locus of change is the health belief model (HBM). The model evolved from the premise that the world of the perceiver determines action. The model had its inception during the late 1950s, when America was breathing a collective sigh of relief after the development of the polio vaccine. When some people chose not to bring themselves or their children into clinics for immunization, social psychologists and other public health workers recognized the need to develop a more complete understanding of factors that influence preventive health behaviors. Their efforts resulted in the HBM.
Kurt Lewin’s work lent itself to the model’s core dimensions. He proposed that behavior is based on current dynamics confronting an individual rather than prior experience (Maiman and Becker, 1974). Fig. 3.1 outlines the variables and relationships in the HBM. The HBM is based on the assumption that the major determinant of preventive health behavior is disease avoidance. The concept of disease avoidance includes perceived susceptibility to disease “X,” perceived seriousness of disease “X,” modifying factors, cues to action, perceived benefits minus perceived barriers to preventive health action, perceived threat of disease “X,” and the likelihood of taking a recommended health action. Disease “X” represents a particular disorder that a health action may prevent. It is important to note that actions that relate to breast cancer will be different from those relating to measles. For example, in breast cancer, a cue to action may involve a public service advertisement encouraging women to make an appointment for a mammogram. However, for measles, a cue to action may be news of a measles outbreak in a neighboring town.
Application of the Health Belief Model Over the years, a number of writers have proposed broadening the scope of the HBM to address health promotion and illness behaviors (Kirscht, 1974; Pender, 1987) and to merge its concepts with other theories that describe health behavior (Cummings et al., 1980). The following section contains a brief personal account of the author’s perceptions addressing the strengths and limitations of the model.
During my nursing education classes at the undergraduate level, I was exposed to a large number of nursing theories. The HBM was probably my least favorite. Most of the content was interesting, but I found it difficult applying the concepts to patients in the community and home settings. The model’s focus on compliance was something that nurses with a critical theoretical perspective would have difficulty applying in their own clinical practice. My perception of the model changed a few years ago when my younger brother had pancreatic cancer diagnosed. This experience allowed me to see how the HBM could offer some insight into an individual’s health behaviors. It helped me organize ideas about why people choose to accept or reject the instructions of well-intended nurses and doctors. Concepts such as perceived seriousness, perceived susceptibility, and cue to action afforded new insights into the dynamics of health decision making. I began to apply the model’s concepts to guide my work with my family. My brother who became ill had smoked much of his life. Another brother also smoked. My family members believed that you are destined to follow a path of life and death, but this experience clearly modified their health beliefs. Until this point, my family members did not quit smoking because they did not perceive the susceptibility and seriousness of smoking; they belonged to a reference group that disdained most traditional medical practices and favored inaction over action. During the next several weeks, my siblings requested information on strategies that would help them quit smoking and hopefully decrease their chances for the development of cancer.
Over the years, I have become more skilled in assessing and identifying patient needs and issues and have gained a better appreciation for the strengths and limitations that any theoretical
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framework imposes on a situation.
Limitations of the HBM The HBM places the burden of action exclusively on the client. It assumes that only those clients who have negative perceptions of the specified disease or recommended health action will fail to act. In practice, this model focuses the nurse’s energies on interventions designed to modify the client’s distorted perceptions.
The HBM offers an explanation of health behaviors that is similar to a mechanical system. Consulting the HBM, a nurse may induce compliance by using model variables as catalysts to stimulate action. For example, an intervention study based on HBM precepts sought to improve follow-up in clients with hypertension by increasing their perceived susceptibility to and seriousness of the dangers of hypertension (Jones et al., 1987). The study provided patients with education over the telephone or in the emergency department and resulted in a dramatic increase in compliance. However, the researchers noted that several patient groups, in particular, a group of patients without child care, failed to respond to the intervention. Studies such as these demonstrate the predictive abilities and the limitations of HBM concepts (Lajunen and Rasanen, 2004; Lin et al., 2005; Mirotznik et al., 1998). The HBM was used for tobacco cessation health education by improving the knowledge, attitudes, and behaviors of tobacco users (Renuka and Pushpanjali, 2014).
The HBM may effectively promote behavioral change by altering patients’ perspectives, but it does not acknowledge the health professional’s responsibility to reduce or ameliorate health care barriers. The model reflects the type of theoretical perspective that dominated nursing education and behavioral health for many years. The narrow scope of the model is its strength and its limitation: nurses are not challenged to examine the root causes of health opportunities and behaviors in the communities we serve.
The Upstream View: Society Is the Focus of Change Milio’s Framework for Prevention Nancy Milio conducted extensive research on tobacco policy (1985). Milio’s approach to advancing people’s health is seen in her seminal book, Promoting Health through Public Policy, and through her detailed studies of tobacco policy and Norwegian farm food policy (Draper, 1986). Milio’s framework for prevention (1976) provides a complement to the HBM and a mechanism for directing attention upstream and examining opportunities for nursing intervention at the population level. Nancy Milio outlined six propositions that relate an individual’s ability to improve healthful behavior to a society’s ability to provide accessible and socially affirming options for healthy choices. Milio used these propositions to move the focus of attention upstream by challenging the notion that a main determinant for unhealthful behavior choice is lack of knowledge. She said that government and institutional policies set the range of health options, so community health nursing needs to examine a community’s level of health and attempt to influence it through public policy. She noted that the range of available health choices is critical in shaping a society’s overall health status. Milio believed that national-level policy making was the best way to favorably affect the health of most Americans rather than concentrating efforts on imparting information in an effort to change individual patterns of behavior.
Milio (1976) proposed that health deficits often result from an imbalance between a population’s health needs and its health-sustaining resources. She stated that the diseases associated with excess (e.g., obesity and alcoholism) afflict affluent societies and that the diseases resulting from inadequate or unsafe food, shelter, and water afflict the poor. Within this context, the poor in affluent societies may experience the least desirable combination of factors. Milio (1976) cited the socioeconomic realities that deprive many Americans of a health-sustaining environment despite the fact that “cigarettes, sucrose, pollutants, and tensions are readily available to the poor” (p. 436). Propositions proposed by Milio are listed in Table 3.2.
Personal and societal resources affect the range of health-promoting or health-damaging choices available to individuals. Personal resources include the individual’s awareness, knowledge, and beliefs and the beliefs of the individual’s family and friends. Money, time, and the urgency of other priorities are also personal resources. Community and national locale strongly influence societal resources. These resources include the availability and cost of health services, environmental
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protection, safe shelter, and the penalties or rewards for failure to select the given options.
TABLE 3.2
Application of Milio’s Framework in Public Health Nursing
Milio’s Proposition Summary Population Health Examples Population health results from deprivation and/or excess of critical health resources.
Individuals and families living in poverty have poorer health status compared with middle- and upper-class individuals and families.
Behaviors of populations result from selection from limited choices; these arise from actual and perceived options available, as well as beliefs and expectations resulting from socialization, education, and experience.
Positive and negative lifestyle choices (e.g., smoking, alcohol use, safe sex practices, regular exercise, diet/nutrition, seatbelt use) are strongly dependent on culture, socioeconomic status, and educational level.
Organizational decisions and policies (both governmental and nongovernmental) dictate many of the options available to individuals and populations and influence choices.
Health insurance coverage and availability are largely determined and financed by federal and state governments (e.g., Medicare and Medicaid) and employers (e.g., private insurance); the source and funding of insurance very strongly influence health provider choices and services.
Individual choices related to health-promoting or health-damaging behaviors are influenced by efforts to maximize valued resources.
Choices and behaviors of individuals are strongly influenced by desires, values, and beliefs. For example, the use of barrier protection during sex by adolescents is often dependent on peer pressure and the need for acceptance, love, and belonging.
Alteration in patterns of behavior resulting from decision making of a significant number of people in a population can result in social change.
Some behaviors, such as tobacco use, have become difficult to maintain in many settings or situations in response to organizational and public policy mandates. As a result, tobacco use in the United States has dropped dramatically.
Without concurrent availability of alternative health-promoting options for investment of personal resources, health education will be largely ineffective in changing behavior patterns.
Addressing persistent health problems (e.g., overweight/obesity) is hindered because most people are very aware of what causes the problem, but are reluctant to make lifestyle changes to prevent or reverse the condition. Often, “new” information (e.g., a new diet) or resources (e.g., a new medication) can assist in attracting attention and directing positive behavior changes.
Adapted from Milio N: A framework for prevention: changing health-damaging to health- generating life patterns, American Journal of Public Health 66:435–439, 1976.
Milio (1976) challenged health education’s assumption that knowledge of health-generating behaviors implies an act in accordance with that knowledge. She proposed that “most human beings, professional or nonprofessional, provider or consumer, make the easiest choices available to them most of the time” (p. 435). Health-promoting choices must be more readily available and less costly than health-damaging options for individuals to gain health and for society to improve health status. Milio’s framework can enable a nurse to reframe this view by understanding the historical play of social forces that have limited the choices available to the parties involved.
Comparison of the HBM and Milio’s Conceptualizations of Health Milio’s health resources bear some resemblance to the concepts in the HBM. The purpose of the HBM is to provide the nurse with an understanding of the dynamics of personal health behaviors. The HBM specifies broader contextual variables, such as the constraints of the health care system, and their influence on the individual’s decision-making processes. The HBM also assumes that each person has unlimited access to health resources and free will. In contrast, Milio based her framework on an assessment of community resources and their availability to individuals. By assessing such factors up front, the nurse is able to gain a more thorough understanding of the resources people actually have. Milio offered a different set of insights into the health behavior arena by proposing that many low-income individuals are acting within the constraints of their limited resources. bibthermore, she investigated beyond downstream focus and population health by examining the choices of significant numbers of people within a population.
Compared with the HBM, Milio’s framework provides for the inclusion of economic, political, and environmental health determinants; therefore the nurse is given broader range in the diagnosis and interpretation of health problems. Whereas the HBM allows only two possible outcomes (i.e., “acts” or “fails to act” according to the recommended health action), Milio’s framework encourages the nurse to understand health behaviors in the context of their societal milieu.
Implications of Milio’s Framework for Current Health Delivery Systems Through its broader scope, Milio’s model provides direction for nursing interventions at many levels. Nurses may use this model to assess the personal and societal resources of individual patients and to analyze social and economic factors that may inhibit healthy choices in populations. Population-based interventions may include such diverse activities as working to improve the
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nutritional content of school lunches and encouraging political activity on behalf of health care reform (Hobbs et al., 2004; Milio, 1981).
Overall, current health care delivery systems perform best when responding to people with diagnostic-intensive and acute illnesses. Those people who experience chronic debilitation or have less intriguing diagnoses generally fare worse in the health care system despite efforts by community- and home-based care to “fill the gaps.” Nurses in both hospital and community-based systems often feel constrained by profound financial and service restrictions imposed by third-party payers. These third parties often terminate nursing care after the resolution of the latest immediate health crisis and fail to cover care aimed toward long-term health improvements. Many health systems use nursing standards and reimbursement mechanisms that originate from a narrow, compartmentalized view of health.
TABLE 3.3
Comparison of Individual and Societal Levels of Change
Personal behavior patterns are not simply “free” choices about “lifestyle” that are isolated from their personal and economic context. Lifestyles are patterns of choices made from available alternatives according to people’s socioeconomic circumstances and how easily they are able to choose some over others (Milio, 1981). It is therefore imperative to practice nursing from a broader understanding of health, illness, and suffering. Public health nurses must often work at both the individual and societal levels. As Milio suggested, it is not only individual behaviors but the economic context as well. This can be seen in Table 3.3, which shows that the focus of change can be at the individual or society level.
Critical Theoretical Perspective Similar to Milio’s framework for prevention, critical theoretical perspective uses societal awareness to expose social inequalities that keep people from reaching their full potential. This perspective is devised from the belief that social meanings structure life through social domination. “A critical perspective can be used to understand the linkages between the health care system and the broader political, economic, and social systems of society” (Waitzkin, 1983, p. 5). According to Navarro (1976), in Medicine Under Capitalism, the health care system mirrors the class structure of the broader society. According to Conrad and Leiter (2012), a critical theoretical perspective is one that does not regard the present structure of health care as sacred. A critical theoretical perspective accepts no truth or fact merely because it has been accepted as such in the past. The social aspects of health and illness are too complex to use only one perspective. The critical theoretical perspective assumes that health and illness entail societal and personal values and that these values have to be made explicit if illness and health care problems are to be satisfactorily dealt with. This perspective is informed by the following values and assumptions:
• The problems and inequalities of health and health care are connected to the particular historically located social arrangements and the cultural values of society.
• Health care should be oriented toward the prevention of disease and illness. • The priorities of any health care system should be based on the needs of the
clients/population and not the health care providers. • Ultimately, society itself must be changed for health and medical care to improve (Conrad
and Leiter, 2012).
Stevens and Hall (1992) used critical theoretical perspective in nursing to address unsafe
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neighborhoods as well as economic, political, and social disadvantages of the communities we serve. They advocate for emancipator nursing actions for our communities. Proponents of this theoretical approach maintain that social exchanges that are not distorted by power imbalances will stimulate the evolution of a more just society (Allen et al., 1986). Critical theoretical perspective assumes that truth standards are socially determined and that no form of scientific inquiry is value free. Allen and colleagues (1986) stated, “One cannot separate theory and value, as the empiricist claims. Every theory is penetrated by value interests” (p. 34).
Application of Critical Theoretical Perspective Critical theory has been applied to nursing in communities (Stevens and Hall, 1992). Application of a critical theoretical perspective can be seen when health care is used as a form of social control. The social control function in health care is used to get patients to adhere to norms of appropriate behavior. This is accomplished through the medicalization of a wide range of psychological and socioeconomic issues. Medicalization is identification or categorization of (a condition or behavior) as being a disorder requiring medical treatment or intervention. Examples include medicalization related to sexuality, family life, aging, learning disabilities, and dying (Conrad, 1975, 1992; Zola, 1972). Medicalization can incorporate many facets of health and illness care, from childbirth and allergies to hyperactivity and hospitals that have become dominated by the medical profession and its explanation of health and illness. When social problems are medicalized, there is often profit to be made. This can be seen when a patient readily receives a prescription for a medication before the root social cause of the illness is addressed by the health care provider. Using medical treatments for “undesirable behavior” has been implemented throughout history, including lobectomies for mental illness and synthetic stimulants for classroom behavior problems.
In this context, the nurse may examine how the concepts of power and empowerment influence access to quality child care (Kuokkanen and Leino-Kilpi, 2000). The nurse may contrast an organization’s policies with interviews from workers who believe the organization is an impediment to achieving quality child care. Data analysis may also include an examination of the interests of workers and administration in promoting social change versus maintaining the status quo.
FIG. 3.2 McKinlay’s model of continuum of health behaviors and corresponding interventions foci applied to tobacco use.
Data from McKinlay J: A case for refocusing upstream: the political economy of illness. In Gartley J, editor: Patients, physicians and illness: a sourcebook in behavioral science and health, New York, 1979, Free
Press, pp 9–25.
Wild (1993) used critical social theory to analyze the social, political, and economic conditions associated with the cost of prescription analgesics and the corresponding financial burden of clients who require these medications. Wild compared the trends in pharmaceutical pricing with the inflation rates of other commodities. The study stated that pharmaceutical sales techniques, which market directly to physicians, distance the needs of ill clients from the pharmaceutical industry. Wild’s analysis specified nursing actions that a downstream analysis would not consider, such as challenging pricing policies on behalf of client groups.
Challenging Assumptions about Preventive Health Through Critical Theoretical Perspective The HBM and Milio’s prevention model focus on personal health behaviors from a disease avoidance or preventive health perspective; nurses may also analyze this phenomenon using critical social theory. Again, McKinlay’s upstream analogy refers to health workers who were so busy fishing sick people out of the river that they did not look upstream to see how they were ending up
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in the water. Later in the same article, McKinlay (1979) used his upstream analogy to ask the rhetorical question, “How preventive is prevention?” (p. 22). He used this tactic to critically examine different intervention strategies aimed at enhancing preventive behavior. Fig. 3.2 illustrates McKinlay’s model, which contrasts the different modes of prevention. He linked health professionals’ curative and lifestyle modification interventions to a downstream conceptualization of health; the majority of alleged preventive actions fail to alter the process of illness at its origin. Political-economic interventions remain the most effective way to address population determinants of health and to ameliorate illness at its source.
McKinlay (1979) delineated the activities of the “manufacturers of illness—those individuals, interest groups, and organizations which, in addition to producing material goods and services, also produce, as an inevitable by-product, widespread morbidity and mortality” (pp. 9, 10). The manufacturers of illness embed desired behaviors in the dominant cultural norm and thus foster the habituation of high-risk behavior in the population. Unhealthy consumption patterns are integrated into everyday lives; for example, the American holiday dinner table offers concrete examples of “the binding of at-riskness to culture” (p. 12). The existing U.S. health care system, in a misguided attempt to help, devotes its efforts to changing the products of the illness manufacturers and neglects the processes that create the products. Manufacturers of illness include the tobacco industry, the alcohol industry, and multiple corporations that produce environmental carcinogens.
Waitzkin (1983) continued this theme by asserting that the health care system’s emphasis on lifestyle diverts attention from important sources of illness in the capitalist industrial environment and “it also puts the burden of health squarely on the individual rather than seeking collective solutions to health problems” (p. 664). Salmon (1987) supported this position by noting that the basic tenets of Western medicine promote an understanding of individual health and illness factors and obscure the exploration of their social and economic roots. He stated that critical social theory “can aid in uncovering larger dimensions impacting health that are usually unseen or misrepresented by ideological biases. Thus the social reality of health conditions can be both understood and changed” (p. 75).
In the past decade, a critical theoretical perspective has been used with symbolic interactionism, a theory that focuses predominantly on the individual and the meaning of situations. Critical interactionism brings the two theories together to address some issues at both upstream and downstream levels to make health care system changes (Burbank and Martins, 2010; Martins and Burbank, 2011). Nurses can use both upstream and downstream approaches to address health issues through critical interactionism (Table 3.4).
Nurses in all practice settings face the challenge of understanding and responding to collective health within the context of a health system that allocates resources at the individual level. The Tavistock Group (1999) released a set of ethical principles that summarizes this juxtaposition by noting that “the care of individuals is at the center of health care delivery, but must be viewed and practiced within the overall context of continuing work to generate the greatest possible health gains for groups and populations” (pp. 2, 3). This perspective is an accurate reflection of Western- oriented thought, which generally gives individual health precedence over collective health. Although nurses can appreciate the concept of individual care at the center of health delivery, they should also consider transposing this principle. Doing so allows the nurse to consider a health care system that places the community in the center of health care and holds the goal of generating health gains for individuals. Fortunately, these worldviews of health delivery systems are not mutually exclusive, and nurses can understand the duality of health care needs in individuals and populations.
TABLE 3.4
Critical Interactionism: Comparison of Upstream and Downstream Focuses
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Data from Martins DC, Burbank P: Critical interactionism: an upstream-downstream approach to health care reform, Advances in Nursing Science 34(4):315–329, 2011.
Active Learning Exercise
• Select a theory or conceptual model. Evaluate its potential for understanding health in individuals, families, a population of 400 children in an elementary school, a community of 50,000 residents, and 2000 workers within a corporate setting.
• Identify one health problem (e.g., substance abuse, domestic violence, or cardiovascular disease) that is prevalent in the community or city. Analyze the problem using two different theories or conceptual models. One should emphasize individual determinants of health, and another should emphasize population determinants of health. What are some differences in the way these different perspectives inform nursing practice?
Ethical Insights Social Injustice in Community-Based Practice Chafey (1996) refers to “putting justice to work in community-based practice” and notes that nursing has a rich historical legacy in social justice activities. Although social justice activities are alive and well in nursing practice, many leaders think that the continuing struggle for resources is taking its toll on the scope of social action within community health systems. In addition, the policies of the current federal administration often emphasize market justice values over social justice values. Market justice refers to the principle that people are entitled to valued ends (e.g., status, income) when they acquire them through fair rules of entitlement. In contrast, social justice refers to the principle that all citizens bear equitably in the benefits and burdens of society (Drevdahl et al., 2001). These are complex concepts that cannot be easily distilled into a clear set of rules or nursing policies. However, in the context of community health nursing, health (and consequently health care) is considered a right rather than a privilege. To the extent that certain citizens, by virtue of their income, race, health needs, or any other attribute, are unable to access health care, our society as a whole suffers. Nurses are well positioned to “stand on the shoulders” of yesterday’s nursing leaders and act on behalf of justice in health care access for all citizens.
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Healthy People 2020 Healthy People 2020 clearly moved to the population level with the addition of social determinants of health. This area was designed to identify ways to create social and physical environments that promote good health for all. All Americans deserve an equal opportunity to make the choices that lead to good health. But to ensure that all Americans have that opportunity, advances are needed not only in health care but also in fields such as education, child care, housing, business, law, media, community planning, transportation, and agriculture. Making these advances would involve working together to (1) explore how programs, practices, and policies in these areas affect the health of individuals, families, and communities; (2) establish common goals, complementary roles, and ongoing constructive relationships between the health sector and these areas; and (3) maximize opportunities for collaboration among federal-, state-, and local-level partners related to social determinants of health (U.S. Department of Health and Human Services, 2017).
The pictures in this chapter’s photo novella present environmental health issues and efforts being taken by nurses to address them.
Nurses Work in Environmental Health in a Variety of Ways
Open mine waste in the rural West can pose a continuing threat to local citizens. Nurses have been involved in advocacy efforts to ensure that citizens receive periodic screening for exposure to lead. Nurses
can be active in policy efforts to prevent environmental disasters in the future.
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A public health nurse inspects the site of an asphalt spill off a rural railway car. Hazardous materials spills often occur in remote areas away from health care services. Broad conceptual frameworks allow nurses to
think upstream and incorporate environmental risks into the consideration of community health issues.
A public health nurse teaches a class on environmental health for local nurses. Environmental health is an important part of community health nursing’s expanding practice.
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Citizens can be unaware of biological and chemical contaminants in their drinking water. Nurses are playing more active roles in water testing and in communicating the results of such tests to community
members. When health is conceptualized broadly, nurses understand and view risk in new ways.
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A nurse practitioner reviews educational materials addressing occupational and environmental health risks. By providing guidance for her clients, she is working to reduce risks and empower her clients to
reduce their personal and community-based risks.
Research Highlights
Assessment of Hunger with the Homeless Populations This study examined the relationship between nutritional status, food insecurity, and health risk among the population experiencing homelessness in Rhode Island (RI). A correlational study used a sample of 319 adults experiencing homelessness surveyed for access to emergency foods, shelters, and Supplemental Nutrition Assistance Program (SNAP). Participants completed a U.S. Department of Agriculture Food Security Module subset. Anthropometric measures included height, weight, and waist circumference. A 24-hour food diary was also collected. Findings indicated that participants had insufficient vegetables, fruit, dairy, and meat/beans but they had excessive amounts of fats. Almost 70% were overweight or obese. Ninety-four percent were food insecure, with 64% of this subset experiencing hunger. Only 55% were currently receiving SNAP benefits. Participants expressed concern about having no kitchen or ability to store or prepare food with their SNAP benefit.
The study results led to policy change in RI. The SNAP was expanded to include a Restaurant Meals Program so that the homeless, elderly, and disabled could use their SNAP benefits for prepared foods. This is now utilized across the state. Adapted from Martins DC., et al.: Assessment of food intake, obesity and health risk among the homeless in Rhode Island, Public Health Nursing 32(5):453–461, 2015.
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Summary Nursing and health service literature often focuses on health care access issues. This topic is interesting because tremendous disparities for access exist between insured and uninsured people in the United States. Access to care is associated with economic, social, and political factors, and, depending on individual and population needs, it can be a primary determinant of health status and survival. Structural variables, such as race-ethnicity, educational status, gender, and income, may be highly predictive of health status. These types of factors, which are also strongly grounded in the sociopolitical and economic milieu, identify risk factors for poor health and opportunities for community-based interventions.
Community health nurses have been instrumental in making many of the lifesaving advances in sanitation, communicable diseases, and environmental conditions that today’s society takes for granted. Community health practice helps develop a broad context of nursing practice, because community environments are inherently less restrictive than hospital settings. Clarke and Cody (1994) compared the environmental characteristics in community-based settings with those in hospital-based settings. They proposed that the dynamic nature of community settings lends itself best to the education of professional nurses.
In a discussion addressing the future of community health nursing, Bellack (1998) differentiates between “nursing in the community” and “nursing with the community.” This subtle reframing of the nursing role reinforces the notion that the health agenda originates from natural leaders, church members, local officials, parents, children, teens, and other community members. Forming and advancing a shared vision of health can be a formidable challenge for the nurse; as with any other complex issue, multiple viewpoints are the norm. Even “naming” health problems can be difficult, because different constituents are likely to see issues differently and pursue different lines of reasoning. However, allowing the genesis of change to occur from within the community is the essential challenge of nursing with the community. “Nursing with the community” efforts allow the nurse to create agendas that arise from community members rather than those imposed on community members. Listening, being patient, providing accurate and scientifically sound information, and respecting the experiences of community members are essential to the success of these efforts.
The nursing profession has advanced and with it so has the need to develop nursing theories that formalize the scientific base of community health nursing. The richness of community health nursing comes from the challenge of conceptualizing and implementing strategies that will enhance the health of many people. Likewise, nurses in this practice area must have access to theoretical perspectives that address the social, political, and environmental determinants of population health. The integration of population-based theory with practice gives nurses the means to favorably affect the health of the global community.
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Evolve Website http://evolve.elsevier.com/Nies/community
• NCLEX Review Questions • Case Studies
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Health Promotion and Risk Reduction Bridgette Crotwell Pullis, and Mary A. Nies
OUTLINE
Health Promotion and Community Health Nursing Healthy People 2020
Determinants of Health Theories in Health Promotion
Pender’s Health Promotion Model The Health Belief Model The Transtheoretical Model
The Transtheoretical Model and Change Theory of Reasoned Action
Risk and Health The Relationship of Risk to Health and Health Promotion Activities
Tobacco and Health Risk Alcohol Consumption and Health Diet and Health Physical Activity and Health Sleep
OBJECTIVES
Upon completion of this chapter, the reader will be able to do the following: 1. Discuss various theories of health promotion, including Pender’s Health Promotion Model, the
Health Belief Model, the Transtheoretical Theory, and the Theory of Reasoned Action. 2. Discuss definitions of health. 3. Demonstrate an understanding of the difference between health promotion and health
protection. 4. Define risk. 5. Discuss the relationship of risk to health and health promotion activities. 6. Demonstrate an understanding of stratification of risk factors by age, race, and gender. 7. Discuss the influence of various factors on health. 8. List health behaviors for health promotion and disease prevention. 9. Relate the clinical implications of health promotion activities.
KEY TERMS
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determinants of health health health promotion health protection portion distortion risk risk communication risk reduction
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Health Promotion and Community Health Nursing Since its inception, nursing has focused on helping individuals, groups, and communities maintain and protect their health. Florence Nightingale and other nursing pioneers recognized the importance of nutrition, rest, and hygiene in maximizing and protecting one’s state of health. Though people are responsible for their health and medical care, they often seek advice from nurses in the community regarding health promotion and to help them make sense of the many, often competing recommendations that appear daily on TV, online, and in newspapers and magazines.
Green and Kreuter (1991) define health promotion as “any combination of health education and related organizational, economic, and environmental supports for behavior of individuals, groups, or communities conducive to health” (p. 2). Parse (1990) states that health promotion is that which is motivated by the desire to increase well-being and to reach the best possible health potential. This chapter’s photo novella provides some examples of nurses engaging in health promotion.
Health Promotion in the Community
Elementary school screening: A nursing student takes height and weight measurements, which serve as a baseline to measure the growth rate of students.
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Elementary school screening: A nursing student securely holds the cuff as she takes this little boy’s blood pressure.
Elementary school screening: A nursing student watches and listens as she gives a hearing test.
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A Veggie Fair in the community teaches children and their parents about the benefits of eating vegetables.
Participants have fun educating children at the Veggie Fair, which will hopefully lead children and their parents to enjoy vegetables as a nutritious part of their daily diet.
Consider the clinical example about Jamie R. in Clinical Example 4.1. Jamie exemplifies this
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motivation to stay in her best health, at least at first glance. Let’s look further into Jamie’s health history.
Clinical Example 4.1 Jamie R. is a lifelong athlete. Married with three grown children, she rises at 4:20 each morning to go to the gym to swim for an hour before going to her job as an executive with a large company. A nonsmoker, Jamie rarely drinks alcohol and eats a diet consisting mostly of vegetables, grains, and fruit. Jamie’s body mass index is in the normal range, and though her cholesterol and triglyceride levels are elevated, she does not require medication for this issue. After work, Jamie and her husband relax by walking their two dogs and reading. An early riser, Jamie is in bed by 9:30 almost every night. At 50 years of age, Jamie is youthful and energetic.
We all have friends like Jamie—people who seem to have an endless amount of energy and self- discipline. The rest of us, however, are typically less successful in achieving our health promotion goals.
When it comes to health practices, Jamie is a study in contradictions. Jamie’s father had a myocardial infarction (MI) at the age of 48 years and died of an MI at the age of 50 years. Many of Jamie’s paternal relatives have died of heart disease. Jamie’s mother and one maternal aunt were each diagnosed with breast cancer in their early 50s. Though she has an annual physical examination by her family doctor and monitors her blood cholesterol and triglycerides, Jamie has never been screened for cardiac disease. Jamie receives the flu vaccine every year but has not had a tetanus-diphtheria vaccine booster in 14 years and has not had the shingles vaccine; though she sees her gynecologist yearly, she has had only one mammogram, 3 years ago.
In skipping annual mammograms and in not pursuing cardiac screening despite her high risk, Jamie is neglecting an important step in maintaining her health—health protection. Health protection consists of those behaviors in which one engages with the specific intent to prevent disease, to detect disease in the early stages, or to maximize health within the constraints of disease (Parse, 1990). Immunizations and cervical cancer screening are examples of health protection activities.
In discussing health promotion, it is helpful to define what is meant by health. One definition states that health is “being sound in body, mind, and spirit: freedom from physical disease or pain” (Merriam-Webster, 2009). As health promotion has become an important strategy to improve health, the way health is defined has shifted from a focus on the curative model to a focus on multidimensional aspects such as the social, cultural, and environmental facets of life and health (Benson, 1996). The well-known definition by the World Health Organization (WHO) states that health is “a state of complete physical, mental and social well-being, and not merely the absence of disease” (WHO, 2009). WHO also states that health is the extent to which an individual or group is able to realize aspirations, to satisfy needs, and to change or cope with the environment. In this aspect, health is viewed not only as an important goal but also as a resource for living (WHO, 1986).
Healthy People 2020 Healthy People 2020 is the health promotion initiative for the nation. Developed through a consortium and managed by the U.S. Department of Health and Human Services (USDHHS), Healthy People 2020 “challenges individuals, communities, and professionals, to take specific steps to ensure that good health, as well as long life, are enjoyed by all” (USDHHS, 2012).
The broad goals of Healthy People 2020 are to attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; achieve equity, eliminate disparities, and improve the health of all groups; create social and physical environments that promote good health for all; and promote quality of life, healthy development, and healthy behaviors across all life stages. Objectives toward achieving these goals are organized into 38 topic areas with corresponding priorities for action for each objective. Leading health indicators, or determinants of health, in each topic area help track progress toward meeting the goals of Healthy People 2020. A list of leading health indicators common to most of the topic areas is shown in Table 4.1. Fig. 4.1 illustrates the relationships among the determinants of health. The home page for Healthy People 2020 can be
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accessed at http://www.healthypeople.gov/2020/. New topic areas such as sleep health, adolescent health, dementia, and genomics have been added.
Active Learning Exercise
1. How has Healthy People changed? Get to know the Healthy People 2020 proposed objectives at www.healthypeople.gov/hp2020/objectives/TopicAreas.aspx. Read over the new objectives and compare them with the Healthy People 2010 objectives at www.healthypeople.gov/About/.
2. How did Americans do in meeting the Healthy People 2010 objectives? Choose a focus area from Healthy People 2010, and access the periodic reviews for Healthy People 2010. What are the challenges to meeting the objectives? What are the strategies for meeting the objectives? Did the objective change for Healthy People 2020?
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Determinants of Health Biology is an individual’s genetic makeup, family history, and any physical and mental health problems developed in the course of life. Aging, diet, physical activity, smoking, stress, alcohol or drug abuse, injury, violence, or a toxic or infectious agent may produce illness or disability, changing an individual’s biology.
Behaviors are the individual’s responses to internal stimuli and external conditions. Behaviors interact with biology in a common relationship, as one may influence the other. If a person chooses behaviors such as alcohol abuse or smoking, his or her biology may be changed as a result (e.g., liver cirrhosis, chronic obstructive pulmonary disease [COPD]). On the other hand, if an individual has a history of colon cancer in his or her family, the individual may choose to have regular screenings, thereby preventing advanced cancer and possibly death and changing his or her biology for the better. One’s biology may affect behavior; if a person has hypertension or diabetes, he or she may choose to begin an exercise regimen and to eat more healthfully.
TABLE 4.1
Leading Health Indicators
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From Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services: Leading health indicators touch everyone, Healthy People 2010, 2009. Retrieved from http://www.healthypeople.gov/2020/LHI/default.aspx.
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FIG. 4.1 The relationship among the determinants of health. From U.S. Department of Health and Human Services: Healthy People 2010: Understanding and
improving health, 2001. Retrieved from www.healthypeople.gov/Document/tableofcontents.htm#under.
Social environment includes interactions and relationships with family, friends, coworkers, and others in the community. Social institutions, such as law enforcement, faith communities, schools, and government agencies, are also part of the social environment, as well as housing, safety, public transportation, and availability of resources. The social environment has a great impact on the health of individuals, groups, and communities, yet it is complex in nature because of differing cultures and practices.
Physical environment is what is experienced with the senses—what is smelled, seen, touched, heard, and tasted. The physical environment can affect health negatively or positively. If there are toxic or infectious substances in the environment, this is certainly a negative influence on health. If the environment is clean with areas to recreate and play, this is a good influence on health.
Policies and interventions can have a profound effect on the health of individuals, groups, and communities. Positive effects such as policies against smoking in public places, seatbelt and child restraint laws, litter ordinances, and enhanced health care promote health. Policies are implemented at local, state, and national levels by many agencies, such as Transportation, Health and Human Services, Veterans’ Affairs, Housing, and Justice departments.
Expansion of access to quality health care is essential to decrease health disparities and to improve the quality of life and the quantity of years of healthy life (USDHHS, 2013).
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Theories in Health Promotion Health promotion activities are broad in scope and in setting. Community health nurses and their clients engage in health promotion activities in workplace settings, schools, clinics, and communities. The theories that are used most in health promotion are very diverse to accommodate the variety of settings, clients, and activities in community health. A working knowledge of theory is important in understanding why people act as they do and why they may or may not follow advice given to them by medical professionals and in helping clients progress from knowledge to behavior change. Some of the most frequently used health promotion theories and models are discussed here.
Pender’s Health Promotion Model Developed in the 1980s and revised in 1996, Pender’s Health Promotion Model (HPM) explores the myriad biopsychosocial factors that influence individuals to pursue health promotion activities. The HPM depicts the complex multidimensional factors with which people interact as they work to achieve optimum health. This model contains seven variables related to health behaviors, as well as individual characteristics that may influence a behavioral outcome.
Pender’s model does not include threat as a motivator, as threat may not be a motivating factor for clients in all age groups (Pender et al., Parsons, 2011). The HPM is depicted in Fig. 4.2.
Let’s relate the HPM to Jamie R. in Clinical Example 4.1. The experience of having relatives who died of heart disease and cancer has probably increased her desire to engage in healthful behavior. Similarly, her busy schedule and lack of communication with her doctor may be reflected in her failure to obtain screenings or immunizations. Jamie has a habit of engaging in exercise and a high self-efficacy related to her success with exercise in the past. Jamie feels better after exercise, and she receives positive comments from significant others regarding her appearance, also increasing her motivation to exercise. Jamie works out in a lovely gym and is very committed to her workout routine. Jamie has found that working out first thing in the morning minimizes the competing demands that may keep her from exercising.
The Health Belief Model Initially proposed in 1958, the Health Belief Model (HBM) provides the basis for much of the practice of health education and health promotion today. The HBM was developed by a group of social psychologists to attempt to explain why the public failed to participate in screening for tuberculosis (Hochbaum, 1958). Hochbaum and his associates had the same questions that perplex many health professionals today: Why do people who may have a disease reject health screening? Why do individuals participate in screening if it may lead to the diagnosis of disease? This research documented that information alone is rarely enough to motivate one to act. Individuals must know what to do and how to do it before they can take action. Also, the information must be related in some way to the individual’s needs. One of the most widely used conceptual frameworks in health behavior, the HBM has been used to explain behavior change and maintenance of behavior change and to guide health promotion interventions (Champion and Skinner, 2008).
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FIG. 4.2 The Health Promotion Model. From Pender, N. [2009]. The Health Promotion Model. The University of Michigan School of Nursing.
Retrieved from www.nursing.umich.edu/faculty/pender/chart.gif.
The HBM has several constructs: perceived seriousness, perceived susceptibility, perceived benefits of treatment, perceived barriers to treatment, cues to action, and self-efficacy. These components can be found in Table 4.2. All of these constructs relate to the client’s perception. How does the client perceive the seriousness of the condition? His or her susceptibility to the condition? The benefits of prevention or treatment? The barriers to prevention or treatment? The HBM is depicted in Fig. 4.3 (McEwen and Pullis, 2009).
Let’s apply the HBM to Jamie. She may not perceive that she is susceptible to heart disease or breast cancer, or she may not perceive that there is a benefit of screening, or of treatment for heart disease or cancer—thus her failure to take up screening for these diseases.
The Transtheoretical Model The Transtheoretical Model (TTM) combines several theories of intervention, giving its name. Table 4.3 lists the core constructs of the model, which also include the constructs of self-efficacy and the processes of change. The TTM is depicted in Fig. 4.4.
TABLE 4.2
Key Concepts and Definitions of the Health Belief Model
Concept Definition Perceived susceptibility One’s belief regarding the chance of getting a given condition Perceived severity One’s belief regarding the seriousness of a given condition Perceived benefits One’s belief in the ability of an advised action to reduce the health risk or seriousness of a given condition Perceived barriers One’s belief regarding the tangible and psychological costs of an advised action Cues to action Strategies or conditions in one’s environment that activate readiness to take action Self-efficacy One’s confidence in one’s ability to take action to reduce health risks
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From Janz JK, Champion VL, Stretcher VJ: The health belief model. In Glanz K, Rimer BK, Lewis FM, editors: Health behavior and health education: Theory, research, and practice, San Francisco, CA, 2002, Jossey-Bass.
FIG. 4.3 The Health Belief Model. From Becker, Maiman: Sociobehavioral determinants of compliance with health and medical care
recommendations, Medical Care 13:10, 1975.
TABLE 4.3
The Transtheoretical Model
Modified from Prochaska JO, Redding CA, & Evers KE: The transtheoretical model and stages of change. In Glanz K, Rimer B, Viswanath K, editors: Health behavior and health education: Theory, research, and practice, San Francisco, CA, 2008, Jossey-Bass, pp 97–121.
The TTM is based on the assumption that behavior change takes place over time, progressing through a sequence of stages. It also assumes that each of the stages is both stable and open to
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change. In other words, one may stop in one stage, progress to the next stage, or return to the previous stage.
The Transtheoretical Model and Change Change is difficult, even for the most motivated of individuals. People resist change for many reasons. Change may:
• Be unpleasant (exercising) • Require giving up pleasure (eating desserts or watching TV) • Be painful (insulin injections) • Be stressful (eating new foods) • Jeopardize social relationships (gatherings with friends and family that involve food) • Not seem important any more (older individuals or those with the ill effects of lifestyle
choices, such as diabetes and hypertension) • Require change in self-image (from couch potato to athlete) (Westberg and Jason, 1996).
Theory of Reasoned Action Developed by Fishbein and Ajzen, the Theory of Reasoned Action (TRA) attempts to predict a person’s intention to perform or not to perform a certain behavior (Montano and Kasprzyk, 2008). The TRA is based on the assumption that all behavior is determined by one’s behavioral intentions. These intentions are determined by one’s attitude regarding a behavior and the subjective norms associated with the behavior (Montano and Kasprzyk, 2008). One’s attitude is determined by one’s beliefs about the outcomes of performing the behavior, weighed by one’s assessment of the outcomes. Consider Jamie R. for a moment. Jamie must believe strongly that exercise will have positive results, as she rises early and takes time from her busy schedule to work out daily. Conversely, Jamie may believe strongly that routine immunizations or health screenings will have negative results.
One’s subjective norm is determined by one’s normative beliefs, or whether or not important people in one’s life approve or disapprove of the behavior under consideration, weighed by one’s motivation to comply with those important persons (Montano and Kasprzyk, 2008). If Jamie believes that her husband or children think that she should get a mammogram, and if she is motivated to comply with their wishes, Jamie will have a positive subject norm regarding getting a mammogram.
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FIG. 4.4 The Transtheoretical Model. From Prochaska J, DiClemente C: Transtheoretical therapy: Towards a more integrative model of change,
Psychotherapy: Theory, Research & Practice 19:276–288, 1982.
FIG. 4.5 The theory of reasoned action and the theory of planned behavior. From Montano DE, Kaspryzyk D: Theory of reasoned action, theory of planned behavior, and the
integrated behavioral model. In Glanz K, Rimer BK, Viswanath K, editors, Health behavior and health education, San Francisco, CA, 2008, Jossey-Bass, pp 67–96.
Recently, the variable of perceived control has been added to the TRA to account for the amount of control an individual may have over whether or not he or she performs the behavior. With the addition of perceived control, the Theory of Planned Behavior was developed (Montano and Kasprzyk, 2008). Fig. 4.5 illustrates the TRA and the Theory of Planned Behavior.
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Risk and Health Oleckno defines risk as “the probability that a specific event will occur in a given time frame” (2002, p. 352). A risk factor is an exposure that is associated with a disease (Friis and Sellers, 2004). Jamie R. has an increased risk of heart disease and cancer. Jamie’s risk factors include a family history of both of these diseases, work stress, her age, environmental exposures, and gender. There are known risk factors for some diseases, such as smoking and its association with lung cancer, as well as high blood pressure and heart disease. Some risk factors are assumed, such as cell phones and brain tumors. The three criteria for establishing a risk factor are as follows:
• The frequency of the disease varies by category, or amount of the factor. Lung cancer is more likely to develop in cigarette smokers than in nonsmokers and in those who smoke heavily than in those who smoke little.
• The risk factor must precede the onset of the disease. Cigarette smokers have lung cancer after they have been smoking for a while. If smokers had lung cancer before starting to smoke, this fact would cast doubt on smoking as a risk factor for lung cancer.
• The association of concern must not be due to any source of error. In any research study (especially one involving human behavior), there are many sources of error, such as study design, data collection methods, and data analysis. Other criteria that have been noted in the literature include strength of the association, consistency with repetition, specificity, and plausibility (Friis and Sellers, 2004).
In order to determine the health risks to individuals, groups, and populations, a risk assessment may be conducted. A risk assessment is a systematic way of distinguishing the risks posed by potentially harmful exposures. The four main steps of a risk assessment are hazard identification, risk description, exposure assessment, and risk estimation (Savitz, 1998).
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The Relationship of Risk to Health and Health Promotion Activities Health is directly related to the activities in which we participate, the food we eat, and the substances to which we are exposed daily. Where we live and work and our gender, age, and genetic makeup also affect health. In the assessment of risk regarding health and health promotion activities, there are two types of risks: modifiable risks and nonmodifiable risks. Modifiable risk factors are those aspects of a person’s health risk over which he or she has control. Examples include smoking, leading a sedentary or active lifestyle, type and amount of food eaten, and the type of activities in which he or she engages (skydiving is riskier than bowling). Nonmodifiable risk factors are those aspects of one’s health risk over which one has no or little control. Examples include genetic makeup, gender, age, and environmental exposures. A useful tool to help clients assess their family history for possible health risks is available at the U.S. Surgeon General’s website at http://www.hhs.gov/familyhistory/. This assessment is easy to use and can create a dialogue between family members to discuss family health history. As the nurse assesses the various aspects of a client’s health, it is important to evaluate behaviors that have a positive effect on the client’s health, not only those behaviors that are detrimental to health. Healthful behaviors, such as maintaining an exercise regimen and following an eating plan, build self-efficacy and self-esteem. Positive health behaviors also provide a foundation on which a nurse can build to address unhealthful behaviors. If a client has been successful at smoking cessation, the confidence and self- efficacy learned from this change can be drawn upon to help him or her stick to a low-sodium, low- fat diet to address the hypertension.
Risk reduction is a proactive process in which individuals participate in behaviors that enable them to react to actual or potential threats to their health (Pender, 1996). Risk communication is the process through which the public receives information regarding possible or actual threats to health. Risk communication is affected by the way individuals and communities perceive, process, and act on their understanding of risk (Finnigan and Vinswanath, 2008). Individuals, groups, and communities receive information on health risks from many sources besides health care professionals today. The Internet is a newer source of risk communication for many community members, with 60% of Internet users accessing it for health information (Atkinson et al., 2009). Newspapers, periodicals, radio, TV, and billboards are long-standing sources of health information in public health. Though there are many sources of information on health risks available to the public, the quality varies widely in terms of the accuracy of the information presented (Hendrick et al., 2012; Kupferberg and Protus, 2011). The use of social media to communicate with audiences has also increased among public and private entities. Chat rooms, forums, Facebook, Twitter, and many specialized websites such as Five Wishes, which offers information on advance care planning, and nutrition websites such as Eating Well provide a wide range of information. Health care professionals are endeavoring to make risk communication as personalized and specific as possible for individuals, groups, and communities in an effort to improve uptake of screening and behavior change. Research has not shown personalized risk communication to be any more effective than traditional methods of risk communication (Edwards et al., Ahmed, 2013).
Approximately 50% of annual U.S. deaths occur as a result of modifiable or lifestyle factors (McGinnis and Foege, 1993; Mokdab et al., 2004). Fig. 4.6 depicts the leading causes of death and the numbers of deaths related to each. Those causes of death with the highest mortality (heart disease, cancer, stroke, and chronic respiratory disease) are all related to lifestyle factors (McGinnis and Foege, 2004; NRC and IOM, 2015). The relationship of lifestyle factors to mortality is so strong that medical care has been found to play a minor role in preventing premature deaths. (Schroeder, 2007) Table 4.4 details the relationship of the leading causes of death and common risk factors. A 2012 study found that people adopting healthful behaviors such as exercising, eating a healthful diet, not using tobacco, and maintaining a normal weight had a 66% lower risk of death than did those who did not adopt these behaviors (Loef and Walach, 2012).
Unfortunately many people experience a clustering of unhealthy lifestyle behaviors such as poor diet, physical inactivity, obesity, and smoking. The American Heart Association has developed a useful self-assessment of cardiovascular health. Life’s Simple Seven (LS7) (http://www.heart.org/HEARTORG/Conditions/My-Life-Check---Lifes-Simple- 7_UCM_471453_Article.jsp#.WOKWg2ckq70) is based on physical activity, diet, tobacco use, body
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weight, cholesterol, blood pressure, and blood sugar. This tool uses data entered by the user to derive a score and to offer feedback on areas needing improvement.
Tobacco and Health Risk Smoking cessation is an important step in achieving optimum health. In the United States, smoking is the leading cause of preventable death, accounting for approximately one out of every five deaths, or 438,000 deaths, per year. Smoking is a causal factor in cancers of the esophagus, bladder, stomach, oral cavity, pharynx, larynx, cervix, and lung, with more than 90% of lung cancers in men and 80% of lung cancers among women attributable to smoking (Centers for Disease Control and Prevention [CDC], January 2, 2013). Smoking also has an economic impact, costing $97.2 billion annually in health care and lost productivity (American Lung Association, n.d.).
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FIG. 4.6 Leading causes of death, United States, 2014–2015. From Centers for Disease Control and Prevention, National Center for Chronic Disease: Age-adjusted death rates for the 10 leading causes of death in 2015: United States, 2014 and 2015. NCHS, National
vital statistics system, Mortality. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db267.htm.
TABLE 4.4
Relationship Between Risk Factors and 10 Leading Causes of Death
From Centers for Disease Control and Prevention. Health United States 2010. Retrieved from http://www.cdc.gov/heartdisease/statistical_reports.htm.
Most smokers are between the ages of 18 and 44 years, and more men than women smoke. In 2015, 16.7% of adult men and 13.6% of adult women were smokers. The prevalence of smoking is highest among American Indians/Alaskan Natives and Caucasians. Smoking is most common among adults who are less educated and adults who live below the poverty level. Kentucky, West Virginia, Oklahoma, and Mississippi have the highest rates of smokers, with Utah, California, and Idaho having the lowest rates (CDC, 2016). Persons with a disability smoke at a higher rate than do persons without a disability. Gay, lesbian, and bisexual adults are more likely to smoke than straight Americans (CDC, 2016).
More than 70% of current smokers report that they would like to quit smoking (CDC, n.d.). Nicotine addiction is the most common form of chemical dependence in the United States. Smokers
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who are trying to quit experience withdrawal symptoms such as anxiety, increased appetite, irritability, and difficulty concentrating. These symptoms make quitting difficult, and most people relapse several times before being able to quit successfully. Nicotine replacement, pharmaceutical alternatives, hypnosis, and acupuncture may be helpful in the attempt to quit smoking. The American Cancer Society recommends the following steps to quit smoking:
• Make the decision to quit. Any change is scary, and smoking cessation is a big change, requiring a long-term commitment.
• Set a date to quit and choose a plan. • Mark the date on your calendar. • Tell your family and friends about the date, and ask for their support. • Get rid of all tobacco products, ashtrays, and lighters in your environment. • Stock up on oral substitutes such as sugarless gum, hard candy, fruit, and carrot sticks. • Decide on a plan and prepare to implement it; register for the stop-smoking class, or see
your doctor about nicotine replacement therapy or pharmaceutical alternatives. • Practice saying “No thank you, I don’t smoke.” • Think back to your previous attempts to quit and see what worked and what did not work. • If you are taking bupropion or varenicline, take your medication each day of the week
leading up to your quit day.
Deal with withdrawal by:
• Avoiding temptation. • Changing your habits. Walk when you are stressed or during breaks. Use hard candy,
carrot sticks, or gum to satisfy the need to put something in your mouth. If you feel the urge to light up, tell yourself that you are going to wait 10 minutes before giving in. Usually, the urge will pass within that time.
• Staying off of tobacco is a lifelong process. Many former smokers state that they experienced strong desires to smoke after weeks, months, even years of smoking cessation. These unexpected cravings can be difficult to deal with.
• Remind yourself of the reasons why you quit. • Wait out the craving. There is no such thing as just one cigarette or just one puff. • Avoid alcohol. • Begin an exercise program and work on eating a healthy diet to avoid gaining weight
(American Cancer Society, 2016).
Information on quitting can be accessed at the CDC website at http://www.cdc.gov/tobacco/quit_smoking/how_to_quit/index.htm. The American Lung Association also has information on smoking cessation at http://www.lung.org/stop-smoking/. The American Cancer Society offers a quit-smoking guide at https://www.cancer.org/healthy/stay-away- from-tobacco/guide-quitting-smoking/deciding-to-quit-smoking-and-making-a-plan.html.
It is important to remember that smokers who are trying to quit smoking need support, and most families and loved ones want to help. The American Cancer Society has suggestions for supporting someone who is quitting smoking at https://www.cancer.org/healthy/stay-away-from- tobacco/helping-a-smoker-quit.html.
Teens are a population of concern regarding smoking. Though the rate of smoking has declined among Americans since the 1990s, more high school juniors and seniors smoke than do adults. Half of high school–aged smokers have tried to quit at least once. Those who start using tobacco in their teens have a harder time giving up smoking later in life. Most smokers pick up the habit at age 18, with very few initiating smoking after the age of 25 (American Cancer Society, 2012). A resource for teens who are trying to quit smoking is available at http://www.lung.org/associations/states/colorado/tobacco/not-on-tobacco/.
Only 4% to 7% of smokers are able to quit smoking on any attempt without pharmaceutical or other interventions to help them, so nurses must provide information and referrals to help clients access resources that help them to get off and to stay off tobacco.
Smokeless tobacco also poses a health threat. Commonly called spit tobacco, smokeless tobacco is a significant health threat and is not a safe substitute for smoking tobacco. Smokeless tobacco is
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known to be a cause of cancer and oral health problems. Smokeless tobacco causes nicotine addiction and dependence, and adolescents who use smokeless tobacco are more likely to take up smoking. Smoking bans may be increasing the use of smokeless tobacco as smokers use these products in settings where smoking is prohibited (CDC, 2014).
In the United States, 3% of adults use smokeless tobacco, with far more men (7%) than women (0.4%) using it. It is estimated that 6% of high school students use smokeless tobacco. Smokeless tobacco use is more common among young white males, with its heaviest use among those living in the southern or north central states and among blue collar workers, service workers, and laborers as well as the unemployed. American Indian/Alaska Natives are the heaviest users of smokeless tobacco, followed by whites. School nurses are in an important position to intervene early in the use of smokeless tobacco. Most smokeless tobacco use begins in middle school, and interventions to prevent or stop this habit are essential in the school setting (CDC, 2014).
The clinical implications of tobacco use are clear. First, community health nurses must ask about tobacco use at every clinic visit or home visit and look for teachable moments, when the client may be interested in discussing his or her tobacco habit (a respiratory illness or a scare with an oral lesion may prompt the client to reconsider the habit). Assess the client’s tobacco use: “Do you use tobacco?” “What kind of tobacco (cigarettes, cigars, chewing tobacco, pipe) do you use?” “How much do you smoke (dip, chew)?” “Have you thought about quitting?” Explore with the client why he or she may or may not have considered giving up the tobacco habit and what options are available to help should he or she desire to quit. Refer the client to smoking cessation websites or other health care professionals for assistance in quitting. Chances are great that the client is very well acquainted with the health risks posed by tobacco but not with the options for helping him or her to quit. Encourage the client to attempt to give up tobacco, and encourage him or her in any attempts to decrease or stop the use of tobacco.
Alcohol Consumption and Health Alcohol use is very common in our society. In 2010, half of Americans reported being current drinkers, with 5% reporting being heavy drinkers and 17% engaging in binge drinking. Though only 6% of the U.S. population is addicted to alcohol, about 25% of the population drinks excessively. One in five adults reported drinking five or more drinks per day. Men are more likely (63%) than women (55%) to be current drinkers and to binge drink. Men are also more than twice as likely to suffer death or injury related to drinking. Nationally, women are nearly twice as likely as men to be lifetime abstainers, yet one in two women of childbearing age drinks alcohol (NIH, 2010).
Binge drinking is an unrecognized problem among women and girls. One in five high school– aged girls and one in eight adult women reported binge drinking. The intensity and frequency of binge drinking are similar among pregnant and nonpregnant women: about three times per month and six drinks per occasion (Marchetta et al., 2012). It takes less alcohol for females to become impaired than males because of body size and differences in the way alcohol is processed by females. About 7.6% of women use alcohol while pregnant, with about 1 in 20 women using alcohol heavily before discovering that they are pregnant. For both men and women, those aged 25 to 44 years had the highest prevalence of drinking. The drinking prevalence declines at age 44 years and declines steadily with age thereafter. Non-Hispanic white people have the highest drinking prevalence, with non-Hispanic white men being the heaviest drinkers (CDC, October 16, 2016).
Alcohol use, particularly heavy alcohol use, is responsible for many health problems such as liver disease and for unintentional injuries. Excessive alcohol use is drinking more than two drinks per day on average for men or more than one drink per day for women; binge drinking is drinking five or more drinks on a single occasion for men or four or more drinks in a single occasion for women. Binge drinking is the most common form of excess alcohol use in America. Most people who binge drink are not alcohol dependent. A drink is any drink containing 0.6 ounces or 1.2 tablespoons of pure alcohol. A drink is:
• 12 ounces of beer or wine cooler • 8 ounces of malt liquor • 5 ounces of wine • 1.5 ounces of 80-proof distilled spirits or liquor (gin, rum, vodka, whiskey) (CDC, July 25,
2016)
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The Dietary Guidelines for Americans states that alcohol should be consumed in moderation—no more than one drink per day for women and no more than two drinks per day for men (USDHHS, 2015). People who should not drink are those who:
• Are less than 21 years of age • Are taking medications that can cause harmful reactions when mixed with alcohol • Are pregnant or trying to become pregnant • Are recovering from alcoholism or are unable to control the amount that they drink • Have a medical condition that may be worsened by alcohol • Are driving or planning to drive or to perform activities requiring coordination and
concentration (USDHHS, 2015)
Responsible for 80,000 deaths annually, alcohol use is the third leading lifestyle-related cause of death for the nation. In 2006 there were more than 1.2 million emergency department visits for alcohol-related conditions. The short-term risks of alcohol consumption are usually due to binge drinking or excess drinking and include risky sexual behavior, violence, unintentional injuries from motor vehicle accidents, falls, firearms, and drowning. Miscarriage or stillbirth and alcohol poisoning are also possible immediate effects of excessive alcohol use. The long-term risks of alcohol use are neurological conditions such as dementia and stroke; cardiovascular problems such as MI, hypertension, and cardiomyopathy; psychiatric problems such as depression and anxiety; social problems such as unemployment and family dysfunction; cancer of the mouth, throat, liver, and breast; and liver disease, including cirrhosis and hepatitis. Pancreatitis and gastritis are other gastrointestinal consequences of long-term alcohol consumption (CDC, July 25, 2016).
The prevalence of underage drinking declined significantly when states established the minimum legal drinking age as 21 years, and those states with more stringent drinking laws have a lower prevalence of adult and underage binge drinking. Despite age limits for legal consumption of alcohol, alcohol is the number-one used and abused drug among U.S. youth. People aged 12 to 20 drink 11% of all alcohol consumed annually in the United States, 90% of it during binge drinking. Alcohol consumption contributes to more than 43,000 deaths among underage youth annually, and 20% of youth aged 12 to 20 reported drinking alcohol in 2011. Initiation to alcohol begins early: a national report found that 33% of eighth graders had tried alcohol and 13% had drunk alcohol in the previous month. Youth who start drinking prior to age 15 are six times more likely to experience alcohol dependence or abuse than those who begin drinking at or after 21 years of age. The prevalence of adult binge drinking behavior is strongly predictive of binge drinking behavior by college students living in the same state (CDC, October 20, 2016).
Clinical implications for health promotion related to alcohol consumption emphasize prevention of underage drinking and identifying and assisting groups and individuals at risk for alcohol abuse and dependence. A helpful resource for locating and contacting local agencies for alcohol treatment is the National Drug and Alcohol Treatment Referral Routing Service, available at 1-800-662-HELP. Alcohol Screening and Brief Intervention (SBI) consists of screening for those who are at risk for excessive alcohol consumption and providing brief counseling. In trauma centers and emergency departments where SBI has been implemented, medical costs and readmissions related to alcohol have been reduced (CDC, 2015).
Preventing underage drinking is a public health priority. Enforcement of the legal drinking age, as well as enforcement of bans on sales of alcohol to minors, is an important aspect of prevention. Increased excise tax on alcoholic beverages has also been found to decrease underage drinking. Education of both adults and youth regarding alcohol and the myriad of risks posed by underage alcohol consumption must accompany enforcement efforts. The “Too Smart to Start” program targets parents and caregivers of 9- to 13-year-olds. The goal of the program is to increase the percentage of youth and their caregivers who view underage drinking unfavorably (CDC, October 17, 2016). Preventing excessive alcohol consumption must consider several prominent environmental factors:
• Alcohol is cheap. • Alcohol is readily available. • Americans are exposed to $4 billion of alcohol advertising per year. • New alcohol products cater to youthful tastes and may promote underage drinking (U.S.
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Department of Justice, 2002).
Decreasing the morbidity and mortality related to overconsumption of alcohol requires a community-wide effort to address the problem on several fronts. Youth tend to model their drinking behavior after adults, and adults are often the source of alcohol for many youth, meaning that interventions must be aimed at the population across the lifespan. Interventions supported by research include:
• Increase taxes on alcohol—a 10% increase in price results in a 7% decrease in alcohol consumption.
• Decrease alcohol outlet density—higher outlet density is associated with greater alcohol consumption and negative impacts of alcohol.
• Hold alcohol retailers responsible for harm caused by inebriated or underage drinkers.
Diet and Health Diet is one of the most modifiable of risk factors. A healthy diet contributes to the prevention of such chronic diseases as type 2 diabetes, hypertension, heart disease, and some cancers. With 17% of U.S. children 2 to 19 years and 36.5% of U.S. adults being obese (Ogden et al., 2016), diet is an important topic in health promotion. Americans are bombarded with nutrition information, and many are confused and have no idea how to apply the information regarding diet that they have received. As portion sizes get larger, Americans of all ages are spending more time engaged in inactive pursuits such as watching TV and using a computer. Commonly, the terms “portion” and “serving” are misused. A portion is the “amount of a single food item served in a single eating occasion.” A meal or a snack is a single eating occasion, with the amount of green beans or roast beef on your plate being the portion. A serving is a “standardized unit of measuring foods” used in dietary guidelines. A cup or an ounce is an example of a serving size (CDC, 2006).
What does it mean to be overweight or obese? Both of these terms are used to indicate a condition of excess weight for height. Both terms also identify ranges of weight that have been found to be associated with an increased risk of certain diseases or conditions. The body mass index (BMI) is used to determine weight status in adults and children. The BMI takes both height and weight into account and has been found to correlate well with the amount of body fat present. An adult with a BMI of 25 to 29.9 is considered overweight, and an adult with a BMI of 30 or higher is considered obese. Though there are many contributing factors to overweight and obesity, controlling one’s weight is a matter of balancing caloric intake with physical activity. Too many calories in and too few calories out eventually result in overweight. Fig. 4.7 illustrates this energy balance.
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FIG. 4.7 Caloric balance equation. From Centers for Disease Control and Prevention: Overweight and obesity: An overview, 2009. Retrieved
from www.cdc.gov/nccdphp/dnpa/obesity/contributing_factors.htm.
The rate of obesity in the United States was unchanged from 2003 to 2004 and 2011 to 2012; no state met the Healthy People 2010 goal to reduce the obesity prevalence to 15%. California, Colorado, Massachusetts, Montana, Utah, Hawaii, and the District of Columbia had the lowest prevalence rates of between 20% and 25% (CDC, April 10, 2017). Persons aged 40 to 59 are most likely to be overweight in the United States (40.2%), and obesity rates vary among races and ethnicities. Non- Hispanic black persons have the highest rates of obesity (48.1%), followed by Hispanics (42.5%), and non-Hispanic whites (34.5%) (CDC, April 10, 2017. See Fig. 4.8 for specific details on trends in obesity.
Though most obese Americans could not be classified as low income, the prevalence of obesity among women rises as income decreases, with 42% of women whose income is at or below the poverty level being obese. The prevalence of obesity among women also rises as education level decreases. Among men, there is no correlation between obesity prevalence, education, or income level.
Obesity is also a concern for children. Since 1976 the prevalence of childhood obesity has increased, with 17% of children between the ages of 2 and 19 being obese. From 1999 to 2008 there was no trend in obesity prevalence for any age group among children. There are ethnic disparities in childhood obesity, with Mexican American adolescents having a significantly higher rate of obesity (21.9%) than non-Hispanic white adolescents (14.5%).
As rates of obesity have risen, so has the cost associated with the health comorbidities of obesity. It is well known that obesity is related to the most common causes of death—heart disease, stroke, some cancers, and type 2 diabetes. In 2008, medical costs associated with obesity were estimated to be approximately $147 billion, with obese persons each costing $1429 more in medical expenditures than individuals of normal weight. It is estimated that about 27% of the increase in health care spending between 1987 and 2001 was related to obesity, and about half of this cost was paid for by Medicare and Medicaid. An obese beneficiary costs Medicare more than $600 more annually than a beneficiary of normal weight.
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FIG. 4.8 Trends in obesity among children and adolescents: United States, 1963–2008. From Ogden C, Carroll M: Prevalence of obesity among children and adolescents: United States, 1963–
1965 through 2007–2008, 2010, NCHS Health E-Stat, 2010. Retrieved from – http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.htm. Data from
CDC/NCHS, National Health Examination Surveys II [ages 6–11], III [ages 12–17] and National Health and Nutrition Examination Surveys [NHANES] I–III, and NHANES 1999–2000, 2001–2002, 2003–2004,
2005–2006, and 2007–2008.
Fats are an essential nutrient for energy and serve many purposes in the body, but too much fat in the diet, especially trans-fats, saturated fats, and cholesterol, may increase the risk of heart disease (U.S. Department of Agriculture [USDA]/USDHHS, 2010). Trans-fatty acids are deleterious to health, leading to an increased risk for heart disease and stroke. The Food and Drug Administration revoked the “generally recognized as safe” status for trans-fatty acids on June 16, 2015, and gave food manufactures until June 2018 to remove trans-fats from their products. Most trans-fats are found in fried foods, margarine, pizza, and commercially prepared baked goods such as cookies. New York City instituted restrictions on trans-fatty acids in commercial eateries beginning July 1, 2007.
In 2013, the median intake of fruits and vegetables for adults in the United States was only 1.6 times per day. Only 70% of census tracts report having retail establishments that sell healthier food within the census tract or within 1 half-mile of the census tract boundary. Though the benefits of eating a diet rich in fruits and vegetables is well known, this trend is unchanged since 1996 (USDA/USDHHS, 2013). The CDC has information on incorporating fruits and vegetables into a daily diet at https://www.cdc.gov/healthyweight/healthy_eating/index.html.
Although the same eating plan is not appropriate for everyone, the USDA does make some key recommendations regarding a healthy diet based on a 2000 calorie per day intake, as follows:
• Select 2 cups of fruit and 2½ cups of vegetables per day. Select a variety of colors and types. • Consume three or more 1-ounce-equivalent servings per day of whole-grain products. • Consume 3 cups per day of fat-free or low-fat milk or milk products. • Keep total fat intake to 20% to 35% of caloric intake. • When choosing fats, emphasize lean meats, beans, poultry, and fat-free or low-fat milk
products. • Limit intake of trans-fatty acids or saturated fats. • Choose fiber-rich fruits and vegetables often. • Prepare beverages and foods with little added sugar.
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• Consume less than 1 teaspoon of salt per day. • Consume alcoholic beverages moderately—up to one drink per day for women and two
drinks per day for men.
Special populations such as pregnant or lactating women, infants, children, older adults, athletic or very active adults, and adolescents have differing nutritional needs.
The USDA recommends that all Americans go to http://www.choosemyplate.gov/ to develop a personalized eating plan based on individual needs and preferences. My Plate (Fig. 4.9) was released in 2011, replacing the Food Guide Pyramid. This tool helps users easily translate the USDA guidelines into the kinds and amounts of food to eat each day. My Plate is applicable to children as well as adults and is simple and fun enough that children can use it themselves. My Plate illustrates a healthful eating plan in a simple and familiar format—a place setting. The key messages of My Plate are that half of the plate should be fruits and vegetables; a quarter of the plate should be grains, and half of the grains consumed daily should be whole grain; one quarter of the plate should be protein; and a serving of a low-fat or nonfat dairy product should be included in each meal. Oils, a source of essential nutrients, are also included in My Plate, with the emphasis on oils low in trans- fats. The Choose My Plate homepage at http://www.choosemyplate.gov/ contains information on eating on a budget, weight management, and a food and activity tracker to help users balance food intake with activity. Many popular foods, such as pizza and spaghetti, are mixed dishes in that they do not fit into only one food group.
FIG. 4.9 My Plate logo. From the United States Department of Agriculture. (n.d.). My Plate 2013, Retrieved from
http://www.choosemyplate.gov/print-materials-ordering/graphic-resources.html.
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Studies confirm that eating away from home is associated with an increased likelihood of being overweight (Bauer et al., 2012 Rafferty). Busy families have more opportunities to eat away from home as the number of eateries has increased in recent years. The latest findings indicate that from 1999 to 2004, American families spent 45% of their food budget on foods eaten away from home (The Keystone Center, 2006). Though parental employment is a benefit to families, the stresses of balancing family and work demands affect nutrition and the kinds of foods consumed. Families with parents who work full time spend less time on food preparation, eat fewer family meals, eat more fast food, and spend less time encouraging healthful eating behaviors (Bauer et al., 2012). Men between ages 40 and 59 years consume the most food prepared away from home (Van der Horst et al., 2011). (This author can attest to the fact that when her 53-year-old husband is left to fend for himself at mealtime, he will most likely eat out.) Adolescents also consume a large amount of fast food, with 30% of adolescent males and 27% of adolescent females reporting eating fast food at least three times per week (Bauer et al., 2009). Among adults the percentage of calories consumed from fast food rises as weight status increases, with obese adults consuming the highest percentage of their calories from fast food (Fryar and Ervin, 2013). Economics can also determine the quality of a family’s diet, with families with lower incomes having a poorer-quality diet than do families with higher incomes. Research has found that families with less money to spend on food eat diets lower in fruits and vegetables than do families who have more money to spend on food (Rehm et al., 2015).
Portions served in restaurants are larger than portions served at home, in some cases up to 40% larger. Convenience foods and prepackaged foods contain larger portion sizes than in the 1970s. When presented with a large portion size, individuals often unknowingly eat larger amounts than they would usually eat or than they intend to eat. This phenomenon, called portion distortion, occurs frequently when people are dining out (NHLBI, 2013). Portion control is an important aspect of weight management, and distortion of portion sizes makes this difficult task harder. There are several reasons why we tend to overeat when we eat away from home: foods presented in restaurants are high in energy density (high number of calories for a particular weight of food); restaurant foods are very palatable and there is a wide variety of this great-tasting food to choose from; and we want to get more food for our money, so we order the larger entrées (The Keystone Center, 2006).
For many people, eating at home all the time is impossible or impractical, and food is central to many social interactions. In order to consume fewer calories when eating out, one may:
• Patronize establishments that offer a variety of food choices and are willing to make substitutions or changes
• Order lower-fat steamed, broiled, baked, roasted, or poached items, or ask that an item be prepared in a lower-calorie way, such as grilled rather than fried
• Choose lower-calorie sauces or condiments, or do without them altogether • Substitute colorful vegetables for other side dishes (such as French fries) • Ask for half of the meal to be boxed to take home before the meal is brought to the table • Share an entrée with someone • Order a vegetarian meal • Select a fruit for dessert
To decrease reliance on away-from-home foods, plan ahead and:
• Pack healthy snacks to avoid the use of vending machines • Cook a healthful dinner at home, and make extra to pack for lunch the next day • Purchase healthful foods when grocery shopping to pack for lunch, such as prepackaged
salads, fresh fruits, vegetables, and low-calorie soups • For travel or longer excursions, bring along nutritious foods that will not spoil, such as
fresh fruits and vegetables, or pack a cooler with healthy foods
Various online communities and other support groups are available to help individuals manage their weight. Social media is harnessing the power of the Internet to help the public meet fitness goals. Sites such as Sparkpeople and Livestrong offer interactive and social networking opportunities. Group support is helpful for those who want them, whereas others prefer to have
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programs that they can implement on their own. The cost to join a weight management community ranges from free to moderate in price. Another popular option for weight control is the large selection of applications for mobile devices. With these applications it is possible to easily track foods eaten and calories expended throughout the day. Many are free and available for mobile devices.
Physical Activity and Health There are many reasons why people engage in physical activity and exercise: for weight management, increased energy, or better appearance; to fit into those favorite jeans; to prevent development or worsening of a chronic health condition; to manage stress; to improve mood and self-esteem; or any combination of these reasons.
Several factors acting individually and in concert can affect the likelihood that one is physically active. Men are a little more likely to engage in leisure physical activity and are more likely to engage in strength training than are women. The percentage of adults who engage in leisure-time physical activity decreases with age, from its highest among adults aged 18 to 24 years. White adults and Asian adults are more likely to engage in leisure-time physical activity than are black and Hispanic adults. The percentage of adults participating in leisure-time physical activity increases with level of education; adults with advanced degrees are twice as likely to engage in some physical activity than are high school graduates. The percentage of adults who engage in regular leisure-time physical activity also increases with income level. Adults whose income is four times the federal poverty level are nearly twice as likely to engage in some form of regular leisure- time physical activity than are adults whose income is below the poverty level. Adults living in the southern region of the United States get the least amount of leisure-time physical activity (CDC, May 23, 2014).
As has been previously mentioned, one’s surroundings also affect whether one will choose to exercise. The Walk Score has ranked cities across the United States for suitability for walking. So what makes a city walkable?
• A center: It may be a shopping center, park, or main street. • Mixed use, mixed income: Businesses are located next to homes at all price points. • Pedestrian-centric design: Businesses are close to the street to encourage foot traffic with
parking in back. • Density: The city is compact enough to allow businesses to flourish and for public
transportation to run frequently. • Parks and public spaces: There are plenty of public areas in which to gather. • Nearby schools and workplaces: Schools and workplaces are close enough that most people
can walk from home (Walk Score, 2013).
Research has found that one’s environment is a significant factor in health promotion. Adults and adolescents living in neighborhoods with high walkability engage in significantly more walking and cycling than those living in neighborhoods with low walkability. As a result, the rates of obesity are lower in communities that are walkable than in communities that do not encourage physical activity (Brown et al., 2013; CDC, 2015; Slater et al., Chriqui, 2013).
How much exercise do I need? What counts as exercise? Nurses in the community hear these questions commonly as they educate the public on the need to increase physical activity. The answers to these questions depend on the age, physical condition, and gender of the client. The CDC website at https://www.cdc.gov/physicalactivity/basics/index.htm presents the amount of exercise recommended for adults and children. Videos on the website further explain and illustrate the use of these guidelines. People may feel overwhelmed by the idea that they must add one more demand to an already busy schedule, and some think, “I’m in such bad shape, I’ll never be able to exercise.” The most important idea is that one must take a first step to try exercise. Walking, biking, taking the stairs, swimming—there is something for everyone, and any exercise is better than none. Exercise may also be broken up into smaller blocks of time during the day if it is not possible or convenient to do it all at once. Physical activity can also be a family affair, with the entire family using the time to reconnect and have fun together. Walking has been found to be one of the most beneficial exercises. It does not require special skills or expensive equipment, and many people with
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disabilities are able to participate in a walking program using assistive devices. Walking is an easy form of physical activity to perform and to maintain. Walking is a safe activity with a lower likelihood of injury than more vigorous forms of exercise. And it is a good activity for those who are physically inactive, as it can be adapted to one’s abilities, time, and circumstances.
Active Learning Exercise
1. How is your community doing in comparison with other communities? Prevalence and incidence rates for diseases or health conditions allow us to make comparisons between communities. Rates of activities such as smoking and physical activity allow us to make comparisons between communities regarding other areas of health promotion. Consider a community of which you are a member (e.g., your state, your county, your age group, or your school). Choose a health promotion topic that is of particular importance to your community of interest, such as sexual health, obesity, communicable disease, or physical activity. How does your community compare with a similar community in a different area of the state or the country? How does your community compare with a similar community in another part of the world?
2. View the Institute of Medicine series Weight of the Nation at http://theweightofthenation.hbo.com/. As you watch the series consider the following: What is the largest contributing factor to obesity among children? What interventions can you think of that would be effective in preventing or reducing obesity prevalence in your community? What are common barriers to preventing or reducing obesity among people across the lifespan? What negative effects will the United States as a whole face due to obesity?
Sleep Sleep is an essential component of chronic disease prevention and health promotion, yet 74% of adults report having a sleeping problem one or more nights per week. One-quarter of the U.S. population reports that they occasionally do not get enough sleep, 39% report getting less than 7 hours of sleep per night, and 37% report being so sleepy during the day that it interferes with daily activities. Insufficient sleep is associated with diabetes, heart disease, obesity, and depression. Insufficient sleep contributes to 100,000 motor vehicle crashes each year and 15,000 deaths. Sleep requirements change as people age (Table 4.5), and depending on life circumstances, one may require more than the minimum hours listed. If a person is so tired or sleepy that it interferes with his or her daily activities, that person probably needs more sleep (National Sleep Foundation, n.d.).
TABLE 4.5
How Much Sleep Do We Really Need?
Age Sleep Needs Newborns (1–2 mo) 10.5–18 hr Infants (3–11 mo) 9–12 hr during night and 30-min to 2-hr naps, 1–4 hr a day Toddlers (1–3 yr) 12–14 hr Preschoolers (3–5 yr) 11–13 hr School-aged children (5–12 yr) 10–11 hr Teens (11–17 yr) 8.5–9.25 hr Adults 7–9 hr Older adults 7–9 hr
Used with permission of the National Sleep Foundation. For further information, please visit www.sleepfoundation.org/how-much-sleep-do-we-really-need.
As we age, sleep is often interrupted by pain, trips to the bathroom, medications, medical conditions, and sleep disorders. In order to get enough sleep, we must plan to set aside enough time for sleep. Preferably, this means that we can awaken naturally, without an alarm clock, ensuring adequate rest. The need for sleep is regulated by two processes. One is the number of hours we are
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awake. The longer we are awake, the stronger the desire is to sleep. The other process is the circadian biological clock in the brain, the suprachiasmatic nucleus, which responds to light. This clock makes us tend to be sleepy at night when it is dark and to be active during the day when it is light. The circadian rhythm is why we are sleepiest between 2:00 and 4:00 AM and 1:00 and 3:00 PM. The circadian rhythm also regulates the 24-hour cycle of the body. While we sleep, important hormones are released, memory is consolidated, blood pressure is decreased, and kidney function changes (National Sleep Foundation, n.d.).
One of the results of lack of sleep is drowsy driving. More than one-third of U.S. drivers admit to having fallen asleep while driving, and 4% have had an accident due to driving while drowsy. An estimated 1550 deaths result from driver fatigue annually. Sleep-related motor vehicle accidents are most common among young people, shift workers, men, and adults with children. Adults between 18 and 29 years of age are the most likely to drive when sleepy. The less people sleep, the greater their risk for being involved in a vehicular crash. People who sleep 6 to 7 hours per night are twice as likely to be involved in a crash as those sleeping 8 hours per night or more. People sleeping 4 to 5 hours have a four to five times higher risk of being involved in a sleep-related accident. Being awake for 18 hours produces the same degree of impairment as being legally intoxicated (National Sleep Foundation, 2013).
Practicing sleep hygiene will help achieve optimum sleep, as follows:
• Avoid caffeine and nicotine close to bedtime. • Avoid alcohol, as it can cause sleep disruptions. • Go to bed and get up at the same time every day. • Exercise regularly, but finish all exercise and vigorous activity at least 3 hours before
bedtime. • Establish a regular, relaxing bedtime routine (a warm bath, reading a book). • Create a dark, quiet, cool sleep environment. • Have a comfortable mattress and bedding. • Use the bed for sleep only; do not read, listen to music, or watch TV in bed. • Avoid large meals before bedtime (National Sleep Foundation, n.d.).
Sleep assessment is an important nursing function. If a client reports snoring, apnea, restlessness, or insomnia, he or she may have a sleep disorder. Recommend keeping a sleep log that details how many hours are spent in sleep each night and any problems with sleep. If insufficient sleep is causing trouble concentrating or completing daily activities, recommend consulting a doctor, as a sleep disorder may be to blame. A sleep assessment tool and a list of sleep disorders and descriptions of each may be found at the National Sleep Foundation’s website, at http://www.sleepfoundation.org/.
Because of the 24-hour-per-day nature of nursing, nurses are among many workers who must work night shifts. Negative physical effects of working nights include an increased risk for stroke and heart disease, increased development of metabolic syndrome, and irregular menstrual cycles. Sleep deprivation related to shift work can cause practice errors related to a lack of attention to detail, impaired psychomotor skills, and reduced coordination, among others.
Those who work night shifts often experience shift work disorder. Shift work disorder is caused by night shifts, rotating shifts, and sometimes morning shifts. It causes chronic sleep deprivation in which a person never catches up on needed sleep. This sleep deprivation affects one’s health, safety, productivity, and quality of life. Many shift workers struggle with excess sleepiness during work or leisure hours that interferes with their ability to work, study, or engage in social activities.
The National Sleep Foundation has helpful ways to cope with shift work disorder at https://sleepfoundation.org/shift-work/content/living-coping-shift-work-disorder.
Active Learning Exercise
How do people, groups, and populations meet health promotion goals? Interview someone who is successful at meeting his or her health promotion goals. For example: How did the person manage to keep his or her weight at a healthy level? How did the person stop smoking? How does he or she make time to exercise daily? Does the individual have a philosophy of health that helps him or
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her stay on track with health promotion goals? How does the individual incorporate health promotion into daily life? What advice does he or she have for others striving to achieve better health?
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Summary Health promotion is an essential component to ongoing good health and well-being, yet many Americans have difficulty with one or more of the components of health promotion. Exercise, diet, sleep, and tobacco and alcohol use all affect our health. Nurses, particularly community health nurses, are in a position to assess and counsel clients on their health habits. Community health nurses also possess the unique combination of community familiarity and the knowledge and training to affect health at the policy level. As the environment is made safer and more walkable, or with a lower density of available alcohol or fast food, the community as a whole will benefit.
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Evolve Website http://evolve.elsevier.com/Nies/community
• NCLEX Review Questions • Case Studies
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Westberg J, Jason H. Fostering healthy behavior: the process. In: Woolf S.H, Jonas S, Lawrence R.S, eds. Health promotion and disease prevention in clinical practice. Baltimore: Williams & Wilkins; 1996.
World Health Organization. Health promotion: a discussion document on the concept and principles. Public Health Rev. 1986;14:245–254.
World Health Organization. Mental health. 2009. March 23, 2009 Available from. <www.who.int/topics/mental_health/en/>.
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UNIT 2 The Art and Science of Community Health Nursing
OUTLINE
5. Epidemiology
6. Community Assessment
7. Community Health Planning, Implementation, and Evaluation
8. Community Health Education
9. Case Management
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Epidemiology Holly B. Cassells
OUTLINE
Use of Epidemiology in Disease Control and Prevention Calculation of Rates
Morbidity: Incidence and Prevalence Rates Other Rates
Concept of Risk Use of Epidemiology in Disease Prevention
Primary Prevention Secondary and Tertiary Prevention Establishing Causality Screening Surveillance
Use of Epidemiology in Health Services Epidemiological Methods
Descriptive Epidemiology Analytic Epidemiology
OBJECTIVES
Upon completion of this chapter, the reader will be able to do the following: 1. Identify epidemiological models used to explain disease and health patterns in populations. 2. Use epidemiological methods to describe the state of health in a community or aggregate. 3. Calculate epidemiological rates in order to characterize population health. 4. Understand the use of epidemiological methods in primary, secondary, and tertiary prevention. 5. Evaluate epidemiological study designs for researching health problems.
KEY TERMS age adjustment of rates age-specific rates analytic epidemiology attack rates cause-and-effect relationship crude rates
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descriptive epidemiology ecosocial epidemiology epidemiological triangle epidemiology incidence rates infant mortality rate morbidity rates mortality rates natural history of disease person–place–time model prevalence rate proportionate mortality ratio rates risk risk factors screening screening programs standardization of rates surveillance web of causation Epidemiology is the study of the distribution and determinants of health and disease in human populations (World Health Organization, 2017) and is the principal science of public health. It entails a body of knowledge derived from epidemiological research and specialized epidemiological methods and approaches to scientific research. Community health nurses use epidemiological concepts to improve the health of population groups by identifying risk factors and optimal approaches that reduce disease risk and promote health. Epidemiological methods are important for accurate community assessment and diagnosis and in planning and evaluating effective community interventions. This chapter discusses the uses of epidemiology and its specialized methodologies.
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Use of Epidemiology in Disease Control and Prevention Although epidemiological principles and ideas originated in ancient times, formal epidemiological techniques developed in the nineteenth century. Early applications focused on identifying factors associated with infectious diseases and the spread of disease in the community. Public health practitioners hoped to improve preventive strategies by identifying critical factors in disease development.
Specifically, investigators attempted to identify characteristics of people who had a disease such as cholera or plague and compared them with characteristics of those who remained healthy. These differences might include a broad range of personal factors, such as age, gender, socioeconomic status, and health status. Investigators also questioned whether there were differences in the location or living environment of ill people compared with healthy individuals and whether these factors influenced disease development. Finally, researchers examined whether common time factors existed (i.e., when people acquired disease). Use of this person-place-time model organized epidemiologists’ investigations of the disease pattern in the community (Box 5.1). This study of the amount and distribution of disease constitutes descriptive epidemiology. Identified patterns frequently indicate possible causes of disease that public health professionals can examine with more advanced epidemiological methods.
In addition to investigating the person, place, and time factors related to disease, epidemiologists examine complex relationships among the many determinants of disease. This investigation of the causes of disease, or etiology, is called analytic epidemiology.
Even before the identification of bacterial agents, public health practitioners recognized that single factors were insufficient to cause disease. For example, while exploring the cholera epidemics in London in 1855, Dr. John Snow collected data about social and physical environmental conditions that might favor disease development. He specifically examined the contamination of local water systems. Snow also gathered information about people who became ill—their living patterns, water sources, socioeconomic characteristics, and health status. A comprehensive database helped him develop a theory about the possible cause of the epidemic. Snow suspected that a single biological agent was responsible for the cholera infection, although the organism, Vibrio cholerae, had yet to be discovered. He compared the death rates among individuals using one water well with those among people using a different water source. His findings suggested an association between cholera and water quality (Box 5.2).
BOX 5.1 Person–Place–Time Model
Person: “Who” factors, such as demographic characteristics, health, and disease status Place: “Where” factors, such as geographic location, climate and environmental conditions,
and political and social environment Time: “When” factors, such as time of day, week, or month and secular trends over months
and years
The epidemiologist examines the interrelationships between host and environmental characteristics and uses an organized method of inquiry to derive an explanation of disease. This model of investigation is called the epidemiological triangle because the epidemiologist must analyze the following three elements: agent, host, and environment (Fig. 5.1). The development of disease depends on the extent of the host’s exposure to an agent, the strength or virulence of the agent, and the host’s genetic or immunological susceptibility. Disease also depends on the environmental conditions existing at the time of exposure, which include the biological, social, political, and physical environments (Table 5.1). The model implies that the rate of disease will change when the balance among these three factors is altered. By examining each of the three elements, a community health nurse can methodically assess a health problem, determine protective factors, and evaluate the factors that make the host vulnerable to disease.
Conditions linked to clearly identifiable agents, such as bacteria, chemicals, toxins, and other exposure factors, are readily explained by the epidemiological triangle. However, other models that
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stress the multiplicity of host and environmental interactions have developed, and understanding of disease has progressed. The “wheel model” is an example of such a model (Fig. 5.2). The wheel consists of a hub that represents the host and its human characteristics, such as genetic makeup, personality, and immunity. The surrounding wheel represents the environment and comprises biological, social, and physical dimensions. The relative size of each component in the wheel depends on the health problem. A relatively large genetic core represents health conditions associated with heredity. Origins of other health conditions may be more dependent on environmental factors (Mausner and Kramer, 1985). This model subscribes to multiple-causation rather than single-causation disease theory; therefore it is more useful for analyzing complex chronic conditions and identifying factors that are amenable to intervention.
After the discovery of the causative agents of many infectious diseases, public health interventions eventually resulted in a decline in widespread epidemic mortality, particularly in developed countries. The focus of public health then shifted to chronic diseases such as cancer, coronary heart disease, and diabetes during the past few decades. The development of these chronic diseases tends to be associated with multiple interrelated factors rather than single causative agents.
In studying chronic diseases, epidemiologists use methods that are similar to those used in infectious disease investigation, thereby developing theories about chronic disease control. Risk factor identification is of particular importance to chronic disease reduction. Risk factors are variables that increase the rate of disease in people who have them (e.g., a genetic predisposition) or in people exposed to them (e.g., an infectious agent or a diet high in saturated fat). Therefore their identification is critical to identifying specific prevention and intervention approaches that effectively and efficiently reduce chronic disease morbidity and mortality. For example, the identification of cardiovascular disease risk factors has suggested a number of lifestyle modifications that could reduce the morbidity risk before disease onset. Primary prevention strategies, such as dietary saturated fat reduction, smoking cessation, and hypertension control, were developed in response to previous epidemiological studies that identified these risk factors (Box 5.3). The web of causation model illustrates the complexity of relationships among causal variables for heart disease (Fig. 5.3).
BOX 5.2 Example of the Epidemiological Approach An early example of the epidemiological approach is John Snow’s investigation of a cholera epidemic in the 1850s. He analyzed the distribution of person, place, and time factors by comparing the death rates among people living in different geographic sectors of London. His geographic map of cases, shown here, is an early example of the use of geographic information to formulate a hypothesis about the causes of an epidemic. Snow noted that people using a particular water pump had significantly higher mortality rates from cholera than people using other water sources in the city. Although the cholera organism was yet unidentified, the clustering of disease cases around one neighborhood pump suggested new prevention strategies to public health officials (i.e., that cholera might be reduced in a community by controlling contaminated drinking water sources). As an immediate response, in September 1854, Snow persuaded local leaders to remove the handle of the pump, which to this day can be seen on Broadwick Street in London (Snow, 1855.)
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John Snow’s map of London neighborhood showing location of cholera case cluster surrounding the Broad Street water pump.
Published by C. F. Cheffins, Lith, Southhampton Buildings, London, England, 1854. In Snow J, editor: On the mode of communication of cholera, ed 2, London, 1855, John Churchill. Retrieved from:
http://www.ph.ucla.edu/epi/snow/snowmap1_1854_lge.html.
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Replica of the famous Broad Street pump. Broadwick Street, London. Photo courtesy of http://commons.wikimedia.org/wiki/File:John_Snow_memorial_and_pub.jpg, Creative
Commons Attribution-Share Alike 2.0 Generic [CC BY-SA 2.0].
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FIG. 5.1 Epidemiological triangle.
A newer paradigm, ecosocial epidemiology, challenges the more individually focused risk factor approach to understanding disease origins. This ecosocial approach emphasizes the role of evolving macro-level socioenvironmental factors, including complex political and economic forces, along with microbiological processes, in understanding health and illness (Smith and Lincoln, 2011). Investigating the context of health will necessitate alternative research approaches, such as qualitative and ecological studies and studies of social institutions and processes. In turn, the examination of social and contextual origins will enlighten the interventions of public health practitioners.
TABLE 5.1
A Classification of Agent, Host, and Environmental Factors that Determine the Occurrence of Diseases in Human Populations
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Modified from Lilienfeld DE, Stoley PD: Foundations of epidemiology, New York, NY, 1994, Oxford University Press.
For example, Buffardi et al. (2008) analyzed the ecosocial and psychosocial correlates of diagnosis of sexually transmitted infections (STIs) among young adults. Specifically, they examined STI diagnosis within “contextual conditions” such as low income, “housing insecurity,” childhood physical or sexual abuse, intimate partner abuse, gang participation, personal history of having been arrested, and drug/alcohol use. It was determined that STIs were statistically associated with housing insecurity, exposure to crime, and having been arrested. The researchers concluded that ecosocial or contextual conditions strongly enhance STI risk by increasing sexual risk behaviors and likelihood of exposure to infection.
In another study, Phillips (2011) applied an ecosocial perspective when examining the effects of social/contextual factors on adherence to antiretroviral therapy (ART) among black men who tested positive for human immunodeficiency virus (HIV). He examined both individual factors (e.g., psychological state of mind, psychological distress, illicit drug use) and interpersonal/social
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contextual factors (e.g., partner status, housing status, patient–provider relationship, social capital [groups/networks]). He concluded that adherence to the medication regimen was strongly associated with homelessness and how well the individual tolerated the ART. Other factors included the individual’s state of mind and illicit drug use. Practice implications included the observation that providers should assess social and behavioral factors and intervene accordingly. This would include identification of psychological distress or presence of substance abuse. He also suggested assessment of housing status and facilitation of effective patient–provider relationships to mitigate tolerability issues with ART.
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FIG. 5.2 Wheel model of human–environment interaction. Redrawn from Mausner JS, Kramer S: Mausner and Bahn epidemiology: an introductory text, ed 2,
Philadelphia, 1985, Saunders
BOX 5.3 Coronary Heart Disease (Chd) Risk Factors Supported by Epidemiological Data From the Framingham Study
• Age • Gender (male) • Current cigarette smoking • Hypertension • High level of low-density lipoprotein (LDL) cholesterol • Low level of high-density lipoprotein (HDL) cholesterol • (Diabetes)1
• Family history of premature coronary heart disease2
1 Diabetes is not included in the Framingham Global Risk Score but is now considered to be a
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coronary heart disease risk equivalent, meaning that persons with diabetes will be treated as intensively as those with coronary heart disease.
2 Included in NCEP list of major risk factors but not in the Framingham Global Risk Score. Data from the Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III), JAMA 285:2486–2497, 2001. The 2013 recommendations from the American College of Cardiology/American Heart Association indicate these risk factors predict 10- year cardiovascular disease incidence (rather than CHD as in NCEP ATP III), Circulation, 2013. http://dx.doi.org/10.1161/01.cir.0000437741.48606.98, 2013.
FIG. 5.3 The web of causation for myocardial infarction: A current view. From Friedman GD: Primer of epidemiology, ed 5, New York, 2004, McGraw-Hill.
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Calculation of Rates The community health nurse must analyze data about the health of the community to determine disease patterns. The nurse may collect data by conducting surveys or compiling data from existing records (e.g., data from clinic facilities or vital statistics records). Assessment data often are in the form of counts or simple frequencies of events (e.g., the number of people with a specific health condition). Community health practitioners interpret these raw counts by transforming them into rates.
Rates are arithmetic expressions that help practitioners consider a count of an event relative to the size of the population from which it is extracted (e.g., the population at risk). Rates are population proportions or fractions in which the numerator is the number of events occurring in a specified period. The denominator consists of those in the population at the specified time period (e.g., per day, per week, or per year), frequently drawing on demographic data from the U.S. census. This proportion is multiplied by a constant (k) that is a multiple of 10, such as 1000, 10,000, or 100,000. The constant usually converts the resultant number to a whole number, which is larger and easier to interpret. Thus a rate can be the number of cases of a disease occurring for every 1000, 10,000, or 100,000 people in the population, as follows:
When raw counts or numbers are converted to rates, the community health nurse can make meaningful comparisons with rates from other cities, counties, districts, or states; from the nation; and from previous periods. These analyses help the nurse determine the magnitude of a public health problem in a given area and allow more meaningful and reliable tracking of trends in the community over time (Box 5.4).
Sometimes a ratio is used to express a relationship between two variables. A ratio is obtained by dividing one quantity by another, and the numerator is not necessarily part of the denominator. For example, a ratio could contrast the number of male births to that of female births. Proportions can describe characteristics of a population. A proportion is often a percentage, and it represents the numerator as part of the denominator.
BOX 5.4 Using Rates in Everyday Community Health Nursing Practice The following school situation exemplifies the value of rates:
A community health nurse screened 500 students for tuberculosis (TB) in Southside School and identified 15 students with newly positive tuberculin test results. The proportion of Southside School students affected was 15/500, or 0.03 (3%), or a rate of 30/1000 students at risk for TB. Concurrently, the nurse conducted screening in Northside School and again identified 15 students with positive tuberculin test results. However, this school was much larger than the Southside School and had 900 potentially at-risk students. To place the number of affected students in perspective relative to the size of the Northside School, the nurse calculated a proportion of 15/900, or 0.017 (1.7%), or a rate of 17/1000 students at risk in Northside School.
On the basis of this comparison, the nurse concluded that although both schools had the same number of tuberculin conversions, Southside School had the greater rate of tuberculin test conversions. To determine whether rates are excessively high, the nurse should compare rates with the city, county, and state rates and then explore reasons for the difference in these rates.
Morbidity: Incidence and Prevalence Rates The two principal types of morbidity rates, or rates of illness, in public health are incidence rates
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and prevalence rates. Incidence rates describe the occurrence of new cases of a disease (e.g., tuberculosis, influenza) or condition (e.g., teen pregnancy) in a community over a given period relative to the size of the population at risk for that disease or condition during that same period. The denominator consists of only those at risk for the disease or condition; therefore known cases or those not susceptible (e.g., those immunized against a disease) are subtracted from the total population (Table 5.2):
The incidence rate may be the most sensitive indicator of the changing health of a community because it captures the fluctuations of disease in a population. Although incidence rates are valuable for monitoring trends in chronic disease, they are particularly useful for detecting short- term changes in acute disease—such as those that occur with influenza or measles—in which the duration of the disease is typically short.
If a population is exposed to an infectious disease at a given time and place, the nurse may calculate the attack rate, a specialized form of the incidence rate. Attack rates document the number of new cases of a disease in those exposed to the disease. A common example of the application of the attack rate is food poisoning; the denominator is the number of people exposed to a suspect food, and the numerator is the number of people who were exposed and became ill. The nurse can calculate and compare the attack rates of illness among those exposed to specific foods to identify the critical food sources or exposure variables.
TABLE 5.2
Examples of Rate Calculations
A prevalence rate is the number of all cases of a specific disease or condition (e.g., deafness) in a population at a given point in time relative to the population at the same point in time:
When prevalence rates describe the number of people with the disease at a specific point in time, they are sometimes called point prevalences. For this reason, cross-sectional studies frequently use them. Period prevalences represent the number of existing cases during a specified period or interval of time and include old cases and new cases that appear within the same period.
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Prevalence rates are influenced by the number of people who experience a particular condition (i.e., incidence) and the duration of the condition. A nurse can derive the prevalence rate (P) by multiplying incidence (I) by duration (D): (P = I × D). An increase in the incidence rate or the duration of a disease increases the prevalence rate of a disease. With the advent of life-prolonging therapies (e.g., insulin for treatment of type 1 diabetes and antiretroviral drugs for treatment of HIV), the prevalence of a disease may increase without a change in the incidence rate. Those who survive a chronic disease without cure remain in the “prevalence pot” (Fig. 5.4). For conditions such as cataracts, surgical removal of the cataracts permits many people to recover and thereby move out of the prevalence pot. Although the incidence has not necessarily changed, the reduced duration of the disease (because of surgery) lowers the prevalence rate of cataracts in the population.
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FIG. 5.4 Prevalence pot: The relationship between incidence and prevalence. Redrawn from Morton RF, Hebel JR, McCarter RJ: A study guide to epidemiology and biostatistics, ed 3,
Gaithersburg, MD, 1990, Aspen Publishers.
Morbidity rates are not available for many conditions because surveillance of many chronic diseases is not widely conducted. Furthermore, morbidity rates may be subject to underreporting when they are available. Routinely collected birth and death rates, or mortality rates, are more widely available. Table 5.2 provides examples of calculating selected rates.
Other Rates Numerous other rates are useful in characterizing the health of a population. For example, crude rates summarize the occurrence of births (i.e., crude birth rate), mortality (i.e., crude death rates), or diseases (i.e., crude disease rates) in the general population. The numerator is the number of events, and the denominator is the average population size or the population size at midyear (i.e., usually July 1) multiplied by a constant.
The denominators of crude rates represent the total population and not the population at risk for a given event; therefore these rates are subject to certain biases in interpretation. Crude death rates are sensitive to the number of people at the highest risk for dying. A relatively older population will probably produce a higher crude death rate than a population with a more evenly distributed age range. Conversely, a young population will have a somewhat lower crude death rate. Similar biases can occur for crude birth rates (e.g., higher birth rates in young populations).
This distortion occurs because the denominator reflects the entire population and not exclusively the population at risk for giving birth. Age is one of the most common confounding factors that can
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mask the true distribution of variables. However, many variables, such as race and socioeconomic status, can also bias the interpretation of biostatistical data. Therefore the nurse may use several approaches to remove the confounding effect of these variables on rates.
Age-specific rates characterize a particular age group in the population and usually consider deaths and births. Determining the rate for specific subgroups of a population and using a denominator that reflects only that subgroup remove age bias:
To characterize a total population using age-specific rates, one must compute the rate for each category separately. The reason is that a single summary rate, such as a mean, cannot adequately characterize a total population. Specific rates for other variables can be determined in a similar fashion (e.g., race-specific or gender-specific rates) (Table 5.3).
Age adjustment or standardization of rates is another method of reducing bias when there is a difference between the age distributions of two populations. The nurse uses either the direct method or the indirect standardization method. The direct method selects a standard population, which is often the population distribution of the United States. This method essentially converts age-specific rates for age categories of the two populations to those of the standard population, and it calculates a summary age-adjusted rate for each of the two populations of interest. This conversion enables the nurse to compare the two rates as if both had the standard population’s age structure (i.e., without the prior problem of age distortion).
The proportionate mortality ratio (PMR) method also describes mortality. It represents the percentage of deaths resulting from a specific cause relative to deaths from all causes. It is often helpful in identifying areas in which public health programs might make significant contributions to reducing deaths. In some situations, a high PMR may reflect a low overall mortality or reduced number of deaths resulting from other causes. Therefore the PMR requires consideration in the context of the mortality experience of the population.
TABLE 5.3
Comparison of U.S. Mortality Rates—2014 (Preliminary)
Death Rate Rate Per 100,000 Crude death rate 823.7 Age-adjusted death rate 724.6 Age-specific death rates (years):
<1 (infant) 588.0
1–4 24.0
5–14 12.7
15–24 65.5
25–34 108.4
35–44 175.2
45–54 404.8
55–64 870.3
65–74 1786.3
75–84 4564.2
≥85 13,407.9
Modified from National Center for Health Statistics: Deaths. Preliminary data for 2014, National
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Vital Statistics Reports 65(4):1–122, 2016. Retrieved from: http://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_04.pdf.
Table 5.4 summarizes the advantages and disadvantages of crude, specific, and adjusted rates. Numerous other rates assess particular segments of the population. One that is followed closely by public health professionals is the infant mortality rate, calculated by dividing the number of deaths in infants less than 1 year old by the number of live births for that period. This rate is considered a particularly sensitive indicator of the health of a community or nation and reflective of the care provided to women and children. Disparities in infant mortality rates can be seen within subgroups of the U.S. population, and the rate ranks 32 among 35 developed countries (Organisation for Economic Cooperation and Development [OECD], 2017). Although the United States achieved its Healthy People 2020 goal of 6.0 per 1000, the 2014 rate, 5.8 per 1000, masks disparities within the population. Black infants experienced an infant mortality rate 2.24 times higher than white infants (11.0 vs. 4.9 per 1000 in 2014) (Centers for Disease Control and Prevention [CDC], 2016). Socioeconomic status and racial disparities, which are frequently associated with inadequate prenatal care, prematurity, adolescent pregnancy, and smoking, are key risk factors. Recent concern focuses on the steep rise in pregnancy-related maternal mortality from 10 per 100,000 in 1990 to 17.3 per 100,000 in 2013 (CDC, 2017). Again, racial differences were significant, with the presence of chronic conditions such as hypertension, diabetes, and heart disease likely playing a role. Table 5.5 provides a summary of the major public health rates. A standard epidemiology textbook contains more information.
TABLE 5.4
Advantages and Disadvantages of Crude, Specific, and Adjusted Rates
Rate Advantages Disadvantages Crude Actual summary rates
Readily calculable for international comparisons (widely used despite limitations)
Populations vary in composition (e.g., age); therefore differences in crude rates are difficult to interpret
Specific Homogeneous subgroup Detailed rates useful for epidemiological and public health purposes
Cumbersome to compare many subgroups of two or more populations
Adjusted Summary statements Differences in composition of group “removed,” permitting unbiased comparison
Fictional rates Absolute magnitude dependent on chosen standard population Opposing trends in subgroups masked
Modified from Mausner JS, Kramer S: Mausner and Bahn epidemiology: an introductory text, ed 2, Philadelphia, 1985, W. B. Saunders.
TABLE 5.5
Major Public Health Rates
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∗ 2013 rate from National Center for Health Statistics: Health, United States, 2015: with special features on racial and ethnic health disparities. Retrieved from: http://www.cdc.gov/nchs/data/hus/hus15.pdf. ∗∗ Rate from Centers for Disease Control and Prevention: Deaths: final data for 2014, National Vital Statistics Reports 65(4):49, 2016. Retrieved from: http://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_04.pdf>
Modified from Mausner JS, Kramer S: Mausner and Bahn epidemiology: an introductory text, ed 2, Philadelphia, 1985, Saunders. Rates from U.S. Department of Health and Human Services/National Center for Health Statistics: Health, United States, 2015. Retrieved from: http://www.cdc.gov/nchs/data/hus/hus15.pdf.
Active Learning Exercise
1. Compile a database of relevant demographic and epidemiological data for your community by examining census reports, vital statistics reports, city records, and other sources in libraries and agencies.
2. Using numerators from vital statistics and denominators from census data, compute crude death and birth rates for your community.
3. Compare morbidity and mortality rates for your community with those of the state and the nation. Determine whether your community rates are higher or lower, and hypothesize about reasons for any disparities.
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Concept of Risk The concepts of risk and risk factor are familiar to community health nurses whose practices focus on disease prevention. Risk refers to the probability of an adverse event (i.e., the likelihood that healthy people exposed to a specific factor will acquire a specific disease). Risk factor refers to the specific exposure factor, such as cigarette smoke, hypertension, high cholesterol, excessive stress, high noise levels, or an environmental chemical. Frequently, the exposure factor is external to the individual. Risk factors may include fixed characteristics of people, such as age, sex, and genetic makeup. Although these intrinsic risk factors are not alterable, certain lifestyle changes may reduce their effect. For example, weight-bearing exercise and taking calcium and hormonal supplements may reduce the risk of osteoporosis for susceptible women.
Epidemiologists describe disease patterns in aggregates and quantify the effects of exposure to particular factors on the disease rates. To identify specific risk factors, epidemiologists compare rates of disease for those exposed with those not exposed. One method for comparing two rates is subtracting the rate of nonexposed individuals from the exposed. This measure of risk is called the attributable risk; it is the estimate of the disease burden in a population. For example, if the rate of non–insulin-dependent diabetes were 5000 per 100,000 people in the obese population (i.e., those weighing more than 120% of ideal body weight) and 1000 per 100,000 people in the nonobese population, the attributable risk of non–insulin-dependent diabetes resulting from obesity would be:
This means that 4000 cases per 100,000 people may be attributed to obesity. Thus a prevention program designed to reduce obesity could theoretically eliminate 4000 cases per 100,000 people in the population. Attributable risks are particularly important in describing the potential impact of a public health intervention in a community.
A second measure of the excess risk caused by a factor is the relative risk ratio. The relative risk is calculated by dividing the incidence rate of disease in the exposed population by the incidence rate of disease in the nonexposed population. In the previous example, a relative risk of 5 was obtained by dividing 5000/100,000 by 1000/100,000. This risk ratio suggests that an obese individual has a fivefold greater risk of diabetes than a nonobese individual. In general, a relative risk of 1 indicates no excessive risk from exposure to a factor; a relative risk of 1.5 indicates a 50% increase in risk; a relative risk of 2 indicates twice the risk; and a relative risk of less than 1 suggests that a factor may have a protective effect associated with a reduced disease rate.
The relative risk ratio forms the statistical basis for the risk factor concept. Relative risks are valuable indicators of the excess risk incurred by exposure to certain factors. They have been used extensively in identifying the major causal factors of many common diseases, and they direct public health practitioners’ efforts to reduce health risks.
Community health nurses may apply the concept of relative risk to suspected exposure variables to isolate risk factors associated with community health problems. For example, a community health nurse might investigate an outbreak of probable foodborne illness. The nurse may compare the incidence rate among those exposed to potato salad in a school cafeteria with the incidence rate among those not exposed. The relative risk calculated from the ratio of these two incidence rates indicates the amount of excess risk for disease incurred by eating the potato salad. A community health nurse might also determine the relative risks for other suspected foods and compare them with the relative risk for potato salad. Attack rates are the calculated incidence rates for foods involved in foodborne illnesses. A food with a markedly higher relative risk than other foods might be the causal agent in a foodborne epidemic. The identification of the causal agent, or specific food, is critical to the implementation of an effective prevention program such as teaching proper food- handling techniques.
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Use of Epidemiology in Disease Prevention Primary Prevention The central goals of epidemiology are describing the disease patterns, identifying the etiological factors in disease development, and taking the most effective preventive measures. These preventive measures are specific to the stage of disease progression, or the natural history of disease, from prepathogenesis through resolution of the disease process. When interventions occur before disease development, they are called primary prevention. Primary prevention relies on epidemiological information to indicate those behaviors that are protective, or those that will not contribute to an increase in disease, and those that are associated with increased risk.
Two types of activities constitute primary prevention. Those actions that are general in nature and designed to foster healthful lifestyles and a safe environment are called health promotion. Actions aimed at reducing the risk of specific diseases are called specific protection. Public health practitioners use epidemiological research to understand practices that are likely to reduce or increase disease rates. For example, numerous research studies have confirmed that regular exercise is an important health promotion activity that has positive effects on general physical and mental health. Immunizations exemplify specific protection measures that reduce the incidence of particular diseases.
Secondary and Tertiary Prevention Secondary prevention occurs after pathogenesis. Those measures designed to detect disease at its earliest stage, namely screening and physical examinations that are aimed at early diagnosis, are secondary prevention. Interventions that provide for early treatment and cure of disease are also in this category. Again, epidemiological data and clinical trials determining effective treatments are crucial in disease identification. Mammography, guaiac testing of feces, and the treatment of infections and dental caries are all examples of secondary prevention.
Tertiary prevention focuses on limitation of disability and the rehabilitation of those with irreversible diseases such as diabetes and spinal cord injury. Epidemiological studies examine risk factors affecting function and suggest optimal strategies in the care of patients with chronic advanced disease.
Establishing Causality As discussed earlier, a principal goal of epidemiology is to identify etiological factors of diseases to encourage the most effective prevention activities and develop treatment modalities. During the last few decades, researchers recognized that many diseases have not one but multiple causes. Epidemiologists who examine disease rates and conduct population-focused research often find multiple factors associated with health problems. For example, cardiovascular disease rates may vary by location, ethnicity, and smoking status. Even infectious diseases often require not only an organism but also certain behaviors or conditions to cause exposure. Determining the extent that these correlates represent associative or causal relationships is important for public health practitioners who seek to prevent, diagnose, and treat disease.
Definitively establishing causality—particularly in chronic disease—is a challenge. The following six criteria establish the existence of a cause-and-effect relationship:
1. Strength of association: Rates of morbidity or mortality must be higher in the exposed group than in the nonexposed group. Relative risk ratios, or odds ratios, and correlation coefficients indicate whether the relationship between the exposure variable and the outcome is causal. For example, epidemiological studies demonstrated a higher relative risk for heart disease among smokers than among nonsmokers.
2. Dose–response relationship: An increased exposure to the risk factor causes a concomitant increase in disease rate. Indeed, the risk of heart disease mortality is higher for heavy smokers than for light smokers.
3. Temporally correct relationship: Exposure to the causal factor must occur before the effect, or disease. For heart disease, smoking history must precede disease development.
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4. Biological plausibility: The data must make biological sense and represent a coherent explanation for the relationship. Nicotine and other tobacco-derived chemicals are toxic to the vascular endothelium. In addition to raising low-density lipoprotein (LDL) and decreasing high-density lipoprotein (HDL) cholesterol levels, cigarette smoking causes arterial vasoconstriction and platelet reactivity, which contribute to platelet thrombus formation.
5. Consistency with other studies: Varying types of studies in other populations must observe similar associations. Numerous studies using different designs have repeatedly supported the relationship between smoking and heart disease.
6. Specificity: The exposure variable must be necessary and sufficient to cause disease; there is only one causal factor. Although specificity may be strong causal evidence in the case of infectious disease, this criterion is less important today. Diseases do not have single causes; they have multifactorial origins.
The exposure variable of smoking is one of several risk factors for heart disease. Few factors are linked to a single condition. Furthermore, smoking is not specific to heart disease alone. It is a causal factor for other diseases such as lung and oral cancers. Additionally, smoking is not “necessary and sufficient” to the development of heart disease, because there are nonsmokers who also have coronary heart disease. Therefore the causal criterion of specificity more frequently pertains to infectious diseases.
Although these criteria are useful in evaluating epidemiological evidence, it is important to note that causality is largely a matter of judgment. In reality, absolute causality is only rarely established. Rather, epidemiologists more commonly refer to suggested causal and associated factors. The effect of confounding variables makes it difficult to ascertain true relationships between the exposure and outcome variables. Confounding variables must be independently related to both the dependent variable and the independent variable. Therefore these third variables can distort the true relationship between the dependent and independent variables. For example, researchers frequently control for the confounding effect of exercise and age when they examine the relationship between diet and coronary heart disease. This is because persons with heart disease may exercise less and be older than those without heart disease; that is, there is both an independent relationship between exercise and heart disease and also between age and heart disease. Without controlling for these factors, it is not possible to know if the association between dietary fat and heart disease is real or if it can be attributed to differences in physical activity and age.
By measuring the confounding variable, the researcher can statistically account for its effect in the analysis (e.g., by using multiple logistical regression analysis or stratification). A biostatistics text contains a discussion of these methods. Alternatively, matching subjects in treatment and control groups with respect to the confounding variable minimizes the effects of the confounder. Again, standardization for variables such as age is another method for managing spurious associations, which makes true relationships more apparent. An understanding of such relationships facilitates the practitioner’s interpretation and application of findings.
Screening As explained previously, a central aim of epidemiology is to describe the course of disease according to person, place, and time. Observations of the disease process may suggest factors that aggravate or ameliorate its progress. This information also assists in determining effective treatment and rehabilitation options (i.e., secondary or tertiary prevention approaches).
The purpose of screening is to identify risk factors and diseases in their earliest stages. Screening is usually a secondary prevention activity because indications of disease appear after a pathological change has occurred. In all forms of secondary and tertiary prevention, the identification of illness prompts the nurse to consider which forms of upstream prevention could have interrupted disease development.
Community health nurses commonly conduct screening programs. Community health nurses may devote a large portion of their work activities to performing physical examinations; promoting client self-examination; or conducting screening programs in schools, clinics, or community settings. Although secondary prevention activities are important and provide vital information on
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community health status, they focus on detecting existing disease. In contrast, primary prevention and anticipatory guidance, which are hallmarks of community health nursing practice, attempt to prevent the development of disease.
Community health nurses should consider several guidelines for screening programs. First, nurses must plan and execute adequate and appropriate follow-up treatment for patients who test positive for the disease. It is critical that nurses identify how to contact patients with positive findings and where to refer them and then follow up with patients to determine whether they accessed care. Health fairs have been criticized for the lack of consistent follow-up of screening activities. Second, in the planning phase, the nurse should determine whether early disease diagnosis constitutes a real benefit to clients in terms of improved life expectancy or quality of life. Third, a critical prerequisite to screening is the existence of acceptable and medically sound treatment and follow-up. In the past, public health providers debated the ethical and practical arguments for implementing widespread HIV screening. Concern exists regarding the potential for stigmatic consequences for and discrimination against those who screen positively for a test; therefore people implementing screening programs should establish procedures for ensuring confidentiality. These procedures, in conjunction with the development of effective antiviral treatments, have encouraged earlier and more widespread identification of HIV-positive individuals.
A screening program’s procedures must also be cost effective and acceptable to clients. Although colonoscopy is a routine and effective screening procedure for colon cancer, it is neither simple nor inexpensive. Although it is recommended periodically for all Americans with no known risk factors beginning at age 50 years, less than 60% of that group have undergone the procedure (CDC, 2013b). Annual screening using home fecal immunochemical tests (FIT) are not only cheaper but do not require bowel preparation, anesthesia, or transportation. Therefore non-DNA FITs are suggested by the U.S. Preventive Services Task Force as a more acceptable alternative to colonoscopy (Lin, et.al., 2016). In short, a nurse should consider whether or not to screen a population on the basis of the significant costs of screening programs and procedures, follow-up for clients who test positive, and subsequent medical care (Box 5.5).
When developing a screening program, the community health nurse also must evaluate issues related to the validity of the screening test. Detecting clients with disease is the purpose of screening, and sensitivity is the test’s ability to do so correctly. Conversely, specificity is the extent to which a test can correctly identify those who do not have disease. To obtain estimates of these two dimensions, the nurse must compare screening results with the best available diagnostic procedure. For a given test, the sensitivity and specificity tend to be inversely related to each other. When a test is highly sensitive, individuals without disease may be incorrectly labeled as testing positive. These false-positive results may cause stress and worry for clients and require further expense in the form of testing to confirm a diagnosis. With a highly sensitive test, specificity may be lower and the test may identify people as having the disease who are in fact disease free (i.e., more false-positive results). If the sensitivity is low (and the specificity high), more patients who have the disease will have negative test results. These patients will not be diagnosed and thus presumably will receive care later in the disease process.
BOX 5.5 Guidelines For Screening Programs
• Screen for conditions in which early detection and treatment can improve disease outcome and quality of life.
• Screen populations that have risk factors or are more susceptible to the disease. • Select a screening method that is simple, safe, inexpensive to administer, acceptable to clients,
and has acceptable sensitivity and specificity. • Plan for the timely referral and follow-up of clients with positive results. • Identify referral sources that are appropriate, cost effective, and convenient for clients. • Refer to evidenced-based screening recommendations published by the U.S. Preventive
Services Taskforce (http://www.uspreventiveservicestaskforce.org/Page/Name/recommendations) and other
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organizations.
Optimally, a screening test should be maximally sensitive and specific. To a large extent, this depends on the precision of the test and the stringency of the cutoff point established for determining a positive result. In the past, for example, the tuberculosis skin testing criterion was based exclusively on a skin reaction of 10 mm of induration. As a result, some persons with the disease were missed because their skin reactions were less than 10 mm (false-negative results), and some with 10 mm of reaction were identified as having the disease but further testing showed they did not have it (false-positive results). More recently, risk factors have been considered in addition to induration, creating a more sensitive and specific TB screening algorithm. Currently, high-risk individuals, such as those with HIV disease, are considered to have a positive skin test result with 5 mm of induration, which is more sensitive than the criteria of 15 mm set for those of low risk. Use of the more stringent 5-mm criterion among those with HIV will lead to fewer false-negative results, and use of the 15-mm cut point among low-risk individuals will lead to fewer false-positive results (CDC, 2016). Box 5.6 shows the formula for calculating sensitivity and specificity.
Sensitivity and specificity reflect the yield of a screening test, which is the amount of detected disease. One measure of yield is the positive predictive value of a test, which is the proportion of true-
positive results relative to all positive test results. On the basis of Box 5.6, the formula is . The positive predictive value depends on the prevalence of undetected disease in a population. Screening for a rare disease such as phenylketonuria will yield a lower predictive value and more false-positive results. In phenylketonuria, a low predictive value is acceptable, because the false- negative result has very serious consequences. The predictive value is also affected by the nature of the screened population. Screening only the individuals at high risk for a disease will produce a higher predictive value and can be a more efficient way to identify those with health problems. For example, diabetes screening in an American Indian, Mexican American, or African American adult population should produce a higher predictive value than screening the general adult population.
BOX 5.6 Sensitivity and Specificity of a Screening Test
Screening Test Result Those With Disease Those Without Disease Positive True positives (a) False positives (b) Negative False negatives (c) True negatives (d)
Surveillance
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In addition to screening, surveillance is a mechanism for the ongoing collection of community health information. Monitoring for changes in disease frequency is essential to effective and responsive public health programs. Identifying trends in disease incidence or identifying risk factor status by location and population subgroup over time allows the community health nurse to evaluate the effectiveness of existing programs and to implement interventions targeted to high-risk groups. Again, identifying new cases for calculating incidence rates is particularly useful in evaluating morbidity trends. However, this form of surveillance data is more difficult to collect, and public health practitioners can access the data only for selected diseases. Prevalence rates, mortality data, risk factor data, and hospital and health service data can help indicate a program’s successes or deficiencies.
The Centers for Disease Control and Prevention (CDC) coordinates a system of data collection among federal, state, and local agencies. These groups compile numerous sets of data and base some of these data sets on the entire population (e.g., vital statistics data) and other collections on subsamples of the population (e.g., the National Health Interview Survey). The completeness of data reporting is variable because not all diseases are reportable. For example, practitioners are required to report only four sexually transmitted infections (i.e., HIV/AIDS, syphilis, gonorrhea, and chlamydia) to local and state health departments. Furthermore, not all practitioners report cases on a regular basis, and not all people with sexually transmitted infections actually seek care. Studies have indicated that practitioners also underreport childhood communicable diseases, such as chickenpox and mumps. The CDC conducts studies that estimate the magnitude of this underreporting problem.
Practitioners have a continuing need for comprehensive and systematically collected surveillance data that describe the health status of national and local subgroups. They use this information to evaluate the impact of programs on specific groups in a community.
Healthy People 2020
Objectives for Data Collection and Reporting
PHI HP2020–7: Increase the proportion of population-based Healthy People 2020 objectives for which national data are available for all major population groups.
PHI HP2020–8: Increase the proportion of Healthy People 2020 objectives that are tracked regularly at the national level.
PHI HP2020–9: Increase the proportion of Healthy People 2020 objectives for which national data are released within one year of the end of data collection.
PHI HP2020–10: Increase the percentage of vital events (births, deaths, fetal deaths) reported using the latest U.S. standard certificates of birth and death and the report of fetal death.
From U.S. Department of Health and Human Services: Healthy People 2020: public health infrastructure, n.d. Retrieved from: https://www.healthypeople.gov/2020/topics-objectives/topic/public-health- infrastructure/objectives.
For example, the effectiveness of Healthy People 2020 depends on the availability of reliable baseline and continuing data to characterize health problems and evaluate goal achievement as listed in the Healthy People 2020 box. Healthy People 2020 addresses the ongoing need to extend the inclusiveness of such data collection systems (U.S. Department of Health and Human Services [USDHHS], n.d.). For example, simply documenting children’s mortality rates resulting from injury is insufficient for the development of specific methods of injury prevention. Data on the number of injured children and the nature of injury (e.g., motor vehicle accidents, drowning, abuse) across the nation would increase the usefulness of surveillance information. The Health Indicators Warehouse has compiled indicator data for initiatives like Healthy People and the Center for Medicare Services so that health status and service quality can be monitored through April 2017 (National Center for Health Statistics, n.d.). Databases such as Health, United States, Healthy People, and Health Status Indicators available at the CDC webpage will be the primary source of evaluative information.
Nurses need to describe trends in health and illness according to a community’s locale, demographics, and risk factor status to intervene effectively on behalf of the people. They must
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compare the data for their locale with those of a relevant neighboring area (e.g., a census tract, city, county, state, or nation) to gain perspective on the magnitude of a local problem (see Clinical Example 5.1). Ideally, the nurse should have access to surveillance data at several different levels over a given period. In some instances, community health nurses find it necessary to construct their own surveillance systems that are tailored to specific health conditions or available programs in their community. These smaller data collection systems help nurses evaluate programs when the data are readily accessible and are compatible with data from large city or statewide surveillance systems.
Clinical Example 5.1 In 1991, a cluster of neural tube defects (NTDs) occurred in babies born in Brownsville, Texas, within a span of 6 weeks. Investigation indicated a rate of 27.1 cases per 10,000 live births, in contrast to the U.S. rate of approximately 8 per 10,000 (Texas Department of Health, unpublished report, 1992). The Brownsville rate was more than three times the national rate and represented an increased risk in Hispanic women. This increased risk was partially attributable to cultural and environmental factors, including lower socioeconomic status and migrant farm work. The investigators implemented a surveillance program that obtained more accurate population-based data. Additionally, the program implemented folic acid supplementation in Texas counties along the Mexican border. NTD rates dropped to 13 per 10,000 after the supplementation effort.
Research suggests that 50% to 70% of NTDs may be preventable with folic acid supplementation. This finding supports the fortification of bread and cereal products; in January 1998, the U.S. Food and Drug Administration (FDA) mandated the addition of 140 µg of vitamin B per 100 g of most grain products. It is estimated that there has been a 24% reduction in the number of NTDs since grain fortification with folic acid began.
Dietary intake alone may be insufficient; also, the greatest risk to the fetus occurs within the first 3 to 8 weeks of pregnancy, a time when many women do not yet recognize their pregnancies. Therefore the CDC and U.S. Preventive Services Task Force recommend that all women of reproductive age consume 400 µg (0.4 mg) to 800 µg (0.8 mg) daily of synthetic folic acid in addition to dietary sources such as cereal or grain products, leafy green vegetables, and vitamin supplements. From U.S. Preventive Services Task Force: Folic acid to prevent neural tube defects: preventive medication, 2009. Retrieved from: http://www.uspreventiveservicestaskforce.org/uspstf09/folicacid/folicacidrs.htm.
Research Highlights
Reducing Infant Mortality Rates Using the Perinatal Periods of Risk Model The infant mortality rate is an accepted indicator for measuring a nation’s health. The rate is representative of the health status and social well-being of any nation. Despite decreases in the past 50 years, infant mortality rates in the United States remain higher than in other industrialized countries. Using overall infant mortality rates to determine the effectiveness of interventions does not help communities focus on particular underlying factors contributing to the rates. Targeting interventions to the factors most responsible for the infant mortality rate should help reduce the rate more rapidly and effectively.
The Perinatal Periods of Risk (PPOR) model was developed to provide direction, focus, and suggestions for effective interventions. The model helps users identify and rank four factors as they contribute to the overall infant mortality rate: (1) mother’s health before and between pregnancies, (2) maternal health care systems, (3) neonatal health care systems, and (4) infant health during the first year of life. The PPOR model is based on two major theoretical constructs: age of fetus-infant at death and birth weight. The PPOR model maps each death in a geographic region on the basis of birth weight and age at death, including fetal, neonatal, and postneonatal periods. The lowest birth weight infant deaths are combined into one cell named the maternal health cell. The three remaining groups are put into cells suggesting the primary preventive focus for that group: maternal health, newborn health, and infant health. Multiple interventions are important in
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reducing infant mortality, and the PPOR model guides prioritizing interventions based on the cell contributing the most to infant mortality rates (Peck et al., 2010).
The PPOR model has been used in several programs and research studies to improve mother and infant health. In one intervention study (Chao et al., 2010) the PPOR model was successfully used to improve birth outcomes in very-high-risk populations in the Antelope Valley area of Los Angeles County. On the basis of assessment findings per PPOR directives, efforts were made to infuse resources into the community and expand case management initiatives for high-risk mothers. Long-term findings indicated that the PPOR model was useful for identifying risk and social factors and that it helped mobilize community partnerships that resulted in widely improved birth outcomes. Data from Chao SM, Donatoni G, Bemis C., et al.: Integrated approaches to improve birth outcomes: perinatal periods of risk, infant mortality review and the Los Angeles mommy and baby project, Maternal and Child Health Journal 14:827–837, 2010; Peck MG, Sappenfield WM, Skala J: Perinatal periods of risk: a community approach for using data to improve women and infants’ health, Maternal and Child Health Journal 14:864–874, 2010.
As stated, epidemiologists describe the course of disease over time. These secular trends are changes that occur over years or decades, such as the fairly recent, significant decline in lung cancer deaths in men and the gradual increase in lung cancer deaths in women. Frequently, epidemiologists document the associated patterns of treatment and intervention. In many instances, studies conducted by clinical epidemiologists provide this information. Cancer registries are a form of surveillance that document the prevalence and incidence of cancer in a community and document its course, treatment, and associated survival rates. The Surveillance, Epidemiology and End Results (SEER) program of the National Cancer Institute compiles national cancer data from existing cancer registries covering approximately 28% of the U.S. population (National Cancer Institute, 2017).
Public health practitioners need to conduct community surveys of population segments to plan for the segments’ health. For example, a survey of the disabled population that assesses prevalence may also evaluate the adequacy of current services and project future needs.
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Use of Epidemiology in Health Services Epidemiological approaches, such as the ones presented here, can be used to describe the distribution of disease and its determinants in populations. However, epidemiological principles are also useful in studying population health care delivery and in describing and evaluating the use of community health services. For example, analyzing the ratio of health care providers to population size helps determine the system’s ability to provide care. The clients’ reasons for seeking care, the clients’ payment methods, and the clients’ satisfaction with care are also informative. Regardless of whether community health nurses or other health services professionals collect these data, the information is essential for those who strive to improve clients’ access to quality health care.
Health services epidemiology focuses on the population’s health care patterns. In particular, public health practitioners are concerned with the accessibility and affordability of services and the barriers that may contribute to excess morbidity in at-risk groups. Traditionally, children are a vulnerable group, and they are a particular focus of health services research. Studies examining poverty rates and care access have underscored the need to expand insurance coverage to those who do not have private medical insurance and do not qualify for Medicaid programs or the State Children’s Health Insurance Program.
Ultimately, nurses must apply epidemiological findings in practice. It is essential that they incorporate study results into prevention programs for communities and at-risk populations. Furthermore, the philosophy of public health and epidemiology dictates that nurses extend their application into major health policy decisions, because the aim of health policy planning is to achieve positive health goals and outcomes for improved population health.
A goal of policy development is to bring about desirable social changes. Epidemiological factors, history, politics, economics, culture, and technology influence policy development. The complex interaction of these factors may explain the challenges with application of epidemiological knowledge. Lung disease in the United States exemplifies the incomplete progress in implementing effective health policy. In the early 1950s, studies identified and conclusively linked cigarette smoking to lung cancer and heart disease (Doll and Hill, 1952). Beginning in the 1950s, public policies to address this health threat have included cigarette taxes, cigarette package warning labels, smoking restrictions in public areas, the institution of smoke-free workplaces, and restrictions on selling tobacco to minors. Despite the successes of the past 60 years, approximately 20% of Americans continue to smoke, with rates particularly high among young adults, suggesting a continued need for focused and effective public health policy. Community health nurses should exercise “social responsibility” in applying epidemiological findings, but doing so will require the active involvement of the consumer. Community health nurses collaborating with community members can combine epidemiological knowledge and aggregate-level strategies to effect change on the broadest scale.
Active Learning Exercise
Consult Healthy People 2020 to find the national goals for selected causes of morbidity and mortality. Identify groups at an increased risk for these selected diseases. What are the approaches suggested by these documents for reducing the rates of disease? How can this information be useful in planning for your community?
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Epidemiological Methods Two epidemiological methods—descriptive epidemiology and analytic epidemiology—are used by community health nurses. This section describes both and gives examples of how they are used in population health.
Descriptive Epidemiology Descriptive epidemiology focuses on the amount and distribution of health and health problems within a population. Its purpose is to describe the characteristics of both people who are protected from disease and those who have a disease. Factors of particular interest are age, sex, ethnicity or race, socioeconomic status, occupation, and family status. Epidemiologists use morbidity and mortality rates to describe the extent of disease and to determine the risk factors that make certain groups more prone to acquiring disease.
In addition to “person” characteristics, the place of occurrence describes disease frequency. For example, certain parasitic diseases, such as malaria and schistosomiasis, occur in tropical areas. Other diseases may occur in certain geopolitical entities. For example, gastroenteritis outbreaks often occur in communities with lax water quality standards. Time is the third parameter that helps define disease patterns. Epidemiologists may track incidence rates over a period of days or weeks (e.g., epidemics of infectious disease) or over an extended period of years (e.g., secular trends in the cancer death rate).
These person, place, and time factors can form a framework for disease analysis and may suggest variables associated with high versus low disease rates. Descriptive epidemiology can then generate hypotheses about the cause of disease, and analytic epidemiology approaches can test these hypotheses (Box 5.7).
BOX 5.7 An Example of Descriptive Epidemiology The person–place–time model is illustrated by two measles outbreaks in Utah:
• Person: Initially, an unvaccinated 15-year-old student had contracted measles, likely from a trip to Europe. Subsequently, six more students contracted the illness.
• Place: Salt Lake County; three cases were “school transmission,” and three cases were “household transmission.”
• Time: The index case traveled to Europe during March 3–17, 2011. He attended school on March 21 and subsequently became ill. The other cases occurred between April 5 and April 17, 2011.
From Centers for Disease Control and Prevention: Two measles outbreaks after importation—Utah, March–June 2011, Morbidity and Mortality Weekly Report 62(12):222–225, 2013. Retrieved from: http://www.cdc.gov/mmwr/pdf/wk/mm6212.pdf.
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FIG. 5.5 Cross-sectional, or prevalence, study.
Analytic Epidemiology Analytic epidemiology investigates the causes of disease by determining why a disease rate is lower in one population group than in another. This method tests hypotheses generated from descriptive data and either accepts or rejects them on the basis of analytic research. The epidemiologist seeks to establish a cause-and-effect relationship between a preexisting condition or event and the disease (see previous section on causality). To determine this relationship, the epidemiologist may undertake two major types of research studies: observational and experimental.
Observational Studies Epidemiologists frequently use observational studies for descriptive purposes, but they also use them to discover the etiology of disease. The investigator can begin to understand the factors that contribute to disease by observing disease rates in groups of people differentiated by experience or exposure. For example, differences in disease rates may occur in the obese compared with the nonobese, in smokers compared with nonsmokers, and in those with high stress levels compared with those with low stress levels. These characteristics (i.e., obesity, smoking, and stress) are called exposure variables.
Unlike experimental studies, observational studies do not allow the investigator to manipulate the specific exposure or experience or to control or limit the effects of other extraneous factors that may influence disease development. For example, life stress is related to depression. People with low socioeconomic status also have high depression rates. People with low socioeconomic status frequently experience greater life stresses; therefore the confounding factor of socioeconomic status makes it more difficult to demonstrate the effect of stress on depression. The three major study designs used in observational research are cross-sectional, retrospective, and prospective studies.
Cross-Sectional Studies Cross-sectional studies, sometimes called prevalence or correlational studies, examine relationships between potential causal factors and disease at a specific time (Fig. 5.5). Surveys that simultaneously collect information about risk factors and disease exemplify this design. For example, the National Health and Nutrition Examination Survey (NHANES) has collected cross- sectional data regarding current dietary practices, physical status, and health in adults and children in the United States since the early 1960s (CDC, 2017). Data from the NHANES studies have been analyzed and compared over the years by a number of researchers and have provided important health information.
For example, NHANES studies have tracked contemporary behavior issues such as unsweetened
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beverage consumption in U.S. youth (Kit et al., 2013) and fast food in adults, showing recent declines in the total daily calories consumed from these sources. Although overall fast-food consumption has declined from approximately 13% of daily caloric intake to 11.3% in the period ending 2010, this decline was not shared by all groups, with non-Hispanic African Americans consuming more fast food than other groups, as did all persons who were overweight (Fryar and Ervin, 2013). NHANES has conducted interviews and physical examinations on youth, nutrient studies on children, and dietary surveys of older Americans, contributing important data that suggest risk factors that can be examined through more rigorous study designs.
Although a cross-sectional study can identify associations among disease and specific factors, it is impossible to make causal inferences because the study cannot establish the temporal sequence of events (i.e., the cause preceded the effect). For example, the NHANES was unable to determine whether high salt intake precedes hypertension—thus making it a causal factor—or whether they are unrelated. Therefore cross-sectional studies have limitations in discovering etiological factors of disease. These studies can help identify preliminary relationships that other analytic designs may explore further; therefore they are hypothesis-generating studies.
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FIG. 5.6 Retrospective, or case-control, study.
Retrospective Studies Retrospective studies compare individuals with a particular condition or disease and those who do not have the disease. These studies determine whether cases, or a diseased group, differ in their exposure to a specific factor or characteristic relative to controls, or a nondiseased group. To make unambiguous comparisons, investigators select the cases according to explicitly defined criteria regarding the type of case and the stage of disease. Investigators also select a control group from the general population that is characteristically similar to the cases (Fig. 5.6).
Frequently, people hospitalized for diseases that are not under study become controls if they do not share the exposure or risk factor under study. For example, a researcher may select patients with heart disease to be controls in a study of patients with lung cancer. However, this choice may introduce serious bias because the two groups often share the risk factor of smoking. The methods of data collection must be the same for both groups to prevent further introduction of bias into the study. Therefore it is desirable for interviewers to remain unaware of which subjects are cases and which are controls.
In retrospective studies, data collection extends back in time to determine previous exposure or risk factors. Investigators analyze study data by comparing the proportion of subjects with disease, or cases, who possess the exposure or risk factors with the corresponding proportion in the control group. A greater proportion of exposed cases than of exposed controls suggests a relationship between the disease and the risk factor.
Investigators often use retrospective study designs because these designs address the question of causality better than cross-sectional studies. Retrospective studies also require fewer resources and less data collection time than prospective studies. Many examples of retrospective, or case-control, studies exist in the literature. One classic example is Doll and Hill’s (1952) investigation of risk factors for lung cancer. They compared exposure rates for cases in which lung cancer was diagnosed with those in the control group, in whom cancer was diagnosed outside the chest and
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oral cavity. The researchers recorded detailed smoking histories in all subjects. Compared with the controls, a significantly higher proportion of patients with lung cancer smoked. This study yielded the hypothesis that smoking may be etiologically related to lung cancer.
Prospective Studies Prospective studies monitor a group of disease-free individuals to determine whether and when disease occurs (Fig. 5.7). These individuals, or the cohort, have a common experience within a defined period. For example, a birth cohort consists of all people born within a given period. The study assesses the cohort with respect to an exposure factor associated with the disease and thus classifies it at the beginning of the study. The study then monitors the cohort for disease development. The investigator compares the disease rates for those with a known exposure and the disease rates for those who remain unexposed. The study observes subjects prospectively; therefore it summarizes data collected over time by the incidence rates of new cases (Box 5.8). Again, comparing two incidence rates produces a measure of relative risk:
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FIG. 5.7 Prospective, or cohort, study.
BOX 5.8 Comparison of Time Factors in Retrospective and Prospective Study Designs Cohort Study
Girls with bacteriuria → Women with renal disease Girls with sterile urine → Women without renal disease
Case-Control Study
Girls with bacteriuria ← Women with renal disease Girls with sterile urine ← Women without renal disease PAST---------------PRESENT (BEGINNING)---------------FUTURE Comparison of time factors in prospective design (i.e., cohort) and retrospective design (i.e.,
case-control) approaches to studying the possible effect of childhood bacteriuria on renal disease in adult women.
The relative risk indicates the extent of excess risk incurred by exposure relative to nonexposure. A relative risk of 1 suggests no excess risk resulting from exposure, whereas a relative risk of 2 suggests twice the risk of having disease from exposure.
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Prospective studies, or longitudinal, cohort, or incidence studies, are advantageous because they obtain more reliable information about the cause of disease than do other study methodologies. These studies establish a stronger temporal relationship between the presumed causal factors and the effect than do retrospective and cross-sectional studies. Calculations of incidence rates and relative risks provide a valuable indicator of the level of risk that exposure creates.
Ethical Insights The Tuskegee Syphilis Study In 1932 the U.S. Public Health Service (PHS) began a longitudinal-experimental study of 600 African American sharecroppers, 399 of whom had syphilis and 201 who did not. The study was conducted in one of the poorest counties of Alabama, and the subjects were unaware that they had syphilis; they were told they were being treated for “bad blood.” Enticed by the promise of free medical care and meals, the subjects joined the study without knowledge of their disease, its treatment, or the study procedures. The experimental group was initially treated with ineffective doses of the treatments of the time—bismuth or mercury—and later with aspirin. Even when penicillin became available in the late 1940s, these subjects were actively denied treatment. For 40 years, these men were followed up by PHS investigators affiliated with the Tuskegee Institute and hospital, who claimed to be observing the differences in the progression of the disease in blacks in comparison with the control group. During the course of the study, many subjects died of syphilis or other causes, numerous wives became infected, and children were born with congenital syphilis.
In 1972, a former venereal disease interviewer, Peter Buxtun, “blew the whistle” on the study, and reports were published in newspapers. Only after the public became outraged about the unethical nature of the study did the CDC and the PHS move to end it. In 1973, the National Association for the Advancement of Colored People won a $10 million class action suit on behalf of the subjects. In 1997, President Bill Clinton formally apologized to the few survivors and their families for the harm inflicted on these men and their families in the name of public health research.
The Tuskegee Study raises questions about how a study could proceed without informing and seeking consent of participants, how available treatment could be withheld, and how government researchers could pursue an unethical research plan without periodic review and questioning. Furthermore, the racial and discriminatory issues suggest disturbing questions for researchers and practicing nurses to contemplate, one being that the Tuskegee Study contributes to a legacy of distrust that minorities may harbor toward both the health care delivery system and research programs. Data from Centers for Disease Control and Prevention: The Tuskegee timeline, 2013. Retrieved from: http://www.cdc.gov/tuskegee/timeline.htm; Infoplease: The Tuskegee syphilis experiment, 2005, Pearson Education. Retrieved from: www.infoplease.com/ipa/A0762136.html.
However, certain disadvantages are inherent in the prospective design. It is costly in terms of resources and staff to monitor a cohort over time, and lengthy studies result in subject attrition. Problems arising from the nature of chronic diseases may compound these logistical dilemmas. Frequently, chronic diseases have long latency periods between exposure and symptom manifestation. Furthermore, the onset of chronic conditions may be insidious, making it extremely difficult to document the incidence of disease. In addition, many diseases do not have a unifactorial cause (i.e., single variable) because many interacting factors influence disease. These problems do not negate the benefits of prospectively designed epidemiological studies; rather, they suggest a need to carefully plan and tailor a study specifically to the disease and the study’s purpose.
The literature contains numerous prospective studies. In many cases, these studies have been instrumental in substantiating causal links between specific risk factors and disease. A classic example is a Doll and Hill cohort study of subjects who eventually developed lung cancer during the follow-up period (1956). Doll and Hill originally completed questionnaires on a cohort of physicians in Great Britain. Next, they classified the subjects according to several variables, emphasizing the number of cigarettes smoked. In 4½ years, they accessed death certificate data. These data revealed a higher mortality rate resulting from lung cancer and coronary thrombosis
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among smoking physicians compared with nonsmokers. The death rate for heavy smokers was 166 per 100,000 versus 7 per 100,000 for nonsmokers. Combining these two incidence rates in a measure of excess risk indicated that heavy smokers were 23.7 times more likely to develop lung cancer than nonsmokers:
These findings in a prospective study provided strong epidemiological support for smoking as a risk factor for lung cancer.
Another well-known prospective study is the Framingham Heart Study, which has followed an essentially healthy cohort of Framingham, Massachusetts residents for more than 50 years. Findings from the study suggested that serum cholesterol level and other risk factors are associated with the future development of cardiovascular disease (Kramarow et al., 2013). The Framingham Study and subsequent “offspring studies” helped form the basis for later experimental studies aimed at reducing serum cholesterol through diet modification or drug therapy to ultimately lower the incidence rate of coronary heart disease.
The Nurses’ Health Study was initiated in 1976 with 121,700 registered nurses, with the intent of examining the long-term consequences of oral contraceptives. The initial cohort still returns questionnaires every 2 years, and data have been collected on diet and nutrition, smoking, hormone use, and menopause as well as various chronic illnesses. In 1989 the Nurses’ Health Study II was initiated to study lifestyle issues, contraception, and illness patterns in younger women, and in 2008 a third study was begun looking at similar issues in another cohort.
These studies continue to monitor nurses’ changing health status and risk factors and to examine factors associated with the development of numerous health conditions in women, such as breast cancer and heart disease (Nurses’ Health Study, 2017). For example, research using Nurses’ Health Study data has determined that regular use of nonsteroidal antiinflammatory drugs (i.e., acetaminophen) does not reduce the incidence of skin cancer (Jeter et al., 2012) or breast cancer (Eliassen et al., 2009). Similarly, research from the nurses’ health studies have shown that although consumption of sugar-sweetened beverages is associated with higher risk of type 2 diabetes, caffeine intake lowers the risk (Bhupathiraju et al., 2013). Last, the Nurses’ Health Study suggested the deleterious effects of exposure to foods containing trans-fats. Groundbreaking research found a 50% increase in cardiovascular disease risk for women who consumed the highest trans-fat intakes (Willet et al., 1993). This initial finding set the stage for sweeping policy changes in FDA labeling of these fats on Nutrition Facts boxes on food packages, on restaurant menus in many cities, and an ultimate 2015 FDA determination that partially hydrogenated oils are not “Generally Recognized as Safe” (Curtis et al., 2016). These changes have led to a reduction in population levels of serum cholesterol.
Experimental Studies Another type of analytic study is the experimental design, called the randomized clinical trial (Fig. 5.8). Epidemiological investigations apply experimental methods to test treatment and prevention strategies. The investigator randomly assigns subjects at risk for a particular disease to an experimental or a control group. The investigator observes both groups for the occurrence of disease over time, but only the experimental group receives intervention, although often the control group receives a placebo. The primary statistical analysis is based on “intention to treat,” that is, all subjects remain assigned to the original treatment group, regardless of whether subjects may have decided on their own to discontinue or change their therapy. For example, if a subject in a drug trial who is assigned to the active medication experiences side effects possibly from this medication and therefore discontinues the medication, this subject still is considered to be within the active drug group for the purpose of statistical testing. The change in category from treatment to no treatment, or vice versa, is called a crossover and may decrease the likelihood of finding a significant effect for
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the active treatment. Theoretically, it is possible to introduce a harmful exposure or risk factor as the experimental
factor; however, ethical considerations usually prohibit the use of human subjects for these purposes. For example, it is unacceptable to require an experimental group to smoke cigarettes in an experiment; therefore the investigator uses case-control or cohort epidemiological designs. This limitation usually restricts experimental epidemiological studies to prophylactic and therapeutic clinical trials. Experimental studies testing vaccines and medications for safety and efficacy are examples.
The experimental design is also useful for investigating chronic disease prevention. Thus experimental studies may help evaluate community health nursing interventions. For example, they may help determine the effectiveness of a sex education program in preventing high rates of teenage pregnancy or the feasibility of an AIDS prevention program among intravenous drug users. Randomized trials were used to evaluate the Nurse-Family Partnership program, which established the long-term positive effects nurse home visits had on high-risk pregnant women and their children in comparison with those who did not receive home visits (Olds et al., 2014).
FIG. 5.8 Experimental study, or clinical trial.
case Study Application of the Nursing Process Using an Epidemiological and Public Health Approach to Managing a Foodborne Outbreak Nurses working in schools, daycare centers, camps, and other facilities where food is served must be cognizant of safe food-handling principles. Furthermore, they must be aware of the potential for transmitting disease if proper procedures are not followed. Outbreaks of foodborne illness must be assessed and managed, and often it is the community health nurse who initiates and participates in this process. The following is a scenario in which the nurse utilized the nursing process to analyze and intervene in such an epidemic. Assessment On Wednesday, October 4, the school nurse at Greenly Elementary School saw eight students who complained of abdominal cramping, diarrhea, and fever. Parents of the sick students were called,
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and the students were sent home. On Thursday, the nurse was alerted to a large number of absent students and teachers. Specifically, 62 students and 10 teachers were absent. Most reported diarrhea symptoms. Because the absentee rate of 10% exceeded the average daily rate of 4% for the 620-student school and because the nurse determined that the large number of diarrhea cases suggested an epidemic, the local public health department was notified.
Public health officials arrived at the school and began to assess students still at school and those who were recovering at home. Stool culture specimens were collected and sent to the state laboratory. Results indicated that the organism causing illness was in most cases Shigella sonnei, the most commonly found form of the bacteria. Persons with severe symptoms were referred to their physicians for possible antibiotic therapy. Food histories of meals eaten both at school and outside of school were taken.
Friday saw a continuing increase in absenteeism of students and staff reporting gastrointestinal illness. Public health specialists defined the criteria for identifying cases on the basis primarily of positive laboratory results, symptoms of diarrhea or vomiting, fever with nausea or abdominal pain, or all of these. Cafeteria staff were interviewed, and it was determined that one staff member had had diarrhea over the previous weekend but had returned to work on Monday. Public health staff continued to take dietary histories of affected and unaffected persons and constructed rates of illness for all foods served in the cafeteria beginning on Friday of the previous week. These data are displayed in the following table.
From the data, it can be seen that students who ate lunch at school on Tuesday and ate fajitas and salad had higher rates of illness than those who did not. Therefore it was concluded that the outbreak of Shigella could be attributed to a food source. Diagnosis Determining the likely cause of the outbreak was important in specifying a diagnosis and directing the planning of an intervention. The following diagnosis was formulated:
Increased risk for infectious diarrhea among elementary school children related to inadequate hygiene and food-handling practices as evidenced by a 19% increase in reported cases within a 4- day period. Planning The school nurse, in conjunction with public health specialists, determined that several groups should be targeted in order to eliminate the further spread of disease. They identified a need to assist families in understanding the nature of the disease, how to care for their children who were ill, and how to prevent the spread at home. Within the school, there was a need to review food- handling practices and the training that cafeteria workers received. Staff, including teachers, also required information about Shigella and how it should be prevented in the everyday lives of students. Needs of special ages and developmental levels of children were also important. A formal plan of what needed to be done, by whom, and when was drawn up. Research into the nature and prevention of Shigella was gathered from the CDC and the local health department, among other sources. Health department staff developed a plan to release information to the public about the prevention of gastrointestinal illnesses, as many of these diseases are easily spread and so many students were already ill. Long-Term Goal
• An absence of cases of infectious diarrhea
Short-Term Goals
• Treatment and recovery of all identified cases of diarrhea • Implementation of an effective program of hygienic practices among students and staff • Implementation of a food-handling program for all cafeteria workers • Adequate informing of the larger community in order to prevent spread of the epidemic
Intervention The school nurse took a central leadership role, directing action within the school aimed at staff,
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students, and student families. Teaching of appropriate hand washing was stressed. Hand-washing facilities were inspected for soap, paper towels, and running water. Food preparation guidelines were reviewed with staff, and policies regarding remaining at home when ill were reiterated. The health department staff provided technical assistance and made recommendations. They informed community physicians about surveillance and reporting requirements and provided information regarding case identification and treatment regimens. Daycare centers and preschools were advised to watch for diarrhea outbreaks and to adhere to strict hand-washing and diaper-handling practices, as these facilities tend to be high-risk areas for the transmission of organisms such as Shigella. The media were contacted to elicit their help in disseminating correct and useful information to the community. Evaluation Immediate evaluation involved monitoring the decline in Shigella cases both within the school and in the larger community. The school nurse noted that rates of absenteeism returned to normal on the following Monday. She determined that all classes had received hygiene instruction within the following 2 weeks and that all teachers had received a flyer with specific information about Shigella, its care, and its prevention. She observed that bathrooms had filled soap dispensers, that friendly signs reminding students to wash hands were posted near sinks, and that students were given the opportunity to wash hands before lunch and snacks. The public health department likewise continued surveillance activities after encouraging physicians to collect and submit stool culture specimens for suspected cases and to report cases to the health department. Rates of diarrhea declined rapidly in the week after the school outbreak. The infection did not spread to other schools or community groups. This outcome can be attributed to successful epidemic management, yet surveillance remains critical if the public’s health is to be protected. Levels of Prevention Primary
• Teach students and staff about hand washing and hygienic practices. • Maintain a system that promotes safe food-handling practices. • Exclude those with symptoms from school or food handling.
Secondary
• Collect stool culture specimens from all symptomatic individuals. • Treat those with advanced diarrhea symptoms with antibiotics. • Exclude those with positive culture results from food handling, and exclude those with
symptoms from school. • Advise families and individuals in the care of those with diarrhea.
Tertiary
• Treat and counsel those determined to be carriers of Shigella.
Information on Shigella infections is available at https://www.cdc.gov/shigella/index.html
Number Exposed by Meal and Food Item (N = 143)
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∗ Odds ratios were calculated with the formula: ad/bd.
Modified from Texas Department of Health: Shigella outbreak in an elementary school, Dis Prev News 55(6):1–3, 1995.
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Summary Epidemiology offers the community health nurse methods to quantify the extent of health problems in the community and provides a body of knowledge about risk factors and their association with disease. At each step of the nursing process, epidemiological applications support the practice of the community health nurse. Compiling descriptive data from surveys or studies contributes to the nurse’s understanding of the community’s health level. In assessing community problems, epidemiological rates describe the magnitude of disease and provide support for community diagnoses. Epidemiological studies suggest interventions and their potential efficacy—information that is useful in planning prevention and intervention approaches. Evaluation studies using epidemiological methods, either reported in the literature or conducted by community health nurses, are essential for providing optimal research-based care.
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Learning Activities Evolve Website
http://evolve.elsevier.com/Nies/community
• NCLEX Review Questions • Case Studies
Genetics in Public Health
Community-Based Research for the Prevention of Anencephaly A nurse-led investigation in Washington State exposed a cluster of infants born with anencephaly in a three county region between 2010 and 2015. Subsequent investigation revealed almost five times greater incidence of anencephaly in the counties in question when compared with rates the U.S. (9.5 per 10,000 in select Washington counties vs 2.1 per 10,000 nationwide). Preliminarily review showed that cases were much more commonly identified among Hispanic infants, suggesting that cultural and genetic factors were contributory. Among the risk factors identified were increased dietary consumption of non-fortified corn-based foods, rather than wheat-based products. Also noted were defects in folic acid metabolism among mothers of Hispanic ancestry.
Strategies to address and ultimately reduce the number of babies born with anencephaly were to enhance surveillance activities including both active and passive case finding, counseling to reduce risk factors including stressing the importance of folic acid intake, participating in research, and advocating policy change to protect patients from preventable birth defects, Barron, S: Anencephaly: An ongoing investigation in Washington state. AJN, 116(3), 60-66.
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Community Assessment Holly B. Cassells
OUTLINE
The Nature of Community Aggregate of People Location in Space and Time Social System
Healthy Communities Assessing the Community: Sources of Data
Census Data Vital Statistics Other Sources of Health Data
Needs Assessment Diagnosing Health Problems
OBJECTIVES
Upon completion of this chapter, the reader will be able to do the following: 1. Discuss the major dimensions of a community. 2. Identify sources of information about a community’s health. 3. Describe the process of conducting a community assessment. 4. Formulate community and aggregate diagnoses. 5. Identify uses for epidemiological data at each step of the nursing process.
KEY TERMS aggregate census tracts community diagnosis community of solution geographic community metropolitan statistical areas needs assessment social system vital statistics
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windshield survey The primary concern of community health nurses is to improve the health of the community. To address this concern, community health nurses use all the principles and skills of nursing and public health practice. This process involves using demographic and epidemiological methods to assess the community’s health and diagnose its health needs.
Before beginning this process, the community health nurse must define the community. The nurse may wonder how he or she can provide services to such a large and nontraditional “client,” but there are smaller and more circumscribed entities that constitute a community than towns and cities. A major aspect of public health practice is the application of approaches and solutions to health problems that ensure that the majority of people receive the maximum benefit. To this end, the nurse works to use time and resources efficiently.
Despite the desire to provide services to each individual in a community, the community health nurse recognizes the impracticality of this task. An alternative approach considers the community itself to be the unit of service and works collaboratively with the community using the steps of the nursing process. Therefore the community is not only the context or place where community health nursing occurs; it is the focus of community health nursing care. The nurse partners with community members to identify community problems and develop solutions to ultimately improve the community’s health.
Another central goal of public health practitioners is primary prevention, which protects the public’s health and prevents disease development. Chapter 3 discusses how these “upstream efforts” are intended to reduce the pain, suffering, and huge expenditures that occur when significant segments of the population essentially “fall into the river” and require downstream resources to resolve their health problems. In a society greatly concerned about increasingly high health care costs, the need to prevent health problems becomes dire. In addition to reducing the occurrence of disease in individuals, community health nurses must examine the larger aggregate— its structures, environments, and shared health risks—to develop improved upstream prevention programs.
This chapter addresses the first steps in adopting a community- or population-oriented practice. A community health nurse must define a community and describe its characteristics before applying the nursing process. Then, the nurse can launch the assessment and diagnosis phase of the nursing process at the aggregate level and incorporate epidemiological approaches. Comprehensive assessment data are essential to directing effective primary prevention interventions within a community.
Gathering these data is one of the core public health functions identified in the Institute of Medicine’s (2002) report on the future of public health. The community health nurse participates in assessing the community’s health and its ability to deal with health needs. With sound data, the nurse makes a valuable contribution to health policy development and population-based interventions.
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The Nature of Community Many dimensions describe the nature of community. These include an aggregate of people, a location in space and time, and a social system (Box 6.1).
Aggregate of People An aggregate is a community composed of people who have common characteristics. For example, members of a community may share residence in the same city, membership in the same religious organization, or similar demographic characteristics such as age and ethnic background. The aggregate of senior citizens, for example, comprises primarily retirees who frequently share ages, economic pressures, life experiences, interests, and concerns. This group lived through the many societal changes of the past 50 years; therefore they may possess similar perspectives on current issues and trends. Many elderly people share concern for the maintenance of good health, the pursuit of an active lifestyle, and the security of needed services to support a quality life. These shared interests translate into common goals and activities, which also are defining attributes of a common interest community. Communities also may consist of overlapping aggregates, in which case some community members belong to multiple aggregates.
Many human factors help delineate a community. Health-related traits, or risk factors, are one aspect of “people factors” to be considered. People who have impaired health or a shared predisposition to disease may join together in a group or community to learn from and support each other. Parents of disabled infants, people with acquired immunodeficiency syndrome (AIDS), or those at risk for a second myocardial infarction may consider themselves a community. Even when these individuals are not organized, the nurse may recognize that their unique needs constitute a form of community, or aggregate.
A community of solution may form when a common problem unites individuals. Although people may have little else in common with each other, their desire to redress problems brings them together. Such problems may include a shared hazard from environmental contamination, a shared health problem arising from a soaring rate of teenage suicide, or a shared political concern about an upcoming city council election. The community of solution often disbands after problem resolution, but it may subsequently identify other common issues.
BOX 6.1 Major Features of a Community
• Aggregate of people The “who”: personal characteristics and risks
• Location in space and time The “where” and “when”: physical location frequently delineated by boundaries and
influenced by the passage of time • Social system
The “why” and “how”: interrelationships of aggregates fulfilling community functions
Each of these shared features may exist among people who are geographically dispersed or in close proximity to one another. However, in many situations, proximity facilitates the recognition of commonality and the development of cohesion among members. This active sharing of features fosters a sense of community among individuals.
Location in Space and Time Regardless of shared features, geographic or physical location may define communities of people. Traditionally, a community is an entity delineated by geopolitical boundaries; this view best exemplifies the dimension of location. These boundaries demarcate the periphery of cities, counties, states, and nations. Voting precincts, school districts, water districts, and fire and police protection
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precincts set less visible boundary lines. Census tracts subdivide larger communities. The U.S. Census Bureau uses them for data
collection and population assessment. Census tracts facilitate the organization of resident information in specific community geographic locales. In densely populated urban areas, the size of tracts tends to be small; therefore data for one or more census tracts frequently describe neighborhood residents. Although residents may not be aware of their census tract’s boundaries, census tract data help define and describe neighborhood communities.
Research Highlights
Using Community Participatory Research to Assess Substance Use in a Rural Community Kulbok and colleagues (2012) employed a Community Participatory Model to guide the assessment of youth substance abuse in a rural Virginia county and the development of a prevention model. They integrated multiple assessment modalities that represent current public health nursing competencies. Specifically, this project engaged local community members and leaders with community health professionals in every step of the project, from planning the assessment to developing and evaluating the intervention. This process allowed public health nurses to integrate their knowledge of the local community with that gained from community partners and to develop a deeper understanding of substance use and its local ecological and cultural context.
Researchers used a geographic information system not only to map the location of youth substance use but also to pinpoint areas where preventive behaviors were more common. These maps helped specifically target the location for preventive interventions. Perspectives of the youth about key “teen places” were also geographically mapped. The project used the photographic charity Photovoice to capture participants’ descriptions of local strengths as well as concerns and then employed the images to facilitate conversation about the nature of alcohol, tobacco, and substance use in the community. Qualitative data about youth beliefs about substance use were gathered from focus groups. These data were combined with descriptive information about the local population, the community environment, and local social systems and beliefs to develop a comprehensive picture of the local community. Involvement of a broad range of community members throughout the project planning enabled a more effective, culturally appropriate, and sustainable intervention to be developed for this rural community. Data from Kulbok PA, Thatcher E, Park E, et al.: Evolving public health nursing roles: focus on community participatory health promotion and prevention, Online J Issues Nurs 17(2):1, 2012. Retrieved from http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol- 17-2012/No2-May-2012/Evolving-Public-Health-Nursing-Roles.html.
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FIG. 6.1 Current smokers, percent of adults by tract, BRFSS 500 Cities Project, 2014. Location, Rapid City, South Dakota. Community Commons. Retrieved from www.communitycommons.org.
A geographic community can encompass less formalized areas that lack official geopolitical boundaries. A geographic landmark may define neighborhoods (e.g., the East Lake section of town or the North Shore area). A particular building style or a common development era also may identify community neighborhoods. Similarly, a dormitory, a communal home, or a summer camp may be a community because each facility shares a close geographic proximity. Geographic location, including the urban or rural nature of a community, strongly influences the nature of the health problems a community health nurse might find there. Public health is increasingly recognizing that the interaction of humans with the natural environment and with constructed environments consisting of buildings and spaces, termed the built environment, is critical to healthy behavior and quality of life. The spatial location of health problems in a geographic area can be mapped with the use of geographic information system software, assisting the nurse to identify vulnerable populations and public health departments to develop programs specific to geographic communities. For example, public health practitioners can map the distribution of smoking, the prevalence of hypertension, or the presence of areas classified as “food deserts” to help specifically target areas for intervention (Fig. 6.1).
Location and the dimension of time define communities. The community’s character and health problems evolve over time. Although some communities are very stable, most tend to change with the members’ health status and demographics and the larger community’s development or decline. For example, the presence of an emerging young workforce may attract new industry, which can alter a neighborhood’s health and environment. A community’s history illustrates its ability to
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change and how well it addresses health problems over time.
Social System The third major feature of a community is the relationships that community members form with one another. Community members fulfill the essential functions of community by interacting in groups. These functions provide socialization, role fulfillment, goal achievement, and member support. Therefore a community is a complex social system, and its interacting members constitute various subsystems within the community. These subsystems are interrelated and interdependent (i.e., the subsystems affect one another and affect various internal and external stimuli). These stimuli consist of a broad range of events, values, conditions, and needs.
A health care system is an example of a complex system that consists of smaller, interrelated subsystems. A health care system can also be a subsystem because it interacts with and depends on larger systems such as the city government. Changes in the larger system can cause repercussions in many subsystems. For example, when local economic pressures cause a health department to scale back its operations, many subsystems are affected. The health department may eliminate or cut back programs, limit service to other health care providers, reduce access to groups that normally use the system, and deny needed care to families who constitute subsystems in society. Almost every subsystem in the community must react and readjust to such a financial constraint.
Prevalent health problems also can have a severe impact on multiple systems. For example, the AIDS epidemic required significant funds for clients with this condition and for public education and prevention. It made unrelenting demands on many communities that were already strapped for funds to meet their citizens’ basic health needs. In San Francisco, the allocation of funds for AIDS programs initially reduced funding for other programs, such as immunizations, family planning, and well-child care.
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Healthy Communities Complex community systems receive many varied stimuli. The community’s ability to respond effectively to changing dynamics and meet the needs of its members indicates productive functioning. Examining the community’s functions and subsystems provides clues to existing and potential health problems. Examples of a community’s functions include the provision of accessible and acceptable health services; educational opportunities; and safe, crime-free environments.
The model in Fig. 6.2 suggests assessment parameters that can help a nurse develop a more complete list of critical community functions. The community health nurse can then prioritize these functions from a particular community’s perspective. Americans’ views on health and healthy communities frequently reflect concern for quality-of-life issues over the absence of disease, and in particular safety and low levels of crime are of high priority. These findings are echoed in city- sponsored health surveys across the nation: ensuring safe and healthy environments that allow for healthy lifestyles, which include activity and nutritious food, is as important to residents as accessing quality health care.
Movements such as Healthy Cities and Healthy Places urge community members and leaders to bring about positive health changes in their local environments (CDC, 2014; World Health Organization, 2017). Involving many cities around the nation and world, these models stress the interconnectedness among people and the public and private sectors essential for local communities to address the causes of poor health. In particular, examining the role the “built environment” has on community health (e.g., its physical and environmental design) is an increasing priority (Robert Wood Johnson Foundation, 2017). Urban communities are encouraged to consider the health consequences of new policies and programs they introduce by conducting health impact assessments (Pew Charitable Trusts, 2017). These assessments of projects, such as the potential impact of zoning decisions, transit systems, and sick leave policies, serve the important function of bringing a public health perspective to urban and civic initiatives.
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FIG. 6.2 Diagram of assessment parameters. Modified from Anderson ET, McFarlane J: Community as partner: theory and practice in nursing ed 7,
Philadelphia, PA, 2015, Wolters Kluwer.
Each community and aggregate presumably will have a unique perspective on critical health qualities. Indeed, a community or aggregate may have divergent definitions of health, differing even from that of the community health nurse. Nevertheless, nurses and health professionals work with communities in developing effective solutions that are acceptable to residents. Building a community’s capacity to address future problems is often referred to as developing community competence. The nurse assesses the community’s commitment to a healthy future, the ability to foster open communication and to elicit broad participation in problem identification and resolution, the active involvement of structures such as a health department that can assist a community with health issues, and the extent to which members have successfully worked together on past problems. This information provides the nurse with an indication of the community’s strengths and potential for developing long-term solutions to identified problems.
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Assessing the Community: Sources Of Data The community health nurse becomes familiar with the community and begins to understand its nature by traveling through the area. The nurse begins to establish certain hunches or hypotheses about the community’s health, strengths, and potential health problems through this down-to-earth approach, called shoe leather epidemiology. The community health nurse must substantiate these initial assessments and impressions with more concrete or defined data before he or she can formulate a community diagnosis and plan.
Windshield Survey
Brookshire is a town of about 3500 in Southeast Texas.
Sugar mills and farms are the source of most jobs.
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Accessible and affordable health care is a challenge. This van provides services to unskilled workers and area elders.
The economy of the town is predominantly agriculture and processing.
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The car’s thermometer shows 99°, evidence of a pervasive health threat in the summertime.
Much of the housing is substandard and suggests low-income families.
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Many people live in small homes on multiple-acre lots.
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The important determinants of a health community include a low crime rate, a good place to bring up children, good schools, a strong family life, good environmental quality, and a healthy economy. (iStock 540095516, 683792276, 504534788, 470237304, 638480042) Photos courtesy of University of Texas Health Science Center at Houston, School of Nursing, Community Health Division.
Community health nurses often perform a community windshield survey by driving or walking through an area and making organized observations. See illustrations depicting an actual “windshield survey” in this chapter’s photo novella. The nurse can gain an understanding of the environmental layout, including geographic features and the location of agencies, services, businesses, and industries, and can locate possible areas of environmental concern through “sight, sense, and sound.” The windshield survey offers the nurse an opportunity to observe people and their role in the community. Box 6.2 provides examples of questions to guide a windshield survey assessment.
In addition to direct observational methods, certain public health tools become essential to an aggregate-focused nursing practice. The analysis of demographic information and statistical data provides descriptive information about the population. Epidemiology involves the analysis of health data to discover the patterns of health and illness distribution in a population. Epidemiology also involves conducting research to explain the nature of health problems and identify the aggregates at increased risk. The rest of this section provides data sources and describes how the community health nurse can use demographic and epidemiological data to assess the aggregate.
Active Learning Exercise
Walk through a neighborhood, and describe the sensory information (i.e., smells, sounds, and sights). How does each relate to the community’s health?
BOX 6.2 Questions to Guide Community Observations During a Windshield Survey
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1. Community vitality: • Are people visible in the community? What are they doing? • Who are the people living in the neighborhood? What is their age range? What is
the predominant age (e.g., elderly, preschoolers, young mothers, or school-aged children)?
• What ethnicity or race is most common? • What is the general appearance of those you observed? Do they appear healthy?
Do you notice any people with obvious disabilities, such as those using walkers or wheelchairs, or those with mental or emotional disabilities? Where do they live?
• Do you notice residents who are well nourished or malnourished, thin or obese, vigorous or frail, unkempt or scantily dressed, or well dressed and clean?
• Do you notice tourists or visitors to the community? • Do you observe any people who appear to be under the influence of drugs or
alcohol? • Do you see any pregnant women? Do you see women with strollers and young
children? 2. Indicators of social and economic conditions:
• What is the general condition of the homes you observe? Are these single-family homes or multifamily structures? Is there any evidence of dilapidated housing or of areas undergoing urban renewal? Is there public housing? What is its condition?
• What forms of transportation do people seem to be using? Is there public transit? Are there adequate bus stops with benches and shade? Is transportation to health care resources available?
• Are there any indicators of the kinds of work available to residents? Are there job opportunities nearby, such as factories, small businesses, or military installations? Are there unemployed people visible, such as homeless people?
• Do you see men congregating in groups on the street? What do they look like, and what are they doing?
• Is this a rural area? Are there farms or agricultural businesses? • Do you note any seasonal workers, such as migrant or day laborers? • Do you see any women hanging out along the streets? What are they doing? • Do you observe any children or adolescents out of school during the daytime? • Do you observe any interest in political campaigns or issues, such as campaign
signs? • Do you see any evidence of health education on billboards, advertisements, signs,
radio stations, or television stations? Do these methods seem appropriate for the people you observed?
• What kinds of schools and day care centers are available? 3. Health resources:
• Do you notice any hospitals? What kind are they? Where are they located? • Are there any clinics? Whom do they serve? Are there any family planning
services? • Are there doctors’ and dentists’ offices? Are they specialists or generalists? • Do you notice any nursing homes, rehabilitation centers, mental health clinics,
alcohol or drug treatment centers, homeless or abused shelters, wellness clinics, health department facilities, urgent care centers, mobile health vehicles, blood donation centers, or pharmacies?
• Are these resources appropriate and sufficient to address the kinds of problems that exist in this community?
4. Environmental conditions related to health: • Do you see evidence of anything that might make you suspicious of ground,
water, or air pollutants? • What is the sanitary condition of the housing? Is housing overcrowded, dirty, or in
need of repair? Are windows screened? • What is the condition of the roads? Are potholes present? Are drainage systems in
place? Are there low water crossings, and do they have warning signals? Are there adequate traffic lights, signs, sidewalks, and curbs? Are railroad crossings fitted
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with warnings and barriers? Are streets and parking lots well lit? Is this a heavily trafficked area, or are roads rural? Are there curves or features that make the roads hazardous?
• Is there handicapped access to buildings, sidewalks, and streets? • Do you observe recreational facilities and playgrounds? Are they being used? Is
there a YMCA/YWCA or community center? Are there any daycare facilities or preschools?
• Are children playing in the streets, alleys, yards, or parks? • Do you see any restaurants? • Is food sold on the streets? Are people eating in public areas? Are there trash
receptacles and places for people to sit? Are public restrooms available? • What evidence of any nuisances such as ants, flies, mosquitoes, or rodents do you
observe? Are there stray animals wandering in the neighborhood? 5. Social functioning:
• Do you observe any families in the neighborhoods? Can you observe their structure or functioning? Who is caring for the children? What kind of supervision do they have? Is more than one generation present?
• Are there any identifiable subgroups related to one another either socially or geographically?
• What evidence of a sense of neighborliness can you observe? • What evidence of community cohesiveness can you observe? Are there any group
efforts in the neighborhood to improve the living conditions or the neighborhood? Is there a neighborhood watch? Do community groups post signs for neighborhood meetings?
• How many and what type of churches, synagogues, and other places of worship are there?
• Can you observe anything that would make you suspicious of social problems, such as gang activity, juvenile delinquency, drug or alcohol abuse, and adolescent pregnancy?
6. Attitude toward health and health care: • Do you observe any evidence of folk medicine practice, such as a botánica or
herbal medicine shop? Are there any alternative medicine practitioners, such as healers or curanderos?
• Do you observe that health resources are well utilized or underutilized? • Is there evidence of preventive or wellness care? • Do you observe any efforts to improve the neighborhood’s health? Planned health
fairs? Do you see advertisements for health-related events, clinics, or lectures?
Census Data Every 10 years, the U.S. Census Bureau undertakes a massive survey of all American families. In addition to this decennial census, intermediate surveys collect specific types of information. These collections of statistical data describe the population characteristics of the nation within progressively smaller geopolitical entities (e.g., states, counties, and census tracts). The census also describes large metropolitan areas that extend beyond formal city boundaries, called metropolitan statistical areas (MSAs). An MSA consists of a central city with more than 50,000 people and includes the associated suburban or adjacent counties, which yields a total metropolitan area with more than 100,000 people. Adjacent MSAs with their associated cities and counties constitute very large metropolitan regions called combined statistical areas. A census tract is one of the smallest reporting units. It usually consists of 3000 to 6000 people who share characteristics such as ethnicity, socioeconomic status, and housing class.
The census is extremely helpful to community health nurses familiarizing themselves with a new community. The census tabulates many demographic variables, including population size and the distribution of age, sex, race, and ethnicity. The American Community Survey, conducted annually, reports social data such as income, poverty, and occupational factors. Both data sets can be accessed through use of the Census Bureau’s American Factfinder tools—available at http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml—where the nurse can view several variables in combination (e.g., age and ethnicity). One can easily construct a community profile and
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compare trends with those in other communities. Note that variables that describe the community’s health are not part of census data. However, census numbers are frequently used as denominators for morbidity and mortality rates (see Chapter 5).
The nurse analyzes and interprets data by comparing current and local census data with previous data and information from various locations to pinpoint key local differences and changes over time. The nurse can identify the attributes that make each community unique by comparing data for one census unit, such as a census tract or a city, with those of another community or the entire nation. These attributes provide clues to the community’s potential vulnerabilities or health risks. For example, a community health nurse may review census reports and discover that a district has many elderly people. This knowledge directs the nurse toward further assessment of the social resources (i.e., housing, transportation, and community centers), health resources (i.e., hospitals, nursing homes, and geriatric clinics), and health problems common to aging people. By identifying the trends in the population over time, the community health nurse can modify public health programs to meet the changing needs of the community.
Ethical Insights Attending to Nondominant Trends: “Hidden Pockets” of Need Whereas most public health practitioners are attuned to the leading indicators or dominant trends in data, vital statistics or census data can suggest the existence of small “hidden pockets” of people with special needs. One nurse initially assessed her community as being in an upper-middle-class bracket. She was surprised to find 20 families living below the poverty level and 3 families living without running water. Although these 20 families made up far less than 1% of the community population, they nevertheless necessitated the attention of the community health nurse. Some may view a focus on such a minority segment as insignificant and in conflict with the “rule of utility,” which posits “the greatest good for the greatest number.” However, community health nursing practice combines principles of beneficence and social justice with utilitarianism, and thus small vulnerable segments of the community are considered legitimate clients of community health nursing. Indeed, social justice not only “gives moral privilege to the needs of the most vulnerable” but also suggests the amelioration of conditions that create social and economic disparities (Boutain, 2016). Furthermore, nurses recognize that this “hidden pocket” is a small piece of the total community and, as such, contributes to its overall health. By attending to these families’ health needs, the nurse positively affects the health of the whole.
Vital Statistics The official registration records of births, deaths, marriages, divorces, and adoptions form the basis of data in vital statistics. Every year, city, county, and state health departments aggregate and report these events for the preceding year. When compared with those from previous years, vital statistics provide indicators of population growth or reduction. In addition to supplying information about the number of births and deaths, registration certificates record the causes of death, which is useful in determining morbidity and mortality trends. Similarly, birth certificates document birth information (e.g., cesarean delivery, prenatal care, and teen mothers) and the occurrence of any congenital malformations. This information also is important in assessments of the community’s health status.
Other Sources of Health Data The U.S. Census Bureau conducts numerous surveys on subjects of government interest, such as crime, housing, and labor. Results of these surveys, the census reports, and vital statistics reports are usually available through public libraries and on the Internet. The National Center for Health Statistics (NCHS) compiles annual National Health Interview Survey data, which describe health trends in a national sample. The NCHS publishes reports on the prevalence of disability, illness, and other health-related variables. Specifically, the Behavioral Risk Factor Surveillance System is the world’s largest telephone survey of U.S. citizens’ health behaviors and risk factors. It tracks trends by nation, state, and year, with the goal of identifying emerging health problems. Data also
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are used to evaluate achievement of health objectives and develop prevention strategies. The Behavior Risk Factor Surveillance System’s website allows one to compile graphs and maps to describe specific risk behaviors by state (http://www.cdc.gov/brfss/).
In addition to these important sources of information, community health nurses can access a broad range of local, regional, and state government reports that contribute to the comprehensive assessment of a population. Local agencies, chambers of commerce, and health and hospital districts collect invaluable information on their community’s health. Local health planning agencies also compile and analyze statistical data during the planning process. The community health nurse can use all of these formal and informal resources in learning about a community or aggregate (Table 6.1). Box 6.3 lists additional information about sources of population health data.
Formal data collection does not exist for all community aspects; therefore many community health nurses must perform additional data collection, compilation, and analysis. For example, school nurses regularly use aggregate data from student records to learn about the demographic composition of their population. They conduct ongoing surveys of classroom attendance and causes of illness, which are essential to an effective school health program. Sometimes the nurse must screen the entire school population to discover the extent of a disease. Thus the school nurse is both a consumer of existent data and a researcher who collects new data for the assessment of the school community.
TABLE 6.1
Community Assessment Parameters
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CHN, Community health nursing.
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Needs Assessment The nurse must understand the community’s perspective on health status, the services it uses or requires, and its concerns. Most official data do not capture this type of information. Data collected directly from an aggregate may be more insightful and accurate; therefore community health nurses sometimes conduct community needs assessments. There are several approaches to gathering subjective data; however, a nurse’s careful planning of the process will contribute to its reliability and utility regardless of the method. Box 6.4 presents the required steps in conducting a needs assessment.
The strategy chosen for collecting needs assessment data depends on the size and nature of the aggregate, the purpose for collecting information, and the resources available to the nurse. In some cases, the nurse may survey a small sample of clients to measure their satisfaction with a program. In other situations, a large-scale community needs assessment may help the nurse determine gaps in service. Although the process of needs assessment can indicate a program’s strengths and weaknesses, it can also raise expectations for new services on the part of community members. Involving community members in the planning of the assessment builds trust and ownership in the process, and subsequently in the improvements that result. With the implementation of the U.S. Patient Protection and Affordable Care Act, nonprofit hospitals must conduct comprehensive community health needs assessments, often called CHNAs, which create an important opportunity to coordinate with public health agencies to more effectively make decisions and strategically plan to address local health needs (Community Commons, 2017; National Association of County and City Health Officials [NACCHO], 2017).
BOX 6.3 Retrieval of Data Current data on U.S. population health are stored in many places. Finding the latest statistics at the local, state, or national level can be a challenging experience for a student, community health nurse, graduate student, or nurse researcher. However, statistics provide a necessary comparison in identifying the health status of an aggregate or population in a community. The following guidelines suggest places to begin a search. Reference Librarian The best place to start is in a school or community library or in a large university’s health sciences library. Cultivate a relationship with the reference librarian and learn how to access the literature of interest (e.g., government documents) or how to perform computer-guided literature searches. Government Documents Local libraries have a listing of government depository libraries, which house government documents for the public. If the government document is not available at a local library, ask the reference librarian to contact a regional or state library for an interlibrary loan. The Library of Congress in Washington, D.C., has a Directory of U.S. Government Depository Libraries. Health, United States An annual publication of the National Center for Health Statistics (2017), Health, United States reports the latest health statistics for the country. It presents statistics in areas such as maternal– child health indicators (e.g., prenatal care, low birth weight, and infant mortality), life expectancy, mortality, morbidity (e.g., cancer incidence and survival, AIDS, and diabetes), environmental health indicators (e.g., air pollution and noise exposure), and health system use (e.g., national health expenditures, health insurance coverage, physician contacts, and diagnostic and surgical procedures). Graphs and tables are easy to read and interpret with accompanying texts. Many statistics include a selected number of years to illustrate trends. Some statistics are compared with those from other countries and U.S. minority populations. (For more information, visit http://www.cdc.gov/nchs/hus/index.htm.) Morbidity and Mortality Weekly Report (MMWR) The CDC in Atlanta, Georgia, prepares this publication. State health departments compile weekly reports for the publication that outline the numbers of cases of notifiable diseases such as AIDS, gonorrhea, hepatitis, measles (rubeola), pertussis, rubella, syphilis, tuberculosis, and rabies and
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reports the deaths in 122 U.S. cities by age. It also reports accounts of interesting cases, environmental hazards, disease outbreaks, or other public health problems. Local and state health departments and many local and health sciences libraries house this weekly publication. A subscription is available at http://www.cdc.gov/mmwr/. Centers for Disease Control and Prevention The CDC compiles information on a range of topics, including health behavior, educational and community-based programs, unintentional injuries, occupational safety and health, environmental health, oral health, diabetes and chronic disabling conditions, communicable disease, immunizations, clinical preventive services, and surveillance and data systems. Data are reported in several publications and on the website: http://www.cdc.gov/.
BOX 6.4 Steps in the Needs Assessment Process
1. Identify aggregate for assessment. 2. Engage community in planning the assessment. 3. Identify required information. 4. Select method of data gathering. 5. Develop questionnaire or interview questions. 6. Develop procedures for data collection. 7. Train data collectors. 8. Arrange for a sample representative of the aggregate. 9. Conduct needs assessment.
10. Tabulate and analyze data. 11. Identify needs suggested by data. 12. Develop an action plan.
A first approach to gathering data is to interview key informants in the community. These may be knowledgeable residents, elected officials, or health care providers. It is essential that the community health nurse recognize that the views of these people may not reflect the views of all residents. A second approach is to hold a community forum to discuss selected questions. It is important for the nurse to carefully plan the meeting in advance to gain the most useful information. The community health nurse can also mail surveys to community members to elicit information from a more diverse group of people who may be unwilling or unable to attend a community forum. Focus groups are a third approach; these can be very effective in gathering community views, particularly for remote and vulnerable segments of a community and for those with underdeveloped opinionsNurses who conduct focus groups must carefully select participants, formulate questions, and analyze recorded sessions (University of Kansas, 2017). These sessions can produce greater interaction and expression of ideas than surveys and may provide more insight into an aggregate’s opinions. In addition to encouraging community participation in the identification of assets and needs, focus groups may lay the groundwork for community involvement in planning the solutions to identified problems.
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Diagnosing Health Problems The next step of the nursing process is synthesizing assessment data, in which the nurse plans to examine data and creates a list of all actual and potential problems. Then the nurse develops diagnostic statements about the community’s health. These statements, or diagnoses, specify the nature and cause of an actual or potential community health problem and direct the community health nurses’ plans to resolve the problem. Muecke (1984) developed a format that assists in writing a community diagnosis. The diagnosis consists of four components: the identification of the health problem or risk, the affected aggregate or community, the etiological or causal statement, and the evidence or support for the diagnosis (Fig. 6.3). Each of these components has an important role to play in the nursing process. The problem represents a synthesis of all assessment data. The “among” phrase specifies the aggregate that will be the beneficiary of the nurse’s action plan and whose health is at risk. The “related to” phrase describes the cause of the health problem and directs the focus of the intervention. All plans and interventions will be aimed at addressing this underlying cause. Last, the health indicators are the supporting data or evidence drawn from the completed assessment. These data can suggest the magnitude of the problem and have a bearing on prioritizing diagnoses. Other factors that assist the nurse in ranking the importance of diagnoses include the nature of the diagnosis, its potential impact on a broad range of community residents, and the community’s perceptions of the health issue.
Nursing Care Guidelines
Wellness Diagnosis Sometimes nurses develop wellness diagnoses. These often focus on the individual, but can make a positive statement about the community’s strengths. They are a variant on the North American Nursing Diagnosis Association’s health promotion diagnoses. Wellness diagnoses address the potential of a segment of the population of the community to move toward a higher level of wellness and presume a certain level of readiness to change. For example, a wellness diagnosis might be written to describe a strength that should be reinforced and supported, as follows: Increased potential for positive infant outcomes among teenage mothers related to effective parenting as evidenced by increased participation in mother–baby practice sessions and positive newborn- care behaviors.
As in a community diagnosis, four components lead to a cohesive statement about health status.
With a clear statement of the problem in the form of a diagnosis, the community health nurse is ready to begin the planning phase of the nursing process. Inherent in this phase is a plan for the intervention and its evaluation. Once again, epidemiological data can be useful as a basis for determining success. By comparing baseline data, national and local data, and other relevant indicators, the nurse can construct benchmarks to gauge achievement of program objectives. This step may entail the calculation of incidence rates if the goal is to reduce the development of disease, or primary prevention. Comparing data with national rates or with prevalence rates found in a local community may be other indicators of success. Reducing the presence of risk factors and documenting patterns of healthy behavior are other objective indices of successful programs.
It is evident that epidemiological data and methods are essential to each phase of the nursing process. The community health nurse compiles a range of assessment data that support the nursing diagnosis. Epidemiological studies support program planning by establishing the effectiveness of certain interventions and their specificity for different aggregates. Finally, epidemiological data are important for the community health nurse’s documentation of a program’s long-term effectiveness. Box 6.5 provides an evaluation example.
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FIG. 6.3 Format for community health diagnosis. Redrawn from Muecke MA: Community health diagnosis in nursing, Public Health Nurs 1:23–35, 1984.
Used with permission of Blackwell Scientific Publications.
BOX 6.5 Example of Outcomes Evaluation: A Community-Based Intervention to Promote Smoking Cessation Matthews and colleagues (2013) reported the results of a community-based and culturally tailored smoking cessation program designed for lesbian, gay, bisexual, transgender (LGBT) people, a population with more than double the rate of smoking as heterosexuals and an increased risk for respiratory and cardiac disease. A series of smoking cessation classes designed for and marketed to the LGBT community were conducted for 198 individuals. Adapted from the American Lung Association’s Freedom from Smoking curriculum, the intervention incorporated LGBT concerns related to the role of smoking in LGBT culture, stress due to homophobia as a smoking trigger, relationship between bar culture and smoking and alcohol, and the targeting of LGBT persons by the tobacco industry. Thirty separate small treatment groups were conducted in eight weekly sessions. Three of these included a peer-buddy program in the Call it Quits groups, and free nicotine replacement was available to all. Although only 42% completed treatment, 32.3% self- reported smoking cessation upon completion, with the 24% who used nicotine replacement having the highest cessation rates. These rates were consistent with general community programs; however, the authors cited the benefits of a tailored, culturally specific program and stressed the need to continue to address the formidable barriers to abstention faced by LGBT smokers in preventing relapses. Data from Matthews AK, Chien-Ching L, Kuhns LM, et al.: Results from a community-based smoking cessation program for LGBT smokers, J Environ Public Health, 2013, Article ID 984508, https://doi:10.1155/2013/984508.
Active Learning Exercise
1. Walk through a neighborhood, and compile a list of variables that are important to describe
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with demographic and epidemiological data. Write down hunches or preconceived notions about the nature of the community’s population. Compare ideas with the collected statistical data.
2. Compile a range of relevant demographic and epidemiological data for the community by examining census reports, vital statistics reports, city records, and other library and agency sources.
3. Using the collected data, identify three community health problems and formulate three community health diagnoses.
Case Study Application of the Nursing Process Assessment and Diagnosis The following example demonstrates the process of collecting and analyzing data and deriving community diagnoses. It also exemplifies the multiple care levels within which community health nurses function: the individual client, the family, and the aggregate or community levels. In this scenario, the nurse identified an individual client health problem during a home visit, which provided the initial impetus for an aggregate health education program. Data collection expanded from the assessment of the individual to a broad range of literature and data about the nature of the problem in populations. The nurse then formulated a community-level diagnosis to direct the ensuing plan. This was subsequently implemented at the aggregate level and then evaluated.
School nurses frequently address a broad range of student health problems. In the West San Antonio School District, school nurses generally reserve several hours a week for home visits. In a recent case, a teacher expressed concern for a high school junior named “John” whose brother was dying of cancer. In a health class, John shared his personal fears about cancer, which caused his classmates to question their own cancer risks and how they might reduce them. Assessment The school nurse visited John’s family and learned that the 25-year-old son had testicular cancer. Since his diagnosis 1 year earlier, he had undergone a range of therapies that were palliative but not curative; the cancer was advanced at the time of diagnosis. The nurse spent time with the family discussing care, answering questions, and exploring available support for the entire family.
At a school nurse staff meeting, the nurse inquired about her colleagues’ experiences with other young clients with this type of cancer. Only one nurse remembered a young man with testicular cancer. The nurses were not familiar with its prevalence, incidence, risk factors, prevention strategies, or early detection approaches. The nurse recognized the high probability that high school students would have similar questions and could benefit from reliable information.
The school nurse embarked on a community assessment to answer these questions. The nurse first collected information about testicular cancer. Second, the nurse reviewed the nursing and medical literature for key articles discussing client care, diagnosis, and treatment. Epidemiological studies provided additional data regarding testicular cancer’s distribution pattern in the population and associated risk factors.
The nurse learned that young men aged 20 to 35 years were at the greatest risk. Other major risk factors were not identified. It was learned that healthy young men do not seek testicular cancer screening and regular health care; they may be apprehensive about conditions affecting sexual function. These factors contribute to delays in detection and treatment. Although only an estimated 8850 new cases of testicular cancer will have been diagnosed in the United States in 2017, it is one of the most common tumors in young men. Furthermore, this cancer is amenable to treatment with early diagnosis (American Cancer Society, n.d.).
On the basis of these facts, the nurse reasoned that a prevention program would benefit high school students. However, to perform a comprehensive assessment, it was important that the nurse clarified what students did know, how comfortable they were discussing sexual health, and how much the subject interested them. Therefore the nurse approached the junior and senior high school students and administered a questionnaire to elicit this information. The nurse also queried the health teacher about the amount of pertinent cancer and sexual development information the students received in the classroom. The nurse considered the latter an important prerequisite to dealing with the sensitive subject of sexual health. According to the health teacher, the students did
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receive instruction about physical development and psychosexual issues. Students expressed a strong desire for more classroom instruction on these subjects and more information on cancer prevention. However, they did not have sufficient knowledge of the beneficial health practices related to cancer prevention and early detection. Key Assessment Data
• Health status of John’s brother • Knowledge, coping, and support resources of family • Testicular cancer, its natural history, treatment and prevention, incidence, prevalence,
mortality, and risk factors • High school students’ knowledge about cancer and its prevention • Students’ comfort level with discussing sexual health issues
Community Diagnosis There is an increased risk of undetected testicular cancer among young men related to insufficient knowledge about the disease and the methods for preventing and detecting it at an early stage, as demonstrated by high rates of late initiation of treatment. Planning Clarifying the problem and its cause helped the nurse direct the planning phase of the nursing process and determine both long-term and short-term goals.
The long-term goal was:
• Students will identify testicular lesions at an early stage and seek care promptly.
The short-term goals were:
• Students will understand testicular cancer and self-detection techniques. • Students will exhibit comfort with sexual health issues by asking questions. • Male students will report regular testicular self-examination.
Planning encompassed several activities, including the discovery of recommended health care practices regarding testicular cancer. The nurse also sought to determine the most effective and appropriate educational approaches for male and female high school students. Identifying helpful community agencies was also an essential part of the process. The local chapter of the American Cancer Society provided valuable information, materials, and consulting services. A nearby nursing school’s media center and faculty were also very supportive of the program.
After formalizing her objectives and plan, the nurse presented the project to the high school’s teaching coordinator and principal. Their approval was necessary before the nurse could implement the project. After eliciting their enthusiastic support, the nurse proceeded with more detailed plans. She selected and developed classroom instruction methods and activities that would maximize high school students’ involvement. The nurse also ordered a film and physical models for demonstrating and practicing testicular self-examination. She prepared group exercises designed to relax students and help them be comfortable with the sensitive subject matter. The nurse scheduled two 40-minute sessions dealing with testicular cancer for the junior-level health class. In a final step of the planning phase, she designed evaluation tools that assessed knowledge levels after each class session and measured the extent to which students integrated these health practices into their lifestyles at the end of their junior and senior years.
The nurse was now ready to proceed with the implementation of a testicular cancer prevention and screening program. She initiated the assessment phase by identifying an individual client and family with a health need, and she extended the assessment to the high school aggregate. Her data collection at the aggregate level, for both the general and local high school populations, assisted in her community diagnosis. The diagnosis directed the development of a community-specific health intervention program and its subsequent implementation and evaluation. Intervention
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The nurse conducted the two sessions in a health education class. At the beginning of the class period, students participated in a group exercise, and the nurse asked them about their knowledge of testicular cancer. The nurse showed a film and led a discussion about cancer screening. In the second session, she demonstrated the self-examination procedure using testicular models and supervised the students while they practiced the procedure on the models. The nurse advised the male students about the frequency of self-examination. With the females, she discussed the need for young men to be aware of their increased risk, drawing a parallel to breast self-examination. Evaluation After completing the class sessions, the nurse administered the questionnaires she had developed for evaluation purposes. Analysis of the questionnaires indicated that knowledge levels were very high immediately after the classes. Students were pleased with the frank discussion, the opportunity to ask questions, and the clear responses to a sensitive subject. Teachers also offered positive feedback. Consequently, the nurse became a knowledgeable health resource in the high school.
Intermediate-term evaluation occurred at the end of the students’ junior and senior years. The nurse arranged a 15-minute evaluation during other classes, which assessed the integration of positive health practices and testicular self-examinations into the students’ lifestyles. At the end of the school year, the prevalence of regular self-assessment was significantly lower than knowledge levels. However, 30% of male students reported regularly practicing self-examinations at the end of 1 year, and 70% reported they had performed self-examination at least once during the past year.
The compilation of incidence data is ideal for long-term evaluation, and it documents the reduction of a community health problem. Testicular cancer is very rare; therefore incidence data are not reliable and may not be feasible to collect. However, for more prevalent conditions, objective statistics help reveal increases and decreases in disease rates, and these may be related to the strengths and deficiencies of health programs. Levels of Prevention The following are examples of the three levels of prevention as applied to this case study. Primary
• Promotion of healthy lifestyles and attitudes toward sexuality • Education about sexual health and the care of one’s body
Secondary
• Self-examination to detect testicular cancer in its earliest stage • Referral for medical care as soon as a lump or symptom is discovered • Medical and surgical care to treat and cure testicular cancer
Tertiary
• Advanced care, including hospice services for those with incurable disease • Support services and grief counseling to help families cope with loss of a loved one
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Summary Communities form for a variety of reasons and can be homogeneous or heterogeneous in composition. To help them assess the nature of a given community, community health nurses study and interpret data from sources such as local government agencies, census reports, morbidity and mortality reports, and vital statistics. Nurses can gather valuable information about the causes and prevalence of health and disease in a community through epidemiological studies. On the basis of this information, the community health nurse can apply the nursing process, expanding assessment, diagnosis, planning, intervention, and evaluation from the individual client level to a targeted aggregate in the community.
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Evolve Website http://evolve.elsevier.com/Nies/community
• NCLEX Review Questions • Case Studies
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Academies Press; 2002. Muecke M.A. Community health diagnosis in nursing. Public Health Nurs. 1984;1:23–35. . National Association of County and City Health Officials. Public Health Infrastructure and Systems,
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Community Health Planning, Implementation, and Evaluation Diane Cocozza Martins, and Patricia M. Burbank
OUTLINE
Overview of Health Planning Health Planning Model
Assessment Planning Intervention Evaluation
Health Planning Projects Successful Projects Unsuccessful Projects Discussion
Health Planning Models in Public Health Patch APEX-PH Program MAPP Model
Health Planning Federal Legislation Hill-Burton Act Regional Medical Programs Comprehensive Health Planning Certificate of Need National Health Planning and Resources Development Act Changing Focus of Health Planning
Nursing Implications
OBJECTIVES
Upon completion of this chapter, the reader will be able to do the following: 1. Describe the concept “community as client.” 2. Apply the nursing process to the larger aggregate within a system’s framework. 3. Describe the steps in the Health Planning Model. 4. Identify the appropriate prevention level and system level for nursing interventions in families,
groups, aggregates, and communities. 5. Recognize major health planning legislation. 6. Analyze factors that have contributed to the failure of health planning legislation to control
health care costs.
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7. Describe the community health nurse’s role in health planning, implementation, and evaluation.
KEY TERMS certificate of need community as client health planning Health Planning Model Hill-Burton Act key informant National Health Planning and Resources Development Act Partnership for Health Program Regional Medical Programs Health planning for and with the community is an essential component of community health nursing practice. The term health planning seems simple, but the underlying concept is quite complex. Like many of the other components of community health nursing, health planning tends to vary at the different aggregate levels. Health planning with an individual or a family may focus on direct care needs or self-care responsibilities. At the group level, the primary goal may be health education, and at the community level, health planning may involve population disease prevention or environmental hazard control. Clinical Example 7.1 illustrates the interaction of community health nursing roles with health planning at a variety of aggregate levels.
Clinical Example 7.1 Maria Guitierrez is a registered nurse (RN) in a suburban middle school. During the course of the school year, she noted an increased incidence of sexually transmitted diseases (STDs) among the middle school students. After reviewing information in nursing journals, other professional journals, and Internet sources, Maria understood that there was a national increase in STDs among young adolescents. She found that significant numbers of adolescents are initiating sexual activity at age 13 and younger. The school nurse reviewed the Centers for Disease Control and Prevention (CDC) site on “Adolescent and School Health—Sexual Risk Behavior” (CDC, 2017). The CDC reported:
Many young people engage in sexual risk behaviors that can result in unintended health outcomes. For example, among U.S. high school students surveyed in 2015
• 41% had ever had sexual intercourse. • 30% had had sexual intercourse during the previous 3 months, and, of these • 43% did not use a condom the last time they had sex. • 14% did not use any method to prevent pregnancy. • 21% had drunk alcohol or used drugs before last sexual intercourse. • Only 10% of sexually experienced students have ever been tested for human
immunodeficiency virus (HIV).
Sexual risk behaviors place teens at risk for HIV infection, other sexually transmitted diseases (STDs), and unintended pregnancy:
• Young people (aged 13–24) accounted for an estimated 22% of all new HIV diagnoses in the United States in 2015.
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• Among young people (aged 13–24) diagnosed with HIV in 2015, 81% were gay and bisexual males.
• Half of the nearly 20 million new STDs reported each year were among young people, between the ages of 15 to 24.
• Nearly 230,000 babies were born to teen girls aged 15–19 years in 2015 (CDC, 2017).
Maria reviewed the reasons for the increased STDs. Her assessment of the problem had several findings. LGBT sexual health issues were not being addressed. Sexually active teenagers do not use contraception regularly. Also, a variety of sexual misconceptions lead teens to believe they are invulnerable to STDs. Adolescents also find it difficult or embarrassing to obtain contraceptives that protect from not only pregnancy but also STDs. The suburb does not have a local family planning clinic, and area primary care providers are reluctant to counsel teenagers or prescribe contraceptives without parental permission. The nurse also discovered that several years earlier a group of parents had stopped an attempt by the local school board to establish sex education in the school system. The parents believed this responsibility belonged in the home.
Maria considered all of these factors in developing her plan of action. She met with teachers, officials, and parents. Teachers and school officials were willing to deal with this sensitive issue if parents could recognize its validity. In meetings, many parents revealed they were uncomfortable discussing sexuality with their adolescent children and welcomed assistance. However, they were concerned that teachers might introduce the mechanics of reproduction without giving proper attention to the moral decisions and obligations involved in relationships. The parents expressed their desire to participate in curriculum planning and to meet with the teachers instead of following a previous plan that required parents to sign a consent form for each student. In support of the parents, Maria asked a nearby urban family planning agency to consider opening a part-time clinic in the suburb.
Implementing such a comprehensive plan is time consuming and requires community involvement and resources. The nurse enlisted the aid of school officials and other community professionals. Time will reveal the plan’s long-term effectiveness in reducing teen pregnancy.
This example shows how nurses can and should become involved in health planning. Teen pregnancy is a significant health problem and often results in lower education and lower socioeconomic status, which can lead to further health problems. The nurse’s assessment and planned interventions involved individual teenagers, parents and families, the school system, and community resources.
This chapter provides an overview of health planning and evaluation from a nursing perspective. It also describes a model for student involvement in health planning projects and a review of significant health planning legislation.
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Overview of Health Planning One of the major criticisms of community health nursing practice involves the shift in focus from the community and larger aggregate to family caseload management or agency responsibilities. When focusing on the individual or family, nurses must remember that these clients are members of a larger population group or community and that environmental factors influence them. Nurses can identify these factors and plan health interventions by implementing an assessment of the entire aggregate or community. Fig. 7.1 illustrates this process.
The concept of “community as client” is not new. Lillian Wald’s work at New York City’s Henry Street settlement in the late 1800s exemplifies this concept. At the Henry Street settlement, Miss Wald, Mary Brewster, and other public health nurses worked with extremely poor immigrants.
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FIG. 7.1 The community as client. Chapter 6, Table 6.1, provides assessment parameters that help identify the client’s assets and needs.
The increased focus on community-based nursing practice yields a greater emphasis on the aggregate as the client or care unit. However, the community health nurse should not neglect nursing care at the individual and family levels by focusing on health care only at the aggregate level. Rather, the nurse can use this community information to help him or her understand individual and family health problems and improve their health status. Table 7.1 illustrates the differences in community health nursing practice at the individual, family, and community levels. However, before nurses can participate in health care planning, they must be knowledgeable about the process and comfortable with the concept of community as client or care focus.
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Health Planning Model A model based on Hogue’s (1985) group intervention model was developed in response to this need for population focus. The Health Planning Model aims to improve aggregate health and applies the nursing process to the larger aggregate within a systems framework. Fig. 7.2 depicts this model. Incorporated into a health planning project, the model can help students view larger client aggregates and gain knowledge and experience in the health planning process. Nurses must carefully consider each step in the process, using this model. Box 7.1 outlines these steps. In addition, Box 7.2 provides the systems framework premises that nurses should incorporate.
Several considerations affect how nurses choose a specific aggregate for study. The community may have extensive or limited opportunities appropriate for nursing involvement. Additionally, each community offers different possibilities for health intervention. For example, an urban area might have a variety of industrial and business settings that need assistance, whereas a suburban community may offer a choice of family-oriented organizations, such as boys’ and girls’ “clubs” and parent–teacher associations, that would benefit from intervention.
A nurse should also consider personal interests and strengths in selecting an aggregate for intervention. For example, the nurse should consider whether he or she has an interest in teaching health promotion and preventive health or in planning for organizational change, whether his or her communication skills are better suited to large or small groups, and whether he or she has a preference for working with older adults or with children. Thoughtful consideration of these and other variables will facilitate assessment and planning.
TABLE 7.1
Levels of Community Health Nursing Practice
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FIG. 7.2 Health Planning Model.
BOX 7.1 Health Planning Project Objectives
I. Assessment A. Specify the aggregate level for study (e.g., group, population group, or
organization). Identify and provide a general orientation to the aggregate (e.g., characteristics of the aggregate system, suprasystem, and subsystems). Include the reasons for selecting this aggregate and the method for gaining entry.
A. Describe specific characteristics of the aggregate. 1. Sociodemographic characteristics: Including age, sex, race or
ethnic group, religion, educational background and level, occupation, income, and marital status.
2. Health status: Work or school attendance, disease categories, mortality, health care use, and population growth and population pressure measurements (e.g., rates of birth and death, divorce, unemployment, and drug and alcohol abuse). Select indicators appropriate for the chosen aggregate.
3. Suprasystem influences: Existing health services to improve aggregate health and the existing or potential positive and negative impact of other community-level social system variables on the aggregate. Identify the data collection methods.
B. Provide relevant information from the literature review, especially in terms of the characteristics, problems, or needs within this type of aggregate. Compare the health status of the aggregate with that of similar aggregates, the community, the state, and the nation.
C. Identify the specific aggregate’s health problems and needs on the basis of comparative data collection analysis and interpretation and literature review. Include input from clients regarding their need perceptions. Give priorities to health problems and needs, and indicate how to determine these priorities.
II. Planning A. Select one health problem or need, and identify the ultimate goal of intervention.
Identify specific, measurable objectives as mutually agreed on by the student and aggregate.
B. Describe the alternative interventions that are necessary to accomplish the objectives. Consider interventions at each system level where appropriate (e.g., aggregate/target system, suprasystem, and subsystems). Select and validate the intervention(s) with the highest probability of success. Interventions may use
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existing resources, or they may require the development of new resources. III. Intervention
A. Implement at least one level of planned intervention when possible. B. If intervention was not implemented, provide reasons.
IV. Evaluation A. Evaluate the plan, objectives, and outcomes of the intervention(s). Include the
aggregate’s evaluation of the project. Evaluation should consider the process, product, appropriateness, and effectiveness.
B. Make recommendations for further action based on the evaluation, and communicate them to the appropriate individuals or system levels. Discuss implications for community health nursing.
BOX 7.2 Systems Framework Premises
I. Each system is a goal-directed collection of interacting or interdependent parts, or subsystems.
II. The whole system is continually interacting with and adapting to the environment, or suprasystem.
III. There is a hierarchical structure (suprasystem, system, subsystems). IV. Each system is characterized by the following:
A. Structure: Arrangement and organization of parts, or subsystems. 1. Organization and configuration (e.g., traditional vs. nontraditional;
greater variability [no right or wrong and no proper vs. improper form]).
2. Boundaries (open vs. closed; regulate input and output). 3. Territory (spatial and behavioral). 4. Role allocation.
B. Functions: Goals and purpose of system and activities necessary to ensure survival, continuity, and growth of system.
1. General. a. Physical: Food, clothing, shelter, protection from danger,
and provision for health and illness care. b. Affectional: Meeting the emotional needs of affection and
security. c. Social: Identity, affiliation, socialization, and controls.
2. Specific: Each family, group, or aggregate has its own individual agenda regarding values, aspirations, and cultural obligations.
C. Process and dynamics. 1. Adaptation: Attempt to establish and maintain equilibrium; balance
between stability, differentiation, and growth; self-regulation and adaptation (equilibrium and homeostasis).
a. Internal: Families, groups, or aggregates. b. External: Interaction with suprasystem.
2. Integration: Unity and ability to communicate. 3. Decision making: Power distribution, consensus, accommodation, and
authority.
Assessment As discussed in Chapter 6 on assessment, it is essential to establish a professional relationship with the selected aggregate, which requires that a community health nurse first gain entry into the group. Good communication skills are essential to making a positive first impression. The nurse should make an appointment with the group leaders to set up the first meeting.
The nurse must initially clarify his or her position, organizational affiliation, knowledge, and skills. The nurse should also clarify mutual expectations and available times. Once entry into the
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aggregate is established, the nurse continues negotiation to maintain a mutually beneficial relationship.
Meeting with the aggregate on a regular basis will allow the nurse to make an in-depth assessment. Determining sociodemographic characteristics (e.g., distribution of age, sex, and race) may help the nurse ascertain health needs and develop appropriate intervention methods. For example, adolescents need information regarding nutrition, abuse of drugs and alcohol, and relationships with the opposite sex. They usually do not enjoy lectures in a classroom environment, but the nurse must possess skills to initiate small-group involvement and participation. An adult group’s average educational level will affect the group’s knowledge base and its comfort with formal versus informal learning settings. The nurse may find it more difficult to coordinate time and energy commitments if an organization is the focus group, because the aggregate members may be more diverse.
The nurse may gather information about sociodemographic characteristics from a variety of sources. These sources include observing the aggregate, consulting with other aggregate workers (e.g., the factory or school nurse, a Head Start teacher, or the resident manager of a high-rise senior citizen apartment building), reviewing available records or charts, interviewing members of the aggregate (i.e., verbally or via a short questionnaire), and interviewing a key informant. A key informant is a formal or informal leader in the community who provides data that are informed by his or her personal knowledge and experience with the community.
In assessing the aggregate’s health status, the nurse must consider both the positive and negative factors. Unemployment or the presence of disease may suggest specific health problems, but low rates of absenteeism at work or school may suggest a need to focus more on preventive interventions. The specific aggregate determines the appropriate health status measures. Immunization levels are an important index for children, but nurses rarely collect this information for adults. However, the nurse should consider the need for influenza and/or pneumonia vaccines with older adults. Similarly, the nurse would expect a lower incidence of chronic disease among children, whereas older adults have higher rates of long-term morbidity and mortality.
Public health nursing (PHN) competencies include applying systems theory to PHN practice with communities and populations. This includes integrating systems thinking into public health practice and evaluating new approaches to public health practice that integrate organizational and systems theories (Quad Council of Public Health Nursing Organizations, 2017).
A systems analysis is needed when one is assessing the aggregate. The three levels of the system are the subsystem, the system, and the suprasystem. For example, a community health nurse working with incarcerated women in a prison needs to work at the three levels of the system to assist women planning to reunite with their children at release. The system is the group of women, the subsystem consists of the individual women, and the suprasytem would be the department of corrections and/or the state’s department of social services.
The aggregate’s suprasystem may facilitate or impede health status. Different organizations and communities provide various resources and services to their members. Some are obviously health related, such as the presence or absence of hospitals, clinics, private practitioners, emergency facilities, health centers, home health agencies, and health departments. Support services and facilities such as group meal sites or Meals on Wheels (MOW) for older adults and recreational facilities and programs for children, adolescents, and adults are also important. Transportation availability, reimbursement mechanisms or sliding-scale fees, and community-based volunteer groups may determine the use of services. An assessment of these factors requires researching public records (e.g., town halls, telephone directories, and community services directories) and interviewing health professionals, volunteers, and key informants in the community. The nurse should augment existing resources or create a new service rather than duplicating what is already available to the aggregate.
A literature review is an important means of comparing the aggregate with the norm. For example, children in a Head Start setting, day care center, or elementary school may exhibit a high rate of upper respiratory tract infections during the winter. The nurse should review the pediatric literature and determine the normal incidence for this age range in group environments. Furthermore, the nurse should research potential problems in an especially healthy aggregate (e.g., developmental stresses for adolescents or work or family stresses for adults) or determine whether a factory’s experience with work-related injury is within an average range. Comparing the foregoing assessment with research reports, statistics, and health information will help determine and prioritize the aggregate’s health problems and needs.
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The last phase of the initial assessment is identifying and prioritizing the specific aggregate’s health problems and needs. This phase should relate directly to the assessment and the literature review and should include a comparative analysis of the two. Most important, this step should reflect the aggregate’s perceptions of need. Depending on the aggregate, the nurse may consult the aggregate members directly or may interview others who work with the aggregate (e.g., a Head Start teacher). Interventions are seldom successful if the nurse omits or ignores the clients’ input.
During the needs assessment, four types of needs should be assessed. The first is the expressed need or the need expressed by the behavior. This is seen as the demand for services and the market behavior of the targeted population. The second need is normative, which is the lack, deficit, or inadequacy as determined by expert health professionals. The third type of need is the perceived need expressed by the audience. Perceived needs include the population’s wants and preferences. The final need is the relative need, which is the gap showing health disparities between the advantaged and disadvantaged populations (Issel, 2014).
Finally, the nurse must prioritize the identified problems and needs to create an effective plan. The nurse should consider the following factors when determining priorities:
• The aggregate’s preferences • Number of individuals in the aggregate affected by the health problem • Severity of the health need or problem • Availability of potential solutions to the problem • Practical considerations such as individual skills, time limitations, and available resources
In addition, the nurse may further refine the priorities by applying a framework such as Maslow’s (1968) hierarchy of needs (i.e., lower-level needs have priority over higher-level needs) or Leavell and Clark’s (1965) levels of prevention (primary, secondary, and tertiary prevention). Primary prevention consists of health promotion and activities that protect the client from illness or dysfunction. Secondary prevention includes early diagnosis and treatment to reduce the duration and severity of disease or dysfunction. Tertiary prevention applies to irreversible disability or damage and aims to rehabilitate and restore an optimal level of functioning. Plans should include goals and activities that reflect the identified problem’s prevention level.
Assessment and data collection are ongoing throughout the nurse’s relationship with the aggregate. However, the nurse should proceed to the planning step once the initial assessment is complete. It is particularly important to link the assessment stage with other stages at this point in the process. Planning should stem directly and logically from the assessment, and implementation should be realistic.
An essential component of health planning is to have a strong level of community involvement. The nurse is responsible for advocating for client empowerment throughout the assessment, planning, implementation, and evaluation steps of this process. Community organization reinforces one of the field’s underlying premises, as outlined by Nyswander (1956): “Start where the people are.” Moreover, Labonte (1994) stated that the community is the engine of health promotion and a vehicle of empowerment. He describes five spheres of an empowerment model that focus on the following levels of social organization: interpersonal (personal empowerment), intragroup (small- group development), intergroup (community collaboration), interorganizational (coalition building), and political action. Paying attention to collective efforts and support of community involvement and empowerment, rather than focusing on individual efforts, will help ensure that the outcomes reflect the needs of the community and truly make a difference in people’s lives.
Labonte’s (1994) multilevel empowerment model allows us to consider both macro-level and micro-level forces that combine to create both health and disease. Therefore it seems that both micro and macro viewpoints on health education provide nurses with multiple opportunities for intervention across a broad continuum. In summary, health education activities that have an “upstream” focus examine the underlying causes of health inequalities through multilevel education and research. This allows nurses to be informed by a critical social perspective from education, anthropology, and public health and through community-based participatory research (Israel et al., 2005).
Successful health programs rely on empowering citizens to make decisions about individual and community health. Empowering citizens causes power to shift from health providers to community members in addressing health priorities. Collaboration and cooperation among community
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members, academicians, clinicians, health agencies, and businesses help ensure that scientific advances, community needs, sociopolitical needs, and environmental needs converge in a humanistic manner.
Active Learning Exercise
You are working with U.S. veterans who have served in Iraq and Afghanistan. Refer to the U.S. Department of Veterans Affairs website (http://www.va.gov/health/) to review some health issues you should consider in your assessment.
Planning As already stated, the nurse should determine which problems or needs require intervention in conjunction with the aggregate’s perception of its health problems and needs and on the basis of the outcomes of prioritization. Then the nurse must identify the desired outcome or ultimate goal of the intervention. For example, the nurse should determine whether to increase the aggregate’s knowledge level and whether an intervention will cause a change in health behavior. It is important to have specific and measurable goals and desired outcomes. Doing so will facilitate planning the nursing interventions and determining the evaluation process.
Planning interventions is a multistep process. First, the nurse must determine the intervention levels (e.g., subsystem, aggregate system, and/or suprasystem). A system is a set of interacting and interdependent parts (subsystems) organized as a whole with a specific purpose. Just as the human body can be viewed as a set of interacting subsystems (e.g., circulatory, neurological, integumentary), a family, a worksite, or a senior high-rise can also be viewed as a system. Each system then interacts with, and is further influenced by, its physical and social environment, or suprasystem (for example, the larger community).
Second, the nurse should plan interventions for each system level, which may center on the primary, secondary, or tertiary level of prevention. These levels apply to aggregates, communities, and individuals.
Third, the nurse should validate the practicality of the planned interventions according to available personal as well as aggregate and suprasystem resources. Although teaching is often a major component of community health nursing, the nurse should consider other potential forms of intervention (e.g., personal counseling, policy change, or community service development). Input from other disciplines or community agencies may also be helpful. Finally, the nurse should coordinate the planned interventions with the aggregate’s input to maximize participation.
Goals and Objectives Development of goals and objectives is essential. The goal is generally where the nurse wants to be, and the objectives are the steps needed to get there. Measurable objectives are the specific measures used to determine whether the nurse is successful in achieving the goal. The objectives are instructions about what the nurse wants the population to be able to do. In writing the objectives, the nurse should use verbs and include specific conditions (how well or how many) that describe to what degree the population will be able to demonstrate mastery of the task.
Because the objectives are specific and can be quantified, they may be used to measure outcomes. Objectives may also be referred to as behavioral objectives or outcomes because they describe observable behavior rather than knowledge. An example of the goals and measurable objectives for a city with a high rate of childhood obesity is shown in Box 7.3.
Intervention The intervention stage may be the most enjoyable stage for the nurse and the clients. The nurse’s careful preliminary assessment and planning should help ensure the aggregate’s positive response to the intervention. Although implementation should follow the initial plan, the nurse should prepare for unexpected problems (e.g., bad weather, transportation problems, poor attendance, or competing events). If the nurse is unable to complete the intervention, the reasons for its failure should be analyzed. Interventions should be included from a range of strategies, including mass
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media (public service announcements, radio, television, billboards), general information dissemination (e.g., pamphlets, DVDs, CDs, posters), electronic information dissemination (e.g., websites, blogs, tweets, video stream), and public forums (e.g., town meetings, focus groups, discussion groups).
BOX 7.3 Program Goals and Objectives for Reduction of Childhood Obesity
GOAL Reduce the rate of childhood obesity in the city of New Bedford. OBJECTIVES
1. The percentage of children whose body weight exceeds the 98th percentile for age and height will be reduced to 5%.
2. All the children will be invited to join a 5, 2, 1 program: • Five fruits and vegetables per day • Two-hour limit on screen time (TV, video games, and computer) per day • One hour of physical activity per day
3. The food pyramid will be taught to all school nurses and health educators by the end of the school year.
4. The food pyramid will be presented and distributed to parents at all the summer health fairs.
Evaluation Evaluation is an important component for determining the success or failure of a project and understanding the factors that contributed to its success or failure. The evaluation should include the participant’s verbal or written feedback and the nurse’s detailed analysis. Evaluation includes reflecting on each previous stage to determine the plan’s strengths and weaknesses (process evaluation). Process evaluation is also referred to as formative evaluation. It allows one to evaluate both positive and negative aspects of each experience honestly and comprehensively and whether the desired outcomes were achieved (product evaluation). Product evaluation is summative and can consist of end-of-intervention surveys and other tools that measure whether objectives have been met. Summative evaluation is another term for product evaluation and looks at outcomes. Evaluation should include adequacy, efficiency, appropriateness, and cost–benefit analysis. During both process and product evaluations, the nurse may ask the following questions:
• Was the assessment adequate? • Were plans based on an incomplete assessment? • Did the plan allow adequate client involvement? • Were the interventions realistic or unrealistic in terms of available resources? • Did the plan consider all levels of prevention? • Were the stated goals and objectives accomplished? • Were the participants satisfied with the interventions? • Did the plan advance the knowledge levels of the aggregate and the nurse?
The intervention may have limited impact if the nurse fails to communicate follow-up recommendations to the aggregate upon completion of the project. Although follow-up activity is not necessary for all plans, most require additional interventions within the aggregate using community agencies and resources. A comprehensive health planning project involves a close working relationship with the aggregate and careful consideration of each step. Long-term evaluation may need to be done by those professionals working continuously with the aggregate to determine behavior changes and/or changes in health status.
Research Highlights
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What About the Children Playing Sports? Pesticide Use on Athletic Fields Children come in contact with athletic fields on a daily basis. How these fields are maintained may have an impact on children’s potential exposure to pesticides and associated health effects.
This is a cross-sectional, descriptive study that utilized a survey to assess playing field maintenance practices regarding the use of pesticides. Athletic fields (N = 101) in Maryland were stratified by population density and randomly selected.
A survey was administered to field managers (n = 33) to assess maintenance practices, including the use of pesticides. Analysis included descriptive statistics and generalized estimating equations.
Managers of 66 fields (65.3%) reported applying pesticides, mainly herbicides (57.4%). Managers of urban and suburban fields were less likely to apply pesticides than were managers of rural fields. Combined cultivation practice was also a significant predictor of increased pesticide use.
The use of pesticides on athletic fields presents many possible health hazards. Results indicate that there is a significant risk of exposure to pesticides for children engaged in sports activities. Given that children are also often concurrently exposed to pesticides as food residues and from home pest management, we need to examine opportunities to reduce their exposures. Both policy and practice questions are raised. Data from Gilden R, Friedmann E, Sattler B., et al.: Potential health effects related to pesticide use on athletic fields, Public Health Nursing 29(3):198–207, 2012.
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Health Planning Projects Successful Projects Student projects have used this health planning model with group, organization, population group, and community aggregates. Table 7.2 describes interventions with these aggregates at the subsystem, aggregate system, and suprasystem levels. Clinical Example 7.2 describes a successful project at a textile plant. Clinical Example 7.3 describes a crime watch program, and Clinical Example 7.4 involves clients in a rehabilitation group.
Clinical Example 7.2 Textile Industry A nursing student studied a textile plant that had approximately 470 employees but did not have an occupational health nurse. The student nurse collected data and identified three major problems or needs by collaborating with management and union representatives. First, the student nurse observed that the most common, costly, and chronic work-related injury in plant workers was lower back injury. Second, some employees had concerns about possible undetected hypertension. Third, the first-aid facilities were disorganized and without an accurate inventory system. The student nurse planned and implemented interventions for all three areas.
TABLE 7.2
Interventions by type of Aggregate and System Level
Project Type of Aggregate System Level for Intervention Rehabilitation group Group, organization Subsystem and aggregate system Textile industry Population group Aggregate system and suprasystem Crime watch Group, organization, and population group Aggregate system and suprasystem Bilingual students (case study) Community Aggregate system and suprasystem
On the suprasystem level, the student nurse formulated plans with the company’s physicians and lobbied management to enact an employee training program on proper lifting techniques. The student nurse proposed creating specific and concise job descriptions and requirements to facilitate potential employees’ medical assessments. In addition, the student nurse organized and clearly labeled the first-aid supplies and developed an inventory system. On the aggregate system level, the student nurse planned and conducted a hypertension screening program. Approximately 85% of the employees underwent screening, and 10 people had elevated blood pressure readings. These 10 people were referred for follow-up care, and hypertension was subsequently diagnosed in several of them.
In evaluating the project, management representatives recognized that a variety of nursing interventions could improve or maintain workers’ health. Consequently, management hired the student nurse upon graduation to be the occupational health nurse.
Clinical Example 7.3 Crime Watch Another nursing student was concerned with the rising incidence of crime in a community and organized a crime watch program. The student nurse met periodically with the police and local residents, or aggregate system. Interventions included posting crime watch signs in the neighborhood and establishing more frequent police patrols at the suprasystem level. Evaluation of the program revealed that the residents had greater awareness of and concern for neighborhood safety.
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Clinical Example 7.4 Rehabilitation Group After working at a senior citizens center for a few weeks, a student nurse began a careful assessment of the center’s clients. The student nurse interviewed the center’s clients and visited its homebound clients served by social workers and the MOW program. Several of the homebound clients identified a need for socialization and rehabilitation. The center had recently purchased a van equipped to transport handicapped people in wheelchairs, which was a necessary factor in fulfilling this need.
TABLE 7.3
Unsuccessful Projects
Project Problematic Step of Nursing Process Group home for developmentally delayed Assessment (i.e., mutual identification of health problems and needs) Safe Rides program Planning (i.e., mutual identification of goals and objectives) Manufacturing plant Evaluation (i.e., recommendations for follow-up)
Implementation
After the student nurse assessed the clients’ health and functional status and determined mutual goals, four of these homebound clients expressed a desire to attend a rehabilitation program at the center. The student nurse and the center’s management initiated a weekly program based on the clients’ needs, which included van transportation, a coffee hour, a noontime meal, an exercise class, and a craft class. Although some members were initially reluctant to participate and one man withdrew from the group, the group ultimately functioned very well. Evaluating this new program showed clearly that the student nurse made progress in meeting the goals of increased socialization and rehabilitation among elders at the center.
Unsuccessful Projects Project failure is usually caused by problems with one or more steps of the nursing process. Usually the student does not discover problems until the evaluation phase. The following unsuccessful projects illustrate failures at different steps in the nursing process. Table 7.3 summarizes the identified problem areas for Clinical Examples 7.5 to 7.7.
Clinical Example 7.5 Group Home for Developmentally Delayed Adults A nursing student worked with an aggregate of six women living in a group home for developmentally delayed citizens. The nursing student observed that the clients were all overweight, and she decided to establish a weight reduction program. She proceeded to meet with the women, chart their weight, and discuss their food choices on a weekly basis. After 8 weeks, her evaluation revealed that none of the women had lost weight and a few had actually gained weight. During the assessment phase the student failed to consider the women’s perceptions of need. The women did not consider their weight a priority health problem, and their boyfriends provided positive reinforcement regarding their appearance.
Clinical Example 7.6 Safe Rides Program One student nurse assessed a university student community through a questionnaire and identified a drinking and driving problem. Of those she surveyed, 77% admitted to driving under the influence of alcohol, and 16.5% stated they had been involved in an alcohol-related car
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accident. After identifying the problem and determining student interest, the student nurse worked with the campus alcohol and drug resource center to plan and implement a program called Safe Rides. In this program, student volunteers would work a hotline and dispatch “on-call” drivers to pick up students who were unsafe to drive.
The student nurse resolved many potential complications before implementation (e.g., liability coverage for all participating individuals and expense funds for gasoline). The student nurse formulated a 12-hour training program that lasted 3 weeks to prepare student volunteers for the Safe Rides program. By the end of the semester, Safe Rides was ready to begin. However, the student nurse graduated at the semester’s end, and her commitment had been the program’s prime motivating force. Although others were committed and involved, the student nurse did not arrange for a replacement to coordinate and continue the program upon her departure. The Safe Rides program required ongoing coordination efforts, and no one fully implemented the program in the student nurse’s absence.
Clinical Example 7.7 Manufacturing Plant Even careful planning cannot always eliminate potential obstacles. For example, one student nurse chose to work in an occupational setting involving heavy industry. The occupational health nurse and the nurse’s personnel supervisor both approved the student nurse’s entry into the organization. After reviewing the literature, working with the nurse for several weeks, and assessing the organization and its employees, the student nurse concluded that back injury risk was a primary problem. She planned to reduce the risk factors involved in back injuries by distributing information about proper body mechanics in a teaching session.
The personnel manager resisted this plan. Although he recognized the need for education, he was initially unwilling to allow employees to attend the session on company time. The student nurse and manager reached a compromise by allowing attendance during extended coffee breaks. The personnel manager, however, canceled the program before the student nurse could implement the class; negotiations for a new union contract were forming, and there was high probability of a strike. This situation led management to deny any changes in the usual routine.
The student nurse proceeded appropriately and received clearance from the proper officials, but she could not anticipate or circumvent union problems. The student nurse could only share her information and concern with the nurse and the personnel manager and encourage them to implement her plan when contract negotiations were complete.
Discussion Each of these projects attempted to address a particular level of prevention. Most of these examples focused on primary prevention and health promotion because they were conducted by students and limited by time available due to the length of the academic semester. Table 7.4 lists these projects and their prevention levels. However, the full-time community health nurse working with an aggregate (e.g., in the occupational health setting) would target interventions for all three levels of prevention at a variety of system levels. It is useful to view nursing interventions with aggregates within a matrix structure to address all intervention opportunities. The matrix in Table 7.5 gives examples of how the occupational health nurse may intervene at all system levels and all prevention levels.
TABLE 7.4
Level of Prevention for Each Project
Primary Prevention Secondary Prevention Tertiary Prevention Textile industry Textile industry Rehabilitation group Crime watch Group home for developmentally delayed Manufacturing plant Safe Rides program
In practice, most interventions occur at the individual level and include all prevention levels.
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Interventions at the aggregate level are usually less common. For many community health nurses, time does not allow intervention at the suprasystem level. However, schools and schoolchildren are integral parts of the community system. Factors that affect the community’s health also affect schoolchildren’s health. For school nurses in these school districts, interventions at the suprasystem level may become a reality and improve the health of the community and the students. The suprasystem intervention can be used to reduce hunger and food insufficiency for all schoolchildren in a district. A school nurse working with students in the school office may note that the students are presenting with dizziness, headaches, or abdominal pain in the morning and may keep intervention at the individual level by treating the symptoms presented (e.g., with acetaminophen or food). However, the school nurse may investigate why the students are presenting with the symptoms especially on Monday mornings and may realize that lack of food in the homes is an issue. The nurse then would work to develop a breakfast program for the school district. This strategy is a good example of refocusing upstream by addressing the real source of problems.
These projects illustrate the variety of available opportunities for aggregate health planning. In addition, they exemplify the application of the nursing process within various aggregate types, at different systems levels, and at each prevention level. These examples demonstrate the vital importance of each step of the nursing process:
1. Aggregate assessments must be thorough. The textile industry project exemplifies this point. Assessments should elicit answers to key questions about the aggregate’s health and demographic profile and should compare this information with information for similar aggregates presented in the literature.
2. The nurse must complete careful planning and set goals that the nurse and the aggregate accept. The rehabilitation group project illustrates the importance of mutual planning.
3. Interventions must include aggregate participation and must meet the mutual goals. The crime watch project exemplifies this point.
4. Evaluation must include process and product evaluation and aggregate input.
TABLE 7.5
Occupational Health: Levels of Prevention for System Levels
Getting Involved in Health Planning
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Nurses can support the health planning process to improve aggregate health care with awareness of, and involvement in, the political process. This involvement can consist of following health care legislation at the state and national levels, being an informed voter, contacting legislators on issues of concern, and
participating in rallies and protests. Photo Courtesy of Anthony Ricci, MD.
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Student nurses also provide blood glucose screenings, with appropriate educational information regarding normal ranges, diet-controlled diabetes, and appropriate referral and treatment when necessary at the
statehouse.
Nurses participate in Women’s March on Washington. Photo Courtesy Anthony Ricci MD.
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Nurses speak out for health care as a right. Photo Courtesy Anthony Ricci, MD.
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Health Planning Models in Public Health According to Issel (2014), many planning programs to address public health problems began as environmental planning of water and sewer systems. Additional population-based planning became necessary with the advent of immunizations. Blum (1974) was the first to suggest how public health planning should be done. Perspectives on health planning range from systematic problem solving and an epidemiological approach to a social awareness approach.
Beginning in the mid-1980s the CDC began to develop and promote systematic methods for health planning in public health. These models were important for a structured approach to public health planning.
The PRECEDE-PROCEED model (Fig. 7.3) provides a structure for assessing health and quality- of-life needs. It also assists in designing, implementing, and evaluating health promotion and public health programs to meet those needs. PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation) assesses the diagnostic and planning process to assist in the development of focused public health programs. PROCEED (Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development) guides the implementation and evaluation of the programs (Green and Kreuter, 2005).
The PRECEDE-PROCEED framework is an approach to planning that examines factors contributing to behavior change. They are:
Predisposing factors: The knowledge, attitudes, behavior, beliefs, and values before intervention that affect willingness to change.
Enabling factors: The environment or community of an individual that facilitates or presents obstacles to change.
Reinforcing factors: The positive or negative effects of adopting new behavior (including social support).
FIG. 7.3 Green’s PRECEDE-PROCEED Model. Green’s website provides assistance in guiding use and
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applications of this model at http://www.lgreen.net/index.html. From Green LW, Kreuter MW: Health program planning: An educational and ecological approach, ed 4,
2004, McGraw-Hill.
These factors require that individuals be considered in the context of their community and social structures, and not in isolation, in the planning of communication or health education strategies (Green and Kreuter, 2005).
Patch The Planning Approach to Community Health (PATCH) model was based on Green’s PRECEDE (Green et al., 1980; Green and Kreuter, 2005). This model encouraged the idea that health promotion is a process that enables the population to have more control over its own health. An essential element of the PATCH model is community participation. Another element is the use of data to develop comprehensive health strategies. The PATCH model achieved this through mobilizing the community, collecting health data, selecting health priorities, developing a comprehensive intervention plan, and evaluating the process (Issel, 2014).
APEX-PH Program The Assessment Protocol for Excellence in Public Health (APEX-PH) program began in 1987 as a cooperative project of the American Public Health Association, the Association of Schools of Public Health, the Association of State and Territorial Health Officials, the CDC, the National Association of County and City Health Officials (NACCHO), and the United States Conference of Local Health Officers. The APEX-PH is a voluntary process for organizational and community self-assessment, planned improvements, and continuing evaluation and reassessment. It is a true self-assessment and is intended to be more of a public endeavor involving the community as well as the public organizations (CDC, 2009).
MAPP Model More recently, the CDC and NACCHO have released the MAPP (Mobilizing for Action Through Planning and Partnerships) model. The MAPP model is a health planning model that helps public health leaders facilitate community priorities about health issues and identify sources to address them. The first phase of MAPP is to mobilize the community; the second is to guide the community toward a shared vision for long-range planning; and the third is to conduct four assessments: identifying community strengths, local health systems, health status, and forces of change within the population (NACCHO, 2017).
Active Learning Exercise
Select one of the following community diagnoses from your community: increased rates of violence, asthma, lead poisoning, SDIs, pediculosis, infected tattoos/piercings, childhood obesity, food insufficiency, or homelessness. Write a plan on how to address that diagnosis, including goals and objectives. What resources will be needed?
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Health Planning Federal Legislation Health planning at the national, state, and local levels is another example of aggregate planning. Planning at any of these levels can be a broader extension of the suprasystem level and affects the individual, family, group, population, and organization levels. Again, upstream change can occur on these levels; for example, individual consumers and consumer groups have protested some managed-care practices at the suprasystem level because health policy can directly affect patient care.
Historically, nurses have influenced health planning only minimally at the community level, but health planning has a tremendous effect on nurses and nursing practice. It is necessary to understand planning on a suprasystem level; therefore the following section contains a review of past health planning efforts with projections for the future.
Hill-Burton Act In 1946, Congress passed the Hospital Survey and Construction Act (Hill-Burton Act, PL 79-725) to address the need for better hospital access. This act provided federal aid to states for hospital facilities. A state had to submit a plan documenting available resources and need estimates to qualify for hospital construction and modernization funds under the Hill-Burton Act (Young and Kroth, 2018). In addition, each state had to designate a single agency for the development and implementation of the hospital construction plan. The Hill-Burton Act caused the expenditure of vast sums of money and resulted in an increase in the number of beds, especially in general hospitals. The act and its amendments focused only on construction.
Regional Medical Programs The Hill-Burton Act provided construction-related planning, but it did not address coordination and care delivery directly. In response to recommendations from Dr. Michael DeBakey’s national commission, the Heart Disease, Cancer, and Stroke Amendments of 1965 (PL 89-239) were enacted. This legislation was more comprehensive and established regional medical programs (RMPs).
The regional medical programs intended to make the latest technology for the diagnosis and treatment of heart disease, cancer, stroke, and related diseases available to community health care providers through the establishment of regional cooperative arrangements among medical schools, research institutions, and hospitals. The goals of these cooperative arrangements were to improve the health manpower and facilities available to the communities. The intent was to avoid interfering with methods of financing, hospital administration, patient care, or professional practice.
Although RMPs have been credited with the regionalization of certain services and the introduction of innovative approaches to organization and care delivery, some observers believed the reforms were not comprehensive enough. The RMPs did not partner with the existing federal and state programs; therefore there were gaps and duplication in service delivery, personnel training, and research (National Institute of Health, 2017).
Comprehensive Health Planning Congress signed the Comprehensive Health Planning and Public Health Services Amendments of 1966 (PL 89-749) into law to broaden the previous legislation’s categorical approach to health planning. Combined with the Partnership for Health Amendments of 1967 (PL 90-174), these amendments created the Partnership for Health Program (PHP). The PHP provided federal grants to states to establish and administer a local agency program to enact local comprehensive health care planning. The PHP’s objectives were promoting and ensuring the highest level of health for every person and not interfering with the existing private practice patterns (Shonick, 1995).
To meet these objectives, the PHP formulated a two-level planning system. Under this system, each state had to designate a single health planning agency, or “A” agency. To play a statewide coordinating role, the “A” agency had to partner with an advisory council, which consisted largely of health care consumers. Meanwhile, the local “B” agencies formulated plans to meet designated local community needs, which could be any public or nonprofit private agency or organization. “A” agencies were to encourage the formation of local, comprehensive health planning “B” agencies,
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and federal grants were made available for that purpose (Shonick, 1995). Although the comprehensive health plans were the first of these programs to mandate consumer
involvement, they may have failed in their basic intent. The possible failure may have resulted from funding shortage, conflict avoidance in policy formulation and goal establishment, political absence, and provider opposition (e.g., American Medical Association, American Hospital Association, and major medical centers) (Shonick, 1995).
Certificate of Need In response to increased capital investments and budgetary pressures, state governments developed the idea of obtaining prior governmental approval for certain projects through the use of a certificate of need (CON). New York State passed the first CON law in 1964, which required government approval of hospitals’ and nursing homes’ major capital investments. Eventually all states supported this CON requirement, and it ultimately became a component of health legislation (PL 93-641). In practice, state CON programs differ in structure and goals. These differences include program focus, decision-making levels, review standard scope, and appeals process exemption (Young and Kroth, 2018)
National Health Planning and Resources Development Act Given the perceived failure of the comprehensive health planning programs, the federal government focused on a new approach to health planning. The government was greatly concerned with the cost of health care, which escalated dramatically after the end of World War II; the uneven distribution of services; the general lack of knowledge of personal health practices; and the emphasis on more costly modalities of care. The National Health Planning and Resources Development Act of 1974 (PL 93-641) (Endicott, 1975) combined the strengths of the Hill-Burton Act, RMPs, and the comprehensive health planning program to forge a new system of single-state and area-wide health planning agencies (Harlow, 2006).
The goals and purposes of the new law were to increase accessibility to as well as acceptability, continuity, and quality of health services; control over the rising costs of health care services; and prevention of unnecessary duplication of health resources. The new law addressed the needs of the underserved and provided quality health care. The provider and consumer were to be involved in planning and improving health services, and the law placed the system of private practice under scrutiny.
At the center of the program was a network of local health planning agencies, which developed health systems plans for their geographic service areas. The local agencies then submitted these plans to a state health planning and development agency, which integrated the plans into a preliminary state plan. The state agency presented this preliminary plan to a statewide health coordinating council for approval. The law required that the council consist of at least 16 governor- appointed members and that 50% of these members represent health system agencies and 50% represent consumers. One major function of this council was to prepare a state health plan that reflected the goals and purposes of the act. Once the council formulated a tentative plan, they presented it at public hearings throughout the state for discussion and possible revisions (Thorpe, 2002).
Despite careful deliberations by health planners with input from consumers, not all states accepted the health system plan at the grassroots level. A number of problems were encountered, and in time, the legislation failed to effect major change in the health care system. A significant problem was that the legislation had grandfathered in the entire health care system (i.e., health care delivery methods did not change). Although legislation mandated consumer involvement in the health system agency, it was often difficult to implement this aspect. Additionally, despite the mandated efforts by CON and required reviews, costs continued to rise and the health care system remained essentially unchanged (Thorpe, 2002).
Changing Focus of Health Planning Health planning legislation is heavily influenced by the politics of the administration in power at any given time. The Reagan administration encouraged competition within the health care system. During the 1980s, the administration emphasized cost shifting and cost reduction with greater state
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power, less centralization of functions, and less national control. This approach represented the government’s philosophical shift and combined it with a funding cutback from the Omnibus Budget Reconciliation Act in 1981. The result was a curtailment on federal health planning efforts at that time (Mueller, 1993). The cutbacks caused health system agencies to redefine their roles, and the federal government recommended eliminating these agencies.
A reduction in federal funding and the influence of medical lobbies caused the closure of some health system agencies. Those that remained open experienced a decrease in staff, a resulting drop in overall board functioning, and a reordering of priorities. In an effort to compensate for the decrease in federal funding, some health system agencies sought nonfederal funding or built coalitions to provide the necessary power base for change. Although the administration did not renew federal health planning legislation in the 1980s, it used other regulatory approaches to control costs. These included basing payments to Medicare on diagnosis-related groups, and, in the 1990s, the requirement by many individual states that their Medicaid recipients enroll in health maintenance organizations.
The Clinton administration’s plan for health care reform included mechanisms to revitalize planning at the national level. The failure of Congress to pass the plan in 1994 gave planning efforts back to state and local agencies. As a result, most states have become very involved in various aspects of health planning. Indeed, there is considerable variation as many have statewide health plans, local health plans, and some other type of local health planning (American Health Planning Association [AHPA], 2009).
At the beginning of the twenty-first century, 36 states and the District of Columbia still required CON reviews for selected expenditures that include nursing homes, psychiatric facilities, and expensive equipment (AHPA, 2009). However, within these programs, requirements for approval are more liberal, expedited reviews are conducted, and certain projects are exempted from review, weakening the CON cost-containment mandate. Newer high-technology services (i.e., lithotripsy, gamma knives, and positron emission tomography) still need CON review in most states. Furthermore, it is anticipated that state CON programs will continue to assume a stronger role because states must increasingly monitor and report the quality of, cost of, and access to health care that managed care promised.
Active Learning Exercise
1. Attend a state or local health planning meeting. Observe the number of health care providers and consumers in attendance. Compare the meeting’s issues with the goals of improving care quality and reducing health care costs.
2. Review the American Planning Association’s Planning and Community Health Research Center Plan. Discuss which plans and policies improve the built environment in your community.
Affordable Care Act (ACA) of 2010 The ACA is a national health insurance program that requires all citizens to be covered by one or a combination of insurance programs (Rambur, 2015). This act put individuals, families, and small business owners in control of their health care. It reduced premium costs for millions of working families and small businesses by providing hundreds of billions of dollars in tax relief—the largest middle-class tax cut for health care in history. It also reduced what families will have to pay for health care by capping out-of-pocket expenses and requiring preventive care to be fully covered without any out-of-pocket expense. It kept insurance companies honest by setting clear rules that rein in the worst insurance industry abuses. And it prohibited insurance companies from denying insurance coverage because of a person’s preexisting medical conditions while giving consumers new power to appeal insurance company decisions that deny doctor-ordered treatments covered by insurance (U.S. Department of Health and Human Services, 2017).
The U.S. government provides a website to understand the impact of this legislation for consumers, from pregnant women to older adults, at http://www.hhs.gov/healthcare/rights/index.html, as well as a timeline for the ACA at http://www.hhs.gov/healthcare/facts/timeline/index.html. The Kaiser Family Foundation (2017)
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offers a video that will be helpful for all patients. The Healthy People 2020 objectives support this notion. To help achieve improved health status for
all, health planning needs a coordinated approach that combines public and private cooperation with an emphasis on supplies and services. Advances in planning models and the sophistication level of planners will affect future health planning efforts.
Active Learning Exercise
Review the ACA and your state’s plans for action if repealed.
Case Study Application of the Nursing Process School Bilingual Program José Mendez, a bilingual community health nursing student, worked with the school system in a community that had a large Portuguese subsystem. His primary responsibility was for students enrolled in the town’s bilingual program. His contacts included the school nurse and the program teachers. Assessment José included the specific group of students, the members of the school system’s organizational level, and the population group of the town’s Portuguese-speaking residents in his assessment of the aggregate’s health needs. José identified the subsystem’s lack of primary disease prevention, specifically related to hygiene, dental care, nutrition, and lifestyle choices, by observing the children, interviewing teachers and community residents, and reviewing the literature. José’s continued assessment and prioritization revealed that the problem was related to a lack of knowledge and not a lack of concern. Diagnosis Individual
• Inadequate preparation at home regarding basic hygiene, dental care, nutrition, and healthy lifestyles
Family
• Developing strengths toward self-care regarding basic hygiene, dental care, nutrition, and healthy lifestyles
Community
• Inadequate resources for communicating basics of hygiene, dental care, nutrition, and healthy lifestyles to the Portuguese community
Planning The teachers and staff of the bilingual program helped contract and set goals, which reinforced the need for mutuality at this step in the process. A variety of alternative interventions were necessary to accomplish the following goals: Individual Long-Term Goal
• Students will regularly practice good hygiene, preventive dental care, good nutrition, exercise,
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and adequate sleep habits.
Short-Term Goal
• Students will learn the basics of good hygiene, preventive dental care, good nutrition, exercise, and adequate sleep habits.
Family Long-Term Goal
• Families will regularly practice and teach their children good hygiene, preventive dental care, good nutrition, exercise, and adequate sleep habits.
Short-Term Goal
• Families will learn the basics of good hygiene, preventive dental care, good nutrition, exercise, and adequate sleep habits.
Community Long-Term Goal
• Systematic programs will provide families and their children with education and information regarding the basics of good hygiene, preventive dental care, good nutrition, exercise, and adequate sleep habits.
Short-Term Goal
• Bilingual personnel will translate information into Portuguese, and program teachers will distribute it to families. This information will cover the basics of good hygiene, preventive dental care, good nutrition, exercise, and adequate sleep habits.
Intervention
• Sometimes nursing students’ projects are more limited than the planning stage’s ideal; in this case, interventions assessed only one grade level.
Individual
• The student nurse taught children many healthy lifestyle basics, including nutrition, hygiene, and dental care. Classes presented information in Portuguese and English.
Family
• All parents received a summary of the class content in both languages and in pictures.
Community
• The local teachers communicated the student nurse’s activities to their state-level coordinators, and the coordinators incorporated the student nurse’s materials into the bilingual program throughout the state.
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Evaluation Individual, Family, Community This community health planning project had an impact on the individuals in the specific aggregate and had broader implications for the family system and the community suprasystem. The outcomes, or product, were hugely successful. Mutually identified goals and objectives influenced the development of the process and incorporated input from a variety of sources. The student nurse believed the resources and support for the bilingual program were adequate. Although the student nurse addressed only primary prevention, the continuing nature of the project will allow the teachers, the school nurse, and the families to assess problems related to the program’s content. Future implementation may address secondary and tertiary prevention. Questions
1. How would you evaluate this project? 2. How would you determine process and product evaluation? 3. What would you do differently?
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Nursing Implications Nurses must work collaboratively with health planners to improve aggregate health. Nurses can influence health planning at the local, state, or community level by fusing current technology with their knowledge of health care needs and skills gained through working with individuals, families, groups, and population groups. This is an example of “upstream interventions.” Indeed, nurses may become directly involved in the planning process by participating in CON reviews or gaining membership on health planning councils. Even as students, nurses can begin to participate by engaging in aggregate-level projects, such as those outlined in this chapter, and by tracking health care legislation and contacting their legislators about important issues.
Increased nursing involvement is one method of strengthening local and national health planning. Nurses can use the Health Planning Model presented in this chapter to facilitate a systematic approach to improve aggregate health care. Nurses can assess aggregates from small groups through population groups; identify the group’s health needs; and perform planning, intervention, and evaluations by applying this model. The health of individuals, families, and groups would improve if nurses reemphasized the larger aggregate.
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Summary Community health nurses are responsible for incorporating health planning into their practice. Nurses’ unique talents and skills, augmented by the comprehensive application of the nursing process, can facilitate population health improvement at various aggregate levels. Health planning policy and process constitute part of the knowledge base of the baccalaureate-prepared nurse. Systems theory provides one framework for nursing process application in the community. Interventions are possible at subsystem, system, and suprasystem levels using all three levels of prevention.
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Evolve Website http://evolve.elsevier.com/Nies/community
• NCLEX Review Questions • Case Studies
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practice. In: Hall J.E, Weaver B.R, eds. Distributive nursing practice: a systems approach to community health. ed 2. Philadelphia: Lippincott Williams & Wilkins; 1985.
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Community Health Education Cathy D. Meade
OUTLINE
Connecting With Everyday Realities Health Education in the Community Learning Theories, Principles, and Health Education Models
Learning Theories Knowles’ Assumptions About Adult Learners Health Education Models Models of Individual Behavior Model of Health Education Empowerment Community Empowerment
The Nurse’s Role in Health Education Enhancing Communication Framework for Developing Health Communications
Stage I: Planning and Strategy Development Stage II: Developing and Pretesting Concepts, Messages, and Materials Stage III: Implementing the Program Stage IV: Assessing Effectiveness and Making Refinements
Health Education Resources Health Literacy Assess Materials: Become a Wise Consumer and User Assess Relevancy of Health Materials
Social Media
OBJECTIVES
Upon completion of this chapter, the reader will be able to do the following: 1. Describe the goals of health education within the community setting. 2. Examine the nurse’s role in community education within a sociopolitical and cultural context. 3. Select a learning theory, and describe its application to the individual, family, or aggregate. 4. Examine innovative and effective teaching and learning strategies that exemplify community-
centered health education for the individual, family, or aggregate/group. 5. Compare and contrast Freire’s approach to health education with an individualistic health
education model. 6. Examine the importance of community engagement for affecting health disparities. 7. Outline a systematic process for developing culturally and literacy relevant health education
materials, messages, media, and programs.
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8. Relate and apply factors that enhance the suitability of health education materials, messages, media, and programs for an intended audience.
9. Prepare a meaningful teaching plan and evaluation criteria for the individual, family, and/or group.
KEY TERMS autonomy cognitive theory community empowerment community-based participatory methods culturally effective care health disparities health education health equity health literacy humanistic theories learner verification learning materials, media, and messages participatory action research (PAR) Paulo Freire problem-solving education social justice social learning theory
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Connecting With Everyday Realities The nurse may be tempted to ask the following questions:
• Why does she keep smoking? She is pregnant. • Why doesn’t the 63-year-old man get his colonoscopy? His fecal occult blood test (I-FOBT)
is abnormal. • Why doesn’t the teen take his diabetic medications (insulin) each day? • Why aren’t those parents thinking about the human papilloma virus (HPV) series for their
kids? • Why don’t more women attend the clinic’s cervical cancer screening? It’s free! • Why does the community have such an alarming rate of obesity?
Although these questions show the nurse’s desire and good intentions to understand the link between health behavior and health education, they do not yield actionable answers or empower individuals, families, or groups. In fact, such questions negate critical root health issues and, rather, create a “blaming the victim” approach as recounted by Israel et al. (1994, 2013). Instead, the nurse should try to reframe the questions to get at reasons that help explain the behavior and that lend themselves to nursing actions. Consider these questions the nurse might ask instead:
• What life stressors get in the way of the expectant mom’s quitting smoking for good? What stage of quitting might she be in? What social support could be offered to help her quit?
• What structural factors might be preventing this gentleman from getting a follow-up test (colonoscopy)? For example, is transportation a problem? Are the instructions clear? Might he view the colonoscopy procedure as scary? What beliefs might he have about the tests, for example, “that it has to do with my manhood”? Does he have money for the prep? What can I do better to verify that he understands the importance of the test?
• How does the teen with diabetes like to learn? What makes it difficult for him to remember to take his insulin? Are the needles a concern? Does he have worries about how his diabetes might affect his soccer game? What can I do to better connect my instructions to what is important to him in his everyday school and sports activities?
• What is hindering the parents from getting HPV immunizations for their kids? What have they heard about HPV? Could their religious beliefs play a role? Do they think their children will be sexually active sooner if they get the vaccination? Might the family be worried about side effects of the immunizations that they heard about from their relatives? How could I do a better job of explaining the importance of the importance of the HPV series in light of these concerns?
• What outreach methods might better attract the women to the free cervical cancer screening? Could a promotora help engage women and help them navigate the process? Are the materials and promotional flyers language specific?
• What social, physical, cultural, language, linguistic, or structural factors should be considered when developing nutrition messages? What role can I play to develop links with schools, grocery stores, churches, and community centers to better reach and teach families about nutritional interventions? How can community capacity be strengthened to advocate for greater access to healthier food in their grocery stores?
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Health Education in the Community Historically, teaching has been a significant nursing responsibility since Florence Nightingale’s (1859) early work. Gardner (1936) emphasized that health teaching is one of the most fundamental nursing principles and that “a nurse, in even the most obscure position must be a teacher of no mean order.” There is much support for the nurse’s involvement in health education and health communications, including nurse practice acts, professional statements of the American Nurses Association (2013), The Joint Commission (2017), Quad Council of Public Health Nursing Organizations (2013), Healthy People 2020 objectives (U.S. Department of Health and Human Services [USDHHS], n.d., available thfrom https://www.healthypeople.gov/2020/default.aspx).
Health education is an integral part of the nurse’s role in the community for promoting health, preventing disease, and maintaining optimal wellness (Box 8.1). Moreover, the community is a vital link for the delivery of effective health care and offers the nurse multiple opportunities to provide appropriate health education within the context of a setting that is familiar to community members (Belone et al., 2016; Hébert et al., 2015; Meade et al., 2011; Meade et al., 2011).
The role of the nurse as health educator is especially important in light of the increasing diversity and demographically changing population in the United States, technological advancements in health care and communications, and attention on social determinants of health. Nurses are pivotal to improve the connection between scientific discovery and the delivery of interventions in the community and to advance health equity and social justice (Alcarz et al., 2016; Chu et al., 2008; Freeman, 2004; Marmot and Wilkinson 2000; Quinn et al., 2015; Thurman Pfitzinger-Lippe 2017). More than ever before, health education activities and services are taking place outside the walls of hospitals in such settings as missions, Young Men’s/Women’s Christian Associations, beauty and barber shops, grocery stores, truck stops, youth centers, homeless shelters, Veterans of Foreign Wars halls, churches, community-based clinics, health maintenance organizations, schools, worksites, shopping malls, senior centers, adult education/literacy centers, mobile health units, homes, libraries, etc. Further, health education activities are increasingly occurring via social media, e-health, and/or Internet-based communication channels (Glanz et al., 2015; Koskan et al., 2014). However, at the core of health education is the development of trusting relationships based on nurturing and healing interactions that heavily rely on community-based participatory methods. Such methods highlight community strengths and sustainable collaborations and partnerships (Balls-Berry et al., 2017; Braun et al., 2015; Gwede et al., 2010, 2015; Luque et al., 2012; Meade et al., 2011; Ross et al., 2016; Simmons et al., 2015; Wells et al., 2012).
BOX 8.1 Health Education Roles and Activities of the Nurse in the Community
• Advocate • Administrator • Caregiver • Case manager • Coach • Collaborator • Community care agent • Consultant • Counselor • Culture broker • Educator • Facilitator of health-promoting behaviors • Information agent and broker • Innovator
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• Liaison • Mediator • Navigator • Negotiator • Policy analyst, policy maker, or change agent • Promoter of collaborative partnerships • Promoter of self-care and self-efficacy • Referral resource • Researcher • Sensitizer • Social activist
American Nurses Association (2013), Clark (2015), Meade et al. (2014), Quad Council of Public Health Organizations (2011), Randall et al. (2017), Redman (2007), and Swider et al. (2013).
Health education is any combination of learning experiences designed to predispose, enable, and reinforce voluntary behavior conducive to health in individuals, groups, or communities. Its goal is to understand health behavior and to translate knowledge into relevant interventions and strategies for health enhancement, disease prevention, and chronic illness management. Health education aims to enhance wellness and decrease disability; attempts to actualize the health potential of individuals, families, communities, and society; and includes a broad and varied set of strategies aimed at influencing individuals within their social environment for improved health and well- being (Green and Kreuter, 2005).
Kleinman (1978) described a social and cultural community health care system as one that bridges external factors (e.g., economic, political, and epidemiological) to internal factors (e.g., behavioral and communicative). This view of a sociocultural health care system firmly grounds health education activities within sociopolitical structures, especially within local environmental settings, and views the community as client (Holt et al., 2017; Kelly et al., 2017; Martinez et al., 2016; Meade et al., 2007, 2011; Ramaswamy et al., 2017). As such, because the community level is often the location of health prevention and health promotion programs, it is a significant and enriching venue for obtaining positive health outcomes. Nurses are uniquely qualified to influence the health and well-being of community members’ health behaviors through original and inventive activities that incorporate culturally, linguistically, and educationally relevant health education and messaging due to their knowledge, competencies, and skills. They are able to take on leadership roles to expertly assess community assets and information gaps and put forward effective solutions to complex, multicausal community concerns to advance social justice (Kulbok et al., 2012; Thurman and Pfitzinger-Lippe, 2017).
It is paramount that community nurse educators address the myriad sociopolitical conditions that affect community health by placing value on the contributions of community members’ strengths. Sustained cognitive and behavioral changes often rely heavily on engaging learners in becoming partners in their own health behavior and practice. For example, take a look at the community interventions directed toward empowerment and participatory approaches as remarked by the following writers:
Aranda et al. (2017), who reported that the use of participatory methods (15 focus groups among young people, ages 11–19) were helpful to generate discussions about sexual health. By making the topic more visible, they addressed the complex tensions in designing and delivering acceptable sexual health care services. As a result, the school nurse was instrumental in promoting a positive sexual health culture within the school setting; Kelly et al. (2017), who carried out in-depth interviews with incarcerated women to examine their experiences with Pap tests and how they followed up on abnormal results. A number of contextual factors elucidated in this work included Pap test abnormality as an all-inclusive phrase for women’s health problems, the nature of these women’s unstable lives, the structural challenges of money, and competing demands—all of which played a role in whether they followed up on abnormal Pap test results or with other health problems; Christy et al. (2016), who illustrated how the formation of sustainable community– academic partnerships led to the development of improved colorectal cancer screening rates that
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achieved national screening goals of 80% in community clinics through health education and provision of the Fecal Immunochemical Test; Kille et al. (2017), who conducted a content analysis of web-based advertisements among women, men, and transgender sex workers in Canada to help identify information that could inform the health and safety of Internet-based sex workers and their clients; and Irewall et al. (2016), who highlighted the value of a nurse-led, telephone-based intervention as being more efficient than usual care at improving blood pressure and low-density lipoprotein cholesterol levels at 12 months after hospital discharge, thus contributing to modifying patients’ risk factors after stroke or transient ischemic attack.
In short, nurses have significant roles in providing contextually appropriate health education, which involves practical, useful, and scientifically sound methods that fit the lives and learning needs of diverse groups across the lifespan.
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Learning Theories, Principles, and Health Education Models Learning Theories Learning theories are helpful in understanding how individuals, families, and groups learn. The field of psychology provides the basis for most of these theories and illustrates how environmental stimuli elicit specific responses. Such theories can aid nurses to recognize the mechanisms that potentially modify knowledge, attitude, and behavior. Bigge and Shermis (2004) assert that learning is an enduring change that involves the modification of insights, behaviors, perceptions, or motivations. Although psychology textbooks describe learning theories in great detail, the following broad categories relate to the nursing application in a community setting: stimulus- response (S-R) conditioning (i.e., behavioristic), cognitive, humanistic, and social learning.
Research Highlights
An Examination of Intimate Partner Violence and Sexual Relationship Power Among Adolescents in South Africa A nurse-led team (Teitelman et al., 2016) sought to explore the associations of intimate partner violence (IPV) and relationship power about sexual-risk behaviors and determine if these associations differed by gender among adolescents in South Africa. Their work required careful understanding of the landscape of gender-based sexual norms that often reflect social construction of masculinities and femininities. This perspective was important to understand possible gender inequities and associated sexual risks faced by adolescents. As background, the study built on prior work by Jemmott et al. (2010, 2015) that described a systematic approach to developing and testing an HIV/sexually transmitted infection health education intervention. This 12-hour educational intervention delivered to sixth graders was based on social cognitive theory, the theory of planned behavior, and extensive formative research and was delivered in the Xhosa language. A total of 1057 students took part in the intervention that was carried out in 18 schools in Cape Province, South Africa. Results showed that students retained risk-reduction knowledge, self-efficacy, and outcome expectancies and kept engaging in safer sexual behavior during follow-up at multiple time points.
The current study (Teitelman et al.) reported data from the 54-month follow-up among 786 adolescents who reported sexual debut (mean age = 16.9). The rationale for exploring this aspect of sexual health (IPV and sexual relationship power) is based on literature showing that low relationship power and victimization by IPV is linked to increased HIV risks among adult females and adolescent girls. The data were collected by paper/pencil questionnaires and assessed the adolescents’ sexual risk behaviors (e.g., multiple partners in 3 months, condom use at last sex, IPV, and relationship power). IPV victimization was operationalized as “things that happened to you with a sexual partner while you were having an argument, e.g., physical, sexual and psychological threatening.” Results showed that adolescent boys were less likely to report condom use at last sex (p = .001) and more likely to report multiple partners (p < .001). Also, as IPV increased, reported condom use decreased at last sex for girls, but for boys, it increased. Overall, boys reported lower total relationship power than girls, which may suggest a shift toward more progressive gender norms and gender parity in sexual decision-making power. Findings suggest that sexual risk- reduction interventions for adolescents in South Africa should be developed in light of the social context to reduce adolescent partner violence and sexual relationship power imbalances. It was suggested that interventions should integrate individual attitudes about IPV and interpersonal gender power dynamics, as well as draw on community-level intervention approaches to change harmful social gender norms that perpetuate inequalities. The authors related that HIV risk- reduction policies and programs need to be implemented to address IPV to promote gender equity and respectful and safe relationships among adolescents. It should be noted, though, that a limitation of the study was the use of self-report of behaviors and experiences. Yet, collectively, these studies point to the value of nurse-delivered health education and reinforce the need for
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future studies (both globally and here in the United States) that test the utility of theoretically driven health education interventions that discern key features that contribute to healthy behaviors. Data from Teitelman AM, Jemmott AM, Bellamy SL., et al.: Partner violence, power and gender differences in South African adolescents’ HIV/STI behaviors, Health Psychology 35(7):751–760, 2016. doi:10.1037/hea0000351; Jemmott JB, Jemmott LS, O’Leary A., et al.: School-based randomized controlled trial of an HIV/STD risk-reduction intervention for South African adolescents, Archives of Pediatrics & Adolescent Medicine 164(10):923–929, 2010. doi:10.1001/archpediatrics.2010.176; Jemmott JB, Jemmott LS, O’Leary A., et al.: HIV/ STI risk-reduction-intervention efficacy with South African adolescents over 54 months, Health Psychology 34(6):610–621, 2015. https://doi.org/10.1037/hea0000140
The nurse should remember that theories are not completely right or wrong. Different theories work well in different situations. Knowles (1989) relates that behaviorists program individuals through S-R mechanisms to behave in a certain fashion. Humanistic theories help individuals develop their potential in self-directing and holistic manners. Cognitive theorists recognize the brain’s ability to think, feel, learn, and solve problems and train the brain to maximize these functions. Although social learning theory is largely a cognitive theory, it also includes elements of behaviorism (Bandura, 1977b). Social learning theory’s premise is based on the idea that behavior explains and enhances learning through the concepts of efficacy, outcome expectation, and incentives. Clinical Example 8.1 applies various theories to a community intervention.
Clinical Example 8.1 Application of Characteristics of Adult Learners to the Development of a Community Support Group This example illustrates the long-standing value of incorporating theoretical underpinnings in the development of community-engaged activities designed to meet specific learning needs. It provides a description of how nurses played an active role in bolstering the community capacity and health of their community. Although this account dates back to the 1980s, it serves as an important reminder of the value of applying learning theories to one’s work and how such application leads to sustainability of efforts (a key goal of nursing actions!). It is common for nurses based in the community to be an educational resource for patients, families, and community members as they cope with health, wellness, and disease. Later in the chapter, another example is discussed, LUNA (Latinas Unidas por un Nuevo Amanecer, Inc.), a nonprofit organization whose mission is to provide support and offer culturally and linguistically relevant education to Hispanic breast cancer survivors and their families, and it is based on similar tenets.
As background, the author and another nursing colleague began a community education support group for individuals with amyotrophic lateral sclerosis (ALS), more commonly known as Lou Gehrig’s disease, on the basis of an identified community need. ALS is an incurable degenerative neuromuscular disease that affects nerve and muscle function and the brain’s ability to control muscle movement (see http://alsawi.org/ for more information about ALS). The support group was open to family members and friends. At that time, southeast Wisconsin did not have a support group. Community members provided feedback and identified the need for specific education topics and support for people with ALS. This initial dialogue provided the organizing framework for the inception of the first support group, and based on observations and interactions at the monthly meetings, an illustration of Knowles’ assumptions follows:
Need to know: At the first support group meetings, the facilitators, both nurses, introduced possible topics by describing the reason for the discussion and the rationale for the selected subjects (e.g., common concerns of patients and family members and informal assessments based on conversations and the literature). To prepare for discussion, group members introduced themselves, and the nurses asked what they hoped to learn from the sessions. In some cases, members were unsure why they might want more information on given topics but indicated that they wanted to listen. Progression of the disease is variable; therefore the
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need to know was often facilitated by the nurses and other patients who already noted the importance of specific learning tasks (e.g., need for supportive care, assistive walking devices, financial planning, or information on assistive breathing devices).
Self-concept: A comfortable, informal, and trusting environment allowed patients to express feelings, emotions, and frustrations about the disease. Patients, family members, caregivers, and support persons were encouraged to express themselves. Over time, participants cultivated mutual respect and trust for one another as a result of many commonalities. Hugs were common as members began to understand that others had similar situations and concerns. Group members had an opportunity to share and speak about ways that they managed and coped with their disease (e.g., decisions about life support and feeding tubes). Even if their choices were not the same, participants recognized and acknowledged these decisions without imposing their own value judgments. Facilitators and group members soon became equal partners in the learning process. At the core of the meetings was the formation of therapeutic healing and respectful relationships.
Experiences: Some patients and family members had gone through other difficult life experiences and stressors (e.g., other illnesses or deaths in the family) and helped others cope with the management of ALS. Patients shared their strengths gained from such experiences with other support group members. Additionally, individuals and family members who were going through varying stages of the disease process shared their experiences (e.g., obtaining home care, selecting a computer, and managing swallowing and eating). They shared tips and time-saving strategies with one another and with newly diagnosed families and learned from those experiences.
Readiness to learn: Family members often take on many roles when someone becomes ill, especially with a chronic illness such as ALS. This redefinition of roles creates new learning opportunities; however, it can hinder learning if it is too overwhelming. For example, the well spouse may assume the roles of caregiver, parent, and financial supporter. It is helpful for nurses to identify resources to help the family cope with new roles (e.g., respite care).
Orientation to learning: Learning a variety of psychomotor skills is necessary to care for the patient with ALS (e.g., suctioning, positioning, using a feeding tube, and toileting). The time frame for learning such skills varies depending on the course of illness. Presenting information about such skills too early in the course of the disease may cause fear and anxiety. Families may be resistant to learning such tasks until the need is apparent. In some cases, the need may be evident at a crisis point (e.g., a fall, a choking incident, or severe respiratory distress). However, nurse facilitators of support groups can introduce these topics slowly by providing information via educational sessions, newsletters, e-mails, telephone calls, the Internet, printed brochures, blogs, FaceTime, discussion boards, and one-on-one discussions.
Motivation: Individuals and families often experience a shift in life goals when faced with ALS. Such shifts create new learning opportunities aimed at enhancing quality of life, promoting survivorship, and maintaining self-esteem. For example, a college professor with ALS kept his link to the university. He was highly motivated to continue his research work and supervise his graduate students. To continue his academic work, he learned to manage his breathing by using a ventilator, arranged transportation to the university, obtained nursing care, and created communication methods by using a computer to ensure that his students’ work continued.
As a result of this initial local support group the ALS Association Wisconsin Chapter evolved and became an official ALS Association chapter in 1987. The chapter’s mission is to “lead the fight to cure and treat ALS through global, cutting-edge research, and to empower people with ALS and their families to live fuller lives by providing them with compassionate care and support.” Today, there are more than eight ALS Association Wisconsin Chapter–sponsored patient/caregiver support groups in Wisconsin as well as five additional support groups and meetings in Wisconsin. This is the result from just one meeting held by two nurses on a Saturday several decades ago in response to an unmet need in the community. Over the years, many community and family activities, health education programs, and fundraising events have brought significant awareness, scientific advancements, and patient services to individuals with ALS and their loved ones.
For more information on services, go to ALS national and state websites.
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Active Learning Exercise
In groups of three to four students, discuss how theoretical frameworks help explain health behavior. Identify the strengths and limitations of models that focus on individual health determinants versus models that encompass sociopolitical, environmental, and structural factors.
Knowles’ Assumptions About Adult Learners Knowles (1988, 1989) outlines several assumptions about adult learners. He contends that adults, like children, learn better in a facilitative, nonrestrictive, and nonstructured environment. Nurses who are familiar with these assumptions can develop teaching strategies that motivate and interest individuals, families, and groups and encourage active and full participation in the learning process. Nurses can help create a self-directing, self-empowering learning environment. The following characteristics affect learning: the client’s need to know, concept of self, readiness to learn, orientation to learning, experience, and motivation. Table 8.1 expands on these characteristics.
TABLE 8.1
Characteristics of Adult Learners
Modified from Knowles MS: The making of an adult educator: an autobiographical journey, San Francisco, 1989, Jossey-Bass; Knowles MS: The modern practice of adult education: from pedagogy to andragogy, Chicago, 1988, Cambridge Press.
TABLE 8.2
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Health Belief Model∗
Components Example and Explanation Perceived susceptibility∗ Belief that disease state is present or likely to occur Perceived severity∗ Perception that disease state or condition is harmful and has serious consequences Perceived benefits∗ Belief that health action is of value and has efficacy Perceived barriers∗ Belief that health action is associated with hindrances (e.g., cost) Self-efficacy Belief that actions can be performed to achieve the desired outcome (one’s confidence)
Modifying factors (demographic, psychosocial, structural)
Age, gender, education, experience, motivation
Cues to action Influencing factors to get ready for action (e.g., educational materials, text messaging, billboards, newspapers, computer apps, blogs, reminder cues)
∗ For a more detailed description of the HBM and the original components, see Becker MH, editor: The health belief model and personal health behavior, Thorofare, NJ, 1974, Charles B. Slack.
Health Education Models In addition to learning theories, the application of education theories and principles to situations involving individuals, families, and groups illustrates how ideas fit together, offers explanations for health behaviors or actions, and helps direct community nursing interventions. Such theoretical elements form the basis of understanding health behavior. Theoretical frameworks offer nurses an intervention blueprint that promotes learning and provides them with an organized approach to explaining concept relationships (Padilla and Bulcavage, 1991). It gives nurses the ability to assess an intervention’s strength and impact. Importantly, theory and practice need to coexist, and the best theory is one often rooted from practice (Glanz et al., 2015).
Models of Individual Behavior Two models that explain preventive behavior determinants are the Health Belief Model (HBM), which is presented in Table 8.2 (Becker et al., 1977; Hochbaum, 1958; Kegeles et al., 1965; Rosenstock, 1966), and the Health Promotion Model (HPM) (Pender et al., 2015). Both models are multifactorial; are based on value expectancy; and address individual perceptions, modifying factors, and likelihood of action. The HBM is based on social psychology and has undergone much empirical testing to predict compliance on singular preventive measures. The initial purpose of the HBM was to explain why people did not participate in health education programs to prevent or detect disease, in particular, tuberculosis screening programs (Hochbaum, 1958). Subsequent studies addressed other preventive actions and factors related to adherence to medical regimens (Becker, 1974). Primarily, the HBM is a value expectancy theory that addresses factors that promote health-enhancing behavior. It is disease specific and focuses on avoidance orientation. The HBM considers perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and other sociopsychological and structural variables (modifying factors). Self-efficacy, defined as the notion that an individual can act successfully on a given behavior to produce the desired outcome (Bandura, 1977a, 1977b), was later added to the HBM (Rosenstock et al., 1988; Strecher et al., 1986). In a meta-analysis (data combined from 18 studies with 2702 subjects), it was found that benefits and barriers were the strongest predictors of behaviors over time (Carpenter, 2010).
Champion and Skinner (2008) point out that one of the limitations of the HBM is the variability in measurement of the central HBM constructs, which include the inconsistent measurement of HBM concepts and the failure to establish the validity and reliability of the measures before testing. For example, applying similar construct measures across different behaviors, such as barriers for mammography and colonoscopy, may be quite different. The past decades have produced some good examples of HBM scale development (Champion et al., 2016, 2008; Rawl et al., 2012, 2015), yet caution in the application of the HBM to multicultural settings is warranted. It would be important to determine whether the overall assumptions of the HBM—assumptions related to the value of health and illness—are similar to those of the particular racial/ethnic group under study. Although the HBM identifies an array of variables important in explaining individual health, nurses should view these variables within a larger societal perspective. Checking for cultural distinctions is especially critical to the model’s usefulness among diverse racial/ethnic groups (Brenner et al., 2015; Janz et al., 2002) and is even more important today in light of our demographically changing landscape.
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Pender’s HPM is a competence- or approach-oriented model first appearing in the nursing literature in 1982. The HPM brings together a number of constructs from expectancy value theory and social cognitive theory within a holistic nursing framework. Unlike the HBM, it does not rely on personal threat as a motivating factor. Rather, it aims to explain why individuals engage in health actions. The central focus of the model is based on individual characteristics and experience, behavior-specific cognitions and affect, and behavioral outcomes that can be assessed by the nurse and that serve as key points for nursing intervention (Pender et al., 2015). It is applicable across the lifespan and has been used to examine the multidimensional nature of persons interacting with their physical and interpersonal environments. For example, it was used in studies to identify factors that enhance health-promoting behaviors of military spouses (Padden et al., 2013); to investigate the efficacy of how a “Girls on the Move” intervention could improve cardiovascular fitness among urban middle school girls (Robbins et al., 2013); and to examine ways to improve nutritional status and behaviors of overweight/obese women who presented at clinics in West Iran (Khodaveisi et al., 2017) Table 8.3 lists the main components of the HPM and supplies their definitions. The HBM and HPM can assist community health nurses in examining an individual’s health choices and decisions for influencing health-related behaviors. The models offer nurses a cluster of variables that provide interesting insights into explaining health behavior. These variables are helpful cues. The nurse can consider them in planning programs, but should not try to fit an individual into all the categories. Simply put, models are aids that guide nurses in assessing patients and groups for the development, selection, and implementation of relevant educational interventions.
TABLE 8.3
Health Promotion Model Components and Definitions∗
∗ For a more comprehensive description and explanation of the HPM, see Pender NJ, Murdaugh CL, Parsons MA: Health promotion in nursing practice, ed 6, Englewood Cliffs, NJ, 2010, Prentice Hall; Pender NJ, Murdaugh C, Parsons MA., et al.: Health promotion in nursing practice, ed 7, 2015, Pearson.
Try applying the model to your own life and health behaviors. Consider the following questions:
• Do you continually strive for improved health? • Are you or your family susceptible to heart disease or obesity? • Does a family history of cardiovascular disease motivate you or your family to exercise? • What are your cholesterol and triglyceride numbers? • Does looking fit and toned and having energy motivate you to exercise?
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• Do work, school, or family responsibilities get in the way of your exercise plans? • Has a family member, friend, or health provider recently reminded you of the benefits of
exercise and encouraged you to start exercising? • Do you believe you can initiate and incorporate an exercise program into your lifestyle, or
do you need external reinforcement and cues? • Does money, safety, or time pose any impediments to exercise? • What would make exercise more appealing, such as a “running or walking club”? • What do you see as the benefits to exercise, for example, looking and feeling better and
having more energy? • In modifying your health behaviors, how important is exercise compared with other
behaviors (e.g., getting relief from work and school stresses, cutting down on snacks, spending quality time with your family and friends)?
Think about these questions and consider your answers. Talk about this behavior with your peers, and develop an exercise action plan that is personalized to your own priorities, needs, abilities, and interests.
Model of Health Education Empowerment The HBM and HPM focus on individual strategies for achieving optimal health and well-being. The models are similar in that they are multifactorial; are based on the idea of value expectancy; and address individual perceptions, modifying factors, and likelihood of action. Although such approaches may be quite appropriate in changing individual behaviors, they do not necessarily address the complex relationships among social, structural, and physical factors in the environment, such as inadequate social support systems, racism, discrimination, and inaccessibility of health services (Devia et al., 2017; Israel et al., 2013; Minkler, 2012). Van Wyk (1999) suggests that nurses cannot assign power and control to the individual within the community, but, rather, that the “power” must be taken on by the individual and community with the nurse guiding this dynamic process. This process includes examination of such factors as education, health literacy, gender, racism, social justice, and class and recognition of the structural and foundational changes that are needed to elicit change for socially and politically disenfranchised groups. Thus, knowledge is produced in a social context, and it is inextricably bound to relations of power. Therefore an appropriate and more relevant health education model may be one that embraces a broader definition of health and addresses social, political, and economic aspects of health. Such a theoretical perspective is highly congruent with current community health education practices because it supports learner participation, highlights community engagement, and emphasizes empowerment.
Freire: A Focus on Problem-Solving Education Empowerment and literacy are two concepts that have a common history. The concept of empowerment can be traced back to Paulo Freire, a Brazilian educator in the 1950s who sought to promote literacy among the poorest of the poor and most oppressed members of the population. He based his work on a problem-solving approach to education, which contrasts with what he called the “banking education approach,” which often places the learner in a passive role. Problem- solving education allows active participation and ongoing dialogue and encourages learners to be critical of and reflective about health issues. Freire suggested that when individuals assume the role of objects, they often become powerless and allow the environment to control them. However, when individuals become subjects, they influence environmental factors that affect their lives and community. Thus, community members, or subjects, are the best resources to elicit change (Freire, 2005).
Freire’s methodology, often referred to as critical consciousness, involves not only education but also activism on the part of the educator. The basic tenet of Freire’s work centers on empowerment; the contextualization of peoples’ daily experiences; and collaborative, collegial dialogue in adult education. Freire’s work speaks to a variety of action research applications, including those that relate to improving community health of marginalized populations. Freire’s approach to health education increases health knowledge through a participatory group process and emphasizes establishing sustainable lateral relationships. This process explores the problem’s nature and addresses the problem’s deeper issues. The nurse serves as a central resource person and becomes
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an equal partner with other group members. Listening is a first essential step to understanding the issues. This exchange of ideas and concerns then creates a problem-posing dialogue to identify core problems or generative themes. As this process moves along, the group further delves into the root causes. Finally, the group co-creates relevant action plans that are suitably aligned with their lives (Freire, 2000).
Nurses can use health education as an empowering strategy to help people develop skills in problem solving, critical thinking, networking, negotiating, lobbying, advocacy, policy making, and information seeking to enhance health. Freire’s approach may seem similar to health education’s emphasis on helping people take responsibility for their health by providing them with information, skills, reinforcement, and support. However, Freire purports that knowledge imparted by the collective group is significantly more powerful than information provided by health educators. This learner-centered approach attempts to uncover the social and political aspects of problems and encourages group members to define and develop action strategies. Hence, there is keen recognition that health and behavior changes are multifaceted and usually do not have immediate solutions; therefore the term problem posing, rather than problem solving, better describes this empowerment process (Wallerstein et al., 2015). As Kark and Steuart (1962) once stated, “health education must achieve its ends through means that leave inviolate the rights of self- determination of the individuals and their community. The goal of participatory action research (PAR) is social change. PAR is also quite consistent with the role and responsibilities of nurses who are engaged in community health (Olshansky et al., 2005) and embraces the use of community- based participatory methods. What this means is that participation and action from stakeholders and knowledge about conditions and issues help facilitate strategies reached collectively (e.g., access to care, access to information). By way of definition, stakeholders are individuals, groups, or organizations that have common and direct interests and concern in a topic, situation, or health outcome. Some examples of the use of PAR include the following projects: Marsh et al., (2017) described the use of PAR to inform the creation of a community garden that functioned as a therapeutic place for end-of-life and bereavement support; Clements (2012) demonstrated how the use of PAR and photovoice was well suited as a framework within a community psychosocial recovery rehabilitation center in Winnipeg, Canada; and Zehbe et al. (2016) developed a PAR project in collaboration with 11 Ojibwa and Oji-Cree First Nations—Anishinaabe—communities in northwest Ontario, Canada, to promote cervical cancer screening through education that respectfully depicted female bodies, sexuality, and health behaviors through a First Nations lens.
Active Learning Exercise
1. Identify a specific intended group in the community that you are interested in (e.g., medically underserved, homeless, seniors, pregnant women, new immigrants, deaf children, middle-school children).
a. Describe the group’s characteristics, learning needs, and strengths. b. Identify your methods for obtaining this information. c. Next, describe the application of Freire’s empowerment education model to
address health education priorities. How would you engage them in determining learning priorities?
Examples of Empowerment Education and Participatory Methods To illustrate the use of empowerment principles, consider the following: Moya et al. (2017) related how photovoice was used as a participatory research method with participants experiencing homelessness in El Paso Texas, referred to as “The Voices and Images of the Residents of the Opportunity Center for the Homeless: A Visual Project on the Identity and Challenges Homeless Adults Face on the Border Region.” Four themes that represented their experiences as well as their aspirations were depicted in their pictures: 1) broken systems, 2) invisibility, 3) opportunities and what works, and 4) growth and determination. The photographs were then shown at a gallery along with narratives. Along with the photographs, a “call to action” was formulated that asked the community, policy, and decision makers to commit to change in the current social, economic, and political conditions affecting individuals experiencing homelessness. As such, the use of photovoice
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offered an important and creative way to facilitate shared knowledge to achieve social change. Luque et al. (2010) report the use of empowering processes based on Freire’s popular education
principles (Freire, 1968) and social cognitive theory, which focused on the constructs of environment, behavioral capability, observational learning, and self-efficacy (Bandura, 1977a, 1977b) for creating a barbershop training program about prostate cancer in an urban setting. By employing techniques borrowed from empowerment education (Wallerstein and Bernstein, 1988), barbers were engaged in group learning activities and problem-posing exercises designed around preferences and values related to prostate cancer health. Once the training and curriculum were completed among eight barbers, the team worked closely with the barbers to modify and create a supportive workplace environment for new health education tools (easy-to-read posters, brochures, DVD player, prostate cancer display model) to fuel discussions about prostate cancer health and decision making. Once the barbers were trained, structured surveys with barbershop clients (N = 40) were conducted. Results showed a significant increase in participants’ self-reported knowledge of prostate cancer and an increased likelihood of discussing prostate cancer with a health care provider (P < .001). The barber-administered pilot intervention appeared to be an appropriate and viable communication strategy for promoting prostate knowledge to a priority population in a very convenient and familiar setting. Luque et al. (2015) further extended this work and evaluated the acceptability of barbershops for delivery of prostate cancer information among African Americans in a rural setting in Georgia and found high receptivity again for barbershops as a venue for health education Wells et al. (2012, 2015) reported on the use of community-based participatory research methods framed within a social construct theoretical framework to develop a low-literacy, navigator-delivered cervical cancer and HPV educational intervention. This program, based on empowerment principles, was designed to reach a rural Hispanic farmworker community in response to three gaps in care identified by a collaborating community clinical partner. The gaps were (1) delays in reporting results of Papanicolaou (Pap) tests to patients; (2) the need for navigated follow-up care for abnormal findings; and (3) the need for enhanced and consistent education about cervical cancer and HPV. The development of the lay navigation program was created on the basis of a long-standing community–academic collaboration between Catholic Mobile Medical Services and the Tampa Bay Community Cancer Network (TBCCN), a community network program funded by the National Cancer Institute (NCI). It was informed by formative research conducted with members of the farmworker community. Findings from the pilot were used to generate knowledge about evidence-based patient navigation programs in community- based settings, develop a set of low-literacy Spanish-language educational teaching cards, and guide the creation of a Spanish-language virtual patient educator—“an avatar” to be used with a lay navigator to educate women about cervical cancer and HPV. Overall, these projects that emphasize empowering principles illustrate the wide diversity of settings and methods that can be used to implement health education in the community. Think for a moment how empowerment approaches could be used in a health education outreach activity.
Community Empowerment Community empowerment is a central tenet of community organization, whereby community members take on greater power to create change. It is based on community cultural strengths and assets. An empowerment continuum acknowledges the value and interdependence of individual and political action strategies aimed at the collective while maintaining the community organization as central (Minkler et al., 2012) As such, community organization reinforces one of the field’s underlying premises as outlined by Nyswander (1956): “Start where the people are.” Furthermore, Labonte (1994) states that the community is an engine of health promotion and a vehicle for empowerment. He describes five spheres of an empowerment model, which focus on the following levels of social organization: interpersonal (personal empowerment), intragroup (small-group development), intergroup (community), interorganizational (coalition building), and political action. A multilevel empowerment model allows us to consider both macro-level and micro-level forces that combine to create both health and disease. Therefore it seems that both micro and macro viewpoints on health education provide nurses with multiple opportunities for intervention across a broad continuum.
In summary, health education activities that respond to McKinlay’s (1979) call to study “upstream,” that is, to examine the underlying causes of health inequalities through multilevel education and research allow nurses to be informed by critical perspectives from education,
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anthropology, and public health. For more extensive readings on this topic, see Methods in Community-Based Participatory Research for Health (Israel et al., 2013), Community Organizing and Community Building for Health and Welfare (Minkler, 2012).
To effect change at the community level, nurses should become familiar with and knowledgeable about key concepts central to community organization (Table 8.4). This approach is an effective methodological tool that enables nurses to partner with the community; identify common goals; develop strategies; and mobilize resources to increase community empowerment, capacity, and community competence. Key concepts inherent in community health education programming are empowerment, principle of participation, issue selection, principle of relevance, social capital, and creation of critical consciousness (Minkler et al., 2012).
The development of LUNA in Tampa, Florida, as described in Clinical Example 8.2, illustrates how the basic tenets of community need and organization fueled the development of a locally initiated group. LUNA represents a grassroots initiative to meet the needs of the growing numbers of Hispanic cancer survivors and serves as a model for nurses, researchers, and community advocates working with underserved groups of cancer survivors (Siegel et al., 2015).
Clinical Example 8.2 Example of Community Empowerment-Collaboration-Participation: LUNA More than a decade ago (2002), a Latina nurse (Melba Martinez, RN, BSN), who had been diagnosed with breast cancer in 1995, started the first grassroots support group for Latinas in west central Florida. The group began with five members and within the first year had 38 active members who attended monthly meetings. The group was initiated in response to an unmet need in the Tampa Bay area, that is, lack of education services for Latinas who had been diagnosed with breast cancer and who primarily spoke Spanish. Over the years, LUNA has created a network of more than 200 Latina survivors and has grown and become LUNA (Latinas Unidas por un Nuevo Amanecer, Inc.), a nonprofit organization whose mission is to provide emotional support and health education to cancer survivors and their families, friends, and caregivers from Latin communities of west central Florida .The organization primarily serves underserved, immigrant, low-income Latinas with limited English proficiency; assists with navigating the health care system; and functions as a community resource. LUNA draws on the tenets of community organization and empowerment fueled by problem-posing education. The three components of the LUNA model are (1) education (e.g., classes and presentations, Spanish cancer information, health care navigation, community outreach); (2) support (e.g., peer to peer, home, hospital and phone visits, communications); and (3) social reintegration (e.g., celebration of life events such as birthdays, cancer camps, walks, and other social events), similar to those of the startup of the ALS support group previously described.
Outcomes of LUNA
1. Campamento Alegria: The first-ever Spanish-language oncology camp for Latina cancer survivors. A biennial program designed to provide Latinas in whom cancer has been diagnosed a positive and unforgettable experience through a variety of activities that help sustain them through their cancer journey (Martinez et al., 2008). Campamento Alegria aims to serve 100 women who would otherwise not have the opportunity to participate in such activities. There are no fees for the patients/survivors for a 3-day/2-night stay at the retreat facility, meals and related activities, orientation, and reunion meeting.
2. Community education and outreach: Attendance at various community events and health fairs to increase breast cancer screening awareness and provide cancer information and resources in Spanish. These events are popular, and attendance increases each year.
3. Ongoing monthly educational support group meetings, now at two locations. Presentations and classes provided by Spanish-speaking health professionals on various survivorship issues and cancer-related topics.
4. Plans to develop a patient navigator program for Latina patients with newly diagnosed cancer.
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The process for creating LUNA began with one nurse who, through dedication and dialogue with others in the same situation, began taking charge of the situation on the basis of input from other community members. From both her nursing and personal experiences, she knew how hard it was for Hispanic women in whom cancer was diagnosed to navigate the health care system, how difficult it is to take time for self-care, and how challenging it was for Hispanic women to talk about their fears. She recognized that Latinas with breast cancer should reach out to one another with understanding and compassion in their own language to move toward self-education and self-actualization. Since its inception, LUNA has partnered with various community-based organizations, hospitals, academic centers, churches, and other social support services to create a strong web of support. For example, LUNA has a strong partnership with researchers from the TBCCN, a community network program funded by the NCI’s Center to Reduce Cancer Health Disparities, as well as with local hospitals. LUNA also has worked with researchers to understand the information needs of women undergoing chemotherapy and to transcreate a stress management program for Latinas undergoing chemotherapy (Martinez et al., 2016), which was evaluated in multisite clinical trial. LUNA represents a ground-up effort, which got its start because someone (a nurse) listened to the needs of Hispanic breast cancer survivors. It serves as an excellent model and reminder for nurses, researchers, and community advocates that the best ideas come from the “soul.” For more information, view http://www.lunacancerfl.org/.
”Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”
Margaret Mead
Acknowledgments: Melba Martinez, RN, BSN, and Dinorah (Dina) Martinez-Tyson, MA, MPH, PhD
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The Nurse’s Role in Health Education Although learning theories and health education models provide a useful framework for planning health interventions, the nurse’s ability to facilitate the education process and become a partner with individuals and communities is inherently significant to the method’s application (Clinical Example 8.3). At the core of health education is the therapeutic relationship between the nurse and individuals, families, and the community. Simply put, nurses hold the process together and are catalysts for change in delivering humanistic care. Nurses activate ideas, offer appropriate interventions, identify resources, and facilitate group empowerment. It is beyond the scope of this chapter to describe multiple communication techniques in detail, but the reader is reminded of the value of establishing inclusion and trust before delivering the health education content.
TABLE 8.4
Community Engagement and Organization Practice
Modified from Wallerstein N, Minkler M, Carter-Edwards L., et al.: Improving health through community engagement organization and community building. In Glanz K, Rimer BK, Viswanath K, editors: Health behavior: theory, research and practice, ed 5, San Francisco, 2015, Jossey-Bass; Minkler M, editor: Community organizing and community building for health and welfare, ed 3, 2012, Rutgers University Press.
Clinical Example 8.3 Mr. Chen is new to the area and starts to visit the local neighborhood senior center weekly to play cards and have lunch with his brothers, who have lived in the area for a number of years. Adjacent to the senior center (men call it “the club”) is a nurse-managed clinic, which was started more than 13 years ago by the college of nursing at the local university. The clinic offers education and free or low-cost screenings on a regular basis. Many community members take advantage of this
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convenient service for their primary care. Mr. Chen has limited resources, so this community resource provides him with valuable access to health care services and information. On his first visit to the clinic, his blood pressure is 174/92 mm Hg. He states that the public hospital that cared for him in another city treated him for high blood pressure for more than 7 years, that doctors prescribed several medications 6 months earlier, and that he received many written materials to read (they were all in English). Although he reads somewhat in English, he tells the nurse that it would have been nice to see materials in his familiar Chinese language
The nurse’s assessment reveals that Mr. Chen takes his medication only when he does not “feel so good.” He said his doctor advises him to take his medicines regularly, and he states that he takes them faithfully when he does not feel well. He tells the nurse that he remembers getting some educational booklets about his medications and “blood,” but he found them too long and tiring to read. The nurse’s educational assessment reveals that Mr. Chen has completed 8 years of schooling, does not read much, enjoys television over print, and likes to learn from pictures or from other people in groups. He states that he would really like to get his health information in easy English but would mostly prefer to get some easy materials in Chinese. His reading skills have not been verified by health providers. Yet it seems that he has taken the health instruction literally (e.g., he interprets “take regularly” to mean take consistently when “I don’t feel right” vs. take the pills on a regular schedule).
To facilitate learning, the nurse establishes a teaching plan with Mr. Chen’s input. This plan involves communicating health instructions in more relevant ways (e.g., using pictures, drawings, mnemonics, videotapes), providing word cards for him in Chinese with the help of the local translation services, and putting him in touch with county financial resources to assist in buying his medicines. The nurse also establishes a follow-up plan with a bilingual nurse to verify Mr. Chen’s understanding of how to take his medications by asking him to repeat back in his own words when/how he takes them (teach-back methods). She also plans to develop a series of health education group classes for seniors at “the club” about health and wellness, with high blood pressure as one of the topics of discussion.
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Enhancing Communication The critical step of inclusion establishes the base for possible health action; it sets the relationship. What this means is that the nurse needs to be especially cognizant of those first introductory oral exchanges and interactions. Inclusion may simply entail greeting individuals, families, and groups in a warm fashion; offering comfort; and attending to their immediate concerns or worries. Education does not begin with the first instructional word. Rather, education begins with establishing an atmosphere conducive to learning, whereby a therapeutic trusting relationship forms the foundation for a healing relationship. If the nurse attends to inclusion first, individuals, families, and groups next begin to trust the nurse and thereby trust the content of the health education message. This trust is evident through active participation in and commitment to the education process.
It is important to note that the ongoing enhancement and refinement of nursing knowledge and skills to provide culturally effective care is critical to community health education. Nurses are fundamental in responding to diverse community members’ everyday health concerns with meaningful, understandable, and actionable information. This involves taking time to get to know individuals, their families, and their everyday lived experiences.
Meleis (1999) describes culturally competent care as care that exhibits sensitivity to individuals based on their vast experiences and their responses, which are due to their backgrounds, sexual orientation, socioeconomic status, ethnicity, literacy, and cultural background. She depicts several properties that make up the “essence of health nurses” who deliver culturally competent care. First, they possess an explanatory system that values diversity. This is a system that is not drained by the constant attempt to interpret symbols, but rather is energized by the variations. Second, they show expert assessment skills to discern different and similar patterns of responses that help in planning appropriate educational interventions. Third, culturally competent nurses are aware of the diversity of communication patterns and how language and communication influence “trust within the relationship.” Culturally effective professionals also recognize how marginalization may increase health risks for individuals and that using the expertise of insiders in the culture is a highly valued skill.
For more information on the provision of CLAS and health care standards, view the updated, enhanced 15 standards (USDHHS OMH, 2013) that represent a comprehensive series of guidelines to advance health equity, improve quality, and help eliminate health disparities (https://www.thinkculturalhealth.hhs.gov/). These standards were created in response to growing concerns about health inequities and the need for health care systems to reach increasingly diverse patient populations. The standards reinforce the ability of nurses and organizations to understand and respond well to the cultural and linguistic needs brought by patients and community members to the health care setting. Several standards have particular relevance to community nursing. For example, Standard 1 signifies the importance of providing effective, equitable, understandable, and respectful quality care and services, in light of diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. Standard 13 reinforces the need to partner with communities to design, implement, and evaluate policies, practices, and services to ensure appropriateness. To learn more about their application to nurses, visit the “blueprint” at https://www.thinkculturalhealth.hhs.gov/clas/blueprint. “And remember: cultural competency and effectiveness is an ongoing journey that requires an openness to acknowledge what one does not know and the willingness to seek better ways to get the job done. It is a process, not simply a program or an end point. Consider health literacy as an ethical issue of concern in the community and how it contributes to health equity.
Ethical Insights Ethical Issues Related to Health Education and Health Literacy
Health literacy—Do community members understand the printed, digital, and oral health messages communicated to them in terms of language, ease of reading, and linguistics? Are
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these communications helpful to their decision making? To address the national problem of health literacy, nurses should assess their roles as educators, information brokers, advocates, facilitators, collaborative problem solvers, and navigators. Nurses should consider the impact that the multitude of demands of the health care system has on client autonomy. To explain, health literacy universal precautions refers to strategies to reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy. View the Agency for Healthcare Research and Quality website at https://www.ahrq.gov/professionals/quality-patient-safety/quality- resources/tools/literacy-toolkit/index.html.
Individual vs. collective/societal rights and responsibility for health—What communication factors should the nurse consider when balancing the health education needs of the individual against those of the collective (e.g., family and community)? What communication gaps can be bridged by the development and implementation of health information that is relevant culturally, linguistically, and in terms of literacy?
Social justice and equity—Do all community members enjoy equity in their access to health education and information? Does health information take into account the diversity of a demographically changing country? What types of materials are available for non–English- speaking clients? What strategies, programs, and interventions can be implemented to reduce the discovery-to-delivery disconnect? How can nurses reduce the demands of the health care system and implement navigation strategies?
Allocation of resources—In what way do policies promote and/or hinder promotion of health literacy? Do national/local government and corporate/institutional policies affect the availability, accessibility, and equitable distribution of information resources? In what way do current policies reward and support patient education? How can the nurse get involved in shaping and redirecting health policy and moving policy into practice? This includes policies at the institutional, community, local, and national levels.
Cultural effectiveness—What skills, knowledge, and experiences are necessary to the planning of health education within the context of people’s history and everyday realities? The nurse should assess his or her abilities to approach health education tasks with confidence, compassion, competence, and cultural humility (Marks, 2009; USDHHS, 2013).
Active Learning Exercise
Discuss the role of the nurse in health education. Outline specific activities and roles that the nurse can perform with regard to health education issues. Share with one another personal experience(s) relating to cultural effectiveness that might enhance/impede your education role.
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Framework for Developing Health Communications Within the community, the nurse’s intended audience may be an individual, family, group, or many segments of the community. Using a systematic approach to the development, design, and delivery of health education programs provides the nurse with an organized, user-friendly way to deliver health messages. Although nurses may select and use a variety of educational models, theoretical frameworks, and teaching and learning principles, the NCI suggests using the “Framework for Developing Health Communications” to create a variety of health education messages and programs (USDHHS, 2008).
This organizing framework has four stages (simplified from six) and is depicted by a circular loop that offers the opportunity for continuous assessment, feedback, and improvement. The framework has been used widely by the author to develop cancer education materials and media on such topics as smoking, prostate cancer, biobanking information, genetic counseling, breast and cervical cancer, stress management, and clinical trials (Brandon et al., 2012; Meade et al., 1994; Schapira et al., 1997; Scheer et al., in press; Sehovic et al., 2016; Simmons et al., 2011; Wells et al., 2015, 2012). This framework can be easily adapted to the design and development of all types of health education topics, such as diabetes, hypertension, HIV, and nutrition.
This framework is based on the principles of social marketing and health education and on mass communication theories, and it relies on intended audience assessment to guide the process. It is highly congruent with Freire’s model of empowerment education, which encourages ongoing dialogue with potential consumers and users of health education services. Although this model focuses on communication strategies aimed at the programmatic level, the basic elements are applicable to individual, family, and group systems. The nurse should not expect to apply the model in a linear manner, but rather to move back and forth between the stages. These stages mirror the nursing process (assessment, planning, implementation, and evaluation) and provide a sequential and organized path for continuous assessment, feedback, and improvement so as to achieve a successful communication program. The ideas contained in this Framework for Developing Health Communications model are a practical schema for planning and implementing health education communications programs (see Clinical Example 8.4 and Fig. 8.1).
Stage I: Planning and Strategy Development The planning stage provides the foundation for a communication program’s planning process and is crucial in setting the stage for creating salient communications. Understanding the intended audience’s learning needs and targeting the program or message to the audience are pivotal to activating effective health education. This step reinforces Freire’s philosophical tenets of ascertaining the intended audience’s needs and creating open dialogue. This stage also reduces expensive alterations once the program is under way.
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FIG. 8.1 Planning your health education message.
Questions to Ask
• Who is the intended audience? • What is known about the audience and from what sources? • What are the communication and education objectives and goals? • What evaluation strategies will the nurse use? • What are the issues of most concern? (Note: These may not necessarily be health issues but
may be important ones to link to the health issue when planning, e.g., safety, transportation.)
• What is the health issue of interest?
Collaborative Actions to Take
• Review available data from health statistics, census data, local sources, libraries, newspapers, and local or community stakeholders.
• Get community partners involved. • Obtain new data (e.g., interviews, surveys, and focus groups using problem-posing
dialogue format). • Determine the intended group’s needs and perceptions of health problems (i.e., identify
audiences). • Determine the community’s assets and strengths:
• Physical (e.g., gender, age, and health history) • Behavioral (e.g., lifestyle characteristics and health-related activities) • Demographic (e.g., income, years of schooling, language, and cultural
characteristics) • Psychographics (e.g., beliefs, values, and attitudes) • Identify issues behind the issues and identify health knowledge gaps.
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• Establish goals and objectives that are specific, attainable, prioritized, and time specific.
• Assess resources (e.g., money, staff, and materials).
Stage II: Developing and Pretesting Concepts, Messages, and Materials The nurse’s decisions in stage I can help guide him or her in selecting appropriate communication channels and producing effective and relevant materials. Consider how to reach the intended audience and use interesting and engaging supporting materials and media. Channel refers to how the nurse reaches communication sites (i.e., churches, clinics, missions, other nurses, or community- based organizations). Format refers to how the nurse communicates the health message (e.g., through individual or group discussion) (Table 8.5). Keep in mind that materials and media are the program’s tools, not the program itself (Table 8.6). Education is a human activity and should not focus on audiovisuals exclusively. To ensure that messages are relevant and meaningful, the nurse can employ qualitative research methods (pretesting, learner verification) to obtain feedback about the understandability and acceptability of the materials. Learning now what works and does not work saves a lot of time and money later!
Questions to Ask
• What channels are best? • What formats should be used? • Are there existing resources? • How can the nurse present the message?
TABLE 8.5
Teaching-Learning Formats
Teaching Format Application to Health Education Brainstorming session Allows participants the freedom to generate ideas and discuss them in a group setting.
Cultivates creativity. Fosters empowerment to allow members to identify the issue and find solutions.
Community-wide programs Can reach large numbers of community members through a systematic plan. May include individual or group approaches with a defined intended audience.
Demonstration Effective in learning perceptual motor skills. Aids in visual identification.
Group discussion/charlas Members can learn from each other and receive support. Nurses can personalize teaching content to group needs. Ideal for groups combining patients and families. Nurses, health professionals, or lay members can lead the groups. Facilitator must be comfortable with group method and familiar with group characteristics.
Lecture Varying group sizes can use formal oral presentations. Group members share expertise and experiences. Presenter must be comfortable and possess speaking ability. Requires organizational skills and ability to highlight key points in interesting and creative ways. A combination of lecture media may enhance learning. Audience participation is linked to the presenter’s speaking style and ability. Audience feedback is limited.
Individual discussion Allows individual assessment and identification of cultural barriers, physical impairments, learning needs, literacy, and anxiety. Promotes the tailoring of health education plans. Ideal to capture “teachable moments.” Does not allow sharing and support from others. High cost in terms of staff time.
Role playing Effective in influencing attitudes and opinions. Encourages problem-solving and critical thinking skills. Enhances learner participation. Some members may be hesitant to become involved.
Task force committee/community organizing meetings
Joins individuals with diverse backgrounds and expertise to achieve a goal. May represent many interests and perspectives.
Talking circles/charlas May be held in convenient settings such as missions, homes, or service settings: engages people in small group discussions (Litvin et al., 2011).
Town hall meetings Can offer shared experience in a familiar setting.
Data from Rankin SH., et al.: Patient education in health and illness, ed 5, Philadelphia, PA, 2005,
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Lippincott Williams and Wilkins, etc; Redman BK: The practice of patient education: a case study approach, ed 10, St. Louis, 2007, Elsevier; U.S. Department of Health and Human Services: Making health communication programs work: a planner’s guide, pink book, Bethesda, MD, 2008, Office of Cancer Communications, National Cancer Institute. Available from: https://www.cancer.gov/publications/health-communication/pink-book.pdf.
• How will the intended audience react to the message? • Will the audience understand, accept, and use the message? • What changes can improve the message?
Collaborative Actions to Take
• Identify messages and materials. • Decide whether to use existing materials or produce new ones. • Select channels and formats. • Develop relevant materials with the target audience. • Pretest the message and materials and obtain audience feedback (e.g., through interviews,
questionnaires, focus groups, and readability testing). Pretesting helps ensure comprehension, acceptability, and cultural relevance.
Stage III: Implementing the Program At the third stage, the nurse introduces the health education message and program to the intended audience and reviews and revises necessary components. The nurse also analyzes the program and health message for effectiveness and tracks the mechanisms using process evaluation. This way of organizing the implementation process examines the procedures and tasks involved in the program or message, such as monitoring media, identifying the intended audience’s interim reactions, and addressing internal functioning (e.g., work schedules and expenditures).
Questions to Ask
• How should the health education program/message be launched? • How do we maintain interest and sustainability? • How can we use process evaluation? • What are the strengths of the health program? • How can we keep on track within the timeline and budget? • How can we find out whether we have reached the intended audience? • How well did each step work (i.e., process evaluation)? • Are we maintaining good relationships with our community partners?
Collaborative Actions to Take
• Work with community organizations, adult education centers, businesses, media, and other health agencies to enhance effectiveness.
TABLE 8.6
Materials and Media
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Data from U.S. Department of Health and Human Services: Making health communication programs work: a planner’s guide, pink book, Bethesda, MD, 2008, Office of Cancer Communications, National Cancer Institute. Available from: https://www.cancer.gov/publications/health-communication/pink-book.pdf
• Monitor and track progress. • Establish process evaluation measures (e.g., follow up with users of the service, number of
community members who used the service, and expenditures).
Stage IV: Assessing Effectiveness and Making Refinements Outcome evaluation examines whether changes in knowledge, attitudes, and behavior did or did not occur as a result of the program. Together with the process evaluation, the data inform how well the program is functioning and direct future modifications. The nurse prepares for a new development cycle using information gained from audience feedback, communication channels, and the program’s intended effect. This stage helps continually refine the health message and respond to the intended audience’s needs. New information helps validate the program’s strengths and allows for necessary modifications. Feedback is necessary to continually refine the message and direct new messages.
Questions to Ask
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• What was learned? • How can outcome evaluation be used to assess effectiveness? • What worked well, and what did not work well? • Has anything changed within the intended audience? • How might we refine the methods, channels, or formats? • Overall, what lessons were learned, and what modifications could strengthen the health
education activity?
Collaborative Actions to Take
• Conduct outcome evaluations (e.g., randomized experiment, evaluation studies, definition of data needed for data collection).
• Reassess and revise goals and objectives. • Modify unsuccessful strategies or activities. • Generate continual support from businesses, health care agencies, and other community
groups for ongoing collaboration and partnerships.
Clinical Example 8.4 The H. Lee Moffitt Cancer Center and Research Institute, or Moffitt, formed a partnership with Suncoast Community Health Centers, Inc., or Suncoast, in rural Hillsborough County, Florida. The partnership initially brought breast cancer education and screening services to Hispanic migrant and seasonal farmworkers and low-income rural women via Moffitt’s Lifetime Cancer Screening Mobile Unit. Initiated by a cancer center physician who visited Suncoast, a federally funded, community-based center located about 30 miles south of Tampa, he was struck by the center’s services and impressed with the clinic’s dedication to reaching medically underserved populations. Suncoast consisted of multiple comprehensive federally qualified health care clinics in Plant City, Ruskin, Brandon, and Dover, Florida, and offered a wide range of primary health care services, yet it did not have mammography facilities. Moffitt was expanding its community outreach initiatives through mobile outreach services. Moffitt was a freestanding, private, nonprofit institution located at the University of South Florida campus in Tampa. An NCI-designated comprehensive cancer center in Florida, Moffitt is widely known for state-of-the-art treatment, novel research, ambulatory services, and advanced screening modalities. After a series of meetings between Suncoast and Moffitt’s Lifetime Cancer Screening Center, the groups formed a partnership based on a mutual shared goal—to improve the breast health of high-risk and medically underserved women. Both parties determined that the goal was to develop and offer the community culturally appropriate education, accessible mammography service, and follow-up care. Description of Health Issue and Intended Audience Despite progress in the fight against cancer, many communities continue to bear a disproportionate share of the cancer burden. Cancer disparities very likely arise from the complex interplay of factors—that is, low socioeconomic status, low levels of education and literacy, social injustice, and poverty—that impede awareness about screening and follow-up care. Together, these factors affect access to care and cancer survival and yield an uneven distribution of cancer morbidity and mortality, which substantially affects marginalized populations (American Cancer Society, 2017; Braun et al., 2015; Chu et al., 2008; Meade et al., 2009) suggest that in the development of cancer outreach and screening programs, it is absolutely critical to layer on additional levels of understanding of and sensitivity to the social, cultural, and political conditions of home countries, language and literacy needs, obstacles to basic health care access, cultural significance of gender and age roles, culturally mediated etiologic perceptions of disease, illness experiences, religiosity, and the sociopolitical nature of immigration situations. Such factors affect the design and meaning of health communication and health education. Our assessment revealed that many women did not appear for breast screenings because of a “fear of cancer” and uncertainty of how to navigate the health care system. Typically, many women did not seek preventive health care, but rather sought care for episodic acute illnesses. The lack of mammography screening and education for rural Hillsborough County’s medically underserved women represented a health service gap. In particular, individuals may face a number of potential factors that get in the way of receiving
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acceptable mammography services. These factors may reflect limited access points to health care; low awareness of the importance of the screening; and language, literacy, and linguistic concerns. Educational and communication interventions and tools that address (1) unique value systems, (2) relevant and specific cultural and linguistic factors, and (3) access issues—as well as that capitalize on the strengths of the women—were warranted. Our experiences reminded us that women want and need information about breast health but that they also experience everyday struggles. As such, peer outreach/navigation can help deconstruct those concerns and better engage community members in their health.
What was required in Hillsborough County was the delivery of a culturally relevant health service in a geographically convenient area. Women aged 40 years and older were eligible for this service. The initial intended audience was primarily Hispanic migrant and seasonal farmworkers but also grew to include women from other diverse ethnic backgrounds (i.e., Haitian, rural white).
Goal: To prevent premature death and disability from breast cancer through early detection, screening, and culturally and linguistically relevant education.
Objectives: To increase education, mammograms, clinical breast examinations, and follow-up programs among medically underserved women in rural Hillsborough County.
Selecting Channels and Methods Nurses selected a combination of channels to communicate health information about breast cancer, screenings, and early detection methods (e.g., community-based clinics, missions, social service agencies, health events, and fairs). Nurses conducted individual interactions at the mobile or stationary site at the screening center.
Nurses collected a variety of health materials and media about breast cancer from national, state, and local sources and determined that many of the printed materials were not culturally or educationally suited for the individuals the nurses were serving; for example, the materials were geared toward high reading levels, and few Spanish-language or Haitian Creole materials were available. Developing Materials Grants from Avon, National Alliance of Breast Cancer Organizations, Susan G. Komen for the Cure Florida Suncoast Affiliate, and NCI supported the development of English, Spanish, and Creole materials to educate women about breast health. Additionally, although translators were sporadically present, it became apparent that bilingual/bicultural staff was necessary. Ongoing dialogue with community members and clinics helped refine the screening process, the education component, and follow-up services to ensure effectiveness, efficiency, appropriateness, and timely follow-up. Implementation The mass media publicizes the services and disseminates human-interest stories, especially during October—Breast Cancer Awareness Month. The outreach workers posted flyers at a variety of sites (e.g., beauty shops, laundromats, missions, churches, grocery stores, churches, unemployment offices, and community centers). Twice per month, the mobile unit traveled to rural areas. There, staff greeted women and answered questions about the mammography procedure and follow-up. Assessing Efficiency Process Evaluation A number of newspapers/flyers, television, and radio advertisements publicized the free or low- cost mammography service and highlighted the importance of breast health. Also, several human- interest stories emerged, which communicated the screening services to a wider audience. Since the onset of the program, increases in the number of staff involved in the program, the number of volunteers, and the number of funded projects that support the program enhanced its breadth and depth and sparked the development of new initiatives. Most notably, the TBCCN, an NCI-funded community network program center, a partnership of 28 community organizations, has increased the number of committed key stakeholders who have identified other areas of community need and outreach such as a need for cervical cancer navigation and increased colorectal cancer screening uptake (Davis et al., 2016; Gwede et al., 2013; Wells et al., 2015). As a result of an additional community partner needs assessment, (Gwede et al., 2010; Simmons et al., 2015)
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additional cancer education workshops, health events, and cancer services have been broadened and evaluated.
For example, funding for a Patient Research Navigation Program further augmented outreach efforts. Designed to eliminate barriers to cancer diagnosis and treatment, this project generated new knowledge for the advancement of an evidence-based, culturally and literacy appropriate, lay navigation program for community members who had a breast/colorectal cancer abnormality by evaluating timeliness to resolution of abnormality and enhancing timeliness to diagnosis and delivery of cancer care (Lee et al., 2017; Meade et al., 2015; Roetzheim et al., 2012; Wells et al., 2011). Outcome Evaluation During the mammography screening program’s initial years, fewer than 200 women received mammography screening per year. The number of women screened approached more than 1000 per year in subsequent years. Currently, mammography services are provided at stationary screening sites at the cancer center (women use vouchers), and funding opportunities and institutional support sustain the program. The number of community partners has grown considerably, a reflection of enhanced community capacity and awareness. Regular health events are scheduled; refinement of screening services and follow-up are ongoing. Feedback Reports describing process and outcome evaluation and analysis provide a point of reference for continual improvements. Such reports apply knowledge and outline methods to enhance and improve the service’s efficiency and effectiveness.
The mammography program has incorporated a network of outreach and educational components to reach rural migrant and seasonal farmworkers and other low-income women in south and east Hillsborough County. Although the program provided desired links to screening services and has formed successful community partnerships, it is important to develop and refine community empowerment strategies through outreach and education to sustain and widely disseminate the program. Building on this successful model of education and outreach (Meade 2014; Meade et al., 2009), the administrators of the program applied lessons learned for outreach to other high-risk populations, (e.g., Haitian and African American men and women) in the development of colorectal cancer screening initiatives (Gwede et al., 2013). A key lesson learned here is that community outreach, based on trust, respect, and mutual commitment, can fuel community-identified research priorities and lead to the testing and evaluating of evidence-based interventions for community benefit.
• Provide justification for continuing or ending the program. • Summarize the health education program or message in an evaluation report. • The reader is encouraged to think about how health education messages or programs can be
planned using this model. The exercise in Fig. 8.1 can be helpful to organize your ideas.
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Health Education Resources A variety of health education materials, media, and resources are available from local, state, and national organizations and agencies. Such associations provide helpful information about services, educational materials, and links to support groups or self-help groups. Often, printed and electronic/digital materials are available for free or for a nominal cost. Nurses can help individuals, families, and groups find and access materials, services, or equipment loan programs and can become knowledgeable about community resources. Additionally, identifying gaps in services may help nurses create new resources. Some examples are:
• Local and regional hospitals, clinics, libraries, adult education centers, health education centers, media outlets, and businesses
• Local and state governmental sources (e.g., health departments and social service agencies); literacy associations (check the Internet for listings)
• Community-based organizations (i.e., advertised, nonadvertised, and those recommended by community leaders and stakeholders; National Association of Community Health Centers; parish nursing associations; faith-based organizations; social service agencies)
• Universities and colleges, community colleges, and academic nursing centers • Professional organizations (e.g., American Public Health Association, National Association
of Hispanic Nurses, National Black Nurses Association, National Student Nurses Association, Society for Behavioral Medicine)
• Commercial organizations (e.g., pharmaceutical companies, medical supply companies, and patient and health education companies); printed and electronic sources are often available
• Federal government sources (e.g., National Institutes of Health [NIH]; NCI; National Heart, Lung, and Blood Institute; OMH; CDC; National AIDS Clearinghouse; and Office on Smoking and Health) and related websites
• Voluntary agencies and their local affiliates (e.g., American Cancer Society, American Heart Association, Amyotrophic Lateral Sclerosis Association, American Diabetes Association, American Council for Drug Disorders, American Dairy Council, Alzheimer’s Association, and American Lung Association)
• Internet searches • Medline Plus Health Information (i.e., a service of the National Library of Medicine [NLM]
for patient and consumer information) at medlineplus.gov
Can you think of another organization that you or a family member recently obtained information from relating to a health need? University or college libraries often provide information on beginning and advanced search strategies and are one of the most credible and accessible sources of information. The NLM, at www.nlm.nih.gov/hinfo.html, maintains extensive health- related bibliographies and offers links to the databases Medline Plus Health Information (http://www.nlm.nih.gov/medlineplus/), Household Products Database, Office of the Surgeon General, NIH Senior Health, and much more.
The nurse can locate many health resources through a variety of search engines on the Internet. As the World Wide Web continues to evolve as a major source of information exchange, an assessment of the quantity, quality, and broad nature of information must be undertaken See Google Medline Plus for an array of helpful aids: https://medlineplus.gov/evaluatinghealthinformation.html#cat_94. Key to the plethora of resources is gauging the appropriateness of the materials and media in consideration of literacy (see next section).
Health Literacy In her 1944 text, The Public Health Nurse in the Community, Rue stated that the community’s illiteracy level is an important factor in health program planning. This factor remains a significant issue in planning health education programs and materials. Low literacy is a problem of great magnitude in the United States and has serious implications across the continuum of health care.
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Consider Clinical Example 8.5.
Clinical Example 8.5 A 2-year-old is diagnosed with an inner ear infection and is prescribed an antibiotic. Her mother understands that her daughter should take the prescribed medication twice a day. After carefully studying the label on the bottle and deciding that it does not tell how to take the medicine, she fills the teaspoon and pours the antibiotic into her daughter’s ear (Parker et al., 2003).
The nurse in a community setting who sees a sick child at the pediatric clinic might ask the following questions:
• Do the parents know the names of the medicines for their baby, how they work, and how and when to give them?
• In what way might teach-back methods (described later in this chapter) help the parents have a good understanding of how to administer the antibiotic?
• Will the parents know what to do if their baby gets a fever? • Is the information in their preferred language? • Do the parents know how to read a thermometer? Did I show them? Were they able to “show
me back”? • Do the mom and dad know who to call and under what conditions if their baby’s condition
worsens? Does the family have an understanding of what constitutes worsen? Will the parents know what action to take in case of a very high fever at 1:00 AM? Will they have the critical literacy skills to manage similar situations?
As background, the conceptual definitions of health literacy have evolved greatly over time. At one point, “literacy” was operationally defined as the ability to read and write at the fifth-grade level in any language and was measured on a continuum (National Literacy Act, 1991). Health literacy, on the other hand, is about empowerment, that is, having access to information, knowledge, and innovations. It is viewed as increasingly important for social, economic, and health development; is a key public health issue in the delivery of effective, safe health care; and calls for the development of national policies and programs and intervention tools by community practitioners.
Healthy People 2020
Health Literacy Health literacy also is an essential component of public health goals that aim to create social and physical environments for good health for all. The recognition of this topic as a serious health issue subsequently resulted in the specific naming of topics, goals, and objectives in Healthy People 2020, entitled Health Communication and Health Information Technology (IT). The objectives in this topic area describe many ways in which health communication and health IT can have a positive impact on health, health care, and health equity. Examples especially pertinent to health education actions taken by nurses include delivering accurate, accessible, and actionable health information that is targeted or tailored to increasing health literacy skills, providing personalized self- management tools and resources, and following sound principles in the design of programs and interventions that result in healthier behaviors. See http://www.healthypeople.gov/2020/topicsobjectives2020/ for more information.
So what is health literacy? Health literacy is a constellation of skills needed to perform basic reading tasks required to function in the health care environment for accessing, understanding, and using information to make health decisions. For example, health literacy skills entail knowing when and where to go for health screenings; reading labels on prescription bottles; understanding public health messages about flu, Ebola, or Zika; text messaging while driving; completing health
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insurance forms; recognizing how to read food labels; and being aware of the expectations of research and clinical trials. It might mean being able to understand, make sense, and apply the information contained in this book or chapter to the care of members of your community.
Nutbeam (2009) proposed three levels for intervention that have individual and population benefits: (1) functional/basic literacy (focus on increasing basic reading/writing skills), (2) communicative/interactive literacy (focus on enhancing abilities to extract information and apply in new settings and with providers), and (3) critical literacy (focus on advancing skills to analyze information critically and use the information to control and manage life situations). Too often, he asserts, the provider’s focus is on basic literacy rather than on critical literacy. The latter, he asserts, increases community members’ empowerment abilities to successfully manage their everyday situations.
In 2004, the National Academy of Medicine (NAM), formerly called the Institute of Medicine (IOM) published a landmark report titled Health Literacy: A Prescription to End Confusion that relates that millions of U.S. adults are unable to read and act on the plethora of health instructions and messages (Nielsen-Bohlman et al., 2004). The definition of health literacy adopted by the NAM report is consistent with the Healthy People 2020 program as follows: “the capacity to obtain, interpret and understand basic health information and services and the competence to use such information and services to enhance health.” The NAM report lists a series of recommendations that offer the nurse a blueprint of action. Several recommendations emphasize the need for clear communication, stress the importance of involving consumers in the development of the health communications process, and relate the need to create culturally and linguistically appropriate health information. For more details on this report and other health literacy–related resources and roundtables, go to the NAM’s website, www.nam.edu, and search for the term health literacy. The most recent health literacy roundtable centered on health communication with immigrants, refugees, and migrant workers. Pause for a moment now and consider the skills needed to read the words on this page, the skills needed to assimilate the information, and the skills needed to ultimately apply the information to your interactions with community members.
Nutbeam (2008) further emphasizes that health literacy from public health and health promotion perspectives should be conceptualized as an “asset.” In this manner, strategies to promote literacy move beyond mere transmission of content to the promotion of skills that develop confidence in how to act on the information. This viewpoint regards health literacy as a critical component of empowerment by improving people’s access to health information and their capacity to use it. Moreover, Peerson and Saunders (2009) hold that implicit in understanding the broad concepts of health literacy is that motivation and behavioral activation must be considered separate entities. Simply put, having knowledge does not necessarily equate to action. Therefore the quality of provider interactions and a greater awareness of and sensitivity to the possible impact of low literacy on individuals and communities is paramount (Nutbeam, 2008; Rowlands and Nutbeam, 2013).
Early research shows serious disparities between the reading levels of materials and patients’ reading skills (Meade et al., 1994). Additionally, materials often failed to incorporate the intended audience’s cultural beliefs, values, languages, and attitudes (Doak et al., 1998; Meade et al., 2007). Numerous studies show that low literacy affects utilization and access to health care services and costs (Levy and Janke, 2016; MacLeod et al., 2017; Morrison et al., 2014); decreases self-esteem and increases shame and stigma (Waite et al., 2008; Wolf et al., 2007); and adversely affects diabetes, cancer screenings, medication, HPV, blood pressure control, dialysis maintenance, cervical cancer, smoking, dental health, and use of patient portals (Bailey et al., 2014; Batista Ferrer et al., 2016; Coughlin et al., 2017; Davis et al., 2016; Green et al., 2013; Holtzman et al., 2014; McNaughton et al., 2014; Stewart, et al. 2017; Stewart et al., 2013; Tiraki and Yılmaz, 2017).
Additional studies reveal that health literacy affects participation in research and poses barriers to obtaining informed consent (Donovan-Kicken et al., 2012; Hughson et al., 2016) and affects the number of questions asked at medical visits (Aboumatar et al., 2013). Moreover a number of systematic reviews of health literacy studies offer additional evidence of the high prevalence of limited health literacy, increasingly complex medical systems, and need for high-level navigation skills for self-management of acute and chronic disease, promotion of health, and improvement of understanding of science and scientific research (Chesser et al., 2016; Chinn, 2011; Dewalt et al., 2004; Mancuso, 2009; Snow and Dibner 2016). Clearly, the past decades have seen many advances in translating research findings into public health practices to reduce health risks, yet such successes are not fully realized by all members of society representing various dimensions, including age,
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race and ethnicity, sexual identity and orientation, disability status, location/place, and/or socioeconomic status.
Guzys et al. (2015) suggests that too often the emphasis on health literacy is at the individual level. They contend that health literacy assessment and potential interventions need to shift and promote knowledge and skills for critical health literacy at a societal level. This paradigm shift offers a promising approach to improve community literacy whereby the inclusion of community members is a necessary requirement to coproduce an appropriate literacy framework reflective of societal influences. Similarly, McCormack et al. (2017) and Nutbeam et al. (2017) support the adoption of this broader social ecological perspective that embraces addressing individual educational interventions that are supported and enhanced by interventions at additional levels of societal influence.
As Hasnain-Wynia and Wolf (2010) point out, the intersection of health literacy and disparities in health care represents key contributors to high-quality, equitable health care. Although the exact relational mechanisms between literacy and health are unclear, it is known that individuals with very low literacy skills are at an increased risk for poor health, which contributes to health disparities. Paasche-Orlow and Wolf (2007) describe a conceptual causal model that aims to explain associations between limited health literacy and health outcomes that center on three distinct aspects of care: (1) access and utilization of health care, (2) patient–provider relationships, and (3) self-care. They point out that the relationship of literacy to health outcomes is not necessarily linear —as people exist within a sociocultural network—and suggest that health literacy be viewed as a “risk factor to be managed in clinical care.” This being the case, nurses are ideally qualified and skilled to promote health in the community and address health literacy through the implementation of multiple strategies and techniques, as explained in the upcoming sections.
The Doaks (Leonard and Cecilia), who brought the literacy issue to the forefront in public health, describe the health community as a written culture. Unfortunately, many written instructions are “over the heads” of patients. There is a serious mismatch between the readability levels of health instructions and the reading skills of patients, but nurses can adapt the literacy levels of their instructions and reduce this mismatch. Techniques to reduce this mismatch are cogently outlined in the book Teaching Patients with Low Literacy Skills (Doak et al., 1996), which offers practical suggestions for preparing and evaluating materials. This book is not currently in print, but all chapters can be accessed through the Harvard health literacy website at https://www.hsph.harvard.edu/healthliteracy/resources/teaching-patients-with-low-literacy-skills/. This is a very helpful resource. The author has used the information contained in this book in the development of educational materials, community-based programs, and research interventions.
What steps can nurses employ to address health literacy in the community setting? Within Stage I of the Framework for Developing Health Communications model, the nurse can use assessment skills to determine the reading level of the intended audience. For example, the nurse could employ a number of informal and formal assessment measures to assess an individual’s literacy skills. Informal measures include asking a series of simple questions to provide a better indication of his or her reading skills. For example: Do you enjoy reading? What do you read? How often do you read? Where do you get your health information? Although years of schooling completed can serve as a gauge of literacy, previous studies suggest that a three- to four-grade–level difference often exists between an individual’s literacy level and years of education completed. The nurse could ask patients to read a paragraph from a health document aloud. Skilled readers enjoy reading, are fluent readers, understand content, interpret the meaning of words, and look up unfamiliar words. Limited readers read slowly, miss the intended meaning, take words literally, tire quickly from reading, and skip over uncommon words. Also, the nurse should ask the patients a few questions about the information they read. Readers should be able to answer questions about the material’s content. Although these strategies are especially helpful to individuals with low literacy, people at all literacy levels prefer and better understand simply written, concise materials and are more motivated by materials that are relevant to their learning needs (Doak et al., 1998, 1996).
There has been ongoing attention to the development of literacy screening questions, but validation studies are needed before they become routine in clinical care (Chin et al., 2011; Mancuso, 2009). Some formal instruments that have been used in health care settings to estimate academic skills include the Wide Range Achievement Test, Level IV (Wilkinson and Robertson, 2006) and the Rapid Estimate of Adult Literacy in Medicine (REALM), which assesses the ability to read common terms in English and is used as a brief literacy-screening tool (Davis et al., 1991, 1993, 2006). Please note that there is now a short form of the REALM (only seven terms—see
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https://www.ahrq.gov/professionals/quality-patient-safety/quality- resources/tools/literacy/index.html).
Although these instruments take only a few minutes to administer, few exist in Spanish or other languages. One short assessment tool, called the Newest Vital Sign (NVS), created by Weiss et al. (2005), is available in English and Spanish as a six-question assessment tool based on an ice cream nutrition label and is a quick (3- to 5-minute) assessment. Another measure, the Test of Functional Health Literacy in Adults, long and short forms (TOFHLA and S-TOFHLA; Parker et al., 1995), also has been used in health settings with English- and Spanish-speaking/reading subjects (Kobayashi et al., 2015; Paasche-Orlow and Wolf, 2010; Soto Mas et al., 2015). For example, Robinson et al. (2011) administered the S-TOFHLA to 612 rural older adults with heart failure and found that inaccurate categorization of patients with low or marginal health literacy may occur when the test’s time limits (7 minutes) are enforced. These findings reinforce that some health literacy instruments may not be useful with patients who have undetected and/or declining cognitive impairment. Further, although many new and translated health literacy measures have been reported, many health literacy measures have not been properly validated for racial/ethnic minorities, at-risk groups, and non–English language speaking groups (Haun et al., 2014; Nguyen et al., 2015).
Building on prior work (Chew et al., 2004; Wallace et al., 2006), Morris et al. (2006) developed the Single Item Literacy Screener: “How often do you need to have someone help when you read instructions, pamphlets, or other written material from your doctor or pharmacy (1 = never; 2 = rarely; 3 = sometimes; 4 = often; 5 = always)?” This particular item was found to be reasonably successful in detecting health literacy (in comparison with the TOFHLA), but only moderately sensitive. Yet it focuses on only one aspect of health literacy, which is reading materials. Recently, an “ability to read item,” that is, How would you rate your ability to read? (1–5 scale from very poor to very good) performed the best, supporting use as a screening tool in safety-net systems caring for diverse populations among English/Spanish speakers (Bishop et al., 2016).
Other efforts in this field have centered on the development of tools that measure Internet- seeking abilities or e-health literacy (Norman and Skinner, 2006); assess general health skills across the dimensions of functional, communicative, and critical health, with such questions as “Do you need help to fill out official forms?” (Chinn and McCarthy, 2013); or gauge numeracy skills such as number sense, tables and graphs, probability, and statistics (Jacobs et al., 2016; Schapira et al., 2014). If you are interested in this topic, go to the Health Literacy Toolshed, an outstanding online database of health literacy measures compiled by the NLM in collaboration with Boston University, at https://www.nlm.nih.gov/news/health_literacy_tool_shed.html.
As one can see, there are many formal tools to measure reading level or word recognition, which in turn may be helpful to gauge an individual’s health literacy. Yet the time needed to administer them in community-based settings greatly limits their use. Most importantly, these collective findings underscore that formal assessments should be secondary to the nurse’s informal and ongoing assessments, which allow for verification of understanding about specific health content within a specific health context. Nurses need to be astute in their assessment of people’s skills and to continually monitor the demands of the health care environment and make organizational adjustments as needed. Furthermore, Meade and Calvo (2001) continue to suggest asking patients and community members a series of simple questions on the topic of years of schooling and about their reading habits that will help gauge health literacy, followed by ongoing learner verification and teach-back methods. In this manner, health literacy can be viewed from both content and contextual outlooks.
The promising news here is that health literacy can be realized through health education (Nutbeam, 2009). Fundamental to implementing effective health education strategies is recognizing that health literacy needs to be viewed within its context, that is, the physical and social environment of health care settings (Rudd, 2013). As such, nurses play essential roles in their community outreach and engagement activities for conveying knowledge, deciphering motivations, adapting health education messages, making information accessible, promoting health decisions, and facilitating empowering processes to increase the useful uptake of information. As Sykes et al. (2013) point out, health literacy goes beyond merely the motivation and development of skills within the individual or community, but also entails a number of collaborative efforts at a structural level. It needs to become an organizational value integrated into all aspects of community planning and health operations and should be viewed as a relationship between individuals and their environment (Brach et al., 2012; Koh et al., 2013; Rudd, 2013; McCormack et al., 2016).
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Helpful Tips for Effective Teaching
• Put patients at ease and establish rapport. Focus on inclusion and trust first. • Assess reading skills using informal and formal methods. • Determine what your patient/community member wants to know. • Identify motivating factors for learning new information and behaviors. • Stick with the essentials. Limit the number of concepts or key points. Focus on important
critical and survival skills.
BOX 8.2 Patient Communication: Prostate Cancer and Treatment Options Version A (harder to grasp – passive) The doctor has recently communicated to the patient that he has localized prostate cancer, commonly labeled stage II. In addition to managing the anxieties associated with a life-threatening illness, patients with this disease must carefully consider the available treatment modalities and account for the potential effect each one may have on quality of life. Patients must seriously evaluate the benefits and adverse side effects of each treatment modality and determine the most efficacious intervention for their lifestyle. Version B (easier to grasp – active) You have just been told that you have early-stage prostate cancer. Choosing a treatment is hard, but it is important. Besides dealing with fears that often go along with having cancer, get to know about your treatment options:
• Learn about each treatment and how it may affect your life and your family. • Get to know the benefits and side effects of each treatment. • Ask questions. Write them down. Talk it over with your family. • Choose the best treatment for you.
Modified from Doak CC, Doak LG, Root JH: Teaching patients with low literacy skills, ed 2, Philadelphia, PA, 1996, Lippincott Williams & Wilkins. (Chapter 10 on learner verification can now be accessed at the Harvard health literacy website: http://www.hsph.harvard.edu/healthliteracy/resources/teaching-patients-with-low-literacy-skills/).
• Set realistic goals and objectives. Take cues from your patients about what they want to learn and how to help them learn.
• Use clear and concise language. Avoid technical terms, if possible. For example, substitute problem for complication. Use high blood pressure instead of hypertension, or use chance instead of possibility. Do not needlessly simplify if the intended meaning is lost. Although the words insulin and infection are polysyllabic words, people with diabetes should get to be familiar with these terms (Box 8.2).
• Consider developing a glossary or vocabulary list for common words on the health topic. For example, in teaching a family about dental health, create a list of common words about the topic and words that might substitute well (e.g., flossing, toothbrush, cavity, decay, check-ups, x-rays).
• Space your teaching out over time, if possible. Incorporate health education activities into other activities. For example, ask women about their smoking habits at each prenatal visit. Relate teaching to their everyday concerns. Introduce HPV education into women’s and men’s health visits.
• Personalize health messages. Use the active voice. For example, instead of saying, “It is important that patients read labels if they want to cut down on fat and sodium intake,” say, “Read the labels on foods to know what is in them. This will help you cut down on your fat and salt intake.”
• Incorporate methods of illustration, demonstration, and real-life examples. Connect the
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health message to everyday events and real-life situations. • Give and get. Review information often. Ask the patient questions before, during, and after
teaching. • Summarize often. Provide the patient with feedback. Obtain feedback from the patient.
TABLE 8.7
Components of Learner Verification (Checks the Suitability of the Message with Learners)
• Be creative. Use your imagination to convey difficult concepts (e.g., use picture cards, drawings, objects, streaming videos, audiobooks, podcasts, flip charts, multimedia decision aids, photographs, embodied conversational agents, apps, photovoice, storytelling, use of metaphors).
• Use appropriate resources and materials to enhance teaching and convey ideas (e.g., picture cards, models, tablet devices, whiteboards).
• Praise patients, but do not patronize them. Let them know what they are doing right. Focus on their strengths and assets and what they bring to the teaching encounter.
• Be encouraging throughout the educational steps. We all like to be told what we are doing right.
• Allow time for patients and family members to think and ask questions. • Remember that comprehension and understanding require time and practice. Ongoing
feedback helps refocus the teaching encounter and can keep you on track. • Employ “teach-back” methods. This means asking patients to state in their own words (i.e.,
teach back) key concepts, decisions, or instructions just discussed (Badaczewski et al., 2017; Byck and Sharif, 2017; Glascoe and Trimm 2014).
• Conduct learner verification (a process that checks suitability of information) to ensure understanding (Table 8.7).
• Evaluate the teaching plan, and keep adding new information to the interaction. • Consider your environment and carry out a quick 10-item checklist to see if your institution
is health literate as well (Kowalski et al., 2015)
Assess Materials: Become a Wise Consumer and User Materials are collected, stored, and disseminated within community sites. In many instances, nurses distribute pamphlets, but patients either do not read them or review them only superficially.
People of this country have had so much pamphlet materials passed out to them free that some have lost
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respect for free literature. Health educators may have contributed to this delinquency by passing out health literature carelessly and indiscriminately. The nurse who expects the pamphlet to take the place of the health teacher is employing weak measures in the health education program.
(Rue, 1944, p. 215)
This statement continues to be true today. Moreover, many of today’s pamphlets are even more complex and lengthier because of technological advances and health care innovations. Thus it is important that nurses evaluate health materials, including websites, before they disseminate them to or share them with individuals, families, or the general public. Health materials should strengthen previous teaching and should be used as an adjunct to health instruction.
Assess Relevancy of Health Materials It is critical that nurses find and use materials, documents, and media that are appropriate for the intended target audience in community health education initiatives. Questions that the nurse should ask include the following:
• Do the materials match the intended audience? • Are the materials appealing and culturally and linguistically relevant? • Do they convey accurate and up-to-date information? • Are the messages clear and understandable? • Do the messages promote self-efficacy and motivation?
Fig. 8.2 provides an assessment guide for reviewing health materials that the author has used for gauging the appropriateness of materials. The nurse can use this guide in critiquing printed materials. Similarly, the nurse can make slight modifications in the tool and assess other types of health resources (e.g., booklets, videotapes, websites, and multimedia interactive modules). To use the tool, gather a few materials/media that are commonly used in the clinical setting where you are based. In a group or individually, begin to assess each category and critically assess the suitability for your intended audience. The tool allows the nurse to review health materials systematically for appropriateness for the intended target audience. The material assessment should focus on the following criteria: format/layout, type, verbal content, visual content, and aesthetic quality. This activity probably will take 10 to 15 minutes. It can also be used as a group activity with patients or community members. The feedback your users offer about the materials may surprise you!
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FIG. 8.2 Assessment of health education materials.
Case Study Application of the Nursing Process Selected Teaching Approaches and Learning Needs The following case study and teaching plan provide an example of selected teaching approaches and learning needs for the individual, family, and community.
Emma Jackson, aged 33 years, receives ongoing health care at her neighborhood’s community-
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based clinic, a federally funded community health center. She visits the nurse practitioner, and the nurse confirms that Mrs. Jackson is 2 months pregnant. She is married and has an 8-year-old son. Emma tells the nurse she smokes and wants to quit but she has been unable to quit since her last pregnancy. She tells the nurse, “I smoke when I get stressed. I have so many things on my mind.” Her husband is also a smoker and has tried to quit at times as well. The nurse refers Mrs. Jackson to a community nursing student named Irene Green for counseling, education, and follow-up. Assessment Irene recognizes that smoking during pregnancy is detrimental for the unborn infant, unhealthy for Mrs. Jackson, and harmful for the 8-year-old child, who breathes the secondhand smoke (https://www.cdc.gov/reproductivehealth/maternalinfanthealth/tobaccousepregnancy/index.htm). Irene also knows that smokers often experience stages of readiness in their attempts to quit and that relapse is often part of the process (Prochaska and DiClemente, 1983). She notes that family and community support systems are important.
Irene assesses Mrs. Jackson on an individual level, as follows:
• Smoking history, smoking patterns, and previous attempts to quit • Support systems (e.g., family, friends, and peers) • Perceived barriers to quitting • Perceived benefits to quitting • Perceived priority in addressing this health issue vs. other everyday stresses • Perceived effect of smoking behavior on family communication patterns • Confidence and perceived efficacy in ability to quit
Assessment of other groups includes families, neighborhoods, churches, community organizations, and environmental messages that promote smoking cessation. Diagnosis Individual
• Health concerns related to smoking and personal stressors/triggers • Desire for more information about ways to quit and stay smoke free
Family
• Effect and impact of smoking on family dynamics
Community
• Need for information about community programs and social support resources
Planning Individual Long-Term Goal
• Mrs. Jackson will quit smoking.
Short-Term Goals
• Mrs. Jackson will recognize that continued smoking is unhealthy for herself, her unborn infant, her young child, and her family.
• Mrs. Jackson will become aware of ways to enhance her confidence during smoking cessation.
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• Mrs. Jackson will identify situations and stressors that influence her smoking patterns. • Mrs. Jackson will learn two strategies to cope with stressful situations and will apply those
strategies.
Family Long-Term Goal
• Mr. and Mrs. Jackson will quit smoking and become a smoke-free family.
Short-Term Goals
• Mr. and Mrs. Jackson will acknowledge the benefits of a smoke-free environment. • Mr. Jackson will recognize the need to quit smoking. • The couple will recognize the need to support each other in smoking cessation. • Mr. and Mrs. Jackson will identify and discuss specific supportive actions during the smoking
cessation phases. The couple will enlist the support of another person or network.
Community Long-Term Goals
• The community will support and endorse a smoke-free environment and publicize these efforts through billboards and other media.
• Community agencies and organizations will integrate smoking cessation and relapse programs and messages into their existing health-related activities.
• Cigarette advertising will cease.
Short-Term Goals
• A coalition of community members will develop and implement policies to support smoking cessation and relapse strategies.
• A consortium of health care agencies and community-based organizations will recognize the need to develop partnerships in creating smoking cessation strategies for the community and for high-risk groups.
Intervention Individual Planning interventions encourage self-expression, promote the use of adaptive coping mechanisms, offer positive reinforcement, disseminate appropriate smoking cessation strategies, and provide culturally and educationally relevant materials and media. The nurse applies the “five As” approach to smoking cessation counseling (Ask, Advise, Assess, Assist, and Arrange). Irene offers empowerment strategies to help Mrs. Jackson cope with her smoking cessation attempts and identifies daily hassles and stressors. Irene gives personalized smoking cessation messages and culturally and educationally appropriate materials and initiates a follow-up plan that is acceptable and doable on the basis of ongoing assessment and feedback (American College of Obstetrics and Gynecology, 2010; Brandon et al., 2012) Family Planning and interventions recognize the need for strong support systems within families. Irene provided education and counseling to promote family self-care and recognized that she must address and incorporate Mr. Jackson’s support, or lack thereof, into the care plan. Irene makes links to community resources (e.g., health classes, support groups, and networking with other expectant mothers who have quit or are attempting to quit) to build Mrs. Jackson’s support system.
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Community Planning and interventions implemented on an aggregate level identify key community leaders, agencies, legislators, and lay members who are committed to supporting smoking cessation/relapse initiatives at a sociopolitical level (e.g., creating smoking cessation/relapse initiatives at various community channels). Program initiatives assist community members in defining issues and solutions to the effects of smoking on individuals, families, and community groups. Developing coalitions and partnerships among community-based organizations, health care groups, governmental agencies, and intended audience members through dialogue and increased awareness is essential. Evaluation Evaluation is systematic and continuous and focuses on the individual, family, and community. Individual An evaluation of Mrs. Jackson’s smoking habits occurs within the health system and the community (clinics and Women, Infants, and Children Service). These groups address both process (decrease in number of cigarettes smoked) and outcome (quit or not quit) end points. Mrs. Jackson experiences an increase in her coping skills and support system, which is evident in her personalized care plan.
• Irene tailors smoking cessation messages to Mrs. Jackson to fit her everyday life and addresses negative affect, that is, negative emotional smoking triggers.
• Irene provides Mrs. Jackson with follow-up (e.g., telephone, letter, text messages, and follow- up visits).
• Irene also used a tablet (iPad) to promote knowledge of tobacco risk and cessation resources for pregnant women (Dotson et al., 2017).
• Irene provides educational resources for Mrs. Jackson (https://smokefree.gov/).
Readers are suggested to visit a virtual tour to enhance your counseling skills. See Smoking Cessation for Pregnancy and Beyond: A Virtual Clinic, a multimedia program that provides counseling guidance: https://www.smokingcessationandpregnancy.org/. Family Care plans include supporting pattern development with family or significant other in smoking cessation initiatives.
• Irene assesses family health patterns and screens for other at-risk behaviors. • Irene identifies and addresses family support and communication patterns in the care plan.
Community Irene introduces smoking cessation and relapse programs and smoking prevention initiatives to at least two channels of dissemination (e.g., churches, schools, worksites, community-based clinics, restaurants).
• Smoking cessation/relapse messages are infused throughout the community by means of radio, television, and billboards.
• Community task forces and coalitions demonstrate a collaborative partnership among lay members, community leaders, organizers, and legislators to address smoking-related health issues.
Format/Layout
• Is the information organized clearly? Does it make sense? • Do headers or advance organizers cue the reader? Headers help the reader visualize what
is next. • Is there a 50%/50% allocation of white and black space? This proportion gives the reader
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“breathing space.” • Is the information easy to read and uncluttered?
Type
• Is the type or font a readable size? Consider the age of your intended group and whether visual difficulties are likely.
Verbal Content
• Is the information current, accurate, and relevant to the intended group? • Is the information culturally acceptable? • Are difficult terms defined? • Does the text reflect the racial and ethnic diversity and language of the intended audience? • What is the reading level?
Visual Content
• Are the graphics accurate, current, and relevant and engaging to the intended group? • Does cueing help the reader connect the printed words and pictures? • Will the reader understand the intended meanings of the pictures? • Is the information culturally acceptable? • Are the pictures on the cover reflective of the material inside? • Do the pictures reflect the target audience’s racial and ethnic diversity?
Aesthetic Quality and Appeal
• Is the material appealing and engaging? • Are there helpful special features (e.g., glossary, space for notes, and useful telephone
numbers or websites)?
Assessment of Reading Level Part of the written material’s assessment is reading level. Many formulas are available to estimate the printed text’s readability and grade level, including the SMOG readability formula.
Readability formulas are objective, quantitative tools that measure sentence and word variables. However, they do not consider factors such as motivation, experience, and need for information (Meade and Smith, 1991). Nor do they determine the effects of visuals or design factors that could influence readability and comprehension or address global text characteristics, including fluency, structure, and content of the text (Kauchak and Leroy, 2016). Formulas do estimate reading ease and provide helpful guidelines for assessing and rewriting health information. Two of the most commonly used formulas are the Flesch-Kincaid and the SMOG formulas. The Flesch-Kincaid Formula (Flesch, 1948) is a broad estimate of reading and is programmed into most computer software programs’ grammar editing tools. To test a document’s readability on your computer using the Flesch-Kincaid formula, search the term “readability statistic.” You will be directed to a series of file and option tabs to reach grammar and spelling, and then readability statistics. The SMOG formula is shown in Resource 8D and is frequently used to calculate the readability estimate of health materials (McLaughlin, 1969).
Learner Verification The best way to identify material suitability is to deliver the materials to the intended audience and obtain feedback about acceptability, understanding, and usefulness. Learner verification engages intended members in dialogue and helps uncover unsuitable aspects of the material (i.e., content, visuals, or format) (Doak et al., 1996). If the nurse discovers a need for new educational materials or media, he or she can incorporate Freirean principles to produce empowering products. The Freire approach supports learner participation in the development process, ensures that the learner is the
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active subject of the educational experience, and allows learners to define content and outcomes. The process of learner verification helps identify the likelihood that the message is well suited to
the audience. It involves verifying whether certain elements work well together to result in a good match of information for the learner. See Table 8.7 for a description of the specific elements and sample questions associated with each one.
The author and colleagues have used learner verification processes on many occasions, for example, to develop a series of education toolboxes on breast and cervical cancer and prostate cancer for Hispanic migrant and seasonal farmworkers and African American women and men. After holding a series of focus groups with members of the intended audience to elicit themes about health, illness, cancer, and prevention, we conducted learner verification measures. Through systematic questions and interviewing processes, we were able to collect information in the intended audience’s own words to help shape and refocus the cancer issues (breast, cervical, and prostate) from their own perspective (African American men and women and Hispanic men and women farmworkers). Such verifying checks help assess the understanding of words and pictures; the acceptability of music, narrator, and pictures; the efficacy and persuasion of the message; and the overall attractiveness of the materials/media For example, we found that the word prevention was a term many men found difficult to grasp. What we found was that tuning up one’s car was a familiar concept that could similarly be used to convey the importance of ongoing check-ups, as in maintaining prostate health. Similarly, the author and her colleagues used this approach to adapt smoking-relapse prevention materials for pregnant and postpartum women (Quinn et al., 2006), to develop stress management tools for Latinas undergoing chemotherapy (Meade, 2009), and to create biobanking education materials (Meade et al., 2015). Another useful example can be seen in the study by Hunter et al. (2012), who used learner verification techniques to clarify terminology, translation, preferred content, and illustrations for cervical cancer content for Mexican immigrant women. Their findings challenged the common simplification approaches often linked to teaching learners with low literacy and reinforced the need of learners to know more about their anatomy. Overall, the process of learner verification fits well within the framework of community-based participatory research methods, as outlined earlier in this chapter, and can be a very helpful qualitative tool for the nurse to use in gauging the suitability of his or her health education efforts.
Active Learning Exercise
1. Identify an issue of concern among community members (e.g., obesity, access to care, education of youth). Discuss sociopolitical issues that affect this issue and how it relates to health. Outline specific community-based participatory activities and roles that the community nurse can take on that can address this health issue. Identify at least two ways to promote community engagement on this topic. What educational resources might the nurse use?
2. Select a health education brochure or health website. Apply the assessment criteria presented to assess its appropriateness for an intended audience. Evaluate the relative strengths of the printed material or website and potential areas for improvement using learner verification questions. Describe how you and your group can make it more relevant for your audience. What can be improved? How could you involve your audience in its assessment?
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Social Media Americans today are increasingly connected to the world of digital information. As such, nurses should consider the role of social media channels in connecting communities with reliable health information. Nurses should also think about how mobile health and e-health technologies might improve health outcomes of communities Social media refers to interactive Internet-based communication channels that allow users to create, share, comment on, and modify online content. It facilitates engagement and collaboration and has rapidly become a tool for health promotion and education (Alber et al., 2015). Social media platforms might include blogs, online discussion boards, microblogs such as Twitter, and video-sharing sites such as YouTube, Vimeo, and Flickr. In light of the growing number of people (both here in the United States and globally) who have mobile phones and use social media, such platforms may lend themselves to reaching diverse community constituents with important public health messages (O’Mara, 2012). It is estimated that most Americans (95%) own some type of a cell phone and most send and receive text messages (Pew Research Center, 2017). Ownership of smartphones is now 77%, up from about 35% since Pew Research Center’s first survey of smartphone ownership in 2011. Given this widespread use of cell phones, social media text messaging offers a new and promising way to directly deliver health information to diverse groups in rural and urban areas.
Social media sites have the potential to facilitate interactive communications, increase the sharing of health information, and personalize and reinforce health messages, all of which in turn can empower community members to make informed health decisions (CDC, 2010). For example, Strasser et al. (2012) explored the use of social media (e.g., Facebook) to reduce IPV among gay men in Atlanta; Fortmann et al. (2017) explored the use of a series of text messages to improve glycemic control in Hispanics with type 2 diabetes; and Koskan et al. (2014) conducted a systematic review that reinforced the role of social media in cancer care (and most likely other areas of health). Further, in a study carried out in rural northern Kenya, Kazi et al. (2017) reported phone usage, ownership characteristics, and feasibility of text-based mHealth interventions (short messaging service [SMS]) among patients for enhancing maternal-child health (antenatal care immunizations). Notably, despite remoteness, most pregnant women and caregivers visiting for antenatal care and routine immunizations had some access to mobile phones, liked the idea of text messaging, and stated that they would use it if available. Hence, if designed appropriately, findings suggest that SMS may be an innovative way to engage women in their health and the health of their families.
Recently, Roland et al. (2017) examined the promulgation of online communities of practice that are emerging from interactions on social media using Twitter #Analytics. In particular, nurses in community health education settings are well poised to explore the utility of novel digital technology to connect individuals, families, and groups to communities of learning and to connect them with reliable and credible information, which has meaning for their everyday health concerns and needs.
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Summary Teaching is a significant component of community health nursing, affecting virtually every nursing activity. The goal of health education is to facilitate a process that allows individuals, families, and groups to make well-informed decisions about health practices. An understanding of learning and the theoretical frameworks that explain behaviors and health actions is inherent in community health education. No single theory explains human behavior; the nurse must apply multiple theories and approaches.
Nurses must be knowledgeable about sociopolitical, cultural, environmental, and ecological forces affecting community health to ensure the success of health education strategies. Furthermore, relevant health education (classes, talking circles, support groups, individual/family instruction, health fairs, etc.) is based on the meeting of individual variables and social, structural, political, cultural, and economic factors within the larger community context. To create meaningful education interventions, nurses need to assess their audience(s) and their characteristics thoroughly and to employ systematic approaches when delivering health messages and programs. Implementing social action strategies, such as advocating health-promoting lifestyles, creating an environment for problem-posing dialogue, and providing links to appropriate health resources, supports the philosophy of critical consciousness. Nurses can facilitate the principle of social justice by mastering health information delivery and committing themselves to creating empowerment strategies that equip individuals, families, and communities with knowledge and navigation skills for healthy lifestyles and environments.
Further, a variety of creative methods, materials, media, and mobile health technologies can support health education activities. Continual review and evaluation of such resources are essential to ensure cultural, linguistic, language, and literacy suitability. Embracing the notion that health education is an ongoing interactive process influenced by many internal and external factors is strategic to meeting the needs of individuals, families, and communities. As nurses, important contributions to the prevention of disease and the promotion of community health can be realized with an ongoing community health education mind-set and commitment to community empowerment and engagement strategies.
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Evolve Website http://evolve.elsevier.com/Nies/community
• NCLEX Review Questions • Case Studies
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Case Management Karyn Leavitt Grow, and Jean Cozad Lyon
OUTLINE
Overview of Case Management, Care Management, Care Coordination, Transitional Care Management,
Origins of Case Management, Public Health, Case Management in Behavioral Health, Care Management Tracking System (CMTS), Case Management and the Elderly, Disease-Specific Case Management,
Purpose of Case Management, Care Management, Care Coordination, Utilization Review and Managed Care,
Trends that Influence Case Management, Changes in Health Care Reimbursement, Access to Health Care for More Americans,
Education and Preparation for Case Managers, Nurse Case Managers, Case Manager Certification Options,
Case Manager Services, Case Manager Roles and Characteristics, Case Identification, The Referral Process, Application of Case Management in Community Health,
Primary Care, Patient-Centered Medical Home, High-Risk Clinic Settings, Public Health Clinic Settings, Occupational Health Settings, Home Health and Hospice Settings,
Research in Case Management,
OBJECTIVES
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Upon completion of this chapter, the reader will be able to do the following: 1. Define case management, care management, and care coordination and compare the
differences. 2. Discuss the philosophy and guiding principles of case management. 3. Identify the origin and purpose of case management. 4. Identify the case management process. 5. Discuss the roles and characteristics of case management in a reformed health care
environment. 6. Incorporate case management concepts into clinical practice settings. 7. Identify educational preparation and skills recommended for case managers.
KEY TERMS care management case management chronic care management transitional care management continuum of care patient-centered medical home utilization review
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Overview of Case Management Case management is a term that describes a wide variety of patient care coordination programs in acute hospital and community settings. Case management is also referred to ascare management andcare coordination. These terms apply to community health settings that include patient-centered medical homes (PCMHs), occupational health, geriatric services, ambulatory care clinics, mental health settings, and outpatient primary care settings. Patient populations of all ages receive case management services.
Since the late 1980s and the 1990s, a variety of case management programs have emerged (Huber, 2002). From 1990 to 2005, case management evolved rapidly in response to changes in the health care environment and an increase in the number of managed care programs. Client service use reflects a greater emphasis on health care costs. Third-party payers evaluate the appropriate use of health care resources such as diagnostic tests, laboratory tests, length of hospital visits, and duration of home health care services. Health care providers, interested in close monitoring of resources, introduced various forms of case management programs.
More recently, health care evolved from a quantity-driven delivery system to a quality-driven system. In 2001, the National Academy of Medicine (NAM), formerly called the Institute of Medicine (IOM) published a report,Crossing the Quality Chasm. It recommended a redesign of the health care system to provide care that is safe, efficient, effective, timely, equitable, and patient centered. The report names care coordination as an essential function to reach these goals and improve health care quality (IOM, 2001). The Institute for Healthcare Improvement’s Triple Aim Initiative is a framework of goals to optimize health system performance. The framework includes improving the patient experience, improving the health of populations, and reducing the per capita cost of health care.
Case management has emerged as an intervention strategy for quality improvement initiatives. A single definition of case management does not exist. TheCase Management Society of America (CMSA) (2016) offers the following definition of case management:
Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health care needs through communication and available resources to promote patient safety, quality of care and cost effective outcomes. (p. 11)
The philosophy statement published byCMSA (2016) reads as follows:
Some hospitals, health maintenance organizations (HMOs), and other insurance companies inaccurately use the termcase management to describe “utilization management,” “managed care,” or the method of monitoring and controlling service use within a system or care episode to control cost.
Case management programs, however, aim to provide a service delivery approach to ensure the following: cost-effective care, alternatives to institutionalization, access to care, coordinated services, and patient’s improved functional capacity (Lyon, 1993) (Box 9.1). These goals apply to community health and acute care settings. Subsets of case management are care management, care coordination, and transitional care management (TCM).
Care Management Care management consists of programs that apply systems, science, incentives, and information to improve medical practice and to allow clients and their support systems to participate in acollaborative process with a goal of improving medical, psychosocial, and behavioral health conditions more effectively. Care management is a concept that is evidence based, patient centered, and clinical care focused.
BOX 9.1 Possible Case Management Functions
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• Identifying the target population • Determining screening and eligibility • Arranging services • Monitoring and follow-up • Assessing • Planning care • Reassessing • Assisting clients through a complex, fragmented health care system • Providing care coordination and continuity
The overall goal of care management is to improve the coordination of services provided to clients who are enrolled in a care management program. Examples of groups of people who may be served by care management services are the elderly, children from low-income families who receive Medicaid services, and groups of people with chronic illnesses.
Care Coordination Care coordination was identified in the NAM reportCrossing the Quality Chasm as an essential function in improving health quality (IOM, 2001). It has also been recognized as an approach to integrate fragmented health care, improve the transitions of care between providers, and decrease the unnecessary utilization of resources and costs. Care coordination programs are those that target chronically ill persons at risk for adverse outcomes and expensive care and that meet their needs by filling the gaps in health care. They (1) identify the full range of medical, functional, social, and emotional problems that increase patients’ risk of adverse health events; (2) address those needs through education in self-care, optimization of medical treatment, and integration of care fragmented by setting or provider; and (3) monitor patients for progress and early signs of problems. Such programs hold the promise of raising the quality of health care, improving health outcomes, and reducing the need for costly hospitalizations and medical care (Chen et al., 2000).
There are many definitions of care coordination. In its 2005 reportClosing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 7: Care Coordination, the Agency for Health Care Research and Quality (AHRQ) definescare coordination as:
The deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care. Care coordination is a process component and function of case management.
McDonald et al., 2005
And in the American Nurses Association (ANA) white paper titledThe Value of Nursing Care Coordination, the termcare coordination is defined as follows:
Care coordination is (a) a function that helps ensure that the patient’s needs and preferences are met over time with respect to health services and information sharing across people, functions, and sites; and (b) the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Additionally, the best coordination model is one in which a patient experiences primary care as delivered by an integrated, multidisciplinary team that explicitly includes at least one staff care coordinator.
ANA, 2012
Transitional Care Management Transitional care management (TCM) is the process of providing a postdischarge patient with a
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high or moderate risk of readmission a face-to-face visit with their practitioner within a defined period (7 to 14 days) and care coordination services to prevent readmissions and improve outcomes. The TCM care coordinator follows a patient posthospitalization to improve patient/caregiver understanding and self-management of new disease processes, discharge instructions, medication management, coordination of care and resources, and timely access and follow-up with the patient’s primary care provider (DHHS and CMS, 2016).
The paperTransitions of Care Measures by the National Transition of Care Coalition (NTOCC, 2008) defines TCM as:
A set of actions designed to ensure coordination and continuity. They should be based on a comprehensive care plan and the availability of well-trained practitioners who have current information about the patient’s treatment goals, preferences, and health or clinical status. They include logistical arrangements and education of patient and family, as well as coordination among the health professionals involved in the transition.
In effect, transitions of care are a subpart of the broader concept of care coordination.
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Origins of Case Management Case management has a long history with the mentally ill, elderly patients, and the community setting (Steinberg and Carter, 1983). Public health, mental health, and long-term care settings have implemented and studied case management services and have reported them in their literature for many years (Mahn and Spross, 1996; Weil and Karls, 1985).
Public Health Community service coordination, which was a forerunner of case management, appeared in public health programs in the early 1900s. During this time, health care providers reported these community service and case management programs in the nursing literature. Programs focused on community education in sanitation, nutrition, and disease prevention became prevalent. Lillian Wald and Mary Brewster conducted many of these programs at the Henry Street Settlement House in New York City. The Metropolitan Life Insurance Company later expanded nursing services for individuals, families, and the community to include disease prevention and health promotion (Conger, 1999).
The concept ofcontinuum of care originated after World War II to describe the long-term services required for discharged psychiatric patients (Grau, 1984). Service coordination evolved into case management, a term that first appeared in social welfare literature during the early 1970s.
Case Management in Behavioral Health During the late 1960s and early 1970s, mental health care emphasized moving patients from mental health institutions back into the community (Crosby, 1987; Pittman, 1989). The Community Mental Health Center Act of 1963 placed federal approbation on deinstitutionalization, which emphasized the importance of community mental health services. Mental health providers began to move patients from large state institutions to the community.
Several problems resulted from the deinstitutionalization of mentally ill patients. In 1977, Congress acknowledged that many disabled people had been deinstitutionalized without basic needs, proper follow-up, or health care monitoring. Congress further recognized that a systematic approach to service delivery could have prevented many state hospital readmissions. Case management in community mental health helped avoid client service fragmentation (Pittman, 1989).
Care Management Tracking System (CMTS) CMTS was developed to ensure that all patients are followed, that none are lost to follow-up, and that any patients who are not improving are identified and further interventions are initiated. These systems are often integrated into the electronic health record, or other organizations and clinics use a patient-tracking spreadsheet (University of Washington, 2017).
Case Management and the Elderly Specific elderly services recognized that age-generic programs do not adequately assist older people. Many older people have special, population-specific health care needs. Thus case management services frequently target the elderly population, specifically homebound individuals or those with complex problems. However, not all older people who subscribe to multiple services require a case manager. Older adults may not need a case manager if they possess adequate functional status and can coordinate and access services for themselves, if they have family support, or if they have formal or informal caregivers who provide these functions for them.
Disease-Specific Case Management Case management services are often provided for individuals who are identified as having medical conditions that are high-cost or high-volume acute and chronic illnesses. Examples are chronic obstructive pulmonary disease and chronic cardiac conditions such as congestive heart failure. The
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goalof disease-specific case management is to keep the individuals as healthy as possible and stable in their home environments. One particular goal is to decrease the frequency and length of hospital stays and consequently reduce health care costs.
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Purpose of Case Management Case management, care management, and care coordination are patient-centered and system- centered processes. Patient-centered case management improves self-management of chronic disease; helps the client or patient proceed through a complex, fragmented, and often confusing health care delivery system; and achieves specific client-centered goals. System-centered processes recognize that health care resources are finite. The upward spiral in health care costs leads third- party payers such as Medicare, managed care organizations, and commercial payers to demand cost-effective health care. Providers are reimbursed for care provided on the basis of value-based purchasing; this includes hospitals, skilled-nursing facilities, home health organizations, and practitioners. Client consumers insist on cost-effective, efficient, high-quality care. This demand forces health care providers to reevaluate the way they administer care, to emphasize quality improvement, and to focus on decreasing cost. Health care resources then become allocated to those populations with the greatest needs.
Case management is used to promote and integrate the coordination of clinical services, linking patients to community services and agencies. Case managers monitor resources used by clients, support collaborative practice and continuity of care, and enhance patient satisfaction (Yamamoto and Lucey, 2005).
Care Management Care management has emerged as a primary means of managing the health of a defined population. The purpose of care management is to reduce health risks and cost of care for a defined population (AHRQ, 2015).
In the “Care Management Issue Brief: Implications for Medical Practice, Health Policy and Health Services Research,” AHRQ highlights three key strategies to enhance care management for target populations:
(1) Identify population(s) with modifiable risks; (2) Align CM services to the needs of the population(s); and (3) Identify, prepare, and integrate appropriate personnel to deliver the needed services.
Care Coordination Care coordination is an emerging process. It encompasses collaborating with the patient to develop a plan of care and patient-centered goals, working to develop improved chronic disease self- management skills, and providing coordination of services. AHRQ defines care coordination as
the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care.
McDonald, 2005
Utilization Review and Managed Care Equity and cost effectiveness require management and allocation of available resources in a hospital, community, city, state, or particular health care client population.Utilization review (UR), as defined by CMSA, consists of the evaluation of medical appropriateness or medical necessity of care. This review ensures that patients receive the “right care at the right time” to improve clinical outcomes and lower costs (Stricker, n.d.).
Case management programs are often motivated by the need to evaluate, use, and allocate health care resources. Many case management programs evolved from UR departments. These departments showed that monitoring service use alone is insufficient for managing patient populations with diverse resource needs. Over time, the UR nurses assumed the additional case
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manager responsibilities.
Ethical Insights Ethical Issues in Case Management There are several ethical issues that a case manager should take into consideration when working with populations. Examples are as follows:
1. Right to privacy. Confidentiality of clients served must be maintained. Communicating patient information to others who are involved with the client’s care must be done only with the client’s knowledge and permission.
2. Health care resources are expensive and limited. The case manager must use appropriate, reliable, and accessible resources for individual clients or groups of clients with the same identified needs.
3. Respect for the client’s rights to be informed about his or her care and services and to choose to receive services or not.
4. Clients have the right to know what resources are available to them and have the right to select providers of the resources.
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Trends that Influence Case Management Numerous trends have influenced case management programs. During the 1970s, hospitals billed Medicare, Medicaid, and other third-party payers for client services and received reimbursement. Health care costs skyrocketed and rapidly became the basis for discussion and concern throughout the health care industry and the country. In 1983, PL 98-21 of the Social Security Amendments introduced the prospective payment system (PPS) in the acute care setting. Under the PPS, health care providers receive a fixed amount of money based on the relative cost of resources they use to treat Medicare patients within each diagnosis-related group. Other third-party payers followed this example and negotiated reimbursement schedules through preferred provider programs or managed care contracts (U.S. Department of Commerce, 1990).
Changes in Health Care Reimbursement Title III of the Patient Protection and Affordable Care Act (Public Law 111-148), passed by Congress in March 2010, includes provisions that require improvement in the quality and efficiency of health care. The Centers for Medicare and Medicaid (CMS) have established value-based purchasing programs for hospitals, postacute providers, and practitioners. These programs link Medicare payments to quality performance, utilization of evidence-based practices, cost of care, and patient experience scores (CMS.gov 2017). Providers who participate and exceed in their relative scoring will be eligible for incentive payments; additionally, there are financial penalties for nonparticipating providers (Public Law 111-148, 2010).
To assist practitioners with success in the value-based reimbursement structure, CMS provides reimbursement for chronic care management programs and transitions of care programs.
Access to Health Care for More Americans The Patient Protection and Affordable Care Act removes many barriers to health care for Americans. With insurance coverage available to people through employers or purchased through health care access networks, more Americans have insurance and have access to health care. These changes opened up opportunities for nurses working in case manager or care coordination roles. Case managers have developed and expanded their roles in working with diverse patient populations. These issues have influenced, and continue to influence, the expansion of case management services to control costs and distribute health care resources in a variety of settings.
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Education and Preparation for Case Managers It is essential to determine what classification of health care provider is best qualified to provide case management services. Traditionally, case managers were social workers (SWs) who assumed the role of discharge planner. Client health care needs have become more complex, the need for ongoing patient assessment has emerged, and available resources have become more numerous and diverse; therefore nurses have become case managers. Several health care organizations exclusively employ SWs in case manager roles, others exclusively employ nurses in case management, and others use a combination of SWs and nurses, depending on the client population’s needs. Combining the strength and knowledge of the nurse’s clinical background with the SW’s community service background can efficiently move a client through the complex health care system (Lyon et al., 1995).
Nurse Case Managers Although both nurses and SWs have proved themselves to be excellent case managers, this chapter focuses on the nurse case manager in discussing educational requirements. A nurse case manager’s optimum education level is debatable. The basic nursing education for case managers required by employers can vary. Some require a baccalaureate degree, and others do not. In some settings, a master’s degree is required. Some programs are more interested in prior experience, continuing education, and case management certification than in the entry-level nursing degree. Education and experience requirements may vary, depending on the program’s geographic location, specific client needs, and available staff.
Nurses with master’s degrees and a focus in case management are readily available in urban settings. This gives facilities the opportunity to hire case managers who are academically prepared in theory and clinical experience. Rural areas that do not have master’s-level academic programs are at a great disadvantage in recruiting and hiring qualified nurses. To fill the case manager role, rural facilities promote nurses to case management positions, provide them with continuing education programs, and offer them necessary job-related experience. Although this is not the ideal solution, it is often the only option for facilities that are smaller or in more remote parts of the United States.
Regardless of the educational requirements in the individual case management program, case managers need a minimum skill level to ensure success in the role. These skills include sound knowledge of reimbursement structures; knowledge of available resources within the institution, organization, or community; working knowledge of the identification and evaluation of quality outcomes; the ability to perform cost–benefit ratios; and an understanding of financial strategies. In addition to the required knowledge, the nurse case manager needs flexibility, creativity, excellent communication skills, and the ability to work autonomously.
Case Manager Certification Options There are two options for case managers to become certified. The certifications are offered by the CMSA and by the American Nurses Credentialing Center (ANCC).
Commission for Case Manager Certification The Commission for Case Manager Certification offers certification in case management. The certification granted is the Certified Case Manager (CCM) credential. Following are the requirements for applicants (Commission for Case Manager Certification, 2013):
• Licensed health care worker or a bachelor’s degree in a health or human services field • Twelve months experience supervised by a CCM, or 24 months as a full-time case manager,
or 12 months as a supervisor of individuals who provide case management
American Nurses Credentialing Center The ANCC offers certification in nursing case management. To be eligible to take the certification
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examination, applicants must:
• Hold a current, active registered nurse (RN) license within a state or territory of the United States or the professional, legally recognized equivalent in another country
• Have practiced the equivalent of 2 years full time as an RN • Have a minimum of 2000 hours of clinical practice in case management nursing within the
last 3 years • Have completed 30 hours of continuing education in case management nursing within the
last 3 years
Other Certifications Several other certifications in specialty case management are available: disability management, health care quality, utilization management, managed care, and case management administrator certification. Case management professionals who are interested in obtaining certification should carefully research the options available for certification and should select the credentialing program that fits their work performed, education, and future career goals (CMSA, 2006).
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Case Manager Services Although case management programs differ in structure and design, case managers provide services regardless of the program’s location. There is a consensus in the literature that there are six components to case management: client identification and engagement, assessment, care plan development, implementation and coordination of plan of care, monitoring and evaluation, and closure of professional services (CMSA, 2016). The focus of each of these functions varies depending on the case management model.
Examples of care coordination include assisting the client or family member with medical appointments, equipment acquisition, home meal delivery, home follow-up services (e.g., home health or public health nursing), appointment transportation, and medical insurance or Medicare form completion. The types of services differ depending on the location of the case management program, the population of clients, and the scope of case management services. Some case managers in managed care environments monitor whether the patient keeps medical appointments and follows the prescribed course of treatment.
Depending on the setting, community case management services continue for varying lengths of time. Some programs continue service coordination indefinitely for populations such as the high- risk elderly and the chronically ill. Other programs move clients’ case management status from active to inactive when patients no longer require services. However, the status becomes active again if their conditions change. Case management services continue in the home health care setting until the client is discharged from the program. Care coordination in the primary health care delivery setting is increasingly being provided in PCMHs and primary care clinics. It is widely recognized that early intervention on the part of a case manager and appropriate referrals prevent costly complications and can result in better health outcomes (Thurkettle and Noji, 2003).
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Case Manager Roles and Characteristics The individual case manager’s role will vary depending on the specific program’s services. The role functions of case managers are defined by the CMSA as including assessment, planning, facilitation, coordination, monitoring, evaluation, and advocacy, achieved through collaboration with the client and others involved in the client’s care (CMSA, 2016).
TheANCC (2009) describes the practice of a nurse case manager as follows:
Nurse case managers actively participate with their clients to identify and facilitate options and services, providing and coordinating comprehensive care to meet patient/client health needs, with the goal of decreasing fragmentation and duplication of care, and enhancing quality, cost-effective clinical outcomes. Nursing case management is a dynamic and systematic collaborative approach to provide and coordinate health care services to a defined population. Nurse case managers continually evaluate each individual’s health plan and specific challenges and then seek to overcome obstacles that affect outcomes. A nurse case manager uses a framework that includes interaction, assessment, planning, implementation, and evaluation. Outcomes are evaluated to determine if additional actions such as reassessment or revision to a plan of care are required to meet clients’ health needs. To facilitate patient outcomes, the nurse case manager may fulfill the roles of advocate, collaborator, facilitator, risk manager, educator, mentor, liaison, negotiator, consultant, coordinator, evaluator, and/or researcher.
Nurse case managers must be flexible. The health care environment experiences rapid change, and new regulations and reimbursement schedules frequently emerge. The health care provider must respond to these changes rapidly to remain competitive. It is an ideal job for the self-directed nurse who enjoys being involved in a larger health care team within the organization and in the larger community.CMSA (2016) defines the standards of case management practice (Box 9.2).
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Case Identification Identification of case management clients occurs in many ways, and each program should determine the criteria for eligibility for case management services. These criteria depend on the services provided, the service’s location, the population served, and whether the service is in an acute care or community setting. Some programs are diagnosis based and use many community health care resources; for example, clients with chronic obstructive pulmonary disease often require numerous hospitalizations. Programs may focus on a particular population (e.g., the elderly or chronically ill with a specific chronic condition) and establish criteria to identify which clients to target for services (e.g., the high-risk elderly who are chronically ill, recently discharged from a hospital setting, and would benefit from case management services).
All clients referred for case management must undergo screening to determine their appropriateness for inclusion in the program. Not all referred clients need the services of a nurse case manager. Often, a nurse can arrange community services or instruct the client and family in the most appropriate follow-up based on client need and program design. The screeninginstrument must be comprehensive enough to determine which clients meet the program’s criteria and user friendly enough to allow the screener to evaluate the clients rapidly to determine their appropriateness for the program. The screener should refer clients to more suitable services within the community if they are not appropriate candidates for a particular case management program.
BOX 9.2 CMSA Standards of Case Management Practice
Client Selection Process for Case Management demonstrated by consistent use of high-risk screening criteria
Client Assessment using standard tools to assess health history; cognition; spiritual, cultural, and support systems; resources; and other components
Care Needs and Opportunities Identification that would benefit from case management intervention
Planning the identification of short-term, long-term, and ongoing needs and strategies to address those needs
Monitoring the ongoing assessment and documentation to measure the client’s response to the plan of care
Outcomes demonstrating the efficacy, quality, and cost effectiveness of the case manager’s intervention
Closure of Professional Case Management Services once established case-closure guidelines are met
Facilitation, Coordination, and Collaboration between the client and other stakeholders to achieve goals and maximize positive client outcomes
Qualifications for Case Managers, which are maintaining unrestricted licenses and certifications or involve a bachelor’s or higher health degree from a nationally accredited school
Legal adherence to all local, state, and federal laws, as well as employer policies and practice Confidentiality and Client Privacy, including consent for case management services Ethical Behavior, including the five basic ethical principles—beneficence, nonmalfeasance,
autonomy, justice, and fidelity Advocacy for the client at the service delivery, benefits administration, and policy-making
levels Cultural Competency of the client’s cultural and demographic diversity Resource Management and Stewardship of the health care and financial resources for
effective and efficient utilization Professional Responsibilities and Scholarship to maintain current knowledge,
competencies, and evidence-supported innovations
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The Referral Process The nurse may perform program referrals in a variety of ways. In the acute care hospital setting, referrals are usually based on patient diagnosis, extended length of stay, or rehospitalization. Internal mechanisms alert the case manager of the patient’s admission (e.g., a computerized list). Patients are also screened at discharge for risk of readmission and referred to the TCM case manager as appropriate.
A variety of tools are used to identify people who would benefit from case management services. They include health-risk screening tools; evidence-based criteria; risk stratification through data management; and referrals from hospitals, health care providers, and families. Information is collected by the case manager and analyzed to determine whether the individual being referred is a candidate for case management services (CMSA, 2005).
In community settings, referrals originate from a variety of sources, such as a client’s family, a primary care provider, and a hospital case manager. These referrals may be written or verbal. Staff in community agencies can also make service referrals; for example, the American Heart Association or American Cancer Society may receive calls from clients and families requesting information and assistance.
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Application of Case Management in Community Health Case management can be used in all community health settings, with interventions at the primary, secondary, and tertiary levels of prevention, according to the community program and population served. Nurses working as case managers in the community setting have diverse roles and responsibilities.
Primary Care Chronic Care Management The CMS have recently developed criteria and reimbursement forchronic care management (CCM) and TCM in the primary care setting. Patients are referred to the CCM program by a practitioner who has identified the patient as having two or more chronic conditions that put the patient at a high risk of functional decline or death within the next 12 months (CMS.gov, 2016). Care coordinators work with patients and their caregivers to improve self-management of the disease process via support and education and coordinate care to empower patients to access care appropriately and efficiently.
Transitional Care Management TCM patients are referred by practitioners or hospital staff for follow-up face-to-face visits with the outpatient practitioner and care coordination services for 30 days postdischarge. Patients are educated about new medications, condition-specific processes, and discharge instructions. As mentioned, care is coordinated for the patient, including a follow-up face-to-face visit with a practitioner. The goal of this program is to improve patient outcomes, increase understanding of condition-specific issues, and decrease hospital readmissions (DHHS and CMS, 2016).
Patient-Centered Medical Home Thepatient-centered medical home (PCMH) is a recent model of care developed to provide collaborative, quality-driven, safe primary care. The PCMH utilizes care coordination and case management processes to provide comprehensive, patient-centered, cost-effective, high-quality care (Henderson et al., 2012). In 2007, the reportJoint Principles of the Patient-Centered Medical Home, sponsored by four medical professional organizations, described the seven principles or characteristics of the PCMH, which are listed inBox 9.3 (Patient-Centered Primary Care Collaborative, 2007).
BOX 9.3 Principles of a Patient-Centered Medical Home The patient-centered medical home has the following seven characteristics:
• The patient’s relationship with the primary care physician • The physician-led, team-based care • The patient as a “whole person” who requires comprehensive care at various stages of life • Integration and coordination of care • Quality and safety • Improved access to care • A payment system that accurately reflects the efforts and care provided by the team
PCMHs are a care delivery model that utilizes the care coordination process as a foundational principle. The five key functions of the PCMH are care that is comprehensive, patient centered, coordinated, accessible, and safe (AHRQ, 2017).
The American Academy of Family Physicians (AAFP, 2008) defines the PCMH as follows:
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Transition away from a model of symptom and illness based episodic care to a system of comprehensive coordinated primary care for children, youth and adults. Patient centeredness refers to an ongoing, active partnership with a personal primary care physician who leads a team of professionals dedicated to providing proactive, preventive and chronic care management through all stages of life. These personal physicians are responsible for the patient’s coordination of care across all health care systems facilitated by registries, information technology, health information exchanges, and other means to ensure patients receive care when and where they need it. With a commitment to continuous quality improvement, care teams utilize evidence-based medicine and clinical decision support tools that guide decision making as well as ensure that patients and their families have the education and support to actively participate in their own care. Payment appropriately recognizes and incorporates the value of the care teams, non- direct patient care, and quality improvement provided in a patient-centered medical home.
High-Risk Clinic Settings There are many examples of health care settings that provide services to high-risk clients in which the nurse serves as case manager. A few examples are diabetic clinics, settings that provide health care services to high-risk perinatal clients, clients who have received transplants, dialysis settings, oncology clinics, and infusion centers. The case management services offered by the nurse are determined by the specific needs of the clients seen in these settings. The models of case management are also developed for the needs of the clients.
Public Health Clinic Settings Depending on the services provided in the public health setting, the nurse has an opportunity to provide education, screening, and referrals as needed to the clients served. Examples of primary prevention include an antepartum clinic, where the nurse interacts with women and can teach about pregnancy, diet, and exercise during pregnancy.
Working with parents in pediatric settings, the nurse case manager can teach nutrition, growth, and development and provide anticipatory guidance (primary level of prevention). The nurse can also screen children for growth and development and make referrals as needed to the Women, Infants, and Children program and other specialty programs available in the area for the clients’ needs (secondary prevention).
Nurses can also serve as case managers working with elderly clients, providing nutrition education (primary prevention), screening for hypertension (secondary prevention), and even assisting with medication management and care of chronic diseases (tertiary prevention). The opportunities for community health nurses to provide case management services are vast, depending on the location, the populations served, and the resources available in the community.
Occupational Health Settings More employers are providing health screening and education to their employees to keep their work forces healthy. Community health nurses who work in occupational health settings are in a position to provide primary prevention in health education classes designed to meet the needs of the employees. These classes can be designed on the basis of the health status of workers and to prevent the types of injuries to which they are prone. The nurse in this setting can also provide primary prevention by offering influenza vaccines and other immunizations to keep the employees healthy.
Secondary prevention can be provided to employees through screening clinics for hypertension and other potential chronic illnesses or health problems to which the employees may be more susceptible because of the nature of work performed. Referrals can be made as needed for follow- up with these employees. The occupational health nurse would continue to follow these employees and case-manage any health issues that could affect the employees’ ability to perform the duties of their jobs.
Case management for tertiary prevention can include keeping in touch with injured employees and monitoring their recovery, therapy, or other services that are provided to the employees in the process of returning to health and their jobs. The occupational health nurse who provides case management services to these employees offers them education, referrals as needed, and assistance
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in their recovery process.
Home Health and Hospice Settings The community health nurse working in home health or hospice services is often assigned a case load of clients for whom he or she provides case management services. In both of these settings, the nurse case manager provides primary, secondary, and tertiary prevention to clients. These services are designed on the basis of the individual needs of clients and their families. Coordination of care, referrals, assessment, medication management, patient and family education, and the development of plans of care are just a few of the nursing functions that are provided through a case management model.
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Research in Case Management Case management research is increasing in the last decade, much of it as a result of the quality reforms in health care and the role of case management in these reforms. A literature search inPubMed and theCumulative Index to Nursing and Allied Health found many categories of case management research. These include disease management, evidence-based practice, roles and functions, models, transitions of care, and roles in quality improvement initiatives. Specific research evaluating case management and quality improvement examined the roles of case management in transitions of care and readmissions, core measures, hospital-acquired conditions, and patient satisfaction. Other research evaluated the effect of case management on geriatric populations, disabled populations, and end-of-life situations. The documented studies describe the implemented programs and evaluate the program outcomes. An example is given in the Research Highlights box.
Research Highlights
Geriatric Care Management for Low-Income Seniors: A Randomized Controlled Trial Counsell et al. (2007) conducted a randomized clinical control study of 951 adults 65 years or older with annual incomes less than 200% of the federal poverty level whose primary care physicians were randomly assigned to the intervention group (474 patients) or usual care (477 patients) in community-based health centers. The intervention consisted of 2 years of home-based care management by a nurse practitioner and SW, who collaborated with the primary care physician and a geriatrics interdisciplinary team and were guided by 12 care protocols for common geriatric conditions. Results of the study showed that integrated and home-based geriatric care management resulted in improved quality of care and reduced acute care utilization among a high- risk group, in comparison with community-based care. Improvements in health-related quality-of- life issues were mixed, and physical function outcomes did not differ between the groups.
Case management programs in all settings require further study. Terms used in case management programs should be defined for comparison in various clinical sites. Programs with similar organizational structures and services can then be compared among settings. Critical to the success of case management programs are the inclusion of costs and cost savings and the evaluation of quality outcomes. The researcher or case manager must report the program’s description as well as the case manager’s role and professional background. Well-defined patient and program outcomes are essential to the evaluation of case management programs. With the implementation of well-designed research with measurable outcomes, management in health care settings across the continuum of care can identify the most cost-effective programs for specific populations served.
Case Study Application of the Nursing Process Comprehensive Case Management Program The following case study is an example of a comprehensive case management program. Case management programs and the served populations are diverse; this is only one example of case management implementation.
Bill Wilson is a 76-year-old white male. He recently relocated to the Reno area from Wisconsin to be closer to family. Bill was recently admitted to the hospital for treatment of chest pain, hypertension, and poor glucose control. The case manager contacts Judy, a nurse practitioner at the diabetic clinic, and asks her if she will accept Bill as a primary care client in the TCM program. Judy accepts Bill into the TCM program and makes an appointment tomorrow, the day after Bill’s hospital discharge. Past Medical History
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Metabolic syndrome: obesity (310 pounds, 5’11” BMI 43.2) Type 2 diabetes, poorly controlled, A1c 9.5 during hospitalization Hypertension Coronary artery disease with two stents placed 5 years ago after a myocardial infarction Peripheral vascular disease, both lower legs; healing wound on right foot Diabetic neuropathy, both feet Decreased vision due to diabetic retinopathy
Assessment Bill has a 10-year history of type 2 diabetes, poorly controlled, with an A1c of 9.5. He has been taking metformin 1000 mg oral twice a day. His blood glucose is often 200 to 250. He admits to forgetting his medication more than two times a week. He does not perform fingerstick glucose monitoring because of the cost of supplies and low vision problems. Individual Bill is a retired employee of Johnson and Johnson in Racine, Wisconsin. His monthly income with Social Security and other retirement is $1700 per month. Since Bill moved to Reno, he is residing in a one-bedroom apartment. His rent is $700 a month and includes utilities. He has a car and drives. He recently enrolled in a Medicare managed care program that includes medications. Family Bill was married for 45 years. He is now a widower. He is not currently in a relationship. He has two siblings, a brother and a sister. Both siblings live near their children in the Midwest. Bill moved to Reno to be close to his daughter, Sally, who is his only child. Sally resides in a single-family home with her husband, Harry, and their three teenage children. Sally is an electrical engineer, employed full time, and her husband is a university English professor. Community Because Bill is new to the community, he is not familiar with community services that are available. Judy will put him in contact with senior services that are available and will make referrals as appropriate. Diagnosis Judy saw Bill in the clinic. She took his history, performed a physical examination, and reviewed his discharge medications. With Bill, she developed a care plan with specific goals for Bill’s health promotion and disease stabilization.
The diagnosis list included:
Type 2 diabetes, poorly controlled Metabolic syndrome: obesity (increased body fat around the waist), hypertension, high blood
glucose, elevated cholesterol level Hypertension Hyperlipidemia Coronary artery disease Peripheral vascular Disease Diabetic neuropathy Visual disturbance, retinopathy, and cataracts
Individual Judy and Bill mutually agreed that he lacks knowledge on how to manage his diabetes. Bill often eats foods high in carbohydrates and fats. It is convenient for Bill to eat fast foods. Bill admits that he often forgets to take his medications. He also acknowledged that he does not understand his medications and which medication treats his chronic conditions. Bill has not seen an ophthalmologist in more than 5 years.
Bill has a limited income, but he thinks that he can live on his monthly income, especially now that he is on a Medicare managed care program that covers his medications.
Bill does not exercise and finds exercise boring. Family
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Bill’s daughter, Sally, is concerned about him. She is busy with her job, but is available to assist him on the weekends. She is willing to assist him with meal preparation and invites him to her house for meals at least once a week. Community Bill is new to the community. He does not know what services are available for seniors in the area. Part of his care plan includes an introduction to community services and activities. Planning Individual Bill is at risk for hospital readmission. He requires education to learn how to manage his chronic illnesses. Most importantly, Judy suggests that Bill begin the Diabetic Education course offered at the clinic. The program includes information on how to monitor and control his blood glucose. The program also includes healthy cooking classes to encourage the attendees to prepare healthy meals at home. Judy is also setting an appointment for Bill to meet with the program’s pharmacist to learn about his medications. Short-Term Goals Bill and Judy agreed on short-term goals that include the following:
• Diabetic education classes that include healthy cooking. A meeting with the program’s dietitian to identify specific goals for Bill’s meal plan.
• A referral to a podiatrist who comes to the diabetic clinic three times a week to see patients, with the goal of the foot wound healing completely. Education on foot care, wearing socks, appropriate shoes, and foot inspection.
• A referral to an ophthalmologist for a complete eye examination. • A referral to a local gym. Bill’s Medicare managed care health program pays for the monthly
membership. • An appointment with an exercise physiologist at the gym to evaluate Bill’s current physical
condition and create an exercise plan for Bill. Because Bill finds exercise boring, the physiologist will work with Bill to develop an exercise program that will interest Bill to encourage continuation of the program.
Long-Term Goal Bill’s long-term goals include the following:
• Control of his type 2 diabetes, including an A1c less than 7.5 • Weight loss • Continuation of the exercise program • Continued follow-up with his primary care provider, Judy
Family Short-Term Goal Bill’s daughter, Sally, wants to make sure that Bill has the diabetic testing supplies that he needs. She contacts the Medicare managed care program and requests that the testing supplies be provided. The company representative assures Sally that the supplies are covered. They will provide Bill with a glucometer and testing supplies. They will provide the products as soon as possible so Bill can learn how to do blood glucose monitoring while enrolled in the Diabetic Education program. Long-Term Goal The long-term goals that Bill’s family want him to achieve include:
• Diabetes control • Weight loss through diet and exercise • Independent living in his own apartment
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• Social interaction Community
Short-Term Goal Judy will provide Bill with his referral information. Judy will also provide Bill with resources available in the community that he can explore. Long-Term Goal
• Socialization in the community. Bill plans to start attending the church that his daughter and her family attend. He wants to explore the activities offered at the local senior center.
• Attendance at exercise, completion of the Diabetic Education program.
Intervention Individual Judy’s primary focus for Bill is to stabilize and improve his chronic illnesses. Making referrals to podiatry, ophthalmology, diabetic education, and exercise physiologist. Family Bill has good support from his daughter and her family, who are involved in his life. Community Bill has a stable living environment. He is able to drive and explore the community resources that Judy has provided. Evaluation Individual Judy and Bill work together as a team to evaluate his chronic disease management. As necessary, they make revisions in his care plan. Family Bill’s family remains involved in his life. They are a strong source of social support for him. Community Judy will evaluate Bill’s progress in becoming involved in community activities and services.
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Summary Case management programs continue to emerge in all health care settings. These programs change as health care reform measures are initiated and the needs of the population change. A common need among all programs is to collect data on the efficacy of programs, measuring client and program outcomes to ensure that the services that are offered are meeting targeted goals. Staff who work as case managers should consider obtaining certification to develop common knowledge and skills among case management providers and better validate the services provided.
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Evolve Website http://evolve.elsevier.com/Nies/community
• NCLEX Review Questions • Case Studies
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UNIT 3 Factors That Influence the Health of the Community
OUTLINE
10. Policy, Politics, Legislation, and Community Health Nursing
11. The Health Care System
12. Economics of Health Care
13. Cultural Diversity and Community Health Nursing
14. Environmental Health
15. Health in the Global Community
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Policy, Politics, Legislation, and Community Health Nursing
Cathy R. Arvidson∗
OUTLINE
Overview: Nurses’ Historical and Current Activity in Health Care Policy Definitions A Major Paradigm Shift Structure of the Government of the United States Overview of Health Policy
Public Health Policy Health Policy and the Private Sector The Legislative Process: How a Bill Becomes a Law Major Legislative Actions and the Health Care System Federal Legislation Role of State Legislatures
Public Policy: Blueprint for Governance Policy Formulation: The Ideal Policy Formulation: The Reality Steps in Policy Formulation and Analysis
The Effective Use of Nurses: a Policy Issue Nurses’ Roles in Political Activities
The Power of One and Many Nurses as Change Agents Nurses and Coalitions Nurses as Lobbyists Nurses and Political Action Committees Nurses and Campaigning Nurses and Voting Strength Nurses in Public Office
Health Care Reform and Restructuring of the Health Care Industry Nurses and Leadership in Health Policy Development
OBJECTIVES
Upon completion of this chapter, the reader will be able to do the following: 1. Discuss how the structure of government affects the policy development process. 2. Describe the legislative, judicial, and administrative (executive) processes involved in
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establishing federal, state, or local health policy. 3. Examine the power of nursing to influence and change health policy. 4. Discuss current health policy issues. 5. Identify the social and political processes that influence health policy development. 6. Discuss the nurse’s role in political activities. 7. Discuss nursing’s involvement in private health policy.
KEY TERMS administrative agencies Clara Barton coalition Florence Nightingale government health policy institutional policies Lavinia Dock laws Lillian Wald lobby lobbyist Mary Breckenridge nursing policy organizational policies organizations policy policy analysis political action committee (PAC) politics public health law public policy Ruth Watson Lubic social policy Sojourner Truth sovereign power statutes Susie Walking Bear Yellowtail Sylvia Trent-Adams This chapter addresses the interrelationships of the processes through which health policies are determined and instituted. Politics and legislation are the routes through which public health policies are established. Policy, politics, and legislation are the forces that determine the direction of health programs at every level of government, as well as the private sector. These programs are crucial to the health and well-being of the nation, the state, the community, and the individual. Nurses influence the maintenance and improvement of the health of individuals, groups, and communities by contributing to policy and legislative advancement.
The health care delivery system, including nursing practice and research, is profoundly
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influenced by policies set by both government and private entities. Nurses who understand the system of health policy development and implementation can effectively interpret and influence policies that affect nursing practice; the health of individuals, families, groups, communities, and populations; and, when required, offer an international health perspective.
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Overview: Nurses’ Historical and Current Activity in Health Care Policy The more a nurse knows about the political process, the more he or she tends to become involved. Individual nurses may become politically active on a local, state, or national level. Nurses may work collectively within a group such as the National Student Nurses Association, the American Nurses Association (ANA), and state boards of nursing to lobby for health causes. There are more than 4 million employed registered nurses (Kaiser Foundation, 2016). Together nurses can be patient advocates, change agents, and policy makers. Lawmakers respect nurses and thus are usually effective as consultants in both the legislative and executive branches at local, state, and federal levels. It is the hallmark of the U.S. system of government that citizens have the right to have an influential voice in the governance of the community. Nurses are able to communicate concerns about conditions and issues in health care, the health care needs of individuals and communities, and the profession of nursing. United, nurses can influence political leaders to make changes to the health care system that are beneficial to all. Nurses experienced in the political arena can mentor novices to it.
Many individual nurses in the past and present have been instrumental in working with legislation and politics. A few exemplary nurses who had an impact on public health are:
Florence Nightingale was the first nurse to exert political pressure on a government (Hall- Long, 1995). In the 1850s Nightingale was asked to establish the first nurse corps to tend the soldiers in the Crimea War. She transformed military health and knew the value of data in influencing policy. She was a leader who knew how to use the support of followers, colleagues, and policy makers. As discussed in Chapter 2, Nightingale collected and analyzed data about health services and outcomes, an activity that now is a critical element of public health.
Sojourner Truth beginning in the 1840s became an ardent and eloquent advocate for abolishing slavery and supporting women’s rights. Her work helped transform the racist and sexist policies that limited the health and well-being of African Americans and women. She fought for human rights and lobbied for federal funds to train nurses and physicians (Masonet al., 2007).
Clara Barton was responsible for organizing relief efforts during the U.S. Civil War. In 1882, she successfully persuaded Congress to ratify the Treaty of Geneva, which allowed the Red Cross to perform humanitarian efforts in times of peace. This organization has had a lasting influence on national and international policies (Hall-Long, 1995; Kalisch and Kalisch, 2004).
Lavinia Dock was a prolific writer and political activist. She waged a campaign for legislation to allow nurses to control the nursing profession instead of physicians. In 1893, with the assistance of Isabel Hampton Robb and Mary Adelaide Nutting, she founded the politically active American Society of Superintendents of Training Schools for Nurses, which later became the National League for Nursing (Kalisch and Kalisch, 2004). She was also active in the suffrage movement, advocating that nurses support the woman’s right to vote (Lewinson, 2007).
Lillian Wald’s political activism and vision were shaped by feminist values. Working in the early 1900s, she recognized the connections between health and social conditions. She was a driving force behind the federal government’s development of the Children’s Bureau in 1912. Wald appeared frequently at the White House to participate in the development of national and international policy (Mason et al., 2007).
Mary Breckenridge worked to develop nursing in rural Kentucky in the 1920s, establishing the Frontier Nursing Service.
Susie Walking Bear Yellowtail was a Native American nurse who walked from reservation to reservation, working to improve health services for this population from the 1930s to 1960s. She also established the Native American Nurses Association.
Florence Wald was a nursing leader in establishing hospice care in the United States— modeled after similar services offered in the United Kingdom—in the 1970s.
Dr. Ruth Watson Lubic is a nurse-midwife who crusaded for freestanding birth centers in this
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country, being influential in the opening of New York City’s first birthing center in 1975. After developing the birth center model through the Maternity Center Association in New York City, Dr. Lubic expanded the model to Washington, DC, where the infant mortality rate was twice the national average. In 1993, Lubic was awarded the MacArthur Fellowship Grant and, in 2001, the National Academy of Medicine’s Lienhard Award (Lyttle, 2000; Rychnovsky 2011).
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Definitions Policy denotes a course of action to be followed by a government, business, or institution to obtain a desired effect. Merriam-Webster’s Dictionary defines policy as “a definite course or method of action selected from among alternatives and in light of given conditions to guide and determine present and future decisions” (Merriam-Webster, 2014). Policy encompasses the choices that a society, segment of society, or organization makes regarding its goals and priorities and the ways it allocates its resources to attain those goals. Policy choices reflect the values, beliefs, and attitudes of those designing the policy (Mason et al., 2016).
Public policy denotes precepts and standards formed by governmental bodies that are of fundamental concern to the state and the whole of the general public. The field of public policy involves the study of specific policy problems and governmental responses to them. Political scientists involved in the study of public policy attempt to devise solutions for problems of public concern. They study issues such as health care, pollution, and the economy. Public policy overlaps comparative politics in the study of comparative public policy with international relations in the study of foreign policy and national security policy, and with political theory in considering ethics in policy making. See the examples in Table 10.1.
Health policy is a statement of a decision regarding a goal in health care and a plan for achieving that goal. For example, to prevent an epidemic, a program for inoculating a population is developed and implemented, and priorities and values underlying health resource allocation are determined.
Nursing policy specifies nursing leadership that influences and shapes health policy and nursing practice. Nursing, and therefore nursing leadership, is shaped dramatically by the impact of politics and policy. Effective nursing leadership is a vehicle through which both nursing practice and health policy can be influenced and shaped.
Institutional policies are rules that govern worksites and identify the institution’s goals, operation, and treatment of employees.
Organizational policies are rules that govern organizations and their positions on issues with which the organization is concerned (Mason et al., 2016).
TABLE 10.1
Terminology Example
Topic Example Public policy
A local or regional effort to prevent the sale of tobacco or alcohol to minors. Public policy directs that the right to health of the majority must be preserved over individual freedoms and corporate interests.
Public health law
New York State Public Health Law §2164: “Every person in parental (statute) relation to a child in this state shall have administered to such child an adequate dose of an immunizing agent against poliomyelitis, mumps, measles, diphtheria, rubella, varicella, Haemophilus influenza type B, and hepatitis B…”
Common law
The Supreme Court decision in Roe v. Wade, making first-trimester abortion legal, is an example of how common law becomes enforceable.
Regulation Reporting of communicable diseases to state and local health departments, which then report them to the Centers for Disease Control and Prevention.
Treaty Multilateral treaty: Treaty to eliminate all forms of discrimination against women.
A political action committee (PAC) is a fundraising group usually associated with an organization. Money is raised from the members with the purpose of financially supporting political causes. Organizations are allowed to support candidates, but only PACs are permitted to donate money to candidates or legislation (Mason et al., 2016).
Social policy is policy associated with individuals and communities. In very general terms, social policy can be defined as the branch of public policy that advances social welfare and enhances participation in society. Social safety nets, however, often contribute to social exclusion, especially in urban settings, instead of being universally accessible. In most Western societies, social protection usually depends on contributory social insurance schemes to which only regular job holders have access (either in their own right or as dependents). In the United States, this is particularly evident with respect to the way the health care system and Social Security retirement benefits work. Social justice argues that all individuals and groups receive fair treatment in society as well as impartially share in the benefits of that society (Almgren, 2012).
Administrative agencies are departments of the executive branch with the authority to implement or administer particular legislation.
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Laws are rules of conduct or procedure; they result from a combination of legislation, judicial decisions, constitutional decisions, and administrative actions.
Public health law focuses on legal issues in public health practice and on the public health effects of legal practice. Public health law typically has three major areas of practice: police power, disease and injury prevention, and the law of populations. Statute, ordinance, or code prescribes sanitary standards and regulation for the purpose of promoting and preserving the community’s health. Public health law consists of legislation, regulations, and court decisions enacted by government at the federal, state, and local levels to protect the public’s health. This includes case law and treaties.
Statutes are any laws passed by a legislative body at the federal, state, or local level. Organizations are associations that set and enforce standards in a particular area; a group of
individuals who voluntarily enter into an agreement to accomplish a purpose. A professional association (also called a professional body, professional organization, or professional
society) is a nonprofit organization seeking to further a particular profession, the interests of individuals engaged in that profession, and the public interest. It is a volunteer group that seeks to join large numbers of individuals who have a significant wealth of knowledge and experience in a particular field such as the Association of Public Health. There are also pooled funds for lobbying purposes (Thomas, 1997). The roles of these professional organizations are viewed as maintaining the control and oversight of the professional occupation as well as safeguarding the public trust. There is an element of protecting the interests of the professional practitioners, as in a cartel or labor union. Inherent in these organizations is the promotion of general standards for the performance of its members and the expectation of continued professional development.
Many professional bodies are involved in the development and monitoring of professional educational programs and the updating of skills, and thus they perform professional certification to indicate that a person possesses qualifications in the subject area. Sometimes membership in a professional body is synonymous with certification, though not always. Membership in a professional body, as a legal requirement, can in some professions form the primary formal basis for gaining entry to and setting up practice within the profession. Professional bodies also act as learned societies for the academic disciplines underlying their professions.
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A Major Paradigm Shift Policy is based on values, and the first step in forming policy is identifying the issue. Therefore it would seem rational to define “health” as the starting point for any policy annexed to health care issues. Historically, health was defined in the context of infectious diseases. Current definitions encompass prevention and management of chronic conditions. The World Health Organization (WHO) considers health to be the state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Despite this broad definition, it is only in the most recent decades that the WHO is refocusing on its initial definition as it attempts to deal with environmental issues such as nuclear contamination and industrial toxins in industrialized nations and the exploration of carcinogenic commercial products such as tobacco products. On a global level, the WHO is working to prevent, treat, and care for communicable diseases such as HIV/AIDS, tuberculosis, malaria, and, most recently, the Zika virus. In addition, WHO focuses on noncommunicable diseases such as heart disease, stroke, cancer, diabetes, and lung diseases, which are responsible for more than 70% of all deaths worldwide. WHO emphasizes promoting health through the life cycle, taking into account environmental risks and social determinants of health. Thus there is a realization that health is a basic human right and that health problems are linked to government actions and, hence, affect human rights.
Human rights violations occur when governments fail to provide their people with the infrastructure, services, and information necessary to promote health, reduce risk, and control disease. For example, for every year of education women have, their infant mortality is decreased by 10%; yet education of women is not a global reality.
On a national level, an example of changing emphasis is the Centers for Disease Control and Prevention (CDC). It is committed to achieving true improvements in people’s lives by accelerating health impact and reducing health disparities. Box 10.1 describes this priority for the CDC. All people, and especially those at greater risk of health disparities, will achieve their optimal lifespan with the best possible quality of health in every stage of life. However, a shift in the paradigm of health concepts would necessitate a substantial reallocation of resources, because the vast majority of health spending is directed at medical care and biomedical research and, as such, reflects a viewpoint of health care as a commodity. If one considers that in 2015 28.4 million people in the United States younger than 65 years had no health insurance and 4.5% of children were uninsured, it becomes clear that the health and human rights relationship is not yet reflected in our health policies (CDC, 2015). In addition, many people are underinsured. Their insurance coverage is not at the level it should be to cover full services or longer-term needs. The economics of health care are discussed further in Chapter 12.
The publication of Healthy People 2000 by U.S. Surgeon General C. Everett Koop in 1990 led to a resurgence of interest by the federal government in the health and welfare of Americans. However, fiscal resources for public health interventions declined, and only marginal progress was made in meeting the goals. In early 2000, Healthy People 2010 marked the beginning of the new millennium and an enhanced focus on population-based health promotion strategies (U.S. Department of Health and Human Services [USDHHS], 2000). Many Healthy People 2020 objectives directly or indirectly involve health policy with enhanced focus on the social determinants of health and health policy (USDHHS, 2013) (see the Healthy People 2020 box).
Virtually all of the areas of Healthy People 2020 have multiple policy-related objectives, and the Healthy People box lists only a few of them. Building on previous iterations, the updated 2020 version has four “over-arching goals” for 2020: attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; achieve health equity, eliminate disparities, and improve the health of all age groups; create social and physical environments that promote good health for all; and promote quality of life, health development, and health behaviors across all life stages. The Healthy People 2020 box describes Healthy People content related to the public health infrastructure. Another forward-looking recommendation is making Healthy People 2020 into a web- accessible database that is searchable and interactive and allows users to tailor the document to the public’s needs. The intent is that enhanced focus on social determinants represents a “deliberate shift away from the perception that access to health care services will ever solve all of our health care problems” (USDHHS, 2013).
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BOX 10.1 Strategic Plan Priorit ies for the Center of Disease Control Strategic Framework
Strategic Priority #1 Improve health security at home and around the world. Strategic Priority #2 Better prevent the leading causes of illness, injury, disability, and death. Strategic Priority #3 Strengthen public health and health care collaboration.
From Centers for Disease Control and Prevention: CDC strategic framework, 2016. Retrieved from https://www.cdc.gov/about/organization/strategic-framework/index.html
Healthy People 2020
Content Related to Public Health Infrastructure Goal To ensure that federal, state, tribal, and local health agencies have the necessary infrastructure to effectively provide essential public health services. Overview Public health infrastructure is fundamental to the provision 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. Why is Public Health Infrastructure Important? 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 responding to public health needs
These components are necessary to fulfill the following 10 essential public health services:
1. Monitor health status to identify and solve 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 and action 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. Ensure competent public and personal health care workforces. 9. Evaluate effectiveness, accessibility, and quality of personal and population-based health
services. 10. Research for new insights and innovative solutions to health problems.
Understanding Public Health Infrastructure Public health infrastructure is key to all other topic areas in Healthy People 2020. It allows for and supports key goals of Healthy People, including the:
• Improvement of health • Creation of environments that promote good health
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• Promotion of healthy development and behaviors
Public health infrastructure, along with the 10 essential functions of public health, influences— and is influenced by—a number of factors, including the social and political environment. As such, public health infrastructure provides a useful framework for addressing the social determinants of health. Emerging Issues in Public Health Infrastructure Increasing attention to public health infrastructure has led to the identification of a number of emerging issues. Tribal Public Health Infrastructure Each tribe is an independent government that must adopt local strategies to meet its public health challenges; interventions must be tailored to the cultural beliefs and practices of each tribe. There are many ways tribal entities are served through the Indian Health Service, Tribal Epidemiology Centers, and national organizations; however, challenges remain. Disparities in the Public Health Workforce As minority populations in the United States increase, the country will need a more diverse public health workforce. Hispanics, American Indians and Alaska Natives, and African Americans are underrepresented in the public health workforce. Accreditation of Public Health Agencies In an effort to standardize services and improve performance, public health agencies are moving toward a voluntary national accreditation program. This program will highlight agencies’ commitment to service and quality and provide a standard toward which all public health agencies can work. Public Health Systems Research Expanding the evidence base for community interventions and for the effective organization, administration, and financing of public health services is critical to the future development of public health infrastructure. The emerging field of public health systems and services research is playing an important role in the development of this evidence base; its role should be supported and expanded over the decade, with a strong focus on translating research into practice. Public Health Law Novel policies are being developed to address legal and political challenges resulting from new and re-emerging infectious diseases and increasing levels of chronic disease. New centers devoted to the study of public health law are adding to the body of knowledge in this critical area. From U.S. Department of Health and Human Services: Healthy People 2020, 2013, Public Health Infrastructure. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=35.
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Structure of the Government of the United States Government is the structure of principles and rules determining how a state, country, or organization is regulated. Among its purposes are regulation of conditions beyond individual control and provision of individual protection through a population-wide focus. These tasks are accomplished through passage and enforcement of laws. Requirements of childhood immunizations for school attendance, disease vector control, and sewage treatment are examples of regulations to protect the health of the population.
Government can also be viewed as the sovereign power vested in a nation or state. Sovereign power is the independent and supreme authority of the nation or state. Historical documents describe the government’s responsibility for health in the United States and the subsequent authority to enact laws (including health laws). These documents reflect the values of the country’s founders. They give the government the authority to enact laws, but they also limit that power. The earliest of these statements was the Mayflower Compact, through which the Pilgrims committed themselves to making “just and equal laws” for the general good. The Declaration of Independence later established the doctrine of inalienable rights, life, liberty, and the pursuit of happiness. However, it was not until the representatives of the individual states signed the Constitution of the United States that the federal government realized its sovereign power. At the same time that its power was realized, a limit to that power was placed on the federal government. The drafters of the Constitution sought to balance the need to empower the new federal government to “establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare, and secure the Blessings of Liberty” for its people but with limits on that power. That balance is achieved in several important ways.
TABLE 10.2
Government Branches
Branch of Government Includes Executive branch The president, the vice president, and the administrative agencies Legislative branch The Senate and the House of Representatives (Congress) Judicial branch At the federal level: district courts, circuit courts, and the Supreme Court
At the state level: state and county courts
BOX 10.2 An Example of the President’s Response to a House Bill (A President May or May not Respond to a Bill ) State Children’s Health Insurance Program (SCHIP)
H.R. 2 (and related bills H.R. 57, H.R. 72, and S. 275) became Public Law 111-3, The Children’s Health Insurance Reauthorization Act of 2009. This was signed into law by President Barack Obama on February 4, 2009. It went into effect on April 1, 2009. This bill:
• Allows certain state plans under Titles XIX (Medicaid) or Title XXI (State Children’s Health Insurance Program, referred to in this Act as CHIP) of the Social Security Act (SSA) that require state legislation to meet additional requirements imposed by this Act additional time to make required plan changes.
• Provides for coordination of CHIP funding for the 2009 fiscal year. • Amends SSA Title XXI to reauthorize the CHIP program through FY2013 at increased levels.
See http://thomas.loc.gov/home/thomas.php for more information.
The federal government is a government of limited powers, which means that for a federal action to be legitimate, it must be authorized. Only those actions that are within the scope of the Constitution, the supreme law of the land, are authorized. The Constitution separates governmental powers among the branches of government (Table 10.2).
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Some examples of the separation of powers doctrine that are written into the U.S. Constitution are as follows:
• The legislature is prohibited from interfering with the courts’ final judgments. • The Supreme Court cannot decide a “political question”; the issue must be an actual case or
controversy. • Congress must present a bill to the president before it can become law (Box 10.2). • The president needs consent of the Senate to appoint Supreme Court justices or to make
treaties. • The president and members of Congress are elected; the judiciary is appointed.
BOX 10.3 Administrative Agencies One of the most dramatic changes in American government since the ratification of the Constitution is the growth of administrative agencies. Federal administrative agencies have broad power. They exercise all of the powers of government: executive, legislative, and judicial.
The U.S. Food and Drug Administration (FDA) is one such administrative agency. Its power is in regulating the pharmaceutical industry as well as the food industry.
The Constitution not only set forth the responsibilities of the federal government but also provided for the individual citizen’s rights and freedoms. These are contained in the first 10 amendments, which were added after the original Articles of the Constitution were ratified in 1787. These 10 amendments, added in 1791, are known as the Bill of Rights. The rights guaranteed in the Bill of Rights, such as those of free speech and freedom of religion, applied only to the laws and actions of the federal government. It would take another 72 years for these rights to be guaranteed within the states. “Liberty interests” and “privacy rights” have been found to exist by Supreme Court determinations and have become guiding principles in setting policy and enacting legislation. Note that these rights are applicable only to state or federal government’s interaction with people. Violations of restrictions on rights such as free speech do not apply to nongovernmental entities, unless a specific law states otherwise.
The balance of powers is an important concept in the U.S. government. Federalism is the relationship and distribution of power between the national and the state governments. This balance flows directly from the text of the Constitution: “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.” Box 10.3 highlights one of the changes in the federal government since the Constitution: the development of administrative agencies. This development has had a major impact on government functioning.
States retain powers not delegated to the federal government; therefore much of public health law is under state jurisdiction and, as a result, varies considerably from state to state. These powers to enact laws for the public welfare are referred to as the states’ police powers. Additionally, states may delegate these powers to local governments. In the United States, legislative activities of the three levels of government (federal, state, and local) may vary greatly in their expectations, actions, and results. The state legislatures, for the most part, are directly involved in health care, yet the federal government influences health policy, directly and indirectly, through the financing of health care for many groups (e.g., Medicare, Medicaid), regulation activities (e.g., approval of drugs), and setting of standards (e.g., air quality).
Decisions affecting the public’s health are made not only at every level of government but also in each branch of government. The separation and balance of powers, referred to as checks and balances, is as important to health as it is to the economic or military status of the country.
The legislative branch (i.e., Congress at the federal level; legislature, general assembly, or general court at the state level) enacts the statutory laws that are the basis for governance. The executive branch administers and enforces the laws, which are broad in scope, through regulatory agencies. These agencies, in turn, define more specific implementation of the statutes through rules and regulations (i.e., regulatory or administrative law). The judiciary body provides protection against oppressive governance and against professional malpractice, fraud, and abuse. Its function through the courts, both state and federal, is to determine the constitutionality of laws, interpret them, and
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decide on their legitimacy when they are challenged. Decisions of the U.S. Supreme Court are binding law for the nation. Decisions of an individual state’s highest court are binding law within that state alone. The courts also have jurisdiction over specific infractions of laws and regulations.
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Overview of Health Policy Public Health Policy To review, public policy refers to decisions made by legislative, executive, or judicial branches of one of the three levels of government (local, state, or federal). These decisions are intended to direct or influence actions, behaviors, or decisions of others. Public health policies influence health care through the monitoring, production, provision, and financing of health care services. Everyone, from health care providers to consumers, is affected by health policies. Likewise, health policy influences corporations, employers, insurers, colleges of nursing, hospitals, clinics, producers and retailers of medical technology and equipment, and senior care facilities.
The authority for the protection of the public’s health is largely vested with the states, and most state constitutions specifically delineate their responsibility. Municipal subdivisions of states, such as counties, cities, and towns, generally have the power of local control of the services, conferred by the state legislature. The responsibilities of local, state, and federal governments for health services may differ under varying circumstances, sometimes complicating attempts to determine the locus of political decision making. The supremacy of the state prevails in most instances; therefore the state is a critical arena for political action. An example is the state’s authority to license health professionals and health care institutions.
Each state establishes policies or standards for goods or services that affect the health of its citizens. However, if the federal government or the local government imposes a higher standard than the state requires, the lower standard is negated by the higher standard. An example would be standardization of pasteurized milk. A state may hold to one standard, whereas interstate commerce, which is under federal jurisdiction, may dictate a higher standard that must be met by that state.
The federal government has a strong influence on the health services available in each state. Constitutionally, this authority is derived from the federal role in interstate commerce and through broad interpretation of the “general welfare” clause (e.g., Medicare and Medicaid). States vary considerably in resources allocated to provide health programs; therefore significant de facto authority derives from the promise of revenues or threats to remove funding (e.g., funds for interstate highway repair are often tied to air quality requirements). Federal funds typically fund most health care programs fully or partially.
BOX 10.4 History of Several Examples of Government-Funded Health Care Legislation
• 1965: The Social Security Act established both Medicare and Medicaid. Medicare was a responsibility of the Social Security Administration (SSA), whereas federal assistance to the state Medicaid programs was administered by the Social and Rehabilitation Service (SRS). SSA and SRS were agencies in the Department of Health, Education, and Welfare (HEW).
• 1977: The Health Care Financing Administration (HCFA) was created under HEW to effectively coordinate Medicare and Medicaid.
• 1980: HEW was divided into the Department of Education and the Department of Health and Human Services (HHS).
• 2001: HCFA was renamed the Centers for Medicare and Medicaid Services (CMS). CMS is the federal agency that administers the Medicare and Medicaid programs.
• 2010: The Patient Protection and Affordable Care Act was a very comprehensive attempt to improve access to care by providing health insurance to most of the nation’s uninsured.
• 2012: The Food and Drug Administration Safety and Innovation Act reauthorizes user fees for the FDA.
• 2016: VA Health system rule change granting veterans direct access to care by nurse practitioners, certified nurse midwives, and clinical nurse specialists who work in the VA health system.
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Compliance by states with federal program standards is voluntary, but the advantage of the revenue, which is withheld from the states that fail to comply, is seldom ignored. Programs such as a statistical reporting system of sexually transmitted infections and control are standardized across the country in response to the indirect but marked effect of federal funding.
Health Policy and the Private Sector In addition to the public policy–making sector, health policies can be made through the private sector. For example, an insurance company or an employer can determine some of what illnesses and preventive care is covered by the insurance program, what drugs are included in the formulary, and how much to charge for an insurance policy. The private sector includes employers, professional organizations (e.g., American Hospital Association), nonprofit health care organizations (e.g., American Heart Association), and for-profit corporations that deliver, insure, or fund health care services outside government control. In particular, health insurance companies and managed care organizations are increasingly setting policies that affect a large number of individuals.
In the private sector, health policy evolves differently from in the public sector. One difference is that private health policy is largely influenced by theories of economics and business management, as compared with the social and political theories that predominate in the public sector. In the private sector economics is central, whereas in the public sector economics is but one of many factors. In the private sector decisions can be swift and are often proactive, whereas in the public sector decisions are slow, deliberate, and more reactive. Private-sector needs are determined by consumerism, market trends, and economics. Public-sector needs are determined by voting shifts, electoral realignment, and term limits. Box 10.4 provides the history of several critical examples of government-funded health care legislation.
FIG. 10.1 How a bill becomes a law at the federal level. Retrieved from http://publicdomainclip-art.blogspot.com/2007_09_01_archive.html.
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The Legislative Process: How a Bill Becomes a Law As stated in the previous section, there is a balance of powers within the government at both state and federal levels. The three branches of government, executive, judicial, and legislative, form a three-legged stool that is in equilibrium. Along with a separation of powers of the three branches of government, there is an additional mechanism that balances the power of the Congress: bicameralism (consisting of two houses). Bicameralism ensures that the power to enact laws is shared between the House of Representatives and the Senate. The procedure through which legislation must pass to eventually become law is similar for all legislative bodies in the country. Once a concept has been drafted into legislative language, it becomes a bill, is given a number, and moves through a series of steps. The bill’s passage is sometimes smooth, but, more often than not, the bill is extensively altered through amendments or even “killed” (dropped from or stopped in the process).
In Congress and in the 49 states that have bicameral legislatures, a bill must succeed through the two legislative bodies, that is, the House of Representatives and the Senate (Fig. 10.1). Nebraska, which has a single-house legislature, is the exception. A bill that has moved successfully through the legislative process has one final hurdle, which is the chief executive’s approval. The approval may be a clear endorsement, in which case the governor or president signs it. If the executive neither signs nor vetoes it, the bill may become law by default. An explicit veto conclusively kills the bill, which then can be revived only by a substantial vote of the legislature to override the veto. This is another example of the checks and balances of the government process.
Issues that find their way into the legislative arena are commonly controversial, and proponents and opponents quickly align themselves. Defeating a bill is much easier than getting one passed; therefore the opposition always has the advantage.
Health legislation, which usually requires preventive action (e.g., toxic waste management) or creates a new service (e.g., nursing center organizations for Medicare recipients), is at a disadvantage from several standpoints. Few elected officials are knowledgeable about the health care field. Typically, they have staff who have more expertise in this area, and it is the staff who write legislation. Although health is readily recognized as a national resource, it is not easily quantified into the economic terms that make the issue easy to grasp. Health legislation is often costly to implement. As a result even legislation that has large bipartisan support may not pass due to the cost. Other disadvantages are the backgrounds, biases, and ambitions of each legislator. Despite these obstacles, good health laws can be passed when concerned nurses and other health care workers understand the legislative process and use it effectively. Nurses have been recognized as one of the most trusted professions. Nurses should educate their elected officials and function as expert tutors for them. In addition, this is yet another mode of intervention that nurses may perform on behalf of clients.
Major Legislative Actions and the Health Care System An examination of the major legislative actions that federal and state governments have taken and recognition of their influence on health and health care delivery are critical to understanding the evolution of the health care system in the United States. Throughout the twentieth century, the U.S. Congress enacted bills that had a major influence on the private and public health care subsystems. Legislation pertaining to health increased in scope in each decade of the twentieth century, with the goal of improving the health of populations and coping with changing health care needs. During the last two decades, concerns about an increase in health care costs and the growth of managed care stimulated even more legislation. The Patient Protection and Affordable Care Act (ACA) was signed into law in March 2010 with a plan to increase health care coverage to previously uninsured Americans. The ACA had many supporters and opponents, resulting in much debate even after its implementation. Indeed, health care reform/health insurance reform was a major issue during both the 2012 and 2016 presidential elections. The Supreme Court also reviewed a major case related to the health care reform legislation, tying all levels of government to this landmark legislation— administrative, legislative, and judicial. The Court decision did not lead to major changes in the health care reform law. At the time of publication, the debate continues on introducing new legislation to repeal and replace the ACA. Issues of affordability, preexisting conditions, requirements for citizens to buy health insurance, and tax credits are being discussed.
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Federal Legislation This section describes some of the landmark federal laws that have influenced health services and health care professionals. They are listed in Table 10.3.
Pure Food and Drugs Act of 1906: This act established a program to supervise and control the manufacture, labeling, and sale of food. Subsequent legislation included meat and dairy products, pharmaceuticals, cosmetics, toys, and household products. Since 1927, the U.S. Food and Drug Administration (FDA) has administered elements of this act.
Children’s Bureau Act of 1912: The Children’s Bureau was founded to protect children from the unhealthy child labor practices of the time and to enact programs that had a positive effect on children’s health. In 1921, the Sheppard-Towner Act extended children’s health care programs by providing funds for the health and welfare of infants.
Social Security Act of 1935 and its amendments (1965, 1972): The Social Security Act and its subsequent amendments have had a far-reaching effect on health care for many groups. The Social Security Administration (SSA) provides welfare for high-risk mothers and children. Benefits were later expanded to include health care provisions for older adults and the handicapped. This major governmental action was the enactment of legislation for Medicare and Medicaid.
TABLE 10.3
Critical Federal Legislation Related to Health Care
Year(s) Legislation or Other Government Action 1906 Pure Food and Drugs Act 1912 Children’s Bureau Act 1921 Sheppard-Towner Act 1935 Social Security Act 1944 Public Health Act 1945 McCarren-Ferguson Act 1946 Hill-Burton Act 1953 Establishment of the Department of Health, Education and Welfare as a cabinet-status agency; in 1980 establishment of
U.S. Department of Education as separate from Department of Health and Human Services 1956 Health Amendments Act 1964 Nurse Training Act 1965 Social Security Act amendments: Title XVIII Medicare, Title XIX Medicaid 1970 Occupational Safety and Health Act 1972 Social Security Act amendments: Professional Standards Review Organization; further benefits under Medicare and
Medicaid, including dialysis 1973 Health Maintenance Act 1974 National Health Planning Resources Act 1981, 1987, 1989, 1990
Omnibus Budget Reconciliation Acts
1982 Tax Equity and Fiscal Responsibility Act 1985 Consolidated Omnibus Budget Reconciliation Act 1988 Family Support Act 1990 Health Objectives Planning Act 1996 Health Insurance Portability and Accountability Act 1996 Welfare Act 2003 Nurse Reinvestment Act 2004 Medicare Reinvestment Act 2008 Mental Health Parity and Addictions Equity 2010 Patient Protection and Affordable Care Act
Medicare, Title XVIII Social Security Amendment (1965): This federal program, administered by the Centers for Medicare and Medicaid Services (CMS; formerly Health Care Financing Administration [HCFA]), pays specified health care services for all people 65 years of age and older who are eligible to receive Social Security benefits. People with permanent disabilities and those with end-stage renal disease are also covered. The objective of Medicare is to protect older adults and the disabled against large medical outlays. The program is funded through a payroll tax of most working citizens. Individuals or providers may submit payment requests for health care services and are paid according to Medicare regulations. See Chapter 12 for more information on Medicare.
Medicaid, Title XIX Social Security Amendment (1965): This combined federal and state program provides access to care for the poor and medically needy of all ages. Each state is allocated
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federal dollars on a matching basis (i.e., 50% of costs are paid with federal dollars). Each state has the responsibility and right to determine the services to be provided and the dollar amount allocated to the program. Basic services (e.g., ambulatory and inpatient hospital care, physical therapy, laboratory, radiography, skilled nursing, and home health care) are required to be eligible for matching federal dollars. States may choose from a wide range of optional services, including drugs, eyeglasses, intermediate care, inpatient psychiatric care, and dental care. Limits are placed on the amount and duration of service. Unlike Medicare, Medicaid provides long-term care services (e.g., nursing home and home health) and personal care services (e.g., chores and homemaking). In addition, Medicaid has eligibility criteria based on level of income. Table 10.4 provides the U.S. Department of Health and Human Services (HHS) poverty guidelines for 2013. The Medicaid population has complex needs, and managed care organizations may not always be able to provide optimum services to these beneficiaries. See Chapter 12 for more information on Medicaid.
TABLE 10.4
2013 Federal Poverty Guidelines∗ for the 48 Contiguous States and the District of Columbia
∗ Federal poverty guidelines: Typically, in January or February of each year the federal government releases an official income level for poverty called the Federal Poverty Income Guidelines, often informally referred to as the “federal poverty level.” The benefit levels of many low-income assistance programs are based on these poverty guidelines.
From Federal Register 82(19):8831–8832, 2017.
Public Health Act of 1944: The Public Health Act consolidated all existing public health legislation into one law. Since then, many new pieces of legislation have become amendments. Some of its provisions, either in the original law or in amendments, provided for or established the following:
• Health services for migratory workers • Family planning services • Health research facilities • National Institutes of Health • Nurse training acts • Traineeships for graduate students in public health • Home health services for people with Alzheimer disease • Prevention and primary care services • Rural health clinics • Communicable disease control
McCarren-Ferguson Act of 1945: The McCarren-Ferguson Act has had a major influence on the insurance industry through giving states the exclusive right to regulate health insurance plans (Knight, 1998). No federal government agency is solely responsible for monitoring insurance, as this supervision is in the hands of state governments. Some federal agencies are involved in insurance reimbursement; however, the structure of the benefit program for federal employees and military personnel, Medicare, and Medicaid allows Congress to pass laws that can override state health insurance laws if the laws do not meet certain criteria.
Hill-Burton Act of 1946: The Hill-Burton Act authorized federal assistance in the construction of hospitals and health centers with stipulations about services for the uninsured. As a result,
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hospitals with obligations to care for the uninsured were built in towns and cities across the United States. Through these measures, hospital care became more accessible, but by the late 1990s, the high cost of health care, combined with decreasing lengths of stay and increasing use of primary care, forced the closure of many of the hospitals built with Hill- Burton funds.
Health Amendments Act of 1956: The Health Amendments Act, Title II, authorizes funds to aid registered nurses (RNs) in full-time study of administration, supervision, or teaching. In 1963, the Surgeon General’s Consultant Group on Nursing noted that there were still too few nursing schools, nursing personnel were not put to good use, and there was limited nursing research. As a result, in 1964, the Nurse Training Act provided funds for loans and scholarships for full-time study for nurses and funds for construction of nursing schools. Since this time, additional legislation has funded nursing education; even the Patient Protection and Affordable Care Act of 2010 provides some funding opportunities.
Occupational Safety and Health Act of 1970: The Occupational Safety and Health Act focuses on the health needs and risks in the workplace and environment. It continues to provide critical programs important to the workplace and the community. See Chapter 30 for more information on both the Occupational Safety and Health Act and the Occupational Safety and Health Administration.
Health Maintenance Organization (HMO) Act of 1973: The HMO Act provided grants for HMO development. The act required that employers offer federally qualified HMOs as a health care coverage option to employees and established that states were responsible for the oversight of HMOs. Although initially it was not successful in stimulating HMO growth, this legislation has had a long-term effect on the growth of managed care.
National Health Planning and Resources Act of 1974: The National Health Planning and Resources Act assigned the responsibility for health planning to the states and local health systems agencies. In addition, it required health care facilities to obtain prior approval from the state for expansion in the form of a certificate of need.
Omnibus Budget Reconciliation Acts (1981, 1987, 1989, and 1990): The Omnibus Budget Reconciliation Acts were each enacted in response to the huge federal deficit. They have influenced funding for nursing homes, home health agencies, and hospitals and have set up guidelines and regulations about several issues, including a move from process to outcome evaluation, use of restraints, and prescription drugs for Medicaid recipients.
Tax Equity and Fiscal Responsibility Act of 1982: The Tax Equity and Fiscal Responsibility Act was a major amendment to the Social Security Act of 1935, establishing the prospective payment system for Medicare, the diagnosis-related group (DRG) system. This law changed health care radically by introducing a new reimbursement method. See Chapter 12 for more information on DRGs.
Consolidated Omnibus Budget Reconciliation Act of 1985: The Consolidated Omnibus Budget Reconciliation Act (COBRA) is a federal law that affects health care delivery and reimbursement. It requires all hospitals with emergency services that participate in Medicare to treat any client in their emergency services, whether or not that client is covered by Medicare or has the ability to pay. This legislation includes requirements for Medicaid services for prenatal and postnatal care to low-income women in two-parent families in which the primary spouse is unemployed. Another important requirement of COBRA focuses on the problem of the loss of health insurance when a person loses his or her job. With the growing number of unemployed, COBRA is even more important. Employers who terminate an employee must continue benefits for the employee and dependents for a specified period if the employee had health benefits before the termination. COBRA is an example of how a federal law can affect state health care practices. The federal government must determine who receives federal Medicare funds; therefore COBRA provides the opportunity for the federal government to legislate health care delivery at the state level.
Family Support Act of 1988: The Family Support Act expanded coverage for poor women and children and required states to extend Medicaid coverage for 12 months to families who have increased earnings but are no longer receiving cash assistance. This act also required states to expand Aid to Families with Dependent Children (AFDC) coverage to two-parent families in which the principal wage earner is unemployed.
Health Objectives Planning Act of 1990: The Health Objectives Planning Act was initiated in response to the 1979 report Healthy People: The Surgeon General’s Report on Health Promotion
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and Disease Prevention. After that report, the federal government began to take a directive approach in identifying and monitoring national health care goals. Healthy People 2000, Healthy People 2010, and Healthy People 2020 are also results of this act.
Health Insurance Portability and Accountability Act of 1996: The Health Insurance Portability and Accountability Act (HIPAA) addressed several issues. The law offered protections for patient privacy and confidentiality. Critical insurance issues were the portability of coverage and limits on the restrictions health plans place on coverage for preexisting conditions. This law established that insurers cannot set limits on coverage of longer than 12 months. This is a complex law, but it has been important for consumers with preexisting conditions. It should be noted that 2010 health care reform legislation has eliminated HIPAA applicability to preexisting conditions, and this change went into effect in 2014.
Welfare Reform Act of 1996: The Welfare Reform Act placed restrictions on eligibility for AFDC, Medicaid, and other federally funded welfare programs. The Welfare Reform law decreased the number of people on welfare and forced many individuals to take low-paying jobs, many of which do not offer health insurance. Between 1994 and March 1999, welfare rolls dropped 47% (DeParle, 1999). Many individuals, particularly underserved women and children, subsequently lost Medicaid coverage. In 2012 this became the Temporary Assistance for Needy Families.
The State Child Health Improvement Act (SCHIP) of 1997: This has been a critical law, providing insurance for children and families who cannot afford health insurance. This law has been very important to children’s health. The law was extended several times and then it was not renewed by the Bush administration. The program was renewed by the Obama administration in the Children’s Health Insurance Reauthorization Act of 2009. See Box 10.2 (referred to as CHIP or SCHIP if “state” is included).
Medicare Modernization Act of 2003: The Medicare Modernization Act was the most significant law in 40 years for senior health care. After being implemented in January 2006, the law provided seniors and people living with disabilities some prescription drug benefit coverage, more choices, and better benefits.
Nurse Reinvestment Act of 2003: The Nurse Reinvestment Act is significant because it is a response to the critical nursing shortage that has been present across the country. Funding is provided to increase enrollments and the number of practicing nurses.
Mental Health Parity and Addictions Equity Act of 2008: A similar act was passed in the 1990s, but it was not an effective law. Improving the earlier law, this act mandates that if a group health plan includes medical/surgical benefits and mental health benefits and/or substance use disorder benefits, the financial requirements (e.g., deductibles and copayments) and treatment limitations (e.g., number of visits or days of coverage) that apply to mental health benefits must be no more restrictive than the predominant financial requirements or treatment limitations that apply to substantially all medical/surgical benefits.
Patient Protection and Affordable Care Act of 2010: The Patient Protection and Affordable Care Act of 2010, also called the Health Care Reform Act, is an extremely complex and comprehensive piece of legislation. One of the primary intents of the act is to reduce the number of uninsured Americans, and a number of provisions directly address this intent. For example, it requires all U.S. citizens and legal residents to have qualifying health coverage, whether provided through employers, individually purchased, or provided by federal plans (i.e., Medicare, Medicaid, CHIP). It also dramatically changes eligibility requirements for Medicaid, allowing coverage of childless adults with incomes up to 133% of the federal poverty line, and expands CHIP. Furthermore, it subsidizes premiums for lower- and middle-income families and requires coverage of dependent adult children up to age 26 for those with group policies (Kaiser Family Foundation, 2016).
The Health Care Reform Act included significant insurance changes. For example, it (1) establishes high-risk pools to provide health coverage to individuals with preexisting conditions; (2) prohibits insurers from placing lifetime limits on the dollar value of coverage; (3) prohibits insurers from disallowing coverage for some individuals because of preexisting health conditions and dropping policyholders when they get sick; and (4) requires health plans to provide some types of preventive care and screenings without consumer cost-sharing (i.e., copayments or coinsurance). The legislation creates programs to foster nonprofit, member-run health insurance companies that
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can offer health insurance; to establish state-based health insurance exchanges through which individuals and small businesses can buy coverage; and to permit states to form compacts that will allow insurers to sell policies in any participating state.
Funds for government-financed elements (i.e., Medicare, Medicaid, CHIP) are to be provided through a combination of new fees and taxes and a variety of cost-saving measures. For example, there will be taxes on indoor tanning and new Medicare taxes for people in high-income brackets. The act requires fees for pharmaceutical companies and medical devices as well as penalties for individuals who do not obtain health insurance. To cut costs, there are significant cuts to the Medicare Advantage program and modifications and reductions in Medicare spending. It also enhances efforts to reduce administrative costs, streamline care, and reduce fraud and abuse.
Until passage of the Patient Protection and Affordable Care Act of 2010, the focus of federal legislation was on either prevention of illness through influencing the environment, such as the Occupational Safety and Health Act of 1970, or provision of funding to support programs that influence health care, as demonstrated in the Social Security Act of 1935. Beginning with the Sheppard-Towner Act of 1921 and continuing to the present, federal grants have increased the involvement of state and local governments in health care. The involvement of the federal government through fiscal allocations to state and local governments provided money for programs not previously available to states and local areas. Similar services became available in all states. Funds supporting these services were accompanied by regulations that applied to all recipients. Many state and local government programs were developed on the basis of availability of federal funds. The involvement of the federal government through funding has served to standardize public health policy in the United States (Pickett and Hanlon, 1990).
The health reform legislation of 2010 was strongly influenced by the rising numbers of uninsured and underinsured U.S. citizens. Since the implementation of the ACA the rate of uninsured citizens has fallen from 16.6% in 2013 to 10% in 2016 (Kaiser, 2016). These changes do not mean that the country now has universal health care coverage. The United States continues to be the only major developed country to not have universal health care coverage. The ACA has not reduced the cost of health care as promised. Medicaid expansion has been rejected by 19 states despite the federal support. The ACA is being debated with the Trump administration, promising to repeal and replace it.
Role of State Legislatures State governments are also directly involved in health care policy, legislation, and regulation. State governments focus particularly on financing and delivery of services and oversight of insurance. The latter has become important as managed care has grown. The 1988 report titled Future of Public Health from the National Academy of Medicine (NAM), formerly called the Institute of Medicine (IOM)—noted that it is the state’s responsibility to see that functions and services necessary to address the mission of public health are in place throughout the state. The NAM framed the public health enterprise in terms of three functions: assessment, policy development, and assurance. Further the NAM reported in The Future of the Public’s Health in the 21st Century (IOM, 1988) six areas of action and change:
1. Adopting a population health approach that considers the multiple determinants of health 2. Strengthening the governmental public health infrastructure, which forms the backbone of
the public health system 3. Building a new generation of intersectoral partnerships that also draw on the perspectives
and resources of diverse communities and actively engage them in health action 4. Developing systems of accountability to assure the quality and availability of public health
services 5. Making evidence the foundation of decision making and the measure of success 6. Enhancing and facilitating communication within the public health system (e.g., among all
levels of the governmental public health infrastructure and between public health professionals and community members) (IOM, 1988)
The Centers for Disease Control and Prevention (CDC) describes the 10 essential public health services that all communities should have:
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• Monitor health status to identify and solve community health problems. • Diagnose and investigate health problems and health hazards in the community. • Inform, educate, and empower people about health issues. • Mobilize community partnerships and action to identify and solve health problems. • Develop policies and plans that support individual and community health efforts. • Enforce laws and regulations that protect health and ensure safety. • Link people to needed personal health services and assure the provision of health care
when otherwise unavailable. • Assure competent public and personal health care workforces. • Evaluate effectiveness, accessibility, and quality of personal and population-based health
services. • Research for new insights and innovative solutions to health problems.
Active Learning Exercise
Review your state’s legislative agenda. Identify bills that relate to health care, and from those bills, identify any bills that might affect community or public health. Discuss the bills in small groups— their impact in general and how nursing might be involved.
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Public Policy: Blueprint for Governance Policy is directed by values. It articulates the guiding principles of collective endeavors, establishes direction, and sets goals. It influences and, in turn, is influenced by politics. Policy directives may become realized or obstructed at any stage in the political process.
Policy Formulation: The Ideal In ideal circumstances, authorized authoritative bodies (e.g., state health departments, USDHHS, CMS) rationally determine actions to create, amend, implement, or rescind health care policy. These groups decide what is right or best and then develop the political strategies to effect the desired outcomes. Whether a particular policy is advocated or adopted depends on the degree that a group or society as a whole may benefit without harm or detriment to subgroups. Of all the seemingly endless limitless factors that may influence policy formation, group need and group demand should be the strongest determinants. The premises supporting the goals of health policy should be equitable distribution of services and the guarantee that the appropriate care is given to the right people, at the right time, and at a reasonable cost.
Policy Formulation: The Reality In the real world, policy for health care exemplifies both conflict and social change theories. Health policy is the product of continuous interactive processes in which interested professionals, citizens, institutions, industries, and other interested groups compete with one another for health care dollars and policy initiatives. They also compete with one another for the attention of various branches of government. The most obvious and prominent among these is the legislative branch, although policy is also made through regulatory mechanisms and court decisions. Health policy may also be derived from the recommendations of fact-finding commissions established by the legislative or executive branch or nongovernmental organizations such as the NAM and may also be influenced by judicial decisions.
Health policy is rarely created through discrete, momentous determinations in relation to single problems or issues. It often evolves slowly because changes in the social beliefs and values that underlie established policy develop within the context of actual service delivery. Once a direct health care service is offered, especially an official tax-funded service, discontinuing is often difficult. Existing programs create tradition by establishing vested interest and a sense of entitlement on the part of the public. An example is the annual updating of the childhood and adolescent vaccination schedule recommended by the CDC. This is also an example of cooperation between professional organizations and government agencies to promote the well-being of individuals and communities (Box 10.5).
Steps in Policy Formulation and Analysis The tangible formulation of public policy begins with the most critical step, which is defining the issue or describing the problem and placing it on the legislative agenda. This process includes cost– benefit analysis. Health policy analysis determines those who benefit and those who experience a loss as the result of a policy. These considerations are critical in order to develop health policies that are as fair as possible to all who are affected. Then legislation is finalized, typically developed by legislative staff. The bill then winds its way through the process in the legislative body at either the state or federal level. This includes a cost analysis of the bill at the federal level by the Congressional Budget Office. If the bill is passed and is signed by either a governor or the president, it becomes law. The next step is the commitment of resources, most often through the passage of legislation, and the development of regulations, which is done by a governmental agency assigned to ensure implementation of a bill that becomes law. A regulatory schedule for the implementation of the law is formulated. Then, an evaluation process is designed that satisfies regulatory and legislative remedies, should they be needed. Analysis of health policy is an objective process that identifies the sources and consequences of policy decisions in the context of the factors that influence them.
A 30-day window of opportunity is typical for public input into the development of regulations.
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Written comments about a political issue are made part of the public record. To facilitate correspondence, websites have been set up to promote contacting agencies, governmental organizations, and political figures. Nurses need to be aware of some of the important websites. furthermore, many legislators may have their own web pages so that the nurse can easily access their offices.
The Internet can provide almost unlimited access to information. However, access to information does not ensure its quality or credibility. The user is responsible for evaluating the information and separating quality information from misinformation. Nurses need to be information and communication technology literate. Technology literacy is the ability of an individual, working independently and with others, to responsibly, appropriately, and effectively use technology tools to access, manage, integrate, evaluate, create, and communicate information. Technology fluency builds on technology literacy and is demonstrated when nurses apply technology to real-world experiences, adapt to changing technologies, modify current and create new technologies, and personalize technology to meet personal needs, interests, and learning style.
BOX 10.5 Recommended Childhood and Adolescent Immunization Schedule: United States The Advisory Committee on Immunization Practices (ACIP) annually reviews the recommended childhood and adolescent immunization schedule to ensure that the schedule is current with changes in vaccine formulations and reflects revised recommendations for the use of licensed vaccines, including those newly licensed. It is the only federal government body that provides written recommendations for the routine administration of vaccines for children and adults in the civilian population. Recommendations and format of the childhood and adolescent immunization schedule for February 2017 were approved by ACIP, and the American Academy of Family Physicians. From Centers for Disease Control and Prevention: Recommended immunization schedules for persons 0–18 years—United States, 2017, Morbidity and Mortality Weekly Report, 2017, 66(5):134–135. Retrieved from http://www.cdc.gov/vaccines/schedules/hcp/index.html
Active Learning Exercise
Participate in a group organized around a public health issue (e.g., disposable diapers, toxic waste, or fluoride).
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The Effective Use of Nurses: a Policy Issue The Health Resources and Services Administration (HRSA) provides general resources and information to the public and for use in the development of policy by the government. The nursing workforce development programs administered by the HRSA through Public Health Service Act Title VIII funding provide federal support for nurse workforce development. Title VIII provides the largest source of federal funding for nursing education at the undergraduate and graduate levels and favors institutions that educate nurses for practice in rural and medically underserved communities. These programs provide loans, scholarships, traineeships, and programmatic support for nursing students and for nurses who are continuing their education in graduate programs.
An issue that is vital to effective health care delivery relates to nurse staffing. The current nursing shortage has been a topic of concern of nurses for many years and is now a health care crisis. This crisis has taken a strange course as a result of the economic crisis in the United States. Many nurses who were due to retire did not; some nurses who were working part time returned to full-time work; and some nurses who had not been employed in nursing returned to the field. These changes reduced the shortage and have also had a negative impact on new graduates obtaining positions. In addition, in some areas of the country, hospital administrators decided that as there are more new graduates, they could focus on hiring graduates with bachelor’s degrees instead of associate-degree graduates—who have therefore had more difficulty obtaining jobs. Compounding the problem is the fact that nursing colleges and universities across the nation are struggling to expand enrollment to meet the rising demand for nursing care. A shortage of nursing faculty and changing demographics contribute to the concern that all 50 states will experience a shortage of nurses in the next few years. In February 2017 Congress introduced the Title VIII Nursing Workforce Reauthorization Act of 2017, which will reauthorize and improve nursing workforce programs, supporting practice in rural and medically underserved communities, as well as providing support for advanced nursing education, diversity, National Nurse Service Corps, nurse faculty loan forgiveness, and geriatric education (ANA, 2017).
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Nurses’ Roles in Political Activities The Power of One and Many RNs are the largest health care professional group. One in 44 women voters is an RN. Why are nurses not more politically active? Taylor (2016) examined nurses’ motivation for public policy involvement. Reasons nurses become involved in health policy included becoming engaged in an issue, family history of political activity, connection with other nurses, having an influential mentor, and being part of a professional organization. More effort needs to be given to educate nurses about the importance of being informed on health policy issues and to encourage them to be politically active. Exposure to positive role models is particularly important. Nurses must obtain the tools to overcome factors that impede involvement. Nurses most often identify positive role models as the major influence that assisted them to become politically active in the profession. Professional organizations offer a connectiveness that can support the nurse in engaging in political activities. Therefore mentorship from the student level up to the expert level is important. Box 10.6 describes responses to a survey used by Winter and Lockhart (1997) about what methods were useful in developing awareness in the profession, policy, and politics.
Nurses as Change Agents The public, as well as the government, recognizes the nursing profession as indispensable, necessary, and a valuable national resource. In their advocacy role, nurses are seen as professionals whose knowledge, skills, and caring concern are used to promote both the individual’s and the community’s well-being. Nurses have a unique status in caring for patients; they are interpreters of the health care system to the public, and government-funded programs influence their professional activities. The private business sector is also involved. Therefore public health nurses must know how to participate in the political process. To do this effectively, they need a sound knowledge of the community, state, and national government organization and function and a clear understanding of how these bodies collectively interact to influence policy. Nurses must know how to influence the creation of health care legislation and how to contribute to the election and appointment of key officials.
Although there are more nurses than physicians, hospital administrators, insurance administrators, or other health care professionals, nursing traditionally has not been seen as having major political influence because of a lack of public policy consensus within the nursing community. Unity within professional organizations, coalitions, and lobbying efforts is changing this perception. Policy is fundamental to governance; therefore nurses need to know about the formation of public policy and the acts of government and its agencies. Tables 10.5 and 10.6 give sources of information on these issues.
Nurses must become invested and competent in health policy. This includes communicating with elected officials at the local, state, and federal levels. This may be done through writing letters, emails, or doing personal visits. Contacting legislators gives the nurse the opportunity to “tell their story” in how the issue affects nursing practice. In addition, belonging to a professional organization, serving on advisory boards, speaking publicly, and contributing to a PAC all engage the nurse in effecting policy change. By engaging others affected by an issue, nurses can bring voice to their concerns (Kostas-Polston et al., 2015).
BOX 10.6 Responses to Policy Activism Survey
Positive Influences and the Importance of Mentorship “I became involved in politics through a relationship with a professor who felt strongly about an issue.”
“I have found communication among peers to be informative and often inspiring. That has motivated my involvement in health care issues.”
“I became aware of the potential role nurses could play related to policy as an undergrad. I had a few dynamic professors who were very inspiring by their involvement and passion related to
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various issues. At that point I didn’t consider myself as someone to get involved but I think it ignited a spark for ‘someday’… .”
“My exposure to professors who were actually involved in different ‘causes’ and not just teaching the course made a huge difference in my perspective on getting involved. The continual role model/mentor is also a huge inspiration.”
“… .nurses who take an interest in current events and enjoy discussing their opinions regarding public policies.”
“I think if you don’t get exposed to that ‘spark’ throughout your career, it goes out. An inspiring speaker at a professional meeting will get me every time!”
“I was inspired by my professor who was past president for [the] New York State Nurses Association.”
“It would be great if one of the clinical nurse specialists at my hospital were to ask some nurses in a unit what they thought about something and how we could try to change or fix it. We just need that little nudge and some guidance to kindle that passion.” Negative Experiences Influencing Awareness “I became more aware of the policies from my institution, from preceptors, and when I had a problem. I was more aware as a novice because I was scared to do something that was going to get me into trouble.”
“I became more involved at the institutional level after being ‘wronged’ by administration in regard to a policy, procedure, or benefit.”
“I was usually unaware of a policy until it affected me directly; therefore the need to know became paramount.”
Nurses and Coalitions When two or more groups join to maximize resources, increasing their influence and improving their chances of success in achieving a common goal, they have formed a coalition. Coalitions of health care providers often work on issues such as family violence and fluoridation of water supplies. An outstanding example of such cooperative action is the establishment of rehabilitation programs for health professionals whose practice has been impaired by substance abuse or mental health problems.
Nursing and consumer groups often form coalitions to advance their shared interests in health promotion. The ANA joined 16 other organizations (e.g., American College of Nurse Practitioners, American Red Cross, Department of Veterans Affairs, and Sigma Theta Tau) in the 1990s to form a coalition called Nurses for a Healthier Tomorrow. This organization has grown to a membership of 43 organizations. Responding to concerns about a potentially dangerous shortage of nurses, this coalition hopes to raise funds for a national advertising campaign designed to recruit new nurses and encourage existing ones to remain in the profession. The campaign focuses on the message that nurses are essential to the health care team and that they save health care dollars. The campaign shows that an increased demand exists for nurses, both in specialty areas and outside the hospital (NHT, 2014).
Nurses as Lobbyists A lobbyist is a person who, voluntarily or for a fee, represents himself or herself, another individual, an organization, or an entity before the legislature. A lobbyist typically represents special-interest groups. The term derives from the fact that lobbyists usually stay in the areas (lobbies) next to the Senate and House chambers, seeking to speak with legislators and their aides as they walk to and from the chambers, or as lobbyists await legislative action that might affect their interests.
To lobby is to try to influence legislators; it is an art of persuasion. Influencing lawmakers to pass effective health legislation requires the participation of individual nurses and nursing organizations. There are currently more than 100 national nursing organizations. Many also have state chapters. Professional organizations make advocacy easier for members through the use of the Internet. Policy action centers are now part of many organizations’ websites. Email alerts can be sent instantly to members residing in targeted districts to contact their legislators on a particular bill or issue. By entering one’s postal zip code and pushing a button, one can sign a template letter and
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send it to one’s legislator. The goal of the first contact with an official is to establish that the nurse is a concerned constituent
as well as a credible source of information on health issues. The image of nurses caring for people is a definite advantage at this point. Nurses are considered the most ethical of all health care providers and are considered to be trustworthy (Robert Wood Johnson Foundation, 2012). In communities in which nurses have already established strong political credentials, their colleagues will be more readily accepted. An individual who establishes a reputation as a reliable and accurate resource as a lobbyist has substantial influence.
Legislators rely heavily on lobbyists to educate them on issues, and they usually want to hear from all sides before taking a position on an issue. The official must trust the lobbyists to give accurate, though predictably biased, information. Information needs to be timely and up to date.
Each official represents a constituency with varied needs and interests, and each vote must be weighted within this context. The positions taken by legislators will not always be to an individual or organization’s liking. Evaluation of their performance should be based on their overall voting pattern, not just on individual votes. Many organizations regularly tally and publish the records of each federal legislator on all issues related to nursing and health. This information can be helpful in evaluating elected officials. Collective action by nursing and health care organizations is critical to meeting their goals. Professional associations monitor legislative activity related to relevant health issues and link the process to their membership. This continual surveillance of the legislative environment is critical because even seemingly minor amendments can have profound effects on health issues. Thorough legislative surveillance requires the participation of people who are knowledgeable about nursing, health care, and the political intricacies of the legislative process. Some of the nursing organizations that have full-time lobbyists who work in Congress are the ANA, the American Academy of Nursing, and the National League for Nursing. State associations also work with state legislators. State legislative contacts become the eyes, ears, and voices of their professional organizations. These associations can then provide testimony and comment on relevant state and federal issues. However, regardless of the effectiveness of association lobbyists in promoting the interests of nurses and society, they always need grassroots cooperation to truly influence decisions. In the final analysis, a sufficiently high number of communications from individual constituents, via email messages, telephone calls, and letters, has the greatest influence. Lobbying is an ongoing activity for health policy issues influencing nursing and health care delivery. Box 10.7 provides an overview of the lobbying process.
TABLE 10.5
Sources for Legislative Information
Government Level Information Available Location
Federal Background of members of Congress Congressional committee assignments Congressional terms of service Congressional news House/Senate vote tabulations Bills in process or legislated (bill number needed)
Congressional Directory Government documents section of selected public or university libraries Congressional Quarterly Weekly Report U.S. representative or senator (may have local office)
Health and nursing issues in Congress The American Nurse ANA 600 Maryland Ave SW Suite 100 Washington, DC 20024 (202) 554-4444
American Nurses Association Political Action Committee (ANA-PAC)
The American Nurse ANA (see above)
Public health issues in U.S. Congress The Nation’s Health American Public Health Association (APHA) 1015 15th St NW Washington, DC 20005 (202) 789-5600
State Bills in process or legislated (bill number needed)
State representative or senator (may have local office)
Health and nursing issues in state legislature State political action committees for nursing
State nurses association (SNA) (for location, see April directory issue of the American Journal of Nursing) National League for Nursing
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TABLE 10.6
Sources For Electoral Information
Government Level Information Available Location State State government operations
Political subdivisions Legislative information telephone number State election laws and procedures Campaign finance reports
Secretary of State (state capitol) Office of Lieutenant Governor (state capitol)
County or municipal Similar to state as appropriate to local government Political jurisdictions for each household address
County clerk (county courthouse) City clerk (city hall)
General Government information Political jurisdictions for each household address Names of current office holders in local jurisdictions
County clerk (county courthouse) City clerk (city hall)
Active Learning Exercise
1. With a group of two or three, meet with an elected official for a 15-minute appointment to ask about the official’s concerns and priorities. Remember to refer to the “ABCs of Lobbying” prior to meeting with the official.
2. Visit the American Nurses Association website and explore its political action section at http://nursingworld.org/MainMenuCategories/Policy-Advocacy. What type of information is available?
3. Visit the American Public Health Association website for information about policy outcome evaluation at https://www.apha.org/policies-and-advocacy. Review the various evaluation programs to gain an understanding of policy outcome evaluation.
Nurses and Political Action Committees PACs have been important sources of collective political influence since the 1970s. These nonpartisan entities promote the election of candidates believed to be sympathetic to their interests. PACs are established by professional associations, businesses, and labor organizations and are highly regulated by federal and state laws that stipulate how they may contribute financially to campaigns. The advantage of a PAC is that small donations from many members add up to a significant donation to a campaign fund in the name of the organization. This gains the attention of the candidate and earns goodwill for the group.
BOX 10.7 ABCs of Lobbying on a State Level
Before the Meeting
• Appointments will have been made with your legislator(s) for the lobby cay. Tell the staff that you are a constituent and what issue(s) you would like to discuss with your representative. If your legislator is unavailable, you may have a scheduled appointment with a member of the legislative staff.
• If possible, put together a delegation of nurses to attend the meeting. A number of individuals from the legislator’s district who are concerned about the same issue will make a big impression. Take along students from their districts because legislators are impressed with their participation.
Preparing for the Meeting
• Establish your agenda and goals. For example, focus on educating the legislators on the profession of nurse midwifery, the legislation that this group would like them to sponsor, the concerns about the malpractice insurance crisis, and the benefit to women’s and children’s
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health. Nurse practitioners (NPs) would focus on the cost–benefit of NPs as primary care providers in all settings, including health care homes.
• Research your legislator’s stance before the meeting. It is important that you know your official’s position so that you can present your stance more effectively and can have an intelligent discussion.
• Meet with the delegation (e.g., midwives, NPs) that will participate in the lobbying. It is important that you review what each person will say during the meeting. Select someone as the group leader, and make a list of points to be made and questions to be asked by each person.
• Prepare materials. Review the packet of information you will leave with your legislator. It is important to include your name and phone number in the packet so that your legislator will have a contact person for more information. Leaving a business card would be appropriate.
During the Meeting
• Be on time for your meeting. • Be concise and diplomatic. Keep your presentation short and to the point. • Be a good listener. Look for indications of your legislator’s views, and watch for opportunities
to provide useful information in order to strengthen or counter particular views. • Stress why the issues concern you and others in your district. • Don’t be intimidated. Your legislator is in office to serve you. It is important to have a general
knowledge of the issues, but you don’t have to know every little detail. If he or she asks a question that you do not know the answer to, simply say that you do not know but are willing to find out. Find out the best way to get the information to him or her (fax, email, or a follow- up phone call).
After the Meeting
• Write a follow-up letter. After your visit, write a letter thanking your legislator for his or her time.
• Stay in contact with your legislator. Remember: Your goal is to strengthen advanced practice nurse relationships with your legislators.
Modified from New York State Association of Licensed Midwives (NYSALM). The Voice of Midwives letter.
Valid concern exists about the correlation of major PAC contributions and legislators’ votes on special-interest legislation. However, as long as PACs are a reality of political life, nurses need to recognize their power and support those that are committed to electing candidates sympathetic to health care issues.
Most national associations of health care providers, including nursing organizations, have PACs. Among the more powerful are those representing hospitals, nursing homes, health insurers, home health agencies, and pharmaceutical companies. A PAC that makes major political contributions is the American Medical Political Action Committee, sponsored by the American Medical Association. State medical associations also have strong PACs. This means that organized medicine has a powerful influence on national and state elections and on health care legislation at both levels.
Nurses and Campaigning Helping someone win an election is a sure way of gaining influence. All candidates are grateful for campaign assistance and usually remember to thank those who have helped. Although campaign contributions are commonly thought of as financial, they can also take the form of participation in campaign activities. Nurses are frequently unable to contribute much money, but they can provide these invaluable services. For the novice, veteran campaigners are eager to help develop the
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necessary skills. Initially, a volunteer can address or stuff envelopes for mailings. The volunteer can also invite friends and neighbors for a social gathering to meet the candidate, thereby providing an opportunity to discuss issues of concern with constituents. Telephone banks help a candidate identify supporters, opponents, and the critical undecided voters. This last group can make a difference on Election Day and is courted by all candidates. The telephone interviews are highly structured and easily handled by inexperienced campaign workers. Direct contact with potential voters may occur later in the form of house-to-house block walks or poll work on Election Day. The confidence that this process requires comes with experience and a strong commitment to the candidate and the cause. Hosting a social function to allow nurse colleagues to meet the candidate is a welcome contribution to the campaign. Nurses are substantial in number, and their voting record is humanistic; therefore they are valued as a political force. Government employees may be restricted by policies that limit or disallow political activism. Nurses employed at any level of government should be aware of such prohibitions.
Nurses and Voting Strength With over 4 million members, nurses make up the largest profession in health care (Kaiser, 2016). Therefore if every RN voted, their influence on health policy would be tremendous. If the nursing profession is to meet the challenges of the twenty-first century and work as a profession to positively influence the health of populations, political action is necessary, and an understanding of the factors that motivate or impede political action is needed (Winter and Lockhart, 1997).
Nurses in Public Office President Donald Trump named Sylvia Trent-Adams, PhD, RN, on April 20, 2017, as acting surgeon general. Sylvia Trent-Adams is the first nurse to hold the position. The Office of the Surgeon General is within the Office of the Assistant Secretary for Health and is responsible for the Commissioned Corps. In addition, the surgeon general is an advisor on public health and scientific issues. The surgeon general also is a spokesperson for certain focused public health issues.
Other women who have been active in the federal government are Carolyn Davis, who in 2001 served as the administrator of the Health Care Financing Administration (renamed the CMS); Shirley Chater, commissioner of the SSA; and Patricia Montoya, commissioner for Children, Youth, and Families. Virginia Trotter Betts, who served as the president of the ANA, was also the senior advisor on nursing and policy to the secretary of HHS in Washington, DC.
Likewise, Dr. Beverly Malone resigned as president of the ANA in 1999 to assume the position of deputy assistant secretary of the HHS. In this capacity, she advised the assistant secretary for the HHS, Dr. David Satcher, in program and political matters, policy and program development, and setting of legislative priorities. Lastly, Janet Heinrich is associate administrator of the HRSA’s Bureau of Health Professionals, and Michele Richardson is the senior advisor for national workforce diversity in the Bureau of Health Professions (NLN, 2010).
In the 114th Congress, the number of nurses serving was three. This is a major achievement for nursing. It provides a direct voice for nursing concerns and nursing expertise–related health care in general. The Congressional Nursing Caucus provides a nonpartisan forum for the discussion of issues that affect the nursing profession. It also allows members of Congress, nurses, and nonnurse members who care about these issues to come together to address them.
In the future, more nurses need to run for public office at all three levels of government. Whether serving as political appointees or career bureaucrats, nurses have much to offer. New nurses should accept the challenge of helping advance the nursing practice and the nation’s health.
Active Learning Exercise
1. Serve as a volunteer in a campaign for a candidate who is supportive or potentially supportive of public health or nursing issues, or volunteer for a political party.
2. Invite an elected official who is sympathetic to nurses to speak to the local chapter of the National Student Nurses Association to discuss the political process and health policy.
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3. Invite an elected official to spend a day engaging in appropriate activities with a public health nurse or nursing student. Take black-and-white photos for press use.
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Health Care Reform and Restructuring of the Health Care Industry Health care reform was a major topic of discussion during the 2016 presidential election. With the election of President Trump and significant Republican majorities in both the Senate and the House, it appears that health care reform will continue to be a headline. After the failed attempt at comprehensive reform during the early years of the Clinton presidency, politicians recognized some of the major concerns and issues and addressed them proactively. For example, strong opposition from many health care provider groups (e.g., physicians) and health care industry groups (e.g., insurers, pharmaceutical companies, hospitals) led to failure of the Clinton plan. In 2009, congressional leaders early on sought ways to attract leaders of these groups and persuade them to support reform measures, although passage of health care reform was not easy and there continues to be variable support for the initiatives in the legislation.
A great deal of debate on what should be included in reform was evident throughout 2009. Major items of contention included whether to require all Americans to purchase coverage (i.e., a health insurance mandate), whether there would be a “government option” whereby people could elect to be covered by an extension of Medicare (or another similar program sponsored and funded by the government), whether government funds would pay for abortions, and how all of the changes and mandates would eventually be financed. After much public and private debate, in March 2010, the House of Representatives rather reluctantly passed the bill that the Senate had approved in late 2009, and President Obama signed it into law on March 23, 2010.
Although the 2010 Patient Protection and Affordable Care Act remains extremely controversial, health care reform is a nursing issue, and few nurses will argue with the statement that reform is needed in the health system in the United States. In virtually every practice arena, nurses see the inequalities and inadequacies that diminish the nation’s level of wellness. Recognition of these problems is important to discussions of reform, and changing policies and targeting popular beliefs that create barriers to reform are essential in correcting the inequalities and inadequacies.
These are some of the areas targeted by the Health Care Reform Act. For example, insurers will no longer be able to drop coverage for those who are seriously ill because the act prohibits health insurance plans from placing lifetime limits on coverage and prohibits insurers from rescinding coverage for those who are diagnosed with chronic or life-threatening conditions. Additionally, mechanisms to reduce administrative costs are encouraged (Kaiser Family Foundation, 2016).
Popular sentiments about governmental control over health care have mirrored attitudes concerning the government’s role in general; this was very evident during the debates over reform. The politically viable range of cost-control measures available to public programs has been limited to cutbacks in payments to providers rather than limits on the demand for clinical services or limits on individual choice
At the same time the United States is implementing health care reform, the country is also coping with the health problems of today’s military veterans. When these soldiers are discharged, they continue to require care, often for complex physical and mental issues. According to the Kaiser Family Foundation (2016):
Given the growing need for providing health care and related benefits to the nation’s service members, policymakers will continue to focus on strengthening both the Department of Defense [DoD] Military Health System and the Department of Veterans Affairs (VA) health care system, which operate in parallel and in conjunction with each other. There is also greater emphasis in policy circles on ensuring a “seamless transition” process for service members moving from active duty into the VA health care system. Areas of focused attention include coordination between health and other benefits offered by the DoD and the VA, improving care for injured service members, and easing the transition from combat service to other military or civilian life.
Nurses encounter veterans in all types of community and public health settings. Knowledge about these problems and health policies changes is important to providing effective care in the community.
On December 4, 2016, the Department of Veterans Affairs published a final ruling giving veterans
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direct access to care by nurse practitioners, certified nurse midwives, and clinical nurse specialists. Through this ruling these advanced practice RNs are able to have full practice authority when practicing at VA health care centers across the country.
Research Highlights
National Sample of Registered Nurses The Division of Nursing, a component of the HRSA, helps direct policy through the National Sample Survey of Registered Nurses. Conducted nine times since 1977, this survey was done most recently in March 2008, and preliminary findings were released in 2010. The national survey looks at trends in demographics, employment, education, and compensation among RNs. Here are some of the findings:
• Number of licensed RNs in the United States grew by almost 5.3% between 2004 and 2008, to a new high of slightly more than 3 million.
• Average age of RNs climbed to 47 years, the highest average age since the first comparable report was published in 1980.
• Average annual earning for RNs was $66,973. • Real earnings (comparable dollars over time) have grown almost 16% since 2004. • The share of RNs whose initial nursing education was a bachelor’s degree in nursing rose
from 31% to 33.7% between 2004 and 2008. • Employment in nursing rose to almost 85% of RNs with active licenses, the highest since 1980. • The number of RNs with master’s or doctorate degrees rose to more than 400,000, an increase
of 32% from 2000.
Data from Health Resources and Services Administration: The registered nurse population: Initial findings from the 2008 national sample survey of registered nurses, Washington, DC, 2010, Author.
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Nurses and Leadership in Health Policy Development As the role of nurses in changing health care policy increases in importance, more nurses are needed who are equipped for this challenge. A strong cadre of nursing leaders who have the vision for change is essential to promoting nursing’s policy agenda. National fellowships and internships are available for nurses who are interested in taking leadership roles
The Robert Wood Johnson Health Policy Fellowship is a 1-year career development program for midcareer health professionals. The goal of this program is to help its fellows gain an understanding of the health policy process and contribute to the formulation of new policies and programs. Robert Wood Johnson Health Policy fellows are selected from academic faculties from diverse disciplines, including medicine, dentistry, nursing, public health, health services administration, economics, and social services. After an extensive orientation on the legislative and executive branches of government, the fellows work with a member of Congress or on a congressional health committee.
The President’s Commission on White House Fellowships offers 20 fellowships each year to professionals, including nurses, early in their careers; the average age of participants is 33 years. The White House fellows participate in an education program that involves working with government officials, scholars, journalists, and private-sector leaders to explore U.S. policy in action. Nurses who have been White House fellows may work at the CMS and the Office of Science and Technology Policy, among others (White House, n.d.). These fellowship programs are competitive, but strong leaders are desperately needed.
Nursing should also incorporate private health policy into its policy agenda. Nurses can influence private health care organizations from internal and external positions. From an internal perspective, nurses hold important management positions in health care organizations. This placement allows them to have direct involvement in policy setting. Nurses also support and use nursing research that demonstrates positive clinical and economic outcomes. All of these activities serve to validate the importance of nursing within the health system (Pulcini et al., 2000).
External strategies that nurses can use to influence private health policy include participation in discussions regarding quality care and cost of care (Pulcini et al., 2000). Nurses should monitor the quality ratings of health care organizations and suggest changes that would improve care. Nurses also are developing entrepreneurial practices to provide lower-cost services for underserved groups. Nurses need to do more to request that nursing services be reimbursable under all types of health care coverage plans and programs. Interprofessional care is a key topic today, and nurses need to work with other health care providers to build teams that can influence private policy.
Active Learning Exercise
Look at a current public health issue that affects your community, including an understanding of the causes, effect on the public, and possible solutions. Influence its resolution through any of the following activities:
1. Write a succinct letter to the editor of a local newspaper. 2. Write a position paper and submit it to the “opinion page” of a local newspaper. 3. Write to elected or appointed officials whose jurisdiction may be influential on the issue. 4. Meet with an elected or appointed official to discuss the issue in groups of two or three.
Write a one-page summary of your “talking points” to leave with the official. 5. Call in to a radio talk show about the issue. 6. Volunteer to speak on the issue to appropriate consumer or professional groups.
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Summary Historically, nurses have been able to make significant differences in the quality of life experienced by the members of the communities in which they serve. By understanding how government works, how bills become laws, and how legislators make decisions, nurses can influence policy decisions through individual efforts such as electronic letter writing, social networking, participation in political campaigns, and selection of candidates who support policies conducive to improving the health and welfare of all citizens. When organized in lobbying groups, coalitions, and PACs, or when holding office, nurses can be a powerful force that brings about change in the delivery and quality of the health care of aggregates.
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Evolve Website http://evolve.elsevier.com/Nies/community
• NCLEX Review Questions • Case Studies
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Advocacy. www.nursingworld.org/Function/ menucategory/aboutANA.aspx. Centers for Disease Control and Prevention. Ten essential services for public health. 2015 Retrieved
from. https://www.cdc.gov/stltpublichealth/hop/pdfs/Ten_Essential_Public_Health_Services_2011- 09_508.pdf.
DeParle J. States struggle to use windfall born of shifts in welfare law. New York Times; August 29, 1999. Hall-Long B.A. Nursing’s past, present, and future political experiences. Nurs Health Care
Perspect. 1995;16(1):24–28. Health Resources and Services Administration: The registered nurse population: initial findings from the
national 2008 sample survey of registered nurses. Washington, DC, HRSA. Henry J, Kaiser Family Foundation: Military and veterans’ health care,
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Institute of Medicine. Future of public health. Washington, DC: The National Academies Press; 1988. Kaiser Family Foundation. 2016 From. <http://kff.org/>. Kalisch P.A, Kalisch B.J. American nursing: a history. ed 4. Philadelphia: Lippincott Williams &
Wilkins; 2004. Knight W. Managed care: what it is and how it works. Gaithersburg, MD: Aspen Publishers, Inc; 1998. Kostas-Polston E, Thanavaro J, Arvidson C.R, Taub L.F.M. Advanced practice nursing: shaping
health through policy. J Am Assoc Nurse Pract. 2015;27(1):11–20. Lewinson S.B. A historical perspective on policy, politics and
nursing. In: Mason D.J, Leavitt J.K, Chaffee M.W, eds. Policy and politics in nursing and health care. ed 7. Philadelphia: Saunders; 2007.
Litman T: Health, politics and policy, ed 5, Albany, NY, Delmar. Lyttle B. Humanizing childbirth. Am J Nurs. 2000;100(10):52–53. Mason D.J, Leavitt J.K, Chaffee M.W. Policy and politics: a framework for action. In: Policy and
politics in nursing and health care. St. Louis: Saunders; 2007. Merriam-Webster. Merriam-Webster Dictionary. 2014 Retrieved from. http://www.merriam-
webster.com/dictionary/policy. National League for Nursing. 2010. http://www.nln.org/newsletter/aug092010.htm. Nurses for a Healthier
Tomorrow. Mission/purpose. 2014. http://www.nursesource.org/mission.html. Pickett G, Hanlon J.J. Public health administration and practice. ed 9. St. Louis: Mosby; 1990. Pulcini J, Mason D.J, Cohen S.S, et al. Health policy and the private sector: new vistas for
nursing. Nurs Health Care Perspect. 2000;21(1):22–28. Robert Wood Johnson. Enduring trust: nurses again top Gallup’s poll on honesty and ethics 2012.
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Taylor M. Impact of advocacy initiatives on nurses’ motivation to sustain momentum in public policy advocacy. J Prof Nurs. 2016;32(3):235–245.
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DC, USDHHS. U.S. Department of Health and Human Services. Centers for Medicare and Medicaid Services: FY
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in-brief/index.html. U.S. Department of Health and Human Services: Office of Disease Prevention and Health
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∗ The author would like to acknowledge the contributions of Anita Finkelman, who wrote this chapter for the previous edition.
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11
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The Health Care System Melanie McEwen, and Marie E. McBee
OUTLINE
Overview: The Health Care System Components of the Health Care System
Private Health Care Subsystem Public Health Subsystem Health Care Providers
Critical Issues in Health Care Delivery Quality Care Accreditation Managed Care Information Technology Consumerism and Patient Rights Coordination and Access to Health Care Disparity in Health Care Delivery
Future of Public Health and the Health Care System
OBJECTIVES
Upon completion of this chapter, the reader will be able to do the following: 1. Describe the organization of the public health care subsystem at the federal, state, and local
levels. 2. Compare and contrast the scopes of the private health care subsystem and the public health
care subsystem. 3. Describe the roles of the members of the interprofessional health care team. 4. Discuss the relationship of critical health care issues to the health care organization and health
care providers. 5. Discuss future concerns for the health care delivery system.
KEY TERMS accreditation Agency for Healthcare Research and Quality (AHRQ) client rights community health center
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complementary and alternative therapies electronic health record/electronic medical record health disparities Health Plan Effectiveness Stat Information Set (HEDIS) managed care managed care organizations Medicaid Medicare National Committee for Quality Assurance (NCQA) outcomes measures Patient Protection and Affordable Care Act (ACA) patient rights patient-centered medical homes public health quality care telehealth The Joint Commission voluntary agencies
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Overview: The Health Care System The health care system of the United States is dynamic, multifaceted, and not comparable with any other health care system in the world. It is regularly praised for its technological breakthroughs, frequently criticized for its high costs, continues to experience major problems with its quality, and often is difficult to access for those most in need. This chapter describes the major components of the health care system, critical health care organization and provider issues, and the role of government in public health and health care reform and presents a futuristic perspective.
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Components of the Health Care System The current health care system consists of private and public health care subsystems (Fig. 11.1). The private health care subsystem includes personal care services from various sources, both nonprofit and profit, and numerous voluntary agencies. The major focus of the public health subsystem is prevention of disease and illness. These subsystems are not always mutually exclusive, and their functions sometimes overlap.
With the rapid growth of technology and increased demands on the private and public health care subsystems, health care costs have become prohibitive. Cost-effectiveness and cost containment have become critical driving forces as health care delivery system changes are made; however, cost-effectiveness often conflicts with the provision of quality care. Additionally, considerable attention to “health care reform” and subsequent passage of the Patient Protection and Affordable Care Act (ACA) in 2010 have demonstrated the critical importance of access to health care for all Americans, but the enormous challenges that accompany that desire remain. There continues to be a need to apply the vast resources and tools available and to focus science and information technology in a way that will improve effectiveness and efficiency and produce high- quality health care (IOM, 2012a).
FIG. 11.1 U.S. health care system.
Public health nursing requires an understanding of the mission, organization, and role of both the private and the public health care subsystems and the contexts within which they function to effectively collaborate with health care providers and organizations to reach health goals. An organizational framework in which private and voluntary organizations and the government work collaboratively to prevent disease and promote health is essential. Public health nurses are in a unique position to provide leadership and facilitate change in the health care system that will help improve health and safety for all.
Private Health Care Subsystem Most personal health care services are provided in the private sector. Services in the private subsystem include health promotion, prevention and early detection of disease, diagnosis and treatment of disease with a focus on cure, rehabilitative-restorative care, and custodial care. These services are provided in clinics, physicians’ offices, hospitals, hospital ambulatory centers, skilled care facilities, and homes. Increasingly, these private-sector services are available through managed care organizations (MCOs).
Private health care services in the United States began with a simple model. Physicians provided care in their offices and made home visits. Patients were admitted to hospitals for general care if they experienced serious complications during the course of their illness. Currently, a variety of highly skilled health care professionals provide comprehensive, preventive, restorative, rehabilitative, and palliative care. Interprofessional teams have become more important. A broad array of services is available, ranging from general to highly specialized, with multiple delivery configurations.
Personal care provided by physicians and other health care professionals is delivered under the following five basic models:
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1. The solo practice of a physician in an office continues to be present in many communities. 2. The single-specialty group model consists of physicians in the same specialty who pool
expenses, income, and offices. 3. Multispecialty group practice provides for interaction among specialty areas. 4. The integrated health maintenance model has prepaid multispecialty physicians. 5. The community health center, developed through federal funds in the 1960s, addresses
broader inputs into health such as education and housing.
Managed care has become a dominant paradigm in health care, affecting many aspects of health care delivery. Managed care involves capitated payments for care rather than fee-for-service. Health care providers, including physicians, hospitals, community clinics, and home care providers, are integrated in a system such as a health maintenance organization. See Chapter 12 for a more detailed discussion of managed care and reimbursement.
Though change in the configuration of the health care system is common, some of the newer changes relate more to the community than in the past. For example, more physician practices are joining together to form multispecialty groups, and hospitals are buying practices to expand their market into the community. The solo practice is fading. In addition, there are more advanced nurse practitioners (ANPs) and physician’s assistants (PAs) who are assuming primary practice roles in a variety of settings, including community clinics, retail health clinics, and home health, and many who are opening their own practices. Patient-centered medical homes are practices that offer a team approach to assist in coordination of care for positive outcomes, providing comprehensive primary care. This model, which is connected to health care reform, is relatively new, and thus its long-term success is unknown. As health care reform legislation continues to be debated and modified, additional changes will likely occur.
Voluntary Agencies Voluntary or nonofficial agencies refer to the nongovernmental, nonprofit entities that support health care provision and sometimes direct health services. Voluntary agencies are a part of the private health care system that developed in the United States at about the same time that the government was assuming responsibility for public health. During the 1700s and early 1800s, voluntary efforts to improve health were virtually nonexistent, because early settlers from Western Europe were not accustomed to participating in organized charity. Immigration expanded to include slaves from Africa and people from Eastern Europe, and their well-being received little attention.
Toward the end of the nineteenth century, new immigrants brought a heritage of social protest and reform. Wealthy businesspeople, such as the Rockefellers, Carnegies, and Mellons, responded to the needs of the poor and set up foundations that provided funds for charitable endeavors, including health. District nurses, such as Lillian Wald, established nursing practices in the large cities for the poor and destitute. These services were not exclusively focused on illness, but also on work conditions, health, communicable diseases, living conditions, and language skills. Voluntary initiatives from philanthropically focused families remain an important resource even into the twenty-first century. An example is the Gates Foundation, which is very active in health care concerns, particularly from a global perspective.
Voluntary agencies can be classified into those dealing with the following categories of health (Hanlon and Pickett, 1990):
a. Specific diseases, such as the American Diabetes Association, American Cancer Society, and National Multiple Sclerosis Society
b. Organ or body structures, such as the National Kidney Foundation and the American Heart Association
c. Health and welfare of special groups, such as the National Council on Aging and the March of Dimes
d. Particular phases of health, such as the Planned Parenthood Federation of America
Philanthropic groups also support research and programs. Many professional organizations, such as the American Medical Association, the American Nurses Association, the American Hospital Association, and the American Public Health Association, as well as many other professional
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organizations, have a significant role in advocacy and in providing professional expertise. Voluntary organizations are major sources of help in the prevention of disease, promotion of
health, treatment of illness, advocacy, consumer education, and research. For example, private and voluntary organizations currently support clients with human immunodeficiency virus (HIV). In many cities, the Chicken Soup Brigade provides meals for clients with HIV who are unable to cook for themselves, and HIV support groups exist in most larger communities. Services for the homeless such as meals, temporary housing and housing during the winter, medical care, and job support are common in most large cities. Overlap of services often occurs among the numerous private, voluntary, and public agencies. The private and public agencies provide a wide array of services, but sometimes duplication causes them to not be cost effective.
Voluntary agencies and organizations play a very important role in health care delivery. Indeed, it is anticipated that the emerging health care system will become an amalgam of different public and private forces that will work together to provide integrated, resource-conscious, population- based services. Further, the system needs to become more innovative and diverse in how it responds to health problems and more concerned with disease prevention and promotion of health in order to address the very significant disparities in health care (AHRQ, 2015).
Active Learning
Identify a voluntary agency or organization and review its website. What services does it offer? How does the agency collaborate with other groups and organizations? How is the agency/organization funded? How does it interface with the local public health agency? What information is available to consumers and professionals? With classmates, set up a site visit.
Public Health Subsystem Although not explicitly addressing health or health care, the U.S. Constitution mandates that the federal government “promote the general welfare of its citizens.” The public health subsystem therefore is required by law to address the health of populations by promoting their “general welfare.” Legal provisions at the local, state, and federal levels of government direct the establishment, implementation, and evaluation of these activities. At the federal level, Congress enacts laws and writes rules and regulations. The various departments of the executive branch implement and administer them. Interpretations of, and amendments to, the Constitution, as well as Supreme Court decisions over time, have changed and enlarged the role of the federal government in health activities.
Federal policies and practices have had a significant influence on local and state governments in meeting health and social problems, and many laws have been enacted to respond to changing health needs and concerns. Coordination of federal services under several agencies culminated in the establishment of the Department of Health, Education, and Welfare under President Eisenhower in 1953. In 1979, this department was separated into the Department of Education and the Department of Health and Human Services (HHS). Currently, HHS is the second largest department of the federal government; only the Department of Defense is larger.
Public health refers to the efforts organized by society to protect, promote, and restore the people’s health. Public health programs, services, and institutions emphasize the prevention of disease and address the health needs of the population as a whole. Public health activities typically respond to changing technology and social values, but the goals remain the same (i.e., to reduce the amount of disease, premature death, and disease-produced discomfort and disability).
The public health subsystem is concerned with the health of the population and a healthy environment. The scope of public health is broad and encompasses activities that promote good health. The public health subsystem is organized into multiple levels (i.e., federal, state, and local) to establish laws, rules, and regulations to protect the public and to more effectively provide services to those who are unable to obtain health care without assistance. Fig. 11.2 provides an overview of this system, specifically for the state of Ohio, although the basic organization will be similar across states.
Federal-Level Subsystem
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Most health-related activities at the federal level are implemented and administered by the HHS, which consists of 11 major agencies (Box 11.1). This department is divided into 10 regions and is directed by the secretary of Health and Human Services. The secretary is assisted by numerous undersecretaries and assistant secretaries (USDHHS, 2017). The surgeon general is the principal deputy to the assistant secretary of HHS. In spring 2017, Rear Admiral Sylvia Trent-Adams became one of the first nurses to serve as “acting” surgeon general in a role she held for several months; she is currently a deputy surgeon general..
FIG. 11.2 The public health system in Ohio. From Health Policy Institute of Ohio: Ohio public health basics, 2012, p. 4. Retrieved from
http://www.healthpolicyohio.org/wp-content/uploads/2014/01/publichealthbasics_final012520131.pdf
In addition to HHS, many federal agencies perform activities related to health. For example, the Department of Education is involved with health education and school health. The Department of Agriculture administers the inspection of meat and milk and provides funds for the Women, Infants, and Children program (supplemental nutrition), the food stamp program, and the school- based nutrition program. Other federal agencies of interest to public health nurses are the U.S. Environmental Protection Agency, the Occupational Safety and Health Administration, the Veterans Administration, and the Federal Emergency Management Agency.
The scope of health services of the federal-level subsystem targets the following major health areas: the general population, special populations, and international health. For the general population, federal activities include protection against hazards, maintenance of vital and health statistics, advancement of scientific knowledge through research, and provision of disaster relief. In recent years, public health efforts have been directed toward changing behaviors by fostering healthy eating habits, encouraging exercise, and preventing or reducing tobacco, drug, and alcohol use. Other programs have provided nutritional food and food stamps to individuals and families to ensure adequate food intake.
Services for special populations include protection of workers against hazardous occupations and work conditions and health care for military veterans, Native Americans, Alaska natives, federal prisoners, and members of the armed services. In addition, the federal government provides special
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services for children, older adults, the mentally ill, and the vocationally handicapped. In the international arena, the federal government works with other countries and international
health organizations such as the World Health Organization and the Red Cross. These entities combine efforts to monitor health and diseases and to promote various health programs throughout the world.
BOX 11.1 Structure of the U.S. Department of Health and Human Services The USDHHS is composed of many agencies that provide different services related to U.S. health care. Among them are the following:
• The Administration for Community Living combines the Administration on Aging—the agency responsible for coordinating home- and community-based services for older persons and their caregivers—and the Office on Disability and the Administration on Developmental Disabilities in a single agency, with enhanced policy and program support for cross-cutting initiatives to serve these populations.
• The Centers for Medicare and Medicaid Services administers Medicare and Medicaid programs.
• The Administration for Children and Families provides family assistance (welfare), child support, Head Start, and other programs to strengthen the family unit.
• The Centers for Disease Control and Prevention (CDC) conducts and supports programs directed at preventing and controlling infectious diseases; they assist states during epidemics. In addition, they provide services related to health promotion and education and professional development and training. The CDC includes the Agency for Toxic Substances and Disease Registry, which serves the public by using the best science, taking responsive public health actions, and providing trusted health information to prevent harmful exposures and diseases related to toxic substances.
• The Food and Drug Administration provides surveillance over the safety and efficacy of foods, pharmaceuticals, and other consumer goods.
• The Healthcare Resources and Services Administration is concerned with the development of health services programs and facilities. The Division of Nursing is in this unit. A major focus of this agency is funding grants for nursing education and training.
• The Indian Health Service provides health services for Native Americans and Alaska Natives. • The National Institutes of Health (NIH) performs and supports research programs. The focus
of these efforts is to develop and extend the scientific knowledge base related to their respective areas. The National Institute for Nursing Research, which is part of NIH, focuses on nursing research.
• The Substance Abuse and Mental Health Services Administration awards grants and funds research related to problems with substance abuse and mental health.
• The Agency for Healthcare Quality and Research works to improve quality, safety, efficiency, and effectiveness of health care services for all Americans.
The current HHS maintains a strategic plan (USDHHS, 2015). The goals for 2015–2018 are:
• Strengthen health care • Advance scientific knowledge and innovation • Advance health, safety, and well-being of the American people • Ensure the efficiency, transparency, accountability, and effectiveness of HHS programs
The HHS has been deeply involved in implementation of the ACA. This has included oversight of the state exchanges, awarding funding to meet the law’s requirements; measuring program performance to ensure program integrity; and informing the public of requirements, mandates, and results. Changes brought by subsequent changes to the ACA will also likely require supervision of
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the HHS.
State-Level Subsystem States are responsible for the health of their citizens and are the central authorities in the public health care system. The organization and activities of public health services vary widely among the states. A health commissioner or secretary of health is typically appointed by the governor and directs most state health agencies. The health officer is usually a physician with a degree and experience in public health. In some states, the health officer directs the state’s health department. Many states have boards of health, which determine policies and priorities for allocation of funds. Staffing of the state agency varies among states; however, in comparison with other state programs, state health programs usually have a large staff.
The state health department does not exist in a vacuum. The United States requires an integrated system so that both federal and state levels work to the benefit of all citizens. Thus the state health departments are highly dependent on the federal level for resources and guidance. For example, funds contributed by the federal government to Medicaid, which is jointly funded by the federal government and states, have been changed over time and vary with respect to beneficiaries and services covered by each state. This has had a major impact on services that states can provide to their most vulnerable citizens.
One of the major provisions of the ACA resulting in large numbers of Americans receiving health care coverage was through the expansion of Medicaid; however, each state was allowed to determine whether they would accept this expansion. Ultimately, 31 states and the District of Columbia elected to extend Medicaid coverage through the ACA and 19 chose not to (Familiesusa.org, 2017). Without major legislative changes involving the ACA, it is anticipated that more states will elect to expand Medicaid to other beneficiaries with federal assistance.
Cooperation between the state and federal levels of the health care system has also been brought to the forefront with efforts to plan for bioterrorism and disasters. According to the scope of health services, the state-level subsystem is responsible for its own public health laws; therefore state policy varies widely. Factors that affect the level of state services include state-legislated or mandated services; political factors related to division of power between state and local health departments (LHDs); and competition among officials, providers, and the business community.
As discussed in previous chapters, the three core functions of public health are assessment, policy development, and assurance (IOM, 1988). Assessment activities include the collection of data pertaining to vital statistics, health facilities, and human resources; epidemiological activities, such as communicable disease control, health screening, and laboratory analyses; and participation in research projects. In the area of policy development, states formulate goals, develop health plans, and set standards for local health agencies. Assurance activities involve inspection in a variety of areas, licensing of health professionals and organizations, health education, environmental safety, and resource development.
Local Health Department Subsystems LHDs are generally responsible for the direct delivery of public health services and protection of the health of citizens, although not all communities/counties have LHDs. State and local (i.e., city and county) governments delegate the authority to conduct these activities. The organization of LHDs varies widely depending on community size, economics, partnerships with the private health care system, health care facilities, business support, health care needs, transportation, and the number of citizens requiring public health care. Some LHDs function as district offices of the state health department; others are responsible to local government and the state; and still others—particularly those in large cities—are autonomous. An LHD may be a separate agency or a division within an agency, such as the HHS.
A health officer or administrator appointed by local government directs the LHD. At least half of the states require that the health officer of an LHD have a medical degree. An interdisciplinary team carries out the activities of the department. Public health nurses and health inspectors represent the two largest groups of professional staff members. Other professional staff members include dentists, social workers, epidemiologists, nutritionists, and health educators.
According to the designated scope of services, the LHD subsystem is responsible for monitoring the health status and meeting the health needs of their constituents. This includes identifying unmet needs and taking actions to meet these needs. Most services to groups and individuals are provided
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at the local level. These services fall into the following four major categories:
Community health services include control of communicable disease such as surveillance and immunizations, maternal-child health programs, nutrition services, and education. Health promotion education is directed toward changing behavior; individuals are encouraged to eat healthy foods; exercise more; and decrease their use of tobacco, drugs, and alcohol. Other programs provide nutritious food and food stamps to individuals and families. A major activity of LHDs is to perform preventive screening for potential problems throughout the lifespan of their community members.
Environmental health services include food hygiene such as inspection of food-producing and food-processing plants and restaurants; protection from hazardous substances; control of waste, air, noise, and water pollution; and occupational health. The objective of these activities is to provide a safe environment.
Personal health services provide care to individuals and families in clinics, schools, and correctional institutions. In many areas, home health care services are provided through the LHD.
Mental health services are provided through LHDs in many communities. These services are supported by funds offered by local and regional mental health and mental retardation facilities and programs. See Chapter 24 for more information on community-based mental health care.
LHDs establish local health codes, fund public hospitals such as city and/or county hospitals, and provide services to populations and individuals at risk who often lack health insurance. Programs and services for state health departments and LHDs vary among jurisdictions. The services provided reflect the values of the residents and officials, available resources, and perceived needs of their respective populations within their state and local area. Although the goals of the public health subsystem do not change, the programs and services evolve to meet the changing needs of the public.
Several provisions of the ACA addressed improvement of quality and access to care. For example, the law promoted establishment of local consortiums of health care providers to coordinate health care services for low-income uninsured and underinsured populations. It also substantially increased funds for community health centers and financed development of school- based health centers and nurse-managed health clinics.
Summary of Public Health’s Three Levels In the preceding description of the three government levels that provide public health services (i.e., local, state, and federal), distinctive and overlapping roles have been discussed. The federal government has been assuming a larger role in the protection of the population through regulation and funding. It finances specific programs such as Medicare and categorical programs for mothers and infants and provides direct care to special populations, for example, military veterans. States establish health codes, regulate the insurance industry, and license health care facilities and personnel. States also provide funds for services offered through Medicaid. Direct care activities funded by state health departments may include care in mental hospitals, state medical schools, and associated hospitals. LHDs are the primary agencies that provide direct services to communities, families, and individuals.
Active Learning
1. Describe the organization of the state and local health departments. 2. Visit the local health department and learn what services are provided. How do these
services relate to Healthy People 2020 objectives? 3. Identify regional and state health services and providers.
Health Care Providers
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Providers of health care are individuals, groups, and organizations that deliver or support health care services. This section describes the different types of health care providers, including provider organizations, health care professionals, and nontraditional providers.
Provider Organizations The following are examples of health care provider organizations:
• Hospital • Clinic • Physician practice • Ambulatory care center • Home health agency • Long-term care facility • Skilled nursing facility • Rehabilitation center • Hospice service • Public health department • School health clinic • Birthing center • Ambulatory surgical center • Occupational health clinic • Crisis clinic • Community health center • Retail health clinics located in retail stores, supermarkets, and pharmacies • Any other type of organization that provides health care within the community
Health care provider organizations are undergoing tremendous changes. This is particularly true of hospitals, many of which are merging, consolidating, and closing. These changes have an impact on the entire community health system. With the increasing shift to ambulatory and primary care (see Box 11.2), hospital stays have shortened, and the patients who are admitted to the hospital are more acutely ill and require more intensive care. Consequently, reduced hospital stays result in more home care admissions or more discharges to long-term care facilities or skilled nursing units for short-term recovery and rehabilitation.
Ethical Insights Universal Health Care Universal health care coverage has been a topic of interest in the United States at least since the 1960s. The United States is the only developed country that does not have some form of universal health insurance. Although the ACA significantly reduced the number of uninsured individuals, there were 28 million people without health care coverage by the end of 2016 (Kaiser Family Foundation, 2016). Thus universal health coverage remains elusive. Clients without health coverage have a direct impact on communities, and health care providers should consider the following questions: Is health care a right of all citizens? Who is responsible for determining the right to health care access? What additional reforms will be necessary to resolve these questions? These are difficult questions, particularly in light of the growing problem of health care disparities in the United States.
BOX 11.2 Primary Care and Primary Prevention
“Primary health care is essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and
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country can afford to maintain at every stage of their development in the spirit of self- reliance and self-determination.... It is the first level of contact of individuals, the family, and the community with the national health system bringing health care as close as possible to where people live and work.” (World Health Organization, 1978)
A physician, nurse practitioner, or physician’s assistant may provide primary health care. Generally, the primary care provider’s practice is in family medicine, internal medicine, or pediatrics. The primary care provider is responsible for health maintenance and for treatment of common illnesses and may refer clients to specialists as needed.
Primary prevention is a type of intervention that promotes health and prevents disease. Primary prevention includes immunizations and contraception, as well as promotion of good nutrition, exercise, and healthy lifestyle choices (e.g., avoidance of tobacco, limitation of alcohol).
How do these definitions compare? The WHO definition and the definition of primary care that is usually used in the United States are similar. Primary prevention is an intervention that is used in primary care services.
Health Care Professionals The health care team has been growing and evolving significantly over the last decade, with members of the team taking on new responsibilities. There is greater emphasis today in all types of health care settings on using interprofessional teams to better coordinate care and to promote effective outcomes. The community particularly needs an interprofessional approach, because clients often have complex needs. Interprofessional teams have been recommended by the National Academy of Medicine (NAM), formerly called the Institute of Medicine (IOM) (2015a) and others. Indeed, working on interprofessional teams has been identified as a core competency for health care professions. Further, in recent years, there has been a push to move to more interprofessional education (IOM, 2015a; Interprofessional Professional Education Collaborative [IPEC], 2011; World Health Organization [WHO], 2010).
The following is a brief review of the major types of professional and nonprofessional members of the health care team:
• Registered Nurse (RN): This appears to be a simple designation, but different educational routes (i.e., diploma, associate degree, baccalaureate degree) exist to obtain a license to practice as an RN. In addition, many nurses now obtain master’s degrees and doctorates. These advanced degrees provide nurses with the opportunity to do more independent practice, teach, and conduct research. Nurses represent the largest group of professionals providing health services, and they practice in all types of health settings. State legislatures determine licensure requirements and enact nurse practice acts. State boards of nursing are the administrative arm for implementation of these laws and regulations.
• Advanced Nurse Practitioner (ANP): This is a nurse who has obtained education beyond a baccalaureate degree and has studied content related to primary care or acute care. ANPs specialize in such areas as adult health, pediatrics, neonatology, gerontology, and psychiatric nursing. An ANP may work in a clinic, the community, a private practice, the home, a hospital, or a long-term care facility (i.e., any setting in which health care is provided). With health care reform raising the demand for primary care, it is expected that ANPs will provide more and more primary care.
• Clinical Nurse Leader (CNL): Clinical nurse leader is a new position that requires a master’s degree. The CNL is a provider and manager of care at the point of care for individuals and cohorts and does not have a clinical specialty in the master’s program. The types of positions that CNLs are taking are variable, though many are in acute care settings.
• Clinical Nurse Specialist (CNS): The clinical nurse specialist, who has a master’s degree in a specialty area, provides acute care and guides other nursing staff in providing care. There are many fewer CNSs in clinical practice today, as the ANP role has become more common.
• Nurse-Midwife (NM): A nurse-midwife is a nurse who has completed an additional educational program focused on midwifery. NMs work in all types of settings in which women’s health and obstetrical services are provided, and they may be very active in community health services.
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• Certified Registered Nurse Anesthetist (CRNA): A CRNA has a master’s or doctoral degree that educates them to provide anesthesia, often under a doctor’s supervision. They typically work in hospitals, outpatient surgery centers, and physicians’ offices.
• Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN): LPNs and LVNs perform some specific nursing functions and play a critical role in providing direct client care. They have high school degrees and additional training (usually 1 year) and work in all types of settings, typically under the direct supervision of an RN or a physician. They may work in hospitals, long-term care facilities, clinics, and homes.
• Physician (MD or DO): A physician has a medical degree; most physicians specialize in a specific area of practice (e.g., internal medicine, surgery, pediatrics, gynecology).
• Physician Assistant (PA): The PA is a “physician extender” who provides medical services under the supervision of a licensed physician. The role was developed in the 1960s in response to a shortage of primary care physicians in certain areas. PAs often work in primary care, but many specialize.
• Registered Dietitian (RD): This health care professional assesses the client’s nutritional status and needs. RDs work in hospitals, long-term care facilities, clinics, community health centers, and homes.
• Social Worker (SW): SWs assist clients and their families with problems related to reimbursement, access to care, housing, care in the home, transportation, and social problems. They are discharge planners, particularly in acute care facilities or hospitals, often as case managers; however, they work in all types of settings. SWs may also have education to specialize in counseling. SWs are employed in many community agencies to help clients with a variety of needs, such as housing, ensuring that food is accessible, transportation, vocational assistance, medical equipment, and counseling.
• Occupational Therapist (OT): OTs assist clients with impaired functions or disabilities to reach the clients’ maximum level of physical and psychosocial independence. They work in all types of settings, including with clients in their homes through home health agencies.
• Speech-Language Pathologist: Speech-language pathologists assist clients who need rehabilitative services related to speech, hearing, and language/communication disorders, as well as swallowing disorders. They work in all types of settings, including with clients in their homes through home health agencies.
• Physical Therapist (PT): PTs help clients who are experiencing musculoskeletal problems. These providers focus on maximizing physical functioning and work in all types of settings (e.g., hospitals, long-term care/rehabilitation, home health).
• Pharmacist: Pharmacists prepare and dispense medications. Pharmacists have become much more involved in educating clients about medications and in monitoring and evaluating the effects of medications. They work in all types of settings, including hospitals and community pharmacies.
• Respiratory Therapist (RT): RTs provide care to clients with respiratory illnesses. They use oxygen therapy, intermittent positive-pressure respirators, artificial mechanical ventilators, and inhalation therapy. Most RTs work in hospitals and long-term care, but they are becoming more common in home health care.
• Chiropractor: Chiropractors are concerned with improving the function of the clients’ nervous system by means of various treatment modalities (e.g., spinal manipulation, diet, exercise, and massage). Chiropractors are mostly community based.
• Paramedical Technologists: Paramedical technologists work in various medical technology areas (e.g., radiology, nuclear medicine, and other laboratories).
• Unlicensed Assistive Personnel (UAP): Members of the health care team known as unlicensed assistive personnel have caused some controversy in last few years; however, the UAP is a critical member of the team. UAPs provide direct client care, supervised by RNs. The amount of education and training of UAPs is highly variable. UAPs work not only in acute care and long-term care but also for home health agencies.
Nontraditional Health Care Providers Nontraditional health care providers deliver alternative or complementary therapies. During the last two decades, consumers have become more interested in this type of care and have demanded that it be available.
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Although many large medical centers are now developing programs and centers that offer complementary therapies, reimbursement for these services is lagging. The National Institutes of Health (NIH) supports research focused on a wide array of alternative therapies and their effects on health and disease, and in 1998 established the National Center for Complementary and Alternative Medicine to meet the need. The name was recently changed to “National Center for Complementary and Integrative Health” to reflect recognition of the importance of incorporation of nontraditional therapies in health care. Complementary and alternative therapies provided by a variety of health care providers are extremely wide ranging. They include mediation, massage therapy, herbal therapy, healing touch, energetic healing, yoga, acupuncture, and acupressure. Ethnic healers, such as curanderos, and folk healers are also found in some communities. Training and licensure requirements for alternative therapists vary, but will probably become more standard as their care becomes more accepted. Many nurses have incorporated alternative therapies into their practices and seek educational opportunities on a wide range of associated topics.
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Critical Issues in Health Care Delivery Quality Care Quality care has been a concern of consumers and providers for decades. Quality care is a difficult concept to define and more difficult to measure. In 1996, President Clinton established the Advisory Commission on Consumer Protection and Quality to address a number of issues that had been identified. This commission produced a report that supported improvement in consumer power and rights, a focus on vulnerable populations, promotion of accountability, reduction in errors, and an increase in health care safety. Further, they promoted evidence-based practice and enhanced investment in information systems (President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1999).
This report stimulated a series of more in-depth explorations of the health care delivery system. Key among them was the NAM’s “Quality Chasm” series. In their series, the NAM defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 2001a, p. 232). This series has had a major impact on the U.S. health care delivery system and highlights of a number of the key reports are presented in Table 11.1.
The Agency for Healthcare Research and Quality (AHRQ) is the main federal organization that works to improve the safety and quality of the health care system. Following the 1999 NAM report “To Err Is Human,” AHRQ led the response to improving the safety of health care. This was largely through funding research to make care safer and to improve quality by publishing materials to educate health care systems and professionals to put research into practice and through generation of measures and data to be used by providers and policymakers (AHRQ, 2017).
Among their numerous programs and initiatives, AHRQ support efforts for clinicians and providers include clinical guidelines and recommendations, the Team STEPPS program (Strategies and Tools to Enhance Performance and Patient Safety), and evidence-based education and training. With respect to quality and safety reports, AHRQ administers the “Consumer Assessment of Healthcare Providers and Systems” (CAHPS). CAHPS is a survey and reporting entity that collects data and provides reports and detailed information on consumers’ experiences with specific aspects of their health plans and providers. This type of survey provides data that help purchasers of plans compare and contrast plans and allows informed consumers to select providers (AHRQ, 2017). Finally AHRQ publishes research and reports specifically related to health care disparities, quality, and evidence-based practice. These reports can be used by policymakers and others to make critical decisions about funding and promotion of research endeavors.
Accreditation Accreditation is one means to assess the quality of services and care of the organization. Specific minimum standards must be met by an organization to obtain accreditation. Indeed, accreditation serves the purpose of instilling public confidence in a program, institution, or organization (NAM, 2016). Purchasers of care, including insurers and MCOs, are concerned about the accreditation status of health care organizations when they negotiate reimbursement contracts. Other entities, such nursing schools and medical schools, which use health care organizations for clinical sites, are also concerned with accreditation status.
Many groups provide accreditation for health care providers and health care organizations. For example, The Joint Commission was founded in 1951 to promote health care quality through setting and maintaining standards for hospitals. Their work has evolved over the ensuing decades, and The Joint Commission currently accredits and/or certifies more than 21,000 organizations in the United States, including hospitals, home care agencies, long-term care facilities, ambulatory care centers, and laboratories (The Joint Commission, 2017).
The National Committee for Quality Assurance (NCQA) began in 1990 and oversees accreditation programs for individual physicians, health plans, and medical groups, including MCOs (NCQA, 2017). During the accreditation process, the NCQA collects data for a widely used set of performance measures, the Health Plan Effectiveness Data and Information Set (HEDIS). HEDIS collects data on about 90% of health care plans to measure performance and consumer satisfaction; thus it allows consumers—including insurers—to compare performance of health plans
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and providers to regional and national benchmarks. Of note, Medicare uses HEDIS for their Medicare Advantage plans (CMS, 2017).
Currently, quality care monitoring focuses on improvement. Quality data are no longer hidden and will continue to be available when new methods are developed to assess improvement on the basis of outcomes. With the improvement approach, outcomes measures have moved to the forefront. Accrediting organizations require outcomes data, which they use to assess overall performance. Practitioners use outcomes to identify the treatment goals with the client. “Report cards” are used to compare and contrast health care organizations and health care plans. These report cards are available to the consumer, providers, and insurers. Medicare in particular has been increasing the number of its quality initiatives. Among the Medicare quality initiatives are:
• CMS Core Measures • Quality Payment Program • Merit-based Incentive Payment System (MIPS) • Marketplace Quality Incentives • ESRD Quality Incentive Program • Skilled Nursing Facility (SNF) Quality Reporting Program
Managed Care Managed care refers to any method of health care delivery designed to reduce unnecessary use of services, improve cost containment or cost-effectiveness, and ensure high-quality care. Managed care is currently one of the predominant forces in health care delivery. It affects health care organizations, health care providers, and reimbursement and has a direct influence on what care is provided and by whom, where, when, and whether it is to be provided. Chapter 12 provides additional information on managed care and reimbursement.
Information Technology The development and utilization of information technology (IT) over the last decade has been phenomenal. Clinical staff members use computers and related technologies in all health care settings. For example, encouragement of widespread implementation of the electronic health record (EHR)/electronic medical record (EMR) was promoted by the Health Information Technology for Economic and Clinical Health, which was a component of the American Recovery and Reinvestment Act of 2009. The EHR/EMR allows for systematization of the collection of patient health information within a digital format that can be shared across health care settings and among providers through network-connected information systems. The ACA strongly supported expansion of the EHR, as has the CMS. Although EHR support and usage have climbed exponentially as a result of these efforts, there have been several issues with the widespread implementation. These issues include high associated costs, software deficiencies, difficulties with interfaces between and among systems, privacy concerns, and liability issues. Despite these concerns and issues, the EHR will continue to evolve and should eventually promote better-quality, safer, and more effective and efficient health care delivery.
TABLE 11.1
National Academy of Medicine—Landmark Reports on Quality in Health Care
Report Title (year) Major Findings and Recommendations To Err Is Human: Building a Safer Health System (1999)
Medication errors contribute to 44,000–98,000 deaths each year in the United States (more than motor vehicle accidents or breast cancer). Reported that errors largely result from system failures. Health care systems must focus on error prevention and promote changes to improve processes that will promote patient safety.
Crossing the Quality Chasm (2001a)
Among the findings was that the health care system is fragmented, poorly organized, does not use resources well, and quality varies considerably. The health care system needs improvement because of new technologies, rapid availably of information, and new treatments. Concerns were raised related to the rise in the number of people with multiple chronic conditions. Recommendations included the promotion of evidence-based care, more attention to patients’ need for information, and improved access to clinical expertise. Report strongly supported enhanced use of information technology.
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Leadership by Example (2003a)
Focused on government-funded programs: Medicare, Medicaid, CHIP, Dept. of Defense’s TRICARE, VA program, and Indian Health Services. Report noted that federal leadership is needed to coordinate efforts and promote quality, and there is a notable lack of consistence in performance measurements. Recommended a more systematic approach to promote quality and to use technology in government-funded programs.
Who Will Keep the Public Healthy? (2003b)
Focused on the effects of globalization, travel, and technological advances and demographic changes on public health. Pointed out the need to address public health problems and educate public health professionals to meet current and future needs. Recommendations emphasized informatics, genomics, cultural competence, community-based participatory research, global health, and ethics.
Health Professions Education (2003c)
Education of health professionals is viewed as a bridge to quality care. Identified core competencies for all health professions: provide patient-centered care, work in interprofessional teams, employ evidence-based practice, apply quality improvement strategies, and utilize informatics.
Priority Areas for National Action: Transforming Health Care Quality (2003d)
The IOM identified 20 “priority areas” to be developed and/or addressed through an evidence-based approach to improve quality. Among the processes and issues were care coordination, health literacy, frailty of old age, medication management, and treatment for tobacco dependence. Among the health conditions/diagnoses identified as priority areas were nosocomial infections, obesity, asthma, diabetes, hypertension, stroke, major depression, and pregnancy/childbirth.
Future Directions for the National Healthcare Quality and Disparities Reports (2010)
Updated priority areas focusing on disparities. Areas to include were patient and family engagement, population health, safety, care coordination, palliative care, overuse of care, and improvement of access to care.
Future of Nursing: Leading Change, Advancing Health (2011)
This report addresses barriers that prevent nurses from being effectively used in the rapidly changing health care system. Among the main recommendations were that nurses should practice to the full extent of their education and training and that nurses should be encouraged to achieve higher levels of education and training.
Improving Diagnosis in Health Care (2015)
Diagnostic errors affect an estimated 5% of Americans each year; 6%–17% of adverse events in hospitals are the result of diagnostic errors. Reducing diagnostic errors is one of the new efforts to improve quality and safety in health care. Recommendations included the following: 1) promote more effective teamwork among health care professionals, patients, and family members; 2) ensure that health information technology supports patients and providers during the diagnostic process; 3) establish work systems and culture to support diagnostic processes and improvements; and 4) develop a system that facilitates learning from diagnostic errors and near misses.
Telehealth is another avenue in which IT is expanding within health care. Use of telehealth means that clients can receive care via technology, such as computer, video, or interactive television. The IOM (2012b) identified “telehealth” as a key component in ensuring access to health care services in isolated geographic areas. Further, they suggested that telehealth technologies will enhance the ability to better meet the health care needs of those in rural parts of the country, as well as for those in other underserved aggregates.
The Internet has opened doors for consumers and providers, and health information access has expanded rapidly. Although information availability to millions of people has been enhanced, resulting in an explosion of knowledge regarding health and health issues, the quality of this information is sometimes questionable. Providers must address the source and content of information on the Internet.
Social media, likewise, has become a more common source of information and is being widely used to share information about health. This can include health promotion and prevention activities and strategies. Individuals share a great variety of information now through social media, and this venue could be used in more organized efforts to get information out to the public. Finally, smartphones are a rapidly growing resource for engaging the community. Examples include employment of applications (apps) that track weight, exercise, and other health issues (e.g., heart function, blood glucose levels, hypertension).
Consumerism and Patient Rights The growth of managed care and concerns over cost and value have increased the strength of consumerism. Over the past decade, the Baby Boomer generation has been subsidizing the health care system and paying more in premiums than it has taken out in claims. However, growing concern exists that, as this generation ages, it will demand more care than previous generations. Consumers are now critical of the health care system and demand changes as they encounter problems. Health care organizations, individual providers, and insurers recognize the importance of the consumer voice. Client- or customer-centered health care is a term that has become commonly used in health care, and more effort has been made to provide the consumer with information.
Patient or client rights are an important health care issue that individual states and the federal government have addressed through legislation. Patient rights have evolved over time and include
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access to medical records and the right to keep them private (through Health Insurance Portability and Accountability Act). In the United States a number of attempts have been made to enshrine a patients’ bill of rights in law, including a bill rejected by Congress in 2001. The ACA included efforts to promote patients’ rights, but it was not fully implemented.
Many states have promoted laws or regulations protecting patients. Further, health care facilities often have a “patients’ bill of rights.” Typically, a patients’ bill of rights is a list of guarantees or promises for those receiving care at that facility or by providers. Generally included are guarantees of confidentiality, promises of access to information, fair treatment, informed consent, and autonomy over decisions, among other rights. Other patients’ rights issues that are vitally important that continue to be discussed and debated are information disclosure, physician and provider choice, direct access to specialists, reimbursement for emergency care, and reimbursement denial.
Coordination and Access to Health Care Health care providers often function in isolation from one another and provide fragmented services. Although multiple services are available for the wellness–illness continuum, coordination is lacking. Services range from office-clinic, home care, adult day care, acute care institutions, and specialized institutions to skilled nursing facilities. The services provided by one agency or one provider do not help the individual transit, or move, across boundaries and receive services offered by others. “Handoffs,” when patients are transferred from one provider (e.g., individual provider, unit, agency) to another, are a time of increased risk for errors, reducing the quality of care. In addition, the services tend to be geographically separated, and each agency has different criteria for access. Further, the focus of services has not kept pace with the changing needs of individuals and populations. Millions of Americans lack access to health care services, and inadequate financial resources are a deterrent to available health services. Interprofessional teams can address many of these concerns and improve care in the community.
The current health care system continues to be pluralistic and competitive, and it provides fragmented and uncoordinated care. Private care agencies and institutions are in competition with one another for clients, health professionals, and resources. Even with recent reforms, two hospitals in the same geographic area may be competing for the same clients, whereas other communities may not have a hospital at all, may have only minimal services, or may lack essential services such as obstetrics. Hospital home care programs are in direct competition with private or public home care agencies. Hospitals diversify services to become economically viable; therefore they compete with ambulatory care providers for the ambulatory market. Public health services can be viewed as indirectly competing for resources. This fragmentation and duplication must be overcome to provide coordinated, collaborative, and accessible service to all citizens.
Disparity in Health Care Delivery Health disparities refer to observable or quantifiable differences in the presence of disease, health outcomes, or access to health care among different groups or populations. In the United States, health disparities have long been recognized as particularly problematic among ethnic minorities, including blacks, Native Americans, and Hispanics. Research indicates that often these groups have a higher prevalence of chronic conditions and higher rates of mortality and poorer health outcomes when compared with the white population. Further, it is recognized that in addition to racial or ethnic group, health disparities adversely affect those based on such factors as socioeconomic status; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; or geographic location.
For example, the Kaiser Family Foundation (2016) noted that blacks and American Indian and Alaska Native adults have a higher prevalence of asthma, diabetes, and cardiovascular disease than whites. Variations in HIV diagnoses and death rates from AIDS are very pronounced, with blacks experiencing over 8 and 10 times higher rates of HIV and AIDS diagnoses than whites. Further, infant mortality rates are significantly higher for blacks and American Indians and Alaska Natives compared to whites; African Americans and Latinos are also approximately twice as likely to develop diabetes. Finally, black males have the shortest life expectancy compared with other groups.
Disparities in health care provision have been observed, particularly related to cancer,
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cardiovascular disease, HIV/AIDS, diabetes, and mental illness. To address this problem, more cross-cultural education for health care professionals, including nurses, is needed to improve awareness of cultural and social factors and their impact on health care.
Ethical Insights Limited Health Care for Some The health care system in the United States is complex, with social policies that favor pluralism, free choice, and free enterprise. The private-sector personal care subsystem provides the majority of care to individuals. The private sector includes nonprofit agencies, for-profit agencies, and voluntary organizations. The public health subsystem provides limited personal care services for socially marginalized populations, but, for the most part, subsidizes the private sector through Medicare and Medicaid reimbursement to provide these services.
Active Learning
1. Review the current National Health Care Quality Report and the National Disparities Report. They can be accessed at http://www.ahrq.gov/research/findings/nhqrdr/index.html. What frameworks or matrices are used to structure the report? What is the status of health care quality and disparities? What can you learn that would affect planning for health care services in a community?
2. Discuss how critical health care issues (e.g., managed care, quality care, fraud and abuse, diversity, and disparity) affect health care organizations in the community.
3. Cite examples of health care consumerism in the local community. What are their histories? 4. Give a personal reaction to health care fraud and abuse. How should the principles found in
the Code for Nurses apply in practice? 5. Visit the following site on health care reform: https://www.hhs.gov/healthcare/about-the-
aca/index.html. Review the elements of the law and current status. Discuss implications for nursing in the community. Also review http://www.helpingyoucare.com/21950/hhs- provides-tool-to-find-out-how-the-presidents-health-care-law-benefits-you-your-state. HHS provides this site for comparisons.
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Future of Public Health and the Health Care System Many changes are occurring in the health care system. With implementation of the ACA, the health care system is required to set limits on the care provided; identify criteria for the use of technology; and determine which conditions will be treated, which interventions are effective, and who should receive the care. The health care reform debate, however, is far from over, and additional changes are likely in the near future. Questions that continue to be important are:
• What health care services should be provided? • Who should have access to health care services? • Who should pay for health care services? • How can costs of health care be reduced? • How should health care be delivered? • What is the role of the government?
The importance of health promotion, disease prevention, and a population-based approach to health care is becoming increasingly recognized. There is recognition of the need for widespread use of the EHR, which, to be effective, must incorporate care provided in the community. The roles of health care organizations, practitioners, and the government must address the public health component of the system. There is also the problem of the need to address new and emerging threats such as the problems from the opioid crisis, increasing gang violence, and health conditions such as the Zika virus. Finally, local, state, and national political leaders must continue to manage the health of the population and the need to reduce levels of health care expenditures.
Futurists rarely identify the public health subsystem as a component of the health care system, but this situation is changing. Indeed, the history of the public health subsystem’s involvement with the poor and disenfranchised is a major influence on inattention to their problems. Furthermore, focus on environmental influences on the population, such as air quality, is critical for the future health of any nation.
Nursing has also been involved in change. The Future of Nursing (IOM, 2011) focused on how the nursing profession might fit into the change process. The key messages in this report were as follows:
1. Nurses should practice to the full extent of their education and training. 2. Nurses should achieve higher levels of education and training through an improved
education system that promotes seamless academic progression. 3. Nurses should be full partners with physicians and other health professionals in
redesigning health care in the United States. 4. Effective workforce planning and policy making require better data collection and an
improved information infrastructure.
This report offered eight recommendations, many of which are already having a major impact. One of the most significant to date is the drive to increase the number of nurses with bachelor’s of science nursing (BSN) degrees by developing more RN-BSN opportunities. Public health has been one area of health care that often has required a BSN for its entry positions, though with the nursing shortage this situation has been moderated some. Increasing the number of nurses with BSN degrees would help fill empty positions that require a BSN degree. The role of the ANP, as commented on earlier, is also expanding. The IOM report supported significant change, emphasizing these aspects of quality, access, and value:
• The need for patient-centered care • The need for stronger primary care services • The need to deliver more care in the community • The need for seamless, coordinated care • The need for reconceptualized roles for health professionals • The need for interprofessional collaboration
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Predicting future trends in human values is more difficult than predicting scientific discoveries or the patterns of disease. The past two decades have brought a significant shift in thinking about the future of the health care system. Consumer rights and further efforts to control or limit health care costs while improving access will be critical issues to be resolved in the future. How these decisions, and implementation of health care reform law, will affect public health is unclear.
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Summary The health care system is complex and changes quickly. Federal, state, and local legislation and policies affect the system, and understanding the legislation and its effect on the health care delivery system is critical for any nurse. In addition, the implementation and pending changes to the ACA have demonstrated how important it is for health care providers to understand the reimbursement system and to learn how to advocate for their clients.
The many different types of health care organizations and health care providers also affect the health care system. Interprofessional care will be necessary for providers to achieve success in the system and to ensure that the client receives cost-effective, high-quality care. There are many concerns about health care, including cost, access, the number of uninsured, quality, and health care fraud and abuse. Resolving these problems will not be an easy task, but it must be done. Understanding the system helps as health care providers learn to function in the rapidly changing system.
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Evolve Website http://evolve.elsevier.com/Nies/community
• NCLEX Review Questions • Case Studies
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Economics of Health Care Melanie McEwen, and Marie E. McBee
OUTLINE
Factors Influencing Health Care Costs Historical Perspective Use of Health Care Lack of Preventive Care Lifestyle and Health Behaviors Societal Beliefs Technological Advances Aging of Society Pharmaceuticals Shift to For-Profit Health Care Health Care Fraud and Abuse
Public Financing of Health Care Medicare Medicaid Governmental Grants
Philanthropic Financing of Health Care Private Health Care Insurance
Historical Perspective Types of Health Care Plans Reimbursement Mechanisms of Insurance Plans Covered Services
Cost Containment Historical Perspective of Cost Containment Current Trends in Cost Containment
Trends in Health Financing Cost Sharing Health Care Alliances Self-Insurance Health Savings Accounts and Flexible Spending Accounts Reimbursement for Health Promotion and Disease Prevention Initiatives
Health Care Financing Reform Access to Health Care Historical Perspective Societal Perceptions
Roles of the Public Health Nurse in the Economics of Health Care Researcher Educator
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Provider of Care Advocate
Best Care at Lower Cost
OBJECTIVES
Upon completion of this chapter, the reader will be able to do the following: 1. Discuss factors that influence the cost of health care. 2. Identify terms used in the financing of health care. 3. Discuss public financing of health care. 4. Discuss private financing of health care. 5. Discuss health insurance plans. 6. Describe trends in health care financing. 7. Describe the effects of economics on health care access. 8. Identify the future of health care economics.
KEY TERMS access actuarial classifications adverse selection ambulatory care capitated reimbursement carrier carve-out service coinsurance copayment cost containment cost shifting current procedural terminology (CPT) codes deductible diagnosis-related group (DRG) effectiveness flexible spending account (FSA) gatekeepers health care providers health insurance plans health maintenance organization (HMO) health savings account (HSA) high-deductible health plans (HDHP) indemnity plan managed care groups
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managed care plans mandates Medicaid Medicare Medigap insurance outcomes out-of-pocket expenses Patient Protection and Affordable Health Care Act (ACA) point-of-service (POS) preferred provider organization (PPO) premiums primary care provider prospective payment system (PPS) Economics represents the science of allocation of resources. Resources are commonly known as goods or services, for example, health care services. Economics affects all aspects of health care. Nurses have traditionally avoided the arena of health care economics, preferring to focus on the actual, direct care of the client. So strong is the feeling of social justice that some nurses express a reluctance to be informed of the individual client’s health care financing source for fear that this knowledge will influence their care. Public health nurses who deal with the medically underserved have had more experience in this area. However, even these nurses may have only rudimentary knowledge.
Health care costs continue to rise and consume a greater percentage of our nation’s resources. Indeed, health care is currently about 18% of the gross domestic product (GDP) of the United States and is anticipated to rise to 20% in only a few years (CMS, 2017). As a result, nursing can no longer ignore the intricacies of health care financing. The health of individuals, families, and aggregates is significantly influenced by economics. Economically disadvantaged individuals who have difficulty obtaining the basics, such as food and shelter, are less likely to have access to health care. Passage of the Patient Protection and Affordable Care Act (PL 111-148) in 2010 dramatically influenced health care access, resulting in many more individuals having insurance coverage. Indeed, most citizens have health insurance, whether provided by their employers, through private purchase, or, for those from low-income groups, through state and federal government sources (e.g., Medicare, Medicaid, Children’s Health Insurance Plan [CHIP]). This change, however, is not to universal health care coverage—many still remain uninsured.
This chapter focuses on the economics of health care. It specifically discusses factors that influence health care costs, terminology of health care financing, and trends in health care economics and their impact on population health. This chapter also addresses the future of health care financing. Box 12.1 presents terms and definitions that are important to the discussion of these topics.
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Factors Influencing Health Care Costs Historical Perspective Until the 1930s, the predominant method of individual health care financing in the United States was self-payment. Health care providers charged a fee for the services they rendered, and the patient paid these out-of-pocket expenses. The price of the service was under the control of the provider and generally represented the cost of providing that service. A certain amount of “charity” services was expected. The assumption was that those who could pay would pay and those who could not pay should receive care and pay what they could. The concept of public financing of health care for a specific aggregate was restricted and varied from geographic area to area until the term public health came into common use.
The following types of hospitals existed until the mid-twentieth century:
Public hospitals, which received public funds and served the health care needs of the entire population, regardless of ability to pay
Private hospitals, which cared mainly for those whose ability to pay was greater than that of the general population
For-profit hospitals, which were limited in number, received funds from investors, and cared for those who could definitely pay
Over time there has been growth in private and for-profit hospitals, resulting in large national hospital corporations that then expanded into offering more nonacute services.
This system worked well as long as those who could pay outnumbered those who could not. During the Great Depression, with more than 25% of the population out of work, the number of those capable of paying for health care was greatly reduced. Because public financing of health care was limited, hospitals, physicians, and other providers of health care went bankrupt.
In 1929, schoolteachers in Dallas, Texas, negotiated a prepaid health provision contract with Baylor Hospital. The teachers paid a sum of money each month, which guaranteed them access to health care through the hospital. The concept of insurance for health care proved extremely successful for Baylor Hospital. By 1939, this insurance plan had grown to include other groups and hospitals and became Blue Cross-Blue Shield (Momanyi, 2014).
Health insurance, or the idea of paying a small fee for guaranteed health care, appealed to the public. Societal concerns were mainly focused on sick care and acquisitions of curative therapies whenever needed. A public view that health insurance would provide freedom from fear that illness would impoverish them developed and prevails today. Health care providers envisioned guaranteed payment for their services (Higgins, 1997). During World War II, faced with a limited workforce and governmental restrictions on wages, employers began to see health insurance as a means of supplying workers’ benefits without granting a wage increase.
To extend this same “insurance” to the general population, the Social Security Act of 1935 was amended in 1965 to create Medicare and Medicaid. Medicare provided indemnity insurance to those over the age of 65 years, and Medicaid, a state-administered health plan, provided a source for financing health care for some of the poor and the disabled.
BOX 12.1 Terminology Used in Health Care Financing The financing of health care has given rise to new terminology. Nurses, as providers of care and consumers of services, need to be knowledgeable about these terms to improve their understanding of health care financing.
Terms pertaining to consumers:
Access—Ability to obtain health care services in a timely manner, at a reasonable cost, by a qualified practitioner, and at an accessible location.
Carve-out service—A service (e.g., mental health care) provided within a standard benefit package but delivered exclusively by a designated provider or group.
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Charges—The posted prices of provider services. Coinsurance—Cost sharing required by a health plan whereby the individual is responsible
for a set percentage of the charge for each service. Copayment—Cost sharing required by the health plan whereby the individual must pay a
fixed dollar amount for each service. Deductible—Cost sharing whereby the individual pays a specified amount before the health
plan pays for covered services. Fee schedule—List of predetermined payment rates for medical services. Flexible spending account (FSA) or health savings account (HSA)—A mechanism by which
an employee may pay for uncovered health care expenses through payroll deductions using pretax dollars.
Gatekeeper—Person in a managed care organization who decides whether a patient will be referred for specialty care. Doctors, nurses, nurse practitioners, and physician assistants function as gatekeepers.
Health care provider—An individual or institution that provides medical services (e.g., physicians, hospitals, or laboratories).
Health maintenance organization (HMO)—A managed care plan that acts as an insurer and sometimes a provider for a fixed prepaid premium. HMOs usually employ physicians.
Health plan—An insurance plan that pays a predetermined amount for covered health services.
High-deductible health plans (HDHP)—Insurance plan that uses cost sharing (i.e., high deductibles) to encourage employees to select plans with lower premiums. The intent is to encourage health care consumers to become more proactive in health care decisions from a financial perspective.
Indemnity plan—A health plan that pays covered services on a fee-for-service basis. Managed care plan—A health plan that uses financial incentives to encourage enrollees to use
selected providers who have contracted with the plan. Medicaid—Joint federal- and state-funded programs that provide health care services for
low-income people. Medicare—A health insurance program for people who are older than 65 years of age, are
disabled, or have end-stage renal disease. Medicare Advantage—Part of Medicare by which recipients may choose to enroll in a
coordinated care plan, private fee-for-service, or medical savings account plan created by the Balanced Budget Act of 1997.
Medigap insurance—Privately purchased individual or group health insurance plan designed to supplement Medicare coverage.
Out-of-pocket expenses—Payment made by the individual for medical services. Point-of-service (POS) plan—A managed care plan that combines prepaid and fee-for-service
plans. Enrollees may choose to use the services of an uncontracted provider by paying an increased copayment.
Portability—The guarantee that an individual changing jobs continues to receive health care coverage with the new employer without a waiting period or having to meet additional deductible requirements.
Preferred provider organization (PPO)—A health plan that contracts with providers to furnish services to the enrollees of the plan. Usually no insurance copayment is required.
Premium—Amount paid periodically to purchase health insurance benefits. Primary care provider—A generalist physician, typically a family physician, internist,
gynecologist, or pediatrician, who provides comprehensive medical services.
Terms pertaining to providers:
Ambulatory care—Medical services provided on an outpatient basis in a hospital or clinic setting.
Capitation—Payment mechanism that pays health care providers a fixed amount per enrollee to cover a defined set of services over a specified period, regardless of actual services provided.
Care management—Process used to improve quality of care by analyzing variations in and
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outcomes for current practice in the care of specific health conditions. Cost containment—Reduction of inefficiencies in the consumption, allocation, or production
of health care services. Customary charge—Physician payment based on a median charge for a given service within a
12-month period. Diagnosis-related group (DRG)—A system of payment classification for inpatient hospital
services based on the principal diagnosis, procedure, age and gender of the patient, and complications.
Effectiveness—Net health benefit provided by a medical service or technology for a typical patient in community practice.
Full capitation—A stipulated dollar amount established to cover the cost of all health care services delivered for a person.
Maximum allowable costs—Specified cost level established by the health plan. Outcome—The consequences of a medical intervention in a patient. Physician’s current procedural terminology (CPT) codes—A list of codes for medical
services and procedures performed by physicians and other health care providers that has become the health care industry’s standard for reporting physician procedures and services.
Practice guidelines—An explicit statement of what is known and believed about the benefits, risks, and costs of particular courses of medical action intended to assist decisions made by practitioners, patients, and others about appropriate health care for specific and clinical conditions.
Utilization review—A formal prospective, concurrent, or retrospective assessment of the medical necessity, efficiency, and appropriateness of health care services.
Terms pertaining to third-party payers:
Actuarial classification—Classification of enrollees that is determined by use of the mathematics of insurance, including probabilities, to ensure adequacy of the premium to provide future payment.
Administrative costs—Costs that the insurer incurs for utilization review, marketing, medical underwriting, agents’ commissions, premium collection, claims processing, insurer profit, quality assurance activities, medical libraries, and risk management.
Adverse selection—Procedure in which a larger proportion of people with poorer health status enroll in specific plans or options. Plans that enroll a subpopulation with lower-than- average costs are favorably selected.
Capital cost—Depreciation, interest, leases and rentals, taxes, and insurance on tangible assets.
Carrier—An organization that contracts with the CMS to administer claims processing and make Medicare payments to health care providers.
Cost contract—Arrangement between a managed health care plan and the CMS for reimbursement of the costs of services provided.
Cost shifting—The cost of uncompensated care is passed on to the insured, resulting in higher costs for those with insurance coverage.
Mandate—A state or federal statute or regulation that requires coverage for certain health services.
Risk assessment—Statistical method used to estimate claims costs of enrollees.
As a result of these health care resources, a significant majority of the population was protected by indemnity health care insurance from various sources. The early indemnity plans lacked an incentive for limitation of use and had few or no provisions for health promotion. The emphasis was placed on illness care, providers received a fee only when a service was rendered, and all costs of services were reimbursed. Insulated from rising health care costs, health care consumers demanded complex and technologically advanced services whenever illness struck. These demands for costly services represented the major driving force in rising health care costs.
By the 1980s, the first efforts to curtail health care costs were made by the federal government. With institution of the prospective payment system (PPS), hospital reimbursement for Medicare patients was based on a classification system that identified costs according to diagnosis and client
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characteristics—diagnosis-related groups (DRGs). The PPS prompted an evolution toward managed care, dramatically altering health care financing through the end of the twentieth century and into the first decade of the twenty-first century. Despite containment efforts, however, costs of health care and, consequently, health insurance, have continued to rise.
The spiraling health care costs, starting from the mid-1960s and persisting into the twenty-first century, were fueled by the presence of very rapid technological advances, society’s sense of entitlement to these therapies, a guaranteed payer, and the prevailing medical orientation toward curative measures. Prior to implementation of Medicare and Medicaid, national health expenditures represented less than 5% of the GDP. Fifty years later, however, costs have risen exponentially, as described previously.
Use of Health Care According to economic principles, the existence of a desirable product, the demand for the product, and the availability of financial funding influence the use of the product. Health care is the product, and the demand for this product increases when the need expands and funding is available. In an attempt to reduce unnecessary utilization, insurance plans began to limit coverage for certain services and people; thus the move toward “managed care.” Restrictions on use of health care, such as the establishment of a “gatekeeper,” limited patient provider choice, requirement of preauthorization for some services, limited coverage for preexisting illnesses, and exclusion of those participants whose use was deemed exorbitant, have been instituted. However, these restrictions had only limited success in curbing health care costs. Consumers were activated by these changes made by managed care, protesting them, and in many instances alterations were made.
Despite recognition of the problem of increasing health care costs and multiple attempts to address it, spending for health care in the United States is more than double that of many other developed countries (i.e., those in the Organization for Economic Cooperation and Development [OCED]). Indeed, average per capita spending in 2015 was $3625 (8.9% of GDP) for OCED countries, compared with $8713 (17.6% of GDP) in the United States (OCED, 2016). In contrast, Canada, which was tenth highest per capita spending in the OCED, spent $4351 per person on health care. Because the approach in the U.S. health care system is reimbursement with multiple insurers, both private and public, expenses for health care vary according to types of care and sources of funding.
Lack of Preventive Care Until recently, little to no incentive has existed to prevent illness or promote health. Curative measures have traditionally been the focus of health care. Soaring health care costs and an improved knowledge of health have heightened the public’s awareness of their obligation to assume responsibility for their health by amending many unhealthy behaviors. As a result, more people are demanding preventive health care from the provider and their health care contractors. Public financing of health care has increased funding for such preventive care as screening tests, periodic examinations, and immunizations. Use of these preventive health services has increased, but significant disparities persist in relation to ethnic background and economic status (National Center for Health Statistics [NCHS], 2017). There continues to be a gap between the amount of funding available for preventive treatment modalities and funding for curative treatments.
Lifestyle and Health Behaviors A healthy lifestyle does not ensure good health but has been shown to contribute to longevity and productivity (Harvard Medical School, 2009). The five leading causes of death and illness can be positively affected by changes in lifestyle. Studies have now found that a low-fat diet, exercise, maintaining of an optimal body weight, smoking cessation, and stress reduction can modify or even prevent many chronic illnesses. Smoking cessation reduces the incidence of lung cancer. Seat belt use decreases the severity of injuries incurred during moving vehicle accidents. Indeed, effective treatment of illness must often be coupled with a change in lifestyle. In the near future, access to expensive and unique medical treatment will probably be influenced less by the patient’s ability to pay and more by the person’s commitment to compulsory lifestyle changes. For example, legislation has levied “sin taxes” on products whose use has been associated with chronic illnesses.
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Examples include addition of taxes on cigarettes and other tobacco products, large soft drinks, alcoholic beverages, and certain cooking oils. Income from these taxes is intended to be used to care for, prevent, and conduct research on chronic illnesses.
Significant changes in lifestyle have taken place in the past 30 years. The current “smoke-free” environment appears shocking when contrasted to the nonchalant attitude toward smoking that was pervasive in the 1940s, 1950s, and 1960s. The advent of the Health Belief Model and Pender’s Health Prevention Model has given rise to numerous studies into methods of achieving lifestyle changes. The total effects of these changes are just now being seen with dramatic reductions in lung cancer and chronic lung diseases. Meanwhile, the health care system must continue to contend with the results of years of unhealthy lifestyles; most striking is the concerning rise in overweight and obesity and the abuse of opioid medications.
Health care funding is changing to provide more funding for preventive services. Some insurance plans provide monetary incentives, such as reduction in insurance premiums, for those who participate in behavioral changes toward a healthier lifestyle. Medicare will pay for many screening procedures performed for specific persons at specified times (Centers for Medicare and Medicaid Services [CMS], 2017b). Funding for behavioral changes, however, is often limited, inadequate, or unavailable. Similarly, weight loss programs, support groups for smoking cessation, and participation in relaxation programs are not usually considered reimbursable treatment regimens, but more expensive pharmaceutical interventions are reimbursable.
Societal Beliefs With the advent of such wonders as penicillin and insulin, society began to believe that the eradication of disease was just a few years away. More and more resources were dedicated to this elusive search. Armed with the belief that disease would soon be eliminated, society had limited interest in preventive care. The general belief was that making more money available for health care would lead to better health care and the greater likelihood that illness would be cured. Society has viewed insurance as an economic shield protecting against all disease and illness. The belief in cure rather than prevention, combined with this financial safety net, encouraged society to become a passive participant in health care. The feeling “I don’t have to worry, I have insurance” became the pervasive societal thought (Sloan, 2004).
Health care professionals also were slow to embrace preventive care. Most efforts were directed toward curing illness. With what seemed to be an unending source of financing for curative care, illness prevention seemed counterproductive.
As health care costs accelerated at an alarming rate and technological advances did not keep up with the increase in illnesses, the health of society had to become a collaborative effort between society itself and the health care industry. Although the United States spends more money on health care than any other industrialized country, it ranks significantly behind many other countries in health status indicators (NCHS, 2017; OECD, 2017). People still expect the health care system to cure them when they are ill, but there is now an increase in preventive care interest, including interest in health education, health promotion, and behavioral changes. Research into barriers and facilitators to lifestyle changes has increased, but it is not funded at the same level as curative measures (OECD, 2017). As discussed in Chapter 11, the United States continues to spend more money on health care and yet has lower-quality health care than many other countries (Fineberg, 2012).
Technological Advances Modern society has come to expect miraculous technological advances. In response to this expectation, and supplied with funding from various sources, technological advances have become too numerous to mention. The United States leads the world in laboratory and clinical research. People come from all over the world for education and to train in leading American centers for excellence. The United States exceeds other industrialized countries in the availability and use of these technological advances. Such advances can save the lives of people who would otherwise die.
These advances, although remarkable, are expensive. It has been widely suggested that in the United States, 20% of the population consumes 80% of the health care resources; the reality is probably closer to one-third of the population consuming two-thirds of the resources (CMS, 2012). As the health care dollar shrinks, these advances raise ethical questions involving health care access
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and rationing. Restriction on technology can significantly reduce the cost of health care, but the delays, inconvenience, and limitations to care with rationing would be strongly resisted by most Americans. An example of a growing technology area is telehealth:
Telehealth has already started to play an even more important role, especially as we move away from the traditional fee for service system and toward new models of care, including accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and other strategies that focus on outcomes. At the same time, the costs of telehealth technologies are dropping and [they are] becoming even easier to use. These technologies are becoming more widely prevalent in the marketplace, more accessible, and consequently, can be adopted more easily than perhaps 5 or 10 years ago. The pace of technological innovation is accelerating, but the cost of innovation is falling.
(Institute of Medicine [IOM], 2012 , p. 7)
Telehealth has implications for public health as it expands care and access to specialists into the community. A key to success will be the cost factor.
Aging of Society Health care expenditures rise with age, dramatically so at older ages. According to the latest population projections, individuals older than 65 years constituted about 14.1% of the total population in 2015; this proportion is expected to almost double by the year 2050 (U.S. Census Bureau, 2015). As people live longer, the percentage of those older than 85 years is also increasing. Therefore the number of those consuming the greatest amount of health care resources will rise more rapidly than the number of those who provide the monetary support for these resources. For example, the cost of care for Alzheimer disease and related dementias is considerable, and the rate of such dementias is expected to rise as Baby Boomers age, with the expectation that cost for this care—which in 2010 was between $159 and $215 billion, depending on what factors were included —is expected to double by 2040 if no effective treatment or cure is found for the diseases (NIH- supported study, 2013).
Pharmaceuticals A relatively new phenomenon that has influenced health care economics is the utilization of drugs, both over-the-counter and prescription drugs. New drugs are improving health outcomes and quality of life. These new drugs and new uses for older drugs are curing some illnesses, preventing or delaying other chronic diseases, and hastening recovery from yet other illnesses. As a result, during the last several decades, costs of prescription drugs have risen dramatically and have become a significant part of health expenditures. Seniors in particular are affected because many have chronic illnesses that require daily medications.
In 2003, to help alleviate the costs of prescriptions for seniors, Medicare added a pharmaceutical benefit for enrollees. With implementation of the Medicare Prescription Drug and Modernization Act (Medicare Part D), all Medicare recipients are eligible to purchase insurance coverage to offset the costs of prescription drugs. As with other health care services, once a funding source has been established, utilization and costs increase. One result is that as of 2016, about 10% of health care expenditures in the United States is for pharmaceuticals, and these expenditures continue to rise (NCSL, 2017).
Shift to For-Profit Health Care The final contributor to the increase in health care costs is a national shift from nonprofit health care to for-profit health care. This has given rise to the term health care industry. More and more large, for-profit organizations are taking over smaller community organizations. As the emphasis is on profit, mechanisms of achieving higher reimbursement have been developed, which have had an effect on health care costs.
Health Care Fraud and Abuse
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Health care fraud has been an ongoing problem. The billions of dollars spent on health care and the struggles for control between providers, consumers, and health care organizations have increased the risk of fraud and abuse. The Federal Bureau of Investigation (FBI) estimates that health care fraud costs the United States tens of billions of dollars annually (FBI, 2017). The FBI is the primary agency that handles this fraud. Though all areas of health care and all payers experience fraud, Medicare and Medicaid have the highest levels (National Health Care Anti-Fraud Association [NHCAA], 2016). A number of actions have been taken to address this problem. Among them are the False Claims Act Amendments of 1986, which allow private citizens to collect a percentage of recovered funds if they report fraudulent Medicare claims and monies are recovered as a result. The Health Insurance Portability and Accountability Act (HIPAA) contains a set of provisions that address fraud, including a Fraud and Abuse Control Program, the Medicare Integrity Program, and the Health Care Fraud and Abuse Data Collection Program. Each of these programs is designed to address concerns over health care fraud. In addition, HIPAA legislation dramatically raised funding for fraud enforcement activities (HHS/OIG, 2017).
Major health care fraud and abuse incidents have influenced the most vulnerable of the population (i.e., the mentally ill and older adults). For example, overbilling and unnecessary visits in home health care were reported across the United States, resulting in widespread reforms to Medicare reimbursement for home health services (Infante and McAnaney, 2004). Other significant abuses in recent years relate to ambulance/emergency transportation, overbilling/kickbacks, opioid prescription abuse, addiction treatment programs, money laundering, and compounding pharmacies (FBI, 2017).
BOX 12.2 Medicare Fraud What is Medicare fraud?
• Billing Medicare for services not received • Billing Medicare for services other than those received • Use of another’s Medicare card to obtain services
Be suspicious if providers tell you:
• Medicare wants you to have this service • They know how to get Medicare to pay for service • The more services provided, the cheaper they are
Be suspicious if providers:
• Change copayment of Medicare-approved services • Advertise “free” consultations to those with Medicare • Claim they represent Medicare • Use pressure to persuade you of the need for high-priced services • Use telemarketing as a marketing tool
Whenever you receive a Medicare payment notice, review it for errors. Make sure Medicare was not billed for services not received. Modified from Centers for Medicare and Medicaid Services: Help fight Medicare fraud. Retrieved from https://www.medicare.gov/Pubs/pdf/10111-Protecting-Yourself-and-Medicare.pdf
The ACA included additional provisions to reduce fraud and abuse in public programs. It encouraged screening of providers and enhanced oversight for initial claims for durable medical equipment suppliers. The law required Medicare and Medicaid program providers and suppliers to establish compliance programs and developed a database to share fraud and abuse information among federal and state programs. Finally, it increased penalties for submitting false claims and
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increases funding for antifraud activities (Kaiser Family Foundation, 2013). Box 12.2 describes consumer tips related to health care fraud and abuse.
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Public Financing of Health Care As the popularity and benefits of employer-provided insurance plans were recognized during the depression and post-WWII years, it became evident that the health care of some segments of society was being neglected. During the 1960s, a pervasive thrust for social justice in the public and political arenas presented the ideal opportunity for governmental participation in health care financing. In 1965, the federal government under President Lyndon Johnson enacted the first movement toward universal health care coverage. Titles XVIII and XIX, amendments to the Social Security Act, created Medicare and Medicaid, respectively.
Medicare Medicare is a federal entitlement program that is totally funded by a combination of payroll taxes, general federal taxes and beneficiary premiums. This program is intended to help cover the costs of health care for people 65 years of age and older and people who are disabled, have end-stage renal disease, or have been diagnosed with amyotrophic lateral sclerosis (ALS). Medicare is divided into four parts. Medicare Part A is basically hospital insurance. Services covered by Medicare Part A include inpatient care in hospitals and skilled nursing facilities (not unskilled or long-term care). It also covers hospice care and some home health care. Most U.S. residents are eligible for premium- free Medicare Part A benefits when they reach age 65, on the basis of their own or their spouse’s employment. Although Medicare Part A is an entitlement program, the enrollee must pay a deductible for health services. The Part A deductible is the beneficiary’s only cost for up to 60 days of Medicare-covered inpatient hospital care in a benefit period. Beneficiaries have to pay an additional copayment per day for days 61 through 90, and this copayment increases per day for hospital stays beyond the ninetieth day in a benefit period. The Centers for Medicare & Medicaid Services (CMS) website (http://www.cms.gov) provides current information on costs for beneficiaries.
Those individuals who are eligible for Medicare Part A may purchase Medicare Part B for a monthly fee. Medicare Part B is medical insurance that helps pay for out-of-pocket costs related to physician services, hospital outpatient care, durable medical equipment, and other services, including some home health care. The monthly premium paid by beneficiaries enrolled in Medicare Part B has changed over time. Premiums are now pro-rated, based on income, and in 2017 ranged from the standard of $134/month to a high of $428/per month for individuals earning above $214,000 or couples earning above $428,000 per year. In addition to the monthly premium, Part B requires subscribers to pay deductibles and coinsurance (CMS, 2017b). The CMS website provides current information on these costs.
Medicare Part C, also known as the Medicare Advantage plans, is optional “gap” coverage provided by private insurance companies that are approved by, and under contract with, Medicare and may include health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Covered services vary by plan and may include vision, hearing, and dental care, as well as other services and supplies not covered by Medicare Parts A, B, and D. Costs vary by plan, and to be eligible, the individual must have Medicare Parts A and B and must live in the service area of the plan (CMS, 2017b). Enrollment in Medicare Advantage plans has grown steadily, and more than 25% of Medicare beneficiaries are enrolled in these programs.
Medicare Part D was initiated in 2006 to help defray the costs of prescription drugs. Like Parts B and C, Medicare Part D is optional, and if eligible Medicare recipients choose this option, they must enroll in an approved prescription drug plan. Most participants in Medicare Part D pay a monthly premium, a yearly deductible, and copayments, with out-of-pocket costs based on the plan selected and drugs used. In addition to these costs, the enrollee is responsible for cost of prescription drugs once the total costs reach a certain amount in a year, which vary. This is termed the coverage gap or donut hole. When the enrollee’s out-of-pocket total for drugs reaches a particular level, Medicare will pay 95% of the costs of any further prescription drugs. The CMS website provides current information on the amounts to be paid. Fig. 12.1 shows current and projected Medicare costs for each of the four major parts.
Medicaid
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Title XIX of the Social Security Act established the Medicaid Program. Medicaid is a public welfare assistance program that was initially designed to finance health care coverage for the indigent. Eligibility for this program, a joint venture with state and federal funding, is determined by each state. Initially Medicaid was intended to focus benefits to children, pregnant women, the disabled, and impoverished elders. This changed dramatically, however, with implementation of the ACA, as funds were made available to provide health care for all adults below the poverty line—within states that elected to participate.
The federal government sets baseline eligibility requirements for Medicaid. State governments that wish to provide care to more citizens through this program can alter the eligibility requirements. For example, the federal government may set 100% of poverty as an eligibility requirement, but an individual state may set the requirement as 110% of poverty. This means that a family living in that state can have an income slightly above the federal standard and still qualify for Medicaid.
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FIG. 12.1 Average annual growth in Medicare beneficiary costs for Part A, Part, B, and Part D between 2016 and 2026.
Adapted from Kaiser Family Foundation: The facts on Medicare spending and financing, 2017. Retrieved from http://www.kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and-financing/.
The federal government mandates covered services, but state governments may provide more services. Mandated services covered by Medicaid for eligible recipients include inpatient and outpatient hospital care, physician’s services, vaccines for children, family planning services, rural health clinic services, home health care, laboratory and radiography services, and Early and Periodic Screening, Diagnosis, and Treatment services for children younger than 21 years. Care provided by pediatric and family nurse practitioners is covered. Optional services that states may elect to provide include optometrist services and glasses, intermediate care facilities for the mentally disabled, rehabilitation, physical therapy, and hospice (CMS, 2017c).
Aside from Medicaid, many children younger than 18 years are eligible for CHIP. Established in 1997, CHIP is a program that provides insurance for children of low-socioeconomic families who do not qualify for Medicaid. Like Medicaid, the program is administered by the states, which share the cost with the national government. The ACA required expansion of Medicaid and CHIP to cover many of those who were previously uninsured.
The final decision as to whether Medicaid would be expanded in a state was determined by each state. The law covered payment of services for newly eligible Medicaid beneficiaries until 2016; the federal government will pay 90% of the cost for several more years. Initially, 32 states and the District of Columbia opted for Medicaid expansion and 19 did not (Families U.S.A., 2017). It is anticipated that more of the “opt-out” states will reconsider in the future, however, and elect to expand Medicaid coverage to more citizens.
Governmental Grants Unlike individual health care services, governmental grants are directed toward funding large populations and different aggregates. Historically, the bulk of health promotion and disease- preventive measures has been limited to this arena of public health care. All three levels of government provide the major contribution of funding for these programs. On the national level the U.S. Department of Health and Human Services (HHS) administers this funding.
A variety of funding grants are available through the HHS (USDHHS, 2017). These “health- specific” grants are administered through the public health department at each state or community level. A large part of the federal government funding provided to the states is through “block grants.” These “blocks” of funds are provided to the states to affect the health of the public as a
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whole. There are specific restrictions on how these monies can be spent, including limitations on the population that receives the services and what types of programs are to be funded. The states use these monies to provide for the care of the public within these restrictions. Depending on the health needs of the state, these monies may be spent to provide direct aggregate care, but most often they are used for health promotion activities that are directed at a larger percentage of the population. Each level of government may make funds available for a specific health need of the members of the community.
To ensure that the needs of the community are being addressed, health care providers and programs may be required to compete for these funds. Proposals, grant applications, or requests must be submitted, reviewed, and prioritized. Funds are allocated on the basis of need and program merit. This type of funding is directed toward the population in general and not to specific individuals. When the funding is no longer provided, the programs cease, leading to lack of continuity of care. Historically, the funding priorities are closely related to the achievement of the Healthy People 2020 objectives. Limitations on the amounts provided are related to available governmental resources.
Active Learning
Interview an official from your local health department about finances. Identify strengths and weaknesses. Consider solutions for one of the weaknesses.
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Philanthropic Financing of Health Care A limited amount of the nation’s health care bill is paid by philanthropic sources, whose priorities are usually capricious and oriented toward research or treatment/interventions related to a specific disease or population aggregate. Eligibility for services through these associations is generally limited to the specific disease or population of interest, as with the American Heart Association, March of Dimes, or Susan Komen Foundation. Few direct services are rendered, and these services are approved on individual case considerations. Ancillary health care needs such as transportation, parental housing, or wigs may be addressed. Informational and research activities constitute the majority of services provided by these types of organizations. The organizations fund many educational programs that increase awareness of specific diseases, screening procedures, and preventive measures.
An example of a philanthropic national organization designed to provide care for a specific population group is the Shriners Hospitals for Children (http://www.shrinershospitalsforchildren.org). The services and costs related to this care, including transportation, are often provided to the eligible individual free of charge. The only requirement for care is meeting criteria set by the supporting organization.
Some of the private, nonprofit entities or associations that provide philanthropic services include professional associations such as the American Medical Association, the American Dental Association, and the American Nurses Association. Key groups that support research related to health care, health care delivery, and policy making are the Robert Wood Johnson Foundation (http://www.RWJF.org), the Kaiser Family Foundation (http://www.KFF.org), and the Pew Charitable Trusts (http://www.Pewtrusts.org). Examples of disease-specific, philanthropic organizations that provide important, patient-focused education, information, and other resources include the American Cancer Society (http://www.Cancer.org), the Alzheimer’s Association (http://www.Alz.org), and the American Diabetes Association (http://www.Diabetes.org).
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Private Health Care Insurance Historical Perspective During the 1930s, in an effort to provide care and avoid bankruptcy, health care providers began to establish health insurance plans. One of the most recognizable of these early plans is Blue Cross and Blue Shield. Blue Cross/Blue Shield was instituted by an agreement between Baylor University Hospital in Dallas and the Dallas area public school teachers. Those enrolled in the plan, called enrollees, paid a monthly fee for a guarantee of health care. Baylor providers delivered services to the enrollees and collected payment from the health insurance plan. The insurance plan paid fees plus its administrative costs from money collected from the enrollees (Young and Kroth, 2018).
Throughout the Depression and World War II, when prices and wages were frozen, industries began to offer health care insurance as a “fringe benefit” to employees. In 1953, as a further employer incentive to offer health care coverage to employees, money spent on health insurance was declared tax-exempt. Over the years, workers’ union groups began to negotiate for these benefits. With more available financial resources and the patient largely insulated from the costs, health care expenditures increased. Further, reimbursement based on operational expenses represented a strong incentive for health care expansion (Higgins, 1997). Private, employer-based insurance became the prevailing model in the United States. This persisted even through implementation of Medicare and Medicaid in the mid-1960s. For the most part, until passage and implementation of the ACA, reasons for lack of health care insurance were costs, change in employment, or changes in eligibility such as change in marital status or death of spouse or parent. Even though the United States has an employer-based insurance system, only about half of Americans obtain insurance from their place of employment in 2015 (down from more than 60% in 2012) (Kaiser Family Foundation, 2017a). Despite provisions from the ACA, smaller businesses typically find it more costly to provide coverage, and many businesses do not provide coverage for part-time employees. Indeed, despite attempts at controlling them, annual insurance premiums (combined worker and employer contributions) in 2016 averaged more than $18,000 for a family ($6400 for an individual) (Kaiser Family Foundation, 2017b).
Types of Health Care Plans The early Blue Cross and Blue Shield plan was an example of an indemnity plan. This plan paid all of the costs of covered services provided to the enrollee. The enrollee enjoyed free choice of provider and services. Indemnity plans preserved the enrollee’s right of choice and allowed the person to manage his or her own health care. These plans became very costly because there were no incentives for cost containment. Although indemnity plans are still available, the monthly cost of enrollment has increased to exorbitant amounts, making them cost prohibitive. In an effort to support these plans while preserving freedom of choice, mechanisms of cost sharing were introduced. These cost-sharing methods include copayment, deductible amounts, and coinsurance. All of these methods represented efforts to have the enrollee share in the cost of health care.
As health care costs escalated, variations in health care insurance plans were developed. Industries and corporations, the major providers of insurance coverage, began to look for a more economical means of providing health care to their employees. Kaiser Permanente decided to assemble their own health care programs. They built hospitals, hired physicians, and provided health care services to their employees. In an effort to market this concept, Dr. Paul Elwood coined the phrase health maintenance organization (HMO) (Higgins, 1997). HMOs were designed to provide more comprehensive care, but this type of program lacks enrollee freedom of choice. In HMO plans, preventive care is covered and encouraged, but specialty care is somewhat restricted, and HMOs are encouraged to reduce costs by providing only the most necessary services. This loss of choice led to a decrease in the popularity of HMOs. In the United States, the number of HMO plans peaked in the mid-1990s, when about 31% of the population was enrolled in them, and they continue to represent a small portion of the plans. In early years, HMOs were considerably less expensive than other insurance plans, but the difference is now relatively small. In 2010, about 19% of enrollees selected HMO plans, but their popularity has continued to decline, as in 2016 only 15% selected HMOs (Kaiser Family Foundation, 2017b).
In an effort to compete with the HMO, physicians and hospitals organized the independent
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practice model (IPM). The IPM was a separate entity that provided services to enrollees of one insurance company. This model evolved into the preferred provider organization (PPO). These types of insurance plans negotiated with health care providers for services at a reduced rate in exchange for a guaranteed increase in consumers. A negotiated reimbursement rate allows the cost of the plan to be somewhat controlled. Plan enrollees are offered cost incentives for choosing health care from within the plan’s network of health care providers. Because they receive a specific amount of reimbursement, regardless of the rendered services, providers have an incentive to be conscious of the costs of the services provided (Young and Kroth, 2018). PPOs are more flexible than HMOs, but to receive full benefits, the covered individual must use network providers. PPOs are somewhat more expensive than HMO plans (about $90 month on average), but they are the most common type of insurance plan in the United States. Although down from 60% of all plans in 2009, in 2016, almost half (48%) of private insurance plans were PPOs.
Point-of-service (POS) plans combine elements of the HMO and the PPO. In POS plans, the covered individual designates an in-network physician as the primary health care provider (PCP). If the individual goes outside the network for care, he or she will be responsible for most of the costs unless referred by the PCP. POS plans were common during the early years of the twenty-first century (about 12% in 2008), but interest dropped off over time. In 2016, about 9% of all insurance plans were POS plans (Kaiser Family Foundation, 2017b).
High-deductible health plans (HDHP) began in the early 2000s as a method to involve the consumer in health care decisions. The intent was to encourage employees to select plans with lower premiums but more pronounced up-front cost sharing (i.e., higher deductibles). One incentive is to have the health care consumer become more involved in health care decisions from an economic standpoint and to “shop around” for lower-cost care. Many HDHPs included health savings accounts (HSAs), which are tax-free contributions that employees may make to a fund to cover their health care expenses (Young and Kroth, 2018). By 2016, HDHPs have become the second most prevalent insurance plan and represent about 29% of all plans in the United States (Kaiser Family Foundation, 2017b).
Genetics in Public Health
Health Insurance and Genetic Discrimination The National Library of Medicine (2018) explains that “genetic discrimination occurs when people are treated differently by their employer or insurance company because they have a gene mutation that causes or increases the risk of an inherited disorder.” Discrimination with respect to hiring or the ability to get health and life insurance is a common concern of people who seek or are offered genetic testing. These fears may keep them from getting genomics-based tests or participating in research to develop new tests or therapies.
There are federal laws specifically designed to protect people against genetic discrimination. The most comprehensive of these is the Genetic Information Nondiscrimination Act (GINA). GINA has been in effect since 2009 and prohibits genetic discrimination by making it illegal for health insurance providers to use or require genetic information to make decisions about a person’s insurance eligibility or coverage. GINA also prevents genetic discrimination in employment, because employers are forbidden to use a person’s genetic information in hiring or promotion decisions.
It is important to realize that GINA does not extend to those in the U.S. military or those receiving health benefits through the Veterans Health Administration or Indian Health Service. In addition, it does not protect against genetic discrimination for life, disability, or long-term care insurance.
Portions of other laws are also applicable to the prevention of genetic discrimination. Among them are the Health Insurance Portability and Accountability Act, the ACA, and the Americans with Disabilities Act. Adapted from National Human Genome Research Institute: Genetic discrimination, 2017. Retrieved from https://www.genome.gov/10002077/; U.S. National Library of Medicine: What is genetic discrimination? 2018. Retrieved from https://ghr.nlm.nih.gov/primer/testing/discrimination
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Private Insurance Costs of private health insurance are staggering, often prohibitively high, even when sharing the costs with employers. There are, of course, millions of Americans who are self-employed or who do not work for a company that provides health insurance for all employees. This is the group that has been the focus of the ACA’s “health exchanges.” The health exchanges are the government- regulated marketplace for health insurance plans. Some of the health exchanges were developed and monitored by the individual state after implementation of the ACA, but most states opted to use the federally designed exchange (Shi and Singh, 2015). In the individual marketplace, through the exchanges, individuals can chose between four tiers of standardized plans: bronze, silver, gold, or platinum. Costs of the plans vary based on cost-sharing levels selected and other actuarial factors. Because of the costs, many plans are subsidized through tax credits or other mechanisms (Young and Kroth, 2018).
Reimbursement Mechanisms of Insurance Plans Retrospective Reimbursement When insurance plans were initially offered, the customary method of reimbursement was a fee for the service rendered, or retrospective reimbursement. Calculation of the fee was based on the cost of providing the service. Included in this “umbrella” of costs were such things as salaries, supplies, equipment, building depreciation, utilities, and taxes. Cost-based reimbursement encouraged inflated prices and fraud. Physicians were encouraged to overtreat patients, and participants were encouraged to overuse the health care system (Shi and Singh, 2015).
Prospective Reimbursement Prospective reimbursement, or the prospective payment system (i.e., the PPS), a concept derived from the HMO method of payment, was implemented as a financial alternative to cost-based reimbursement. In the PPS, care, no matter what the provider’s cost, is reimbursed to hospitals according to a predetermined amount. The federal government introduced this method of reimbursement for Medicare in 1983, and an immediate savings was noted. The prospective reimbursement rates are based on diagnoses and patient characteristics and are designated by the term diagnosis related group (i.e., DRGs). These factors are represented by codes, following the International Classification of Diseases, Tenth Edition, or ICD-10 (CDC, 2017).
For determination of the prospective amount, Medicare depends on the DRG to calculate the reimbursement. The amount to be paid to the provider is determined according to the client’s primary and secondary diagnoses, age, gender, and complications. This amount is deemed adequate compensation for treatment of the client’s health issues. If the provider, at first limited to hospitals but later other types of providers, can provide the treatment for less than this amount, a profit is made. If the required services cost more than this amount, then the provider incurs a loss (Young and Kroth, 2018).
Implementation of the PPS led to a reduction in Medicare costs but did not result in overall health care cost savings as intended. Hospitals developed cost shifting as a means of supplementing the loss of Medicare funding. Private insurance’s reimbursement continued to be cost-based. Therefore hospitals could include the loss from caring for Medicare patients in their cost. Private insurance companies were paying for the cost of providing care to their enrollees and to Medicare patients.
Only a few years after implementation of the PPS by Medicare, private health care plans followed the government’s lead. In an effort to ensure appropriate reimbursement, more sophisticated methods of calculating the relative cost of health care were developed. Actuarial classifications ensured that adequate premiums were charged for the projected health care needs of those enrolled, and other means of cost control began to emerge. Managed care groups negotiated with health care providers to render care for a specified amount of reimbursement based on community ratings modified by group-specific demographics. Prospective reimbursement creates incentives to control costs but also leads to instances of undertreatment and underuse of the system.
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FIG. 12.2 Personal health care expenditures: Source of funds/type of expenditure. Modified from Department of Health and Human Services, Centers for Medicare and Medicaid Services, Office of Actuary, National Health Statistics Group: Health, United States, 2016—individual charts and
tables: spreadsheet, PDF, and PowerPoint files, 2017. Retrieved from https://www.cdc.gov/nchs/hus/contents2016.htm#fig23.
Similarly, physician services are given current procedural terminology (CPT) codes. Coding of the patient’s illness determines reimbursement. Specialists in coding, as well as computer programs, are employed by both third-party payers and service providers. Third-party payers’ code specialists scrutinize the claims for the appropriate data to support the code. Service provider code specialists are paid to ensure that the code is as accurate as possible to obtain the higher reimbursement. The appropriateness of services is based on the diagnosis code. For example, spirometry is appropriate (reimbursable) when the patient’s diagnosis code indicates a variety of pulmonary and nonpulmonary conditions. Specialists in coding can quickly identify these codes, thus increasing payment for services. Physician visits, or CPT codes, are reimbursed on the basis of the documentation of the degree of “medical decision making” and time spent with the patient. Computerized medical record programs increase the ability to ensure that the visit can be reimbursed at the highest rate possible. This development has changed health care practices to the utilization of services that are low in costs and higher in reimbursement. High-cost services are limited or are not offered.
Fig. 12.2 illustrates how the nation’s health care dollar is spent and the sources of funding for key years.
Covered Services Until implementation of the ACA, insurance plans designated the types of services for which a plan would be financially responsible. When first developed, health insurance was meant to be a means of protecting an individual or family from economic catastrophe should a serious illness occur. Once an employee’s fringe benefits included health insurance coverage, expanded benefit packages were developed. The scope of covered services began to widen to include such things as physician’s office visits, medication, and dental costs. Unions began to negotiate for such expansion of covered medical services in lieu of additional wages.
When health care costs increased, so did the price of enrollment into the insurance plans. Industries began to refuse to pay these higher premium rates. Workers became disgruntled when their employers passed the cost of increased rates to them. To curtail the escalating premium price, insurance companies began to limit the covered services and dictate the conditions under which these services would be covered. Sites of care delivery changed. More treatments were required to be delivered outside the hospital or in ambulatory care clinics or ambulatory surgical centers. The
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patient was held financially responsible for “uncovered” services. Providers were pressured to comply with these requirements. Providers began to modify the delivery of health care to accommodate for these changes. After implementation of the PPS and various managed care options, the rate of hospitalization declined dramatically and the number of outpatient services increased.
All of these changes resulted in conflicts among providers, patients, employers, and the insurance plans, particularly when services deemed necessary by the consumer and provider were denied insurance coverage. Employers looked to the insurance companies to provide health care services at a reasonable price. Insurance companies searched for ways to control costs, and providers searched for ways to deliver needed care within the confines of the health care policy. Table 12.1 describes some of the advantages and disadvantages of insurance reimbursement plans.
TABLE 12.1
Consumer Advantages and Disadvantages of Insurance Reimbursement Plans
Type Advantages Disadvantages Indemnity No gatekeeper High premiums Fee for service Unlimited choice of providers Potential for overuse
Full access to all services No incentive for cost containment Managed care “Credentialed” providers promote quality
assurance Health maintenance organization (HMO)
Comprehensive care/primary care provider to oversee all care
Restricted to plan provider except for emergencies
Lower premium Potential for lower-quality care to maximize costs No or reduced deductibles or copayment Gatekeeper referral needed to see specialist
Preferred provider organization (PPO)
Greater selection of providers than with HMO Most expensive premiums
Expedited provider reimbursement Additional cost for out-of-plan provider Lower premiums Potential for lower-quality care to maximized costs
Point of service (POS) More flexibility than HMO Deductible required Comprehensive services with plan 20%–50% copayment for out-of-network services
Primary care provider referral may be needed for specialized care
High-deductible health plan (HDHP)
Lower deductibles Higher out of pocket when services are utilized
Encourages consumer involvement Must monitor medical expenses to determine when deductible is met
Often have health savings account to help defray costs
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Cost Containment Limiting health care costs is an imperative. All recent presidents have recognized that spiraling health care costs have eroded an already suffering economy. The public’s increasing demand for care has increased costs, and the costs need to be controlled. This concept is known as cost containment. Numerous attempts to control costs have been made over the years, but none has been more than marginally successful.
Historical Perspective of Cost Containment In addition to implementation of the PPS, health insurers and governmental sources attempted in the mid-1980s to curtail unnecessary proliferation of medical technology by requiring a certificate of need for additions to current health care buildings or services. To further reduce use, hospital records were reviewed for the appropriateness of care provided. Admission and treatment of hospitalized patients were reviewed by peer standard review organizations. Physicians and other medical personnel reviewed the hospital records and counseled the attending physician about unnecessary or excessively lengthy stays in the hospital as well as unwarranted services.
Ethical Insights Cost Containment: How Will You Make Decisions? You are the gatekeeper meeting with others in your community health organization to determine what services to provide to clients. You have $400,000 to divide among the needs. Who of the following clients will receive the required treatment? Who will not?
• A child with broken leg needs physical therapy (estimated cost: $10,000). • A 55-year-old man requires knee replacement surgery and physical therapy (estimated cost:
$40,000). • A 76-year-old woman requires hip replacement (estimated cost: $40,000). • A 32-year-old woman with leukemia requires a bone marrow transplant (estimated cost:
$350,000). • The community clinic needs new equipment for laboratory tests (estimated cost: $60,000). • There is need for a new nurse who can act as a case manager for patients with complex
diseases (estimated cost: $75,000 per year).
Questions to consider:
• How does the American Nurses Association Code of Ethics apply to this case? • What factors should be considered in the decision? • How much does the cost of treatment affect the decision? • How much does the age of the patient affect the decision? • Is social justice a factor in the decision?
The cost reduction, as a result of prospective payment and other efforts, gave rise to managed care. Unable to shift costs to other entities, and with a predetermined reimbursement rate, providers searched for the most cost-effective mechanism of care provision. Greater ability to predict the cost of care enabled health care plans to negotiate the best value for their premiums.
Current Trends in Cost Containment The managed care form of health care financing changed economic incentives and forced health care providers to rethink health management decisions. Treatment recommendations may be tied
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more to “Can you afford this?” rather than “This is best for you.” Costs of the service rendered, rather than enhancement of revenue through service provision, must be considered. These economic or cost-containment incentives can be divided into the following broad categories: capitated reimbursement, access limitation, and rationing.
Capitated Reimbursement The growing visibility of managed care models and their associated success in cost containment through the use of prospective reimbursement to influence provider practice gave rise to various arrangements that link health care financing to service delivery such as managed care. Managed care organizations create partnerships with health care providers using financial incentives to prevent overuse. Statistical norms, practice parameters, and population data determine the capitated, or maximum, payment for services. This is the maximum reimbursement amount that the health care provider will receive for the provision of care. The actual cost of provision of care does not affect the reimbursement. Health care providers must provide appropriate medical care while being cognizant of health care costs. As a reward for conservative practices, health care providers may receive a specified amount of money or a percentage of the agreed reimbursement if services are delivered below the limit set by the third-party payer. Providers whose services are inadequate or exceed this limit may be excluded from the network.
Research Highlights
Hospital Readmissions from Home Health Care Before and After Change to Prospective Payment System In an effort to control the Medicare home health expenditure, home health reimbursement was changed from a fee-for-service system to a prospective payment system (PPS). This changed the reimbursement from a per-visit fee to episodes of care. Each episode of care begins on the first billable day and proceeds for a period of 60 days. Reimbursement is based on the diagnosis and type and level of care predicted to be required.
Through the use of a comprehensive evaluative tool, the Outcome and Assessment Information Set, a client is placed in a home health resource group (HHRG). Payment for services is based on the HHRG. Another important factor is that payment is received in two parts: 60% at the start of care and 40% after the episode of care is completed. Adjustments in final payment are made according to changes in the client’s condition and may result in more or less than anticipated.
Anderson and colleagues (2005) studied unplanned hospital readmissions, which are an aspect of adverse change in patient condition or outcome. This study was designed to compare characteristics of clients rehospitalized during home health care before and after the institution of PPS.
The researchers determined that it was difficult to conclude whether PPS has any negative effect on home health care patient outcomes. Post-PPS clients were judged to be sicker at the time of rehospitalization and were almost twice as likely to be readmitted for another diagnosis. The investigators concluded that, since the institution of PPS, the hospital length of stay has decreased, with the result that clients are sicker at time of discharge.
The study shows that the first 2 weeks after hospital discharge are the most critical. Payments for home health services are suspended at the time of readmission, pending a client’s return to home health care after rehospitalization. If the client does not return to home health care and the agency has completed five visits, 60% of the payment will awarded. If the agency has not completed the five visits, only 11% of the amount will be awarded. This arrangement might serve as an incentive for agencies to increase the number of visits after the initial hospital discharge but not after the second discharge. Data from Anderson MA, Clarke MM, Helms LB, et al.: Hospital readmission from home health care before and after prospective payment. J Nurs Scholarsh 37(1):73–79, 2005.
Cost Containment Through Access Limitation All third-party payers, or insurance plans, control access to health care through designation of covered services. Managed care organizations designate the type of covered services and specify the
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conditions under which the service is covered. Some services may only be accessed upon approval or referral from physicians who are used as gatekeepers. The enrollee must choose a primary care provider and consult this provider for a referral before seeking specialty services. Without this referral, the enrollee is financially responsible for the service. Even with the referral, choices may be limited to the providers who have contracted with the managed care plan.
Managed care plans may require that less costly health care modalities or medications be used. Exceptions to these modalities require justification. More technologically advanced and expensive treatments may be accessed under the most stringent conditions. Preauthorization requirements determine the medical necessity of the service. The process is so complex that the client may not be aware that the service is not covered until the reimbursement for the service is denied.
Cost Containment Through Rationing Rationing is best described as determining the most appropriate use of health care or directing the health care where it can do the most good. Clinical Example 12.1 dramatizes the problem.
Clinical Example 12.1 A middle-aged woman was diagnosed with ovarian cancer. She was covered by Medicaid, lived alone in subsidized housing, and had a distant relative in another state. After surgery some years ago, she used home health services through the city home health agency. After conventional and high-dose chemotherapy failed, her physician recommended autologous bone marrow transplantation, which was considered experimental at the time. The procedure was approved and performed. Medical costs exceeded $200,000, but the patient died 2 months later.
Was the treatment in the Clinical Example a wise use of medical resources? Health care is not an exact science; too many variables exist. What appears to be the best course of action for one is not the best course of action for another. Making accurate treatment decisions is difficult, and the ramifications of a mistake are great. Complex socioeconomic factors also must be considered. Health care providers and third-party payers, including the federal government, are currently investigating the outcomes of health care practices to determine what methods, if any, can be instituted to improve the accuracy of these choices. Research into the area of treatment outcomes has led to major changes in treatments, many of which are quite costly. This situation presents a dilemma when decisions must be made as to their use.
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Trends in Health Financing The public’s demand for affordable health care has created a new environment for health care financing. The ACA dramatically changed a number of things, particularly with respect to eligibility for Medicaid and regarding what is included in health insurance plans. Indeed, one of the significant elements of the ACA was the inclusion of the essential health benefits that must be covered in plans offered in the exchanges. Among the essential benefits are ambulatory care, emergency services, hospitalization, pregnancy/maternity and newborn care, mental health and substance use disorder services, and preventive care (healthcare.gov, 2017). It has been argued that requiring everyone to purchase all of these benefits has resulted in increasing the costs for all, even if the purchaser does not want or need the benefit.
Competition among health care providers and third-party payers has led to new and innovative health care. Outpatient services, patient education packages, electronic health records, and telehealth are just a few of these innovations. Increased competition has required insurance plans to be sensitive to the needs of the employee organizations and their enrollees. Individualized plans of covered services can be created. Enrollees can choose the plan that provides them with the services they desire at a selected cost. Health care providers advertise to ensure that the consumer selects an insurance plan that includes their services. Some providers, such as hospitals, campaign for inclusion in a plan.
Despite implementation of the ACA, along with the other measures described here, health care costs have continued to increase. Major changes are still needed, and indeed inevitable, as the status quo is not sustainable. Although more Americans have health insurance now than before implementation of the ACA, the costs of both insurance and of health care per se have continued to rise (Shi and Sing, 2015; Young and Kroth, 2018). Coupled with concerns over evolving demographics (i.e., aging of the Baby Boomers and resultant expansion of Medicare costs), it is apparent that more policy changes and interventions need to take place. Some of the more commonly described are mentioned here.
Cost Sharing Aware of the amount that the employer is willing to contribute for basic coverage, a third-party payer or insurance plan may propose several options, giving the employee freedom to choose services desired. Employees willing to pay may be able to increase the covered services not provided by the basic plan. This arrangement is known as cost sharing. Cost sharing may also require the consumer to pay a greater portion of the bill for covered services in return for lower premiums. Enrollees may opt to pay a higher premium for the freedom to choose providers, or elimination of the gatekeeper. This can result in increased consumer control of health care.
Health Care Alliances The creation of powerful regional or statewide insurance purchasing pools, or health alliances, is seen as one of the means of reform for the health care industry. The alliance would define basic benefits that all insurers would have to offer to everyone at the same price, regardless of health status. These alliances would not regulate insurance prices. Health alliances would collect premiums and help consumers choose among competing insurers and plans. The consumer’s choice would be based on published, simple, standard information about benefits and outcomes of the different available plans. Plans would have to compete by offering better outcomes or lower cost. Insurers would have to contract with providers who find ways of delivering cost-efficient care. Medicare is currently participating in health care alliances. Enrollees are given a choice between traditional Medicare, Parts A and B, and Medicare Advantage.
Self-Insurance Many organizations, such as large companies and governmental entities (e.g., school districts or municipalities), have used health care information collected by insurance plans to self-insure their employees. This development has enabled industries and other types of organizations to reduce the administrative cost of insurance. Unlike the large industrial HMOs, self-insured status
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organizations administer their own health care plan and purchase health care services from an established insurance plan. In these cases the organizations or businesses are relying on a healthy employee population that will require less health care. The organization or business that uses self- insurance takes a risk and needs to ensure that it can cover any major costs. Health care reform will require that there be sufficient funds to cover these costs.
Health Savings Accounts and Flexible Spending Accounts Another source of funding for uncovered services are the HSA (mentioned earlier) and the flexible spending account (FSA). Both are set up during insurance determination by the employee. With both the HSA and the FSA, the employee determines how much he or she will have to spend for uncovered services and arranges to have this amount deducted from his or her paycheck; these monies are “pretax.” When these services are incurred, the employee pays for them with this account. There are some differences between the two types of accounts. First, the HSA is associated with high-deductible health plans (HDHP) and the funds are “owned” by the employee. In contrast, the FSA is set up by the employer through any health insurance plan and is “owned” by the employer. For the FSA, the employee continues to pay into the account until the estimated amount is reached. If the employee overestimates the cost, the remaining amount is forfeited. For HSAs, both the employer and employee contribute to the fund, and the balance does not expire (i.e., unused amounts will remain in the account to be used in subsequent years). Finally, there are limits to the amount of pretaxed funds that can be put into each account. In 2017, FSAs were limited to $2,600; contributions to HSAs were limited to $6,750 for a family with a HDHP.
Reimbursement for Health Promotion and Disease Prevention Initiatives Unfortunately, until recent years, reimbursement for health promotion and disease prevention has been limited. Whereas, most health insurance plans, both private and public, pay for screening procedures, funding or reimbursement for treatment modalities such as support groups for smoking cessation, home safety evaluation, and relaxation techniques has been sporadic. Obesity is one of this nation’s most common health problems, yet the costs of weight loss programs are rarely reimbursed.
Research into barriers and facilitators to changes in lifestyle continues to be funded well below curative treatment research. Lifestyle change interventions are slow to be developed and even more difficult to implement and evaluate. Mandated services required by the ACA include such preventive services as counseling for management of obesity, prevention of sexually transmitted diseases, and tobacco cessation. Until these types of interventions are directly financed, they most likely will not become widely implemented. With the rise in obesity there have been state proposals, and some have been initiated, to incentivize healthy eating habits, such as taxing the sale of sodas and putting calorie counts on restaurant menus. This type of approach relies heavily on policy and subsequent legislation and causes some people to protest because they consider it invasion of their personal decisions. Many businesses, such as restaurants and large fast-food chains, have added calorie and nutritional information to their menus.
Active Learning
1. Evaluate a family’s health care coverage. Investigate the type of coverage and the ability of this coverage type to meet the needs of the family. Would another type of insurance coverage meet more of the family’s needs? What prohibits their ability to obtain this coverage?
2. Interview public health nurses employed in a public health department about their perception of funding for health promotion/disease prevention.
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Health Care Financing Reform It was estimated that in 2011, before implementation of the ACA, about 18% of nonelderly Americans were uninsured (Kaiser Family Foundation, 2016). Underinsurance, likewise, has been a problem, as the underinsured cannot fully cover their health needs. Certain racial/ethnic groups have higher rates for both uninsurance and underinsurance. The ranking of such groups from highest to lowest rate of noninsurance is Hispanic, black/non-Hispanic, Asian, multiracial, and white/non-Hispanic (Kaiser Family Foundation, 2016). After implementation of many provisions of the ACA, by 2016 more than 17 million additional people had obtained health care coverage, dropping the percentage of uninsured Americans to about 10% (Kaiser Family Foundation, 2016).
Lack of insurance is the major factor associated with lack of access to medical care. Uninsured adults are more than three times as likely as insured adults to go without needed medical care (NCHS, 2017). In order to appreciate the potential impact of health care reform, one can look at the issue of lack of insurance among young adults:
The uninsured rate among young adults, ages 19 to 25, has improved slightly in the last year. The share of young adults that were uninsured decreased from 30.0% in 2010 to 27.9% in 2011, due in part to the ACA provision allowing them to remain on a parent’s private health plan until age 26. The change in coverage for this age group accounted for about 40% of the overall decline in the number of uninsured. However, young adults continue to have a high uninsured rate.
(Kaiser Family Foundation, 2012, p. 9)
The National Academy of Medicine (NAM), formerly called the Institute of Medicine (IOM) (2012) notes that health literacy and communication will be key factors in success as consumers try to figure out the key elements of the ACA and to use the exchanges to obtain insurance if their employers are not providing this information directly. The success of this process will affect access to health care.
Access to Health Care Access to health care is a complex situation that is defined by the circumstances of the individual. The primary concern is inadequate access to health care, which leads to unnecessary illness. Most Americans want to believe that the best possible health care will be available for them and their family members at any time, regardless of their age, sex, race, or ability to pay. Anything that obstructs this pursuit can be considered a barrier to health care.
Financial support for health care, through either private insurance coverage or participation in government programs, is the mechanism that is largely responsible for access. Lack of a source for health care financing due to lack of insurance coverage, preexisting conditions, unapproved care, and physicians who do not participate in the health plan available to the patient represent the most common factors attributed to difficulty in obtaining care. Other impediments to health care access are physical barriers, including structural inaccessibility, lack of appropriate equipment, hours of operation, convenient transportation, inadequate services when needed, and inability to communicate.
Inequality in the distribution of health care services represents another type of physical barrier. Even those with insurance coverage may be unable to locate participating health care providers. Opportunities to seek health care, especially preventive health care, during work hours is often discouraged by employers, although this situation is gradually changing as some employers recognize that preventive care can reduce overall costs. Rural areas and inner cities have been recognized as medically underserved for many years. Government incentives for increasing available medical services in these areas have not solved the problem.
Sociological barriers to health care access exist among poor and ethnic Americans. Poor outpatient diagnosis and treatment, increased use of emergency departments for primary care, and reluctance to hospitalize are possible explanations. Language and fear of reprisals have become important sociological barriers. Many of the poor and uninsured are illegal aliens, and seeking medical attention, even during illnesses, may have severe repercussions. Disparities are discussed
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later in the text.
Historical Perspective National health insurance is not a new concept. European countries began a social model of health insurance in the early 1900s. In 1916, President Theodore Roosevelt advocated enactment of a form of national medical coverage. President Franklin Roosevelt wanted national health insurance to be part of the Social Security Act of 1935, but that provision did not pass (Higgins, 1997). During the administration of President Lyndon Johnson, however, a modified form of national health insurance, Medicare and Medicaid, was instituted.
Before the 1930s, most Americans were uninsured. Most health care providers considered it their duty to donate time and services to charity. Hospitals and clinics maintained charity wards. Society believed that those who could, and those who could not, should help themselves. The enactment of governmental entitlement programs, coupled with the availability of health care insurance as a benefit of one’s occupation, helped change this belief. Quickly, the pervasive societal view was that those who could not help themselves should get government assistance or go to work (Higgins, 1997).
As discussed previously, in the 1960s Medicare and Medicaid brought about national health insurance coverage for older adults, the disabled, and those living below the poverty level— particularly children. Expansion of Medicaid with CHIP in the 1990s expanded care coverage for children of the “working poor,” or those whose employers did not provide insurance.
Efforts to address access to health care reemerged in the 1990s, when Bill Clinton attempted to reform the health care system, ensure coverage, and reduce health care costs. The initiative was headed by Hillary Clinton, but after about a year of debate and numerous proposals, the Clinton plan failed to reach a consensus. This was attributed to widespread opposition from various health care provider groups and organizations as well as lack of public support. Continuing rising costs combined with eroding access through the early 2000s contributed to the election of Barak Obama and a new mandate to enact health care reform. After considerable debate, Congress passed the Patient Protection and Affordable Care Act (PL111-148), also known as the Affordable Care Act, which was signed into law March 23, 2010. Although the ACA did not ensure “universal coverage,” it was originally estimated that when fully implemented, an additional 32 million people would have access to health insurance coverage (Kaiser Family Foundation, 2013).
The ACA was an extremely complex piece of legislation, and the final version of the bill exceeded 2000 pages. Among the law’s provisions are mandating that all citizens obtain health insurance, expanding Medicaid eligibility, subsidizing insurance premiums for low-income purchasers, prohibiting denial of coverage for preexisting conditions, and establishing health insurance exchanges. Costs for expansion of coverage and subsidies would be offset by a combination of taxes and fees, reduction in payments for Medicare and Medicaid services and prescription drugs, and enhanced efforts to reduce Medicare fraud and abuse. Box 12.3 outlines some of the major provisions covered in the ACA.
The ACA remains highly controversial, and additional legislative and legal challenges are anticipated. All health care providers and consumers should remain alert to both short- and long- term changes. Additional information about the ACA can be found in Chapters 10 and 11.
Active Learning
1. Learn more about changes in health care reimbursement due to health care reform by visiting https://www.cms.gov/cciio/index.html.
This CMS website is the Center for Consumer Information and Insurance Oversight. What type of information is provided? What is the value of this information to consumers?
2. Investigate the ACA from the points of view of the consumer, health care provider, and third-party payer and community health. How has it affected the concerns of each of these constituents? What more needs to be done?
3. Examine the status of health care reform implementation in your state. How has the community been informed about changes? Has this been effective? How is it affecting
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community health in your state?
BOX 12.3 Key Provisions of the Patient Protection and Affordable Care Act (P.L. 111-148)
Individual Mandate—Requires U.S. citizens and legal residents to have qualifying health coverage.
Employer Requirements—Requires employers with more than 50 employees to offer coverage or vouchers for full-time employees; requires employers with more than 200 employees to enroll employees into health insurance plans offered by the employer.
Expansion of Medicaid—Expands Medicaid to all individuals under age 65 with incomes up to 133% of the federal poverty line.
Expansion of CHIP—Requires states to maintain current income eligibility levels for children enrolled in the Children’s Health Insurance Plan (CHIP) until 2019.
Premium and Cost-Sharing Subsidies to Individuals—Creates insurance exchanges to provide premium credits and subsidies to individuals and families with incomes between 133% and 400% of the federal poverty level.
Changes to Private Insurance—Establishes a temporary national high-risk pool to provide health coverage to individuals with preexisting medical conditions; establishes a process for reviewing increases in health plan premiums and requires justification of increases; provides dependent coverage for children up to age 26 years for all individual and group policies; prohibits health plans from placing lifetime limits on the dollar amount of coverage and from rescinding coverage; establishes a website to help residents identify health coverage options; permits states to form health care choice compacts and allow insurers to sell policies in any state participating in the compacts.
Cost Containment Provisions—Requires rules to simplify health insurance administration by adopting a single set of rules for payment, verification, and claims status; restructures payments to Medicare Advantage plans; reduces waste, fraud, and abuse in public programs by allowing providers to have screening-enhanced oversight periods for new providers and suppliers; increases penalties for submitting false claims.
Prevention and Wellness—Improves prevention by covering preventive services and eliminating cost sharing for preventive services in Medicare and Medicaid; requires qualified health plans to provide preventive services, recommended immunizations, preventive care for infants, children, and adolescents, and additional preventive care and screening for women; provides grants for small employers who establish wellness programs; requires chain restaurants and foods sold from vending machines to disclose the nutritional content of each item.
Modified from The Henry J. Kaiser Family Foundation: Summary of coverage provisions in the Patient Protection and Affordable Care Act, 2013. Retrieved from http://www.kff.org/health-costs/issue- brief/summary-of-coverage-provisions-in-the-patient/
Societal Perceptions Health care for all is a concept that most Americans support. Most people state that health care should be one of those necessities available to all without consideration of what it costs; however, when discussion turns to actually doing this, most people become concerned about the implications. Efforts to provide universal coverage through increased governmental involvement in health care have failed because of a number of factors, including rejection of much higher taxes, objection to paying for care for noncitizens, concerns over access and availability, and fears of rationing.
The ongoing dilemma is how to provide health care to all Americans in a way that is acceptable and affordable. Other countries provide their citizens with universal health care, but there are aspects of this care that are unpopular with U.S. society. The most concerning or pressing problem relates to funding sources, because significant tax increases would be necessary to provide coverage
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for all. Furthermore, the United States already spends much more of our resources on health care than any other country; adding more costs is enormously concerning.
Furthermore, waiting several months for nonemergency treatment, lack of choice of treatment, and inaccessibility or unavailability of diagnostic and treatment modalities are not acceptable to most Americans. Indeed, most Americans want assurance that all of the health care services that they and their families need, now and in the future, will be available no matter what the condition, age of the patient, job status, or ability to pay. The debate and measures to address the problem of health care financing are ongoing. All nurses—and citizens—need to become familiar with the issues.
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Roles of the Public Health Nurse in the Economics of Health Care Researcher Nurses need to be engaged in research about the provision of efficient, cost-effective health care. Nurses are in a pivotal role to investigate culturally sensitive treatment modalities, health education, disease prevention, and factors to change behaviors. Health promotion and disease prevention are more cost effective than curative treatment modalities. Public health nurse researchers need to investigate, develop, and evaluate the effectiveness of health promotion and disease prevention. Research on health promotion intervention outcomes, program cost/benefit analysis, and health informatics are just a few of these areas.
Educator Health education is the foundation of public health nursing practice. Public health nurses agree that knowledge empowers clients to actively participate in their health care. Funding for this education is provided primarily through public, governmental entities (e.g., schools). Educational plans for individuals are rare. In the area of health care economics, the nurse needs to demonstrate the value of this education. Outcome measures for health education need to be established.
Provider of Care Any service delivered by the nurse needs to be appropriate, necessary, and cost effective. Nurses in all areas of practice need to be cost-conscious. Judicious application of the nursing process is imperative. An accurate assessment is the foundation for an appropriate nursing diagnosis. Goals for care, jointly established between members of the community and the community health nurse, will guide the choice of interventions. Evaluation, using previously developed outcome measures, will lead to appropriate modifications of the plan.
Nurses can serve as program service providers, health education providers, and health program participants. Nurses need to participate in the grant proposal process, design, and evaluation for these programs. They need to be familiar with and participate in the statistical information gathering process that serves as the basis for determining community health need.
Advocate Nurses must become more involved in the economics of health care. Too often, nurses are cognizant of the effects of changes in health care economics but feel powerless to act. Increasing knowledge of health care funding and policy making will empower nurses to advocate for the type of funding that provides appropriate care to obtain the greatest good. The large number of nurses gives our occupation potential political clout. Nurses need to utilize this political power to influence health care funding. Nurses need to advocate for increase in health promotion/disease prevention funding from both public and private sectors. Nurses need to plan programs, seek funding, and evaluate program effectiveness through outcome measures. Nurses need to constantly seek sources of funding for health programs through any available sources.
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Best Care at Lower Cost In 2012, the NAM published a report entitled Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Building on its earlier work in relation to quality care (discussed in Chapter 11), the NAM was asked to examine a critical concern.
Health care in America presents a fundamental paradox. The past 50 years have seen an explosion in biomedical knowledge, dramatic innovation in therapies and surgical procedures, and management of conditions that previously were fatal, with ever more exciting clinical capabilities on the horizon. Yet, American health care is falling short on basic dimensions of quality, outcomes, costs, and equity.
(IOM, 2013, p. 1)
Among the factors that are pushing this examination is the fact that there is an estimated $750 billion waste of resources in the health care system, meaning that the United States loses this amount of money that could be spent on improved health care outcomes. We need best care at lower cost, not higher cost. Compared with other countries, the United States is paying more for less poorer outcomes. The system has to manage the complexity that continues to grow and at the same time slow down ever-escalating costs. Citizens want quality care that is evidence based, but the system is not managing this well.
Active Learning
In small groups review the Institute of Medicine report U.S. Health in International Perspective: Shorter Lives, Poorer Health (2013). Divide up the content. Discuss this report from perspectives of the health care delivery system, quality care, diversity, and cost of care. The report is fully accessible and can be downloaded from https://www.ncbi.nlm.nih.gov/books/NBK115854/pdf/Bookshelf_NBK115854.pdf https://www.ncbi.nlm.nih.gov/pubmed/24006554 health-in-international-perspective-shorter-lives-poorer-health.
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Summary Health care economics is influencing health care practice at all levels. Nurses in the community must become aware of the economics of health care to practice in this new era. Patient outcomes are quickly being seen as a measurement for health care financing. As the health care system evolves toward health promotion and disease prevention, nursing will play a pivotal role. Public health nurses, whose domain of practice has encompassed these areas, will be in the forefront of this change. This chapter has presented the basics of health care economics and its importance in providing effective, quality care in all settings, including the community. An understanding of these elements is essential to the practice of nursing. This is an extremely complex subject with innovations and changes coming every day. To be effective, the nurse must be attentive to these developments.
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Evolve Website http://evolve.elsevier.com/Nies/community
• NCLEX Review Questions • Case Studies
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Young K.M, Kroth P.J. Shultz & Young’s Health Care USA: Understanding its organization and delivery. ed 9. Burlington, MA: Jones & Bartlett Leaning; 2018.
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Cultural Diversity and Community Health Nursing
Christina N. DesOrmeaux∗
OUTLINE
Cultural Diversity Transcultural Perspectives on Community Health Nursing Population Trends Cultural Perspectives and Healthy People 2020
Addressing Racial and Ethnic Disparities in Health Care Transcultural Nursing Overview of Culture
Culture and the Formation of Values Culture and the Family
Culture and Socioeconomic Factors Distribution of Resources Education
Culture and Nutrition Nutrition Assessment of Culturally Diverse Groups Dietary Practices of Selected Cultural Groups Religion and Diet
Culture and Religion Religion and Spirituality Childhood and Spirituality
Culture and Aging Cross-Cultural Communication
Nurse–Client Relationship Space, Distance, and Intimacy Overcoming Communication Barriers Nonverbal Communication Touch Gender
Health-Related Beliefs and Practices Health and Culture Cross-Cultural Perspectives on Causes of Illness Biomedical Perspective Naturalistic Perspective Magicoreligious Perspective Folk Healers Cultural Expressions of Illness Cultural Expression of Pain
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Culture-Bound Syndromes Management of Health Problems: A Cultural Perspective
Cultural Negotiation Management of Health Problems in Culturally Diverse Populations
Providing Health Information and Education Delivering and Financing Health Services Developing Health Professionals from Minority Groups Enhancing Cooperative Efforts with the Nonfederal Sector Promoting a Research Agenda on Minority Health Issues
Role of the Community Health Nurse in Improving Health for Culturally Diverse People Culturological Assessment Cultural Self-Assessment Knowledge about Local Cultures Recognition of Political Issues of Culturally Diverse Groups Providing Culturally Competent Care Recognition of Culturally Based Health Practices
Resources for Minority Health Office of Minority Health Indian Health Service
OBJECTIVES
Upon completion of this chapter, the reader will be able to do the following: 1. Critically analyze racial and cultural diversity in the United States. 2. Analyze the influence of sociocultural, political, economic, ethical, and religious factors that
influence the health of culturally diverse individuals, groups, and communities. 3. Identify the cultural aspects of nursing care for culturally diverse individuals, groups, and
communities. 4. Apply the principles of transcultural nursing to community health nursing practice.
KEY TERMS biomedical cultural competence cultural imposition cultural negotiation cultural stereotyping culture culture-bound syndrome culture shock culture specific culture universal culturological assessment
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dominant value orientation ethnocentrism Leininger’s theory of culture care diversity and universality magicoreligious naturalistic norms poverty religion socioeconomic status spirituality subculture transcultural nursing value yin-yang theory
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Cultural Diversity Cultural diversity is a multifaceted and complex concept that refers to the differences among people, especially those related to values, attitudes, beliefs, norms, behaviors, customs, and ways of living. It is essential that all nurses understand how cultural groups view life processes, how cultural groups define health and illness, how healers cure and care for members of their respective cultural groups, and how the cultural background of the nurse influences the way in which care is delivered. Nurses in community health settings also need to understand the diversity or differences that occur in families, groups, neighborhoods, communities, and public and community health care organizations.
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Transcultural Perspectives on Community Health Nursing Nurses’ knowledge of culture and cultural concepts improves the health of the community by enhancing their ability to provide culturally competent care. Cultural competence is respecting and understanding the values and beliefs of a certain cultural group so that one can function effectively in caring for members of that cultural group. Culturally competent community health nursing requires that nurses understand the lifestyle, value system, and health and illness behaviors of diverse individuals, families, groups, and communities. Nurses should also understand the culture of institutions that influence the health and well-being of communities. Nurses who have knowledge of, and an ability to work with, diverse cultures are able to devise effective interventions to reduce risks in a manner that is culturally congruent with community, group, and individual values.
The “Standards of Practice for Culturally Competent Nursing Care” established by the Expert Panel on Global Nursing and Health (2010) provides important guidelines to help nurses provide culturally competent care. The 12 standards are:
1. Social justice 2. Critical reflection 3. Knowledge of cultures 4. Culturally competent practice 5. Cultural competence in health care systems and organizations 6. Patient advocacy and empowerment 7. Multicultural workforce 8. Education and training in culturally competent care 9. Cross-cultural communication
10. Cross-cultural leadership 11. Policy development 12. Evidence-based practice and research
In the United States, metaphors such as melting pot describe the cultural diversity that characterizes the population. Although there is a tendency to identify the federally defined racial and ethnic minority groups when referring to the cultural aspects of community health nursing, all individuals, families, groups, communities, and institutions, including nurses and the nursing profession, have cultural characteristics that influence community health. When planning and implementing health care, community health nurses need to balance cultural diversity with the universal human experience and common needs of all people.
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Population Trends The population of the United States is becoming increasingly diverse. In recent years, the populations within the federally defined minority groups have grown faster than the population as a whole. In 1970, minority groups accounted for 16% of the population. By 2017, this share had increased to 38.7% (U.S. Census Bureau, 2017). Assuming that current trends continue, the U.S. Census Bureau (2015) projects that by 2060 minorities will account for more than 56% of the total population.
Furthermore, the numbers of certain minority groups, such as Hispanics, are growing considerably faster than those of whites and other groups. In 2017, estimates of population by race and ethnicity were: white 61.3%; Hispanic or Latino, 17.8%; black/African American, 13.3%; Asian, 5.7%; American Indians and Alaska Natives, 1.3%; other, 0.6% (U.S. Census Bureau, 2017). If current demographic trends continue, the United States will have the following population composition by the year 2060: white, 43.6%; Hispanic or Latino, 28.6%; black/African American, 14.3%; Asian, 9.3%; American Indians and Alaska Natives, 1.3% and other or combination, 2.9% (U.S. Census Bureau, 2015).
Although the nursing profession has representatives from diverse groups, minorities are generally underrepresented. Currently about 83% of registered nurses in the United States are white/non-Hispanic. Estimates for each minority group are as follows: African American, 6.0%; Hispanic, 3.0%; Asian and Pacific Islander, 5.0%; and Native American and Alaska Native, 1.0% (American Association of Colleges of Nursing, 2016). Additionally, each minority group is distributed differently around the country. African American nurses are more likely to be found in the South, Hispanics in the West or South (i.e., especially states bordering Mexico), and Asian and Pacific Islanders in the West or Northeast. Native American and Alaska Native nurses are predominantly in states with Native American reservations.
The United States has grown and achieved its success largely through immigration. Since 2010, more than 6 million legal immigrants have come to United States (U.S. Department of Homeland Security, 2016). In 2014, the U.S. population included almost 42.3 million foreign-born individuals, or 13.3% of the total population (U.S. Census Bureau, 2015). Among those foreign born, 52% were born in Mexico/Latin America, 26% in Asia, 14% in Europe, and the remaining 8% in other regions of the world (Pew Research Center, 2015b). The number of immigrants and refugees in the United States is projected to continue to increase.
In addition, people from other countries continue to seek treatment in U.S. hospitals, particularly for cardiovascular, neurological, and cancer care. Furthermore, U.S. nurses have the opportunity to travel abroad to work in a variety of health care settings in the international marketplace. In the course of a nursing career, it is possible to encounter foreign visitors, international university faculty members, international high school and university students, family members of foreign diplomats, immigrants, and refugees. Moreover, members of some cultural groups desire culturally relevant health care that incorporates their specific beliefs and practices. A growing expectation exists among members of certain cultural groups that health care providers will respect their “cultural health rights.” However, this expectation frequently conflicts with the unicultural, Western biomedical worldview taught in most U.S. educational programs. Therefore a serious conceptual problem exists within nursing in that nurses are expected to know, understand, and meet the health needs of these culturally diverse individuals, groups, and communities without adequate preparation.
Healthy People 2020
Selected Objectives Related to Cultural Health
• Increase the proportion of all degrees awarded to members of underrepresented racial and ethnic groups among the health professions, allied and associated health profession fields, the nursing field, and the public health field
• Reduce the proportion of adults who are obese
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• Reduce the overall cancer death rate • Reduce the rate of new cases of end-stage renal disease (ESRD) • Reduce the rate of lower-extremity amputations in persons with diabetes • Reduce coronary heart disease and stroke deaths • Reduce pregnancy rates among adolescent females • Reduce low-birth-weight (LBW) and very-low-birth-weight (VLBW) infants • Reduce human immunodeficiency virus incidence among adults and adolescents • Reduce hospitalizations for sickle cell disease among children age 9 years and under • Achieve and maintain effective vaccination coverage levels for universally recommended
vaccines among young children • Reduce past-month use of illicit substances • Reduce firearm-related deaths • Improve health, fitness, and quality of life through daily physical activity
From U.S. Department of Health and Human Services: Healthy People 2020: Topics and objectives, (n.d.) Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx
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Cultural Perspectives and Healthy People 2020 Healthy People 2020 identifies priority areas and objectives. By developing a set of national health targets, which includes eliminating racial and ethnic disparities in health, U.S. health officials, together with state and local officials and members of the private sector, set goals to improve the quality and increase the years of healthy life for all Americans (U.S. Department of Health and Human Services [USDHHS], 2018).
The Healthy People 2020 objectives embrace and focus on ways to close the gaps in health outcomes. Particularly targeted are racial and ethnic disparities in areas such as diabetes, acquired immunodeficiency syndrome (AIDS), heart disease, infant mortality rates, cancer screening and management, and immunizations. The objectives bring focus on disparities among racial and ethnic minorities, women, youth, older adults, people of low income and education, and people with disabilities (USDHHS, 2018). The Healthy People 2020 box lists selected objectives from Healthy People 2020 specific to cultural health issues.
The aims of Healthy People 2020 are the promotion of healthy behaviors, promotion of healthy and safe communities, improvement of systems for personal and public health, and prevention and reduction of diseases and disorders. The initiative is a tool for monitoring and tracking health status, health risks, and use of health services.
Addressing Racial and Ethnic Disparities in Health Care As in many nations, people in the United States who come from various racial, ethnic, cultural, and socioeconomic backgrounds often experience marked disparities in health care. The occurrence of many diseases, injuries, and other public health problems is disproportionately higher in some groups; access to health care may be more restricted, and the overall quality of health care is deemed inferior, for people from certain racial, ethnic, and cultural populations. Although the overall health of the U.S. population has improved during the past several decades, research reveals that all people have not shared equally in those improvements. For example, 25.6% of Hispanic adults and 20.5% of African American adults report that they are in fair or poor health, compared with 15.7% of non-Hispanic whites (Kaiser Family Foundation, 2016).
Primary care provides the foundation for the health care system, and research indicates that having a usual source of care increases the chance that people will receive adequate preventive care and other important health services. Data from the Agency for Healthcare Research and Quality (2017) reveal the following facts:
White Americans are more likely to have health insurance (9% uninsured) than either African Americans (14.6% uninsured) or Hispanics (25.9% uninsured).
Thirty percent of Hispanics and 20% of African Americans lack a usual source of health care (compared with fewer than 16% of whites).
Hispanic children are nearly three times as likely as non-Hispanic white children to have no usual source of health care.
African Americans (16%) and Hispanic Americans (13%) are more likely to rely on hospitals or clinics for health care than are whites (8%).
During the past two decades, health disparities have become the focus of numerous federal, state, and local government studies, and one of the major goals of Healthy People 2020 is to achieve health equity, eliminate disparities, and improve the health of all groups (USDHHS, 2018). Therefore it is essential to look at how to overcome these and other identified factors that contribute to poorer health among members of some minority groups. A survey by the Commonwealth Fund (2007) found that disparities in health care can be reduced or even eliminated when adults have health care insurance and a medical home, which is defined as “a health care setting that provides patients with timely, well-organized care and enhanced access to providers.” According to the survey, when adults have insurance and a medical home, “their access to needed care, receipt of routine preventive screenings, and management of chronic conditions improve substantially.”
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Genetics in Public Health
Genetic Risk Assessment for Cancer: Racial and Ethnic Disparities Racial and ethnic disparities in deaths attributable to cancer vary considerably for some types of cancer. This is particularly true for breast cancer for African American females, prostate cancer for African American males, and colon cancer for both African American men and women. Despite the widespread recognition of the importance of genetic risk assessment and testing, evidence-based practice guidelines are not followed uniformly in many instances.
Although use of genetic testing and risk assessment among specific populations has increased overall, there are differences based on racial and socioeconomic situations. Underhill and colleagues (2016) pointed out that although African American and Hispanic women have higher rates of hereditary-associated cancers (e.g. breast cancer), they are less likely than White women to be tested for genetic markers. This results in disparities in cancer prevention and early detection. The authors point out that nurses should recognize risk factors for hereditary cancers and refer for genetic testing per established clinical guidelines when appropriate. Underhill ML, Jones T, Habin K: Disparities in cancer genetic risk assessment and testing, Oncology Nursing Forum 43(4):519–523, 2016.
Active Learning
Examine the vital statistics of a community, and compare differences in morbidity and mortality rates for whites and racial and ethnic subgroups. What data are available according to racial and ethnic heritage? What data are missing?
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Transcultural Nursing In 1959, Madeleine Leininger, a nurse-anthropologist, used the term transcultural nursing to define the philosophical and theoretical similarities between nursing and anthropology. In 1968, Leininger proposed her theory-generated model, and, in 1970, she wrote the first book on transcultural nursing, Nursing and Anthropology: Two Worlds to Blend (Leininger, 1970). According to Leininger (1978), transcultural nursing is “a formal area of study and practice focused on a comparative analysis of different cultures and subcultures in the world with respect to cultural care, health and illness beliefs, values, and practices with the goal of using this knowledge to provide culture- specific and culture-universal nursing care to people” (p. 493). Culture specific refers to the “particularistic values, beliefs, and patterning of behavior that tend to be special, ‘local,’ or unique to a designated culture and which do not tend to be shared with members of other cultures” (Leininger, 1991, p. 491), whereas culture universal refers to the commonalities of values, norms of behavior, and life patterns that are similarly held among cultures about human behavior and lifestyles and form the bases for formulating theories for developing cross-cultural laws of human behavior” (Leininger, 1991, p. 491).
Although many nurse-scholars have developed theories of nursing, Leininger’s theory of culture care diversity and universality is the only one that gives precedence to understanding the cultural dimensions of human care and caring. Leininger’s theory is concerned with describing, explaining, and projecting nursing similarities and differences focused primarily on human care and caring in human cultures. Leininger used worldview, social structure, language, ethnohistory, environmental context, and the generic or folk and professional systems to provide a comprehensive and holistic view of influences in cultural care and well-being. The following three models of nursing decisions and actions may be useful in providing culturally congruent and competent care (Andrews and Boyle, 2016; Leininger, 1978, 1991, 1995; Leininger and McFarland, 2002):
1. Culture care preservation and maintenance 2. Culture care accommodation and negotiation 3. Culture care repatterning and restructuring
Among the strengths of Leininger’s theory is its flexibility for use with individuals, families, groups, communities, and institutions in diverse health systems. Leininger’s Sunrise Model depicts the theory of cultural care diversity and universality and provides a visual representation of the key components of the theory and the interrelationships among its components (Fig. 13.1).
The term cross-cultural nursing is sometimes used synonymously with transcultural nursing. The terms intercultural nursing and multicultural nursing are also used. Since Leininger’s early work, many nurses have contributed significantly to the advancement of nursing care of culturally diverse clients, groups, and communities, and some of their contributions are mentioned in this chapter.
One of the major challenges that community health nurses face in working with clients from culturally diverse backgrounds is overcoming individual ethnocentrism, which is a person’s tendencies to view his or her own way of life as the most desirable, acceptable, or best and to act in a superior manner toward individuals from another culture. Nurses also must beware of cultural imposition, which is a person’s tendency to impose his or her own beliefs, values, and patterns of behavior on individuals from another culture. When clients’ cultural values and expressions of care differ from those of the nurse, the nurse must exercise caution to ensure that mutual goals have been established.
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FIG. 13.1 Leininger’s Sunrise Model, depicting the theory of cultural care diversity and universality. From Leininger MM: Culture, care, diversity, and universality: A theory of nursing, New York, 1991,
National League for Nursing Press.
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Overview of Culture In 1871, the English anthropologist Sir Edward Tylor was the first to define the term culture. According to Tylor (1871), culture is the complex whole, including knowledge, beliefs, art, morals, law, customs, and any other capabilities and habits acquired by virtue of the fact that one is a member of a particular society. Culture represents a person’s way of perceiving, evaluating, and behaving within his or her world, and it provides the blueprint for determining his or her values, beliefs, and practices. Culture has four basic characteristics:
1. It is learned from birth through the processes of language acquisition and socialization. 2. It is shared by members of the same cultural group. 3. It is adapted to specific conditions related to environmental and technical factors and to the
availability of natural resources. 4. It is dynamic.
Culture is an all-pervasive and universal phenomenon. However, the culture that develops in any given society is always specific and distinctive, encompassing the knowledge, beliefs, customs, and skills acquired by members of that society. Within cultures, groups of individuals share beliefs, values, and attitudes that are different from those of other groups within the same culture. Ethnicity, religion, education, occupation, age, sex, and individual preferences and variations bring differences. When such groups function within a large culture, they are termed subcultural groups.
The term subculture is used for fairly large aggregates of people who share characteristics that are not common to all members of the culture and that enable them to be a distinguishable subgroup. Ethnicity, religion, occupation, health-related characteristics, age, sex, and geographic location are frequently used to identify subcultural groups. Examples of U.S. subcultures based on ethnicity (e.g., subcultures with common traits such as physical characteristics, language, or ancestry) include African Americans, Hispanics, Native Americans, and Chinese Americans. Subcultures based on religion include members of the more than 1200 recognized religions, such as Catholics, Jews, Mormons, Muslims, and Buddhists. Those based on occupation include health care professionals (e.g., nurses and physicians), career military personnel, and farmers. Those based on health-related characteristics include the blind, hearing impaired, and mentally challenged. Subcultures based on age include adolescents and older adults, and those based on sex or sexual preference include women, men, lesbians, and gay men. Those based on geographic location include Appalachians, Southerners, and New Yorkers. Lastly, military veterans are another very common subculture that shares distinct needs and values (see Chapter 22).
Culture and the Formation of Values According to Leininger (1995), value refers to a desirable or undesirable state of affairs. Values are a universal feature of all cultures, although the types and expressions of values differ widely. Norms are the rules by which human behavior is governed and result from the cultural values held by the group. All societies have rules or norms that specify appropriate and inappropriate behavior. Individuals are rewarded or punished as they conform to or deviate from the established norms, respectively. Values and norms, along with the acceptable and unacceptable behaviors associated with them, are learned in childhood.
Every society has a dominant value orientation, a basic value orientation that is shared by the majority of its members as a result of early common experiences. In the United States, the dominant value orientation is reflected in the dominant cultural group, which is made up of white, middle- class Protestants, typically those who came to the United States at least two generations ago from Northern Europe. Members of the dominant cultural group are sometimes referred to as white Anglo-Saxon Protestants, a term that reflects their ancestry and religious beliefs. In the United States, the dominant cultural group places emphasis on educational achievement, science, technology, individual expression, democracy, experimentation, and informality.
Although an assumption is sometimes made that the term white refers to a homogeneous group of Americans, a rich diversity of ethnic variation exists among the many groups that constitute the dominant majority. Countries of origin include those of Eastern and Western Europe (e.g., Ireland,
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Poland, Italy, France, Sweden, and Russia). The origins of people in Canada, Australia, New Zealand, and South Africa can ultimately be traced to Western Europe. Appalachians, Amish, Cajuns, and other subgroups are also examples of whites who have cultural roots that are recognizably different from those of the dominant cultural group.
Values and norms vary, sometimes significantly, among various cultural groups. According to Kluckhohn and Strodtbeck (1961), several basic human problems exist for which all people must find a solution. They identified the following five questions related to values and norms:
1. What is the character of innate human nature (human nature orientation)? 2. What is the relationship of the human to nature (person–nature orientation)? 3. What is the temporal focus (i.e., time sense) of human life (time orientation)? 4. What is the mode of human activity (activity orientation)? 5. What is the mode of human relationships (social orientation)?
Human Nature Orientation Innate human nature may be good, evil, or a combination of good and evil. Some believe that life is a struggle to overcome a basically evil nature; they consider human nature to be unalterable or able to be perfected only through great discipline and effort. For others, human nature is perceived as fundamentally good, unalterable, and difficult or impossible to corrupt.
According to Kohls (1984), the dominant U.S. cultural group chooses to believe the best about a person until that person proves otherwise. Concern in the United States for prison reform, social rehabilitation, and the plight of less fortunate people around the world is a reflective perception of the belief in the fundamental goodness of human nature. Recent scientific advances, such as advances in stem cell research and genome studies, have necessitated consideration of ethical quandaries regarding human nature. Questions emerge as to whether science can or should pursue activities that could alter the basic human orientation.
Person–Nature Orientation The following three perspectives examine the ways in which the person–nature relationship is perceived:
• Destiny, in which people are subjugated to nature in a fatalistic, inevitable manner • Harmony, in which people and nature exist together as a single entity • Mastery, in which people are intended to overcome natural forces and to put them to use
for the benefit of humankind
Most Americans consider humans and nature clearly separated; this is an incomprehensible perspective for many individuals of Asian heritage. The idea that a person can control his or her own destiny is alien to many individuals of culturally diverse backgrounds. Many cultures believe that people are driven and controlled by fate and can do very little, if anything, to influence it. The dominant U.S. cultural group, by contrast, has a mastery perspective.
For example, the reader should consider three individuals in whom hypertension has been diagnosed, each of whom embraces one of the values orientations described. The person whose values orientation is destiny may say, “Why should I bother watching my diet, taking medication, and getting regular blood pressure checks? High blood pressure is part of my genetic destiny and there is nothing I can do to change the outcome. There is no need to waste money on prescription drugs and health checkups.” The person whose values orientation embraces harmony may say, “If I follow the diet described and use medication to lower my blood pressure, I can restore the balance and harmony that were upset by this illness. The emotional stress I’ve been feeling indicates an inner lack of harmony that needs to be balanced.” The person whose values orientation leads to belief in active mastery may say, “I will overcome this hypertension no matter what. By eating the right foods, working toward stress reduction, and conquering the disease with medication, I will take charge of the situation and influence the course of my disease.”
Time Orientation People can perceive time in the following three ways:
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• The focus may be on the past, with traditions and ancestors playing an important role in the client’s life. For example, many Asians, Native Americans, East Indians, and Africans hold particular beliefs about ancestors and tend to value long-standing traditions. In times of crisis, such as illness, individuals with a values orientation emphasizing the past may consult with ancestors or ask for their guidance or protection during the illness.
• The focus may be on the present, with little attention paid to the past or the future. Individuals with this focus are concerned with the current situation, and they perceive the future as vague or unpredictable. Nurses may have difficulty encouraging such individuals to prepare for the future (e.g., to participate in primary prevention measures).
• The focus may be on the future, with progress and change highly valued. Individuals with a future focus may express discontent with the past and present. In terms of health care, they may inquire about the “latest treatment” and the most advanced equipment available for a particular problem.
The dominant U.S. cultural group is characterized by a belief in progress and a future orientation. This combination implies a strong task or goal focus. The group has an optimistic faith in what the future will bring. Change is often equated with improvement, and a rapid rate of change is usually normal.
Activity Orientation There are different values orientations concerning activity. Philosophers have suggested the following three perspectives:
Being, in which a spontaneous expression of impulses and desires is largely nondevelopmental in nature
Growing, in which the person is self-contained and has inner control, including the ability to self-actualize
Doing, in which the person actively strives to achieve and accomplish something that is regarded highly
The person with a doing orientation often directs the doing toward achievement of an externally applied standard, such as a code of behavior from a religious or ethical perspective. The Ten Commandments, Pillars of Islam, Hippocratic Oath, and Nightingale Pledge are examples of externally applied standards.
The dominant cultural value is action oriented, with an emphasis on productivity and being busy. As a result of this action orientation, Americans have become proficient at problem solving and decision making. Even during leisure time and vacations, many Americans value activity.
Social Orientation Variations in cultural values orientation are also related to the relationships that exist with others. Relationships may be categorized in the following three ways:
Lineal relationships: These exist by virtue of heredity and kinship ties. These relationships follow an ordered succession and have continuity through time.
Collateral relationships: The focus is primarily on group goals, and family orientation is important. For example, many Asian clients describe family honor and the importance of working together toward an achievement of the group versus a personal goal.
Individual relationships: These refer to personal autonomy and independence. Individual goals dominate, and group goals become secondary.
The social orientation among the dominant U.S. cultural group is toward the importance of the individual and the equality of all people. Friendly, informal, outgoing, and extroverted members of the dominant cultural group tend to scorn rank and authority. For example, nursing students may call faculty members by their first names, clients may call nurses by their first names, and employees may fraternize with their employers.
When making health-related decisions, clients from culturally diverse backgrounds rely on
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relationships with others in various ways. If the cultural values orientation is lineal, the client may seek assistance from other members of the family and allow a relative (e.g., parent, grandparent, or elder brother) to make decisions about important health-related matters. If collateral relationships are valued, decisions about the client may be interrelated with the influence of illness on the entire family or group. For example, among the Amish, the entire community is affected by the illness of a member because the community pays for health care from a common fund. Members join together to meet the needs of the client and family for the duration of the illness, and the roles of many in the community are likely to be affected by the illness of a single member.
In another example, there are approximately 11.4 million undocumented residents living in the United States as of January 2012 (Baker and Rytina, 2013). These individuals often create their own social groups which may fear that attempting to access the health care system may lead to deportation, and they often have “underground” or private access to home remedies and pharmaceuticals for their health care. As a result, they often enter the formal health care system via emergency departments when their health status has declined considerably (KFF, 2017).
A values orientation that emphasizes the individual is predominant among the dominant cultural majority in the United States. Decision making about health and illness is often an individual matter, with the client being responsible, although members of the nuclear family may participate to varying degrees.
Culture and the Family The family remains the basic social unit in the United States. Although various ways exist to categorize families, the following are commonly recognized types of constellations in which people live together in society:
• Nuclear (i.e., husband, wife, and child or children) • Nuclear dyad (i.e., husband and wife alone, either childless or with no children living at
home) • Single parent (i.e., either mother or father and at least one child) • Blended (i.e., husband, wife, and children from previous relationships) • Extended (i.e., nuclear plus other blood relatives) • Communal (i.e., group of men and women with or without children) • Cohabitation (i.e., unmarried man and woman sharing a household with or without
children) • Lesbian, gay, bisexual, transgender (i.e., same-gender couples, individuals that identify
with another gender, with or without children)
In addition to structural differences in families cross-culturally, accompanying functional diversity may exist. For example, among extended families, kin residence sharing has long been recognized as a viable alternative to managing scarce resources, meeting child care needs, and caring for a handicapped or older family member.
The family constellations associated with teen parenting are unique and provide a special socialization context for infants. For example, Hispanic teen mothers receive more child care help from grandmothers and peers than do white teen mothers. Among African Americans and Puerto Ricans, the presence of the maternal grandmother ameliorates the negative consequences of adolescent childbirth on the infant. In addition, grandmothers are more responsive and less punitive in their interactions with the infant than their daughters (Andrews and Boyle, 2016). Three-generational households can have an influence on the infant’s development: by influencing the mother’s knowledge about development and providing other more responsive social interactions with the infant.
Families from diverse backgrounds are often characterized as being more conservative in terms of sex roles and parenting values and practices than white families. For example, traditional Japanese American and Mexican American families are family centered, enforce strict gender and age roles, and emphasize children’s compliance with authority figures (Giger, 2017). Children of culturally diverse backgrounds are involved in family interactions that differ from those of children from the dominant U.S. cultural group. The values of children of immigrants typically evolve, depending on how far removed they are from the country of origin. These children may detach from their cultural
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traditions, becoming more individually focused or autonomous—often to the dismay of the elders in the family. Often the language of the ancestors is forgotten or, in certain subcultures, forbidden to be spoken, so that the children may assimilate to the dominant culture.
Relationships that may seem apparent sometimes warrant further exploration by nurses interacting with clients from culturally diverse backgrounds. For example, the dominant cultural group defines siblings as two people with the same mother, the same father, the same mother and father, or the same adoptive parents. In some Asian cultures, a sibling relationship is defined as involving infants who are breastfed by the same woman. In other cultures, certain kinship patterns, such as maternal first cousins, are sibling relationships. In some African cultures, anyone from the same village or town may be called “brother” or “sister” (Andrews and Boyle, 2016; Giger, 2017).
When providing care for infants and children, the nurse must identify the primary provider of care because this individual may or may not be the biological parent. For example, among some Hispanic groups, female members of the nuclear or extended family (e.g., sisters or aunts) are sometimes the primary providers of care. In some African American families, the grandmother may be the decision maker and primary caregiver of the children (Andrews and Boyle, 2016).
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Culture and Socioeconomic Factors No single indicator can adequately capture all facets of economic status for entire populations, but measures such as median or average annual income, employment rate, poverty rate, and net worth are most often used. The economic status of most individuals, especially children, is better reflected by the pooled resources of family or household members than by their individual earnings or incomes. Socioeconomic status (SES) is a composite of the economic status of a family or unrelated individuals based on income, wealth, occupation, educational attainment, and power. It is a means of measuring inequalities based on economic differences and the manner in which families live as a result of their economic well-being. Most families with racially or ethnically diverse backgrounds have a lower SES than the population at large, with a few exceptions (e.g., Cuban Americans and subgroups of Asian Americans).
Poverty is another factor that dramatically influences health and well-being. National poverty data are calculated through the use of the official U.S. Census Bureau definition of poverty, which has remained standard since its initial introduction in the mid-1960s. Under this definition, poverty is determined by comparing pretax cash income with the poverty threshold, which adjusts for family size and composition. Table 13.1 provides an overview of the poverty thresholds according to size of family and number of related children under age 18 years residing in the home. The poverty guidelines are issued each year by the USDHHS. The guidelines are a simplification of the poverty threshold for administrative purposes, such as determining financial eligibility for federal programs (e.g., Head Start, National School Lunch, Medicaid, Aid to Families with Dependent Children) (U.S. Census Bureau, 2016).
According to the U.S. Census Bureau per Colby and Ortman (2015), the poverty rate in 2015 was 13.5%, down 1.2% from 2014. The distribution of the poor varies considerably on the basis of certain factors such as age, race or ethnicity, and marital status. For example, 24.1% of the African American population, 11.4% of the Asian population, and 21.4% of the Hispanic population live in poverty. In addition, children under 6 years of age are particularly vulnerable to poverty, with 21% of all U.S. children in this age group being poor (Colby and Ortman, 2015).
TABLE 13.1
Poverty Thresholds ($) For 2016 by Size of Family and Number of Related Children Under 18 Years
Note: The poverty thresholds are updated each year with the use of the change in the average annual Consumer Price Index for All Urban Consumers (CPI-U).
From U.S. Census Bureau: Poverty thresholds by size of family and number of children, 2016, 2016. Retrieved from https://www.census.gov/data/tables/time-series/demo/income-poverty/historical- poverty-thresholds.html
Distribution of Resources
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Status, power, and wealth in the United States are not distributed equally throughout society. Rather, a small percentage of the population enjoys most of the nation’s resources, primarily through ownership of multibillion-dollar corporations, large pieces of real estate in prime locations, and similar assets. The U.S. population has traditionally been divided into the following three social classes: upper, middle, and lower. SES may be calculated by considering a variety of factors, but it is customarily determined by examining factors such as total family income, occupation, and educational level.
A disproportionate number of individuals from the racially and ethnically diverse subgroups are members of the lower socioeconomic class, whereas a larger percentage of members of the dominant cultural group belong to the upper and middle socioeconomic classes. The United States has socioeconomic stratification; therefore the idealization of America as the land of opportunity often applies more to members of the upper and middle classes than to those of the lower class. The outcome of social stratification is social inequality. For example, school systems, grocery stores, and recreational facilities vary significantly between the inner city, which has a high percentage of minority residents, and the suburbs, where the residents are overwhelmingly of European ancestry.
For many years, health care settings and health care access have been the subject of study and concern regarding distribution of resources, with members of racial and ethnic minority groups compellingly pointing out the inequalities. Because financing of health care in the United States largely relies on a combination of federally funded insurance (i.e., Medicare) and employer- provided health insurance, those from the highest SES groups and elders tend to receive the best health care. In contrast, those from low-SES groups (i.e., those without health insurance or with Medicaid) tend to receive less health care. Thus, in the United States, SES largely determines access to health care as well as the quality of care received.
Education One of the components considered in determining SES is educational level. Educational attainment is perhaps the single most important factor. In recent years, there has been an improvement in the level of education among those who have historically been less educated (e.g., elders, women, minorities). For example, women now have a higher rate of high school completion than do men. Also, in 2013, dropout rates for both African Americans and Hispanics have reached all-time lows (Fry, 2014).
Active Learning
1. Visit an inner-city grocery store and compare its quality, prices, customer services, and variety of products with those of a suburban grocery store.
2. Watch prime-time television and note the racial and ethnic diversity that is present during the commercials. During the program, note the roles played by racially and ethnically diverse characters. Are they heroes or heroines or the “bad guys”? What are their occupations, SES, religions, and lifestyles?
3. Skim a popular magazine for references to racially and ethnically diverse subgroups. What is being written? Is the nature of the article favorable or unfavorable?
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Culture and Nutrition Long after assimilation into U.S. culture has occurred, many members of various ethnic groups continue to follow culturally based dietary practices and eat ethnic foods. Often, neighborhood food markets and ethnic restaurants are established soon after the arrival of a new group of immigrants to the United States. The ethnic restaurant is commonly a place for members of a cultural group to meet and mingle, and customers from the dominant cultural group may be of secondary interest. Food is an integral part of cultural identity that extends beyond dietary preferences.
Nutrition Assessment of Culturally Diverse Groups Factors that must be considered in a nutrition assessment include the cultural definition of food, frequency and number of meals eaten away from home, form and content of ceremonial meals, amount and types of food eaten, and regularity of food consumption. Twenty-four-hour dietary recalls or 3-day food records traditionally used for assessment may be inadequate when dealing with clients from culturally diverse backgrounds. Standard dietary handbooks may fail to provide culture-specific diet information, because nutritional content and exchange tables are usually based on Western diets. Another source of error may originate from the cultural patterns of eating. For example, among low-income urban African American families, elaborate weekend meals are frequent, whereas weekday dietary patterns are markedly more moderate (Giger, 2017).
Although community health nurses may assume that food is a culture-universal term, they may need to clarify its meaning with the client. For example, certain Latin American groups do not consider greens, an important source of vitamins, to be food and fail to list intake of these vegetables on daily records. Among Vietnamese refugees, dietary intake of calcium may appear inadequate because low consumption rates of dairy products are common among members of this group. However, they commonly consume pork bones and shells, providing adequate quantities of calcium to meet daily requirements (Giger, 2017).
Food is only one part of eating. In some cultures, social contacts during meals are restricted to members of the immediate or extended family. For example, in some Middle Eastern cultures, men and women eat meals separately, or women are permitted to eat with their husbands but not with other males. Among some Hispanic groups, the male breadwinner is served first, then the women and children eat. Etiquette during meals, use of hands, type of eating utensils (e.g., chopsticks or special flatware), and protocols governing the order in which food is consumed during a meal all vary cross-culturally.
Dietary Practices of Selected Cultural Groups Cultural stereotyping is the tendency to view individuals of common cultural backgrounds similarly and according to a preconceived notion of how they behave. However, not all Chinese like rice, not all Italians like spaghetti, and not all Mexicans like tortillas. Nevertheless, aggregate dietary preferences among people from certain cultural groups can be considered (e.g., characteristic ethnic dishes and methods of food preparation, including use of cooking oils); the reader is referred to nutrition texts on the topic for detailed information about culture-specific diets and the nutritional value of ethnic foods.
Religion and Diet Cultural food preferences are often interrelated with religious dietary beliefs and practices. As indicated in Table 13.2, many religions have proscriptive dietary practices, and some use food as symbols in celebrations and rituals. Knowing the client’s religious practice as it relates to food makes it possible to suggest improvements or modifications that will not conflict with religious dietary laws.
TABLE 13.2
Dietary Practices of Selected Religious Groups
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Religion Dietary Practice Hinduism All meats are prohibited.
Islam Pork and intoxicating beverages are prohibited. Judaism Pork, predatory fowl, shellfish, other water creatures (fish with scales are permissible), and blood by ingestion (e.g., blood
sausage and raw meat) are prohibited. Blood by transfusion is acceptable. Foods should be kosher (meaning “properly preserved”). All animals must be ritually slaughtered by a shochet (i.e., quickly with the least pain possible) to be kosher. Mixing dairy and meat dishes at the same meal is prohibited.
Mormonism (Church of Jesus Christ of Latter-day Saints)
Alcohol, tobacco, and beverages containing caffeine (e.g., coffee, tea, colas, and select carbonated soft drinks) are prohibited.
Seventh-Day Adventism
Pork, certain seafood (including shellfish), and fermented beverages are prohibited. A vegetarian diet is encouraged.
Fasting and other religious observations may limit a person’s food or liquid intake during specified times. For example, many Catholics fast or abstain from meat on Ash Wednesday, and each Friday during the season of Lent, Muslims refrain from eating during the daytime hours for the month of Ramadan but are permitted to eat after sunset, and Mormons refrain from ingesting all solid foods and liquids on the first Sunday of each month.
Active Learning
Dine at an ethnic restaurant. While dining, notice the type of cultural heritage in restaurant decor and information about the culture available from the menu, placemats, or elsewhere in the restaurant. Ask the owner or manager about the history of the restaurant.
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Culture and Religion According to the 2014 U.S. Religious Landscape Study , 70.6% of U.S. citizens identify with Christian faiths, 5.9% non-Christian faiths, and 22.8% unaffiliated with a faith (atheist, agnostic, and nothing in particular) (Pew Research Center, 2015a). Adults who describe themselves as “Christian” have dropped almost 8 points since 2007, according to findings by the Pew Research survey. Furthermore, about 66% note that they are members of a church, synagogue, or mosque. The largest religious groups are Protestant, 46.5%; Catholic, 20.8%; Jewish, 1.9%; and Mormon, 1.6% (Pew Research Center, 2015a). The largest specific Protestant denominations are the United Methodist Church, American Baptist Church, Evangelical Lutheran Church, Presbyterian Church, and Episcopal Church.
Although the nurse cannot be an expert on each of the estimated 1200 religions practiced in the United States, knowledge of health-related beliefs and practices and general information about religious observances are important in providing culturally competent nursing care. For example, when planning home visits or scheduling clinic visits for members of a specific religious group, the nurse should consult the group’s religious calendar and work around designated holy days. The nurse should also know the customary days of religious worship observed by members of the religion. Most Protestants worship on Sundays, whereas Muslims’ holy day of worship extends from sunset on Thursday to sunset on Friday, and Jews and Seventh-Day Adventists’ holy day extends from sunset on Friday to sunset on Saturday. Roman Catholics may worship in the late afternoon or evening of Saturday or all day Sunday. Some religions may meet more than once weekly.
As an integral component of the individual’s culture, religious beliefs may influence the client’s explanation of the cause of illness, perception of its severity, and choice of healer. In times of crisis, such as serious illness and impending death, religion may be a source of consolation for the client and family and may influence the course of action believed to be appropriate.
Religion and Spirituality Religious concerns evolve from, and respond to, the mysteries of life and death, good and evil, and pain and suffering. Nurses frequently encounter clients who find themselves searching for a spiritual meaning to help explain illness or disability. Some nurses find spiritual assessment difficult because the topic is abstract and personal, whereas others feel comfortable discussing spiritual matters. Comfort with personal spiritual beliefs is the foundation for effective assessment of spiritual needs in clients.
Although religions offer various interpretations of many of life’s mysteries, most people seek a personal understanding and interpretation at some time in their lives. Ultimately, this personal search becomes a pursuit to discover a supreme being (e.g., Allah, God, Yahweh, or Jehovah) or some unifying truth that will render meaning, purpose, and integrity to existence.
An important distinction must be made between religion and spirituality. Religion refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe, especially belief in or the worship of a god or gods. As already stated, more than 1200 religions are practiced in the United States. Spirituality, in contrast, is born out of the individual’s unique life experience and personal effort to find purpose and meaning in life. Box 13.1 provides suggested guidelines for assessing the spiritual needs of culturally diverse clients. Table 13.3 illustrates a shared belief among various religions.
Religion may influence decisions regarding prolongation of life, euthanasia, autopsy, donation of a body for research, disposal of a body and body parts including fetus, and type of burial. The nurse should use discretion in asking clients and their families about these issues and gather data only when the clinical situation necessitates that the information be obtained. The nurse should encourage clients and families to discuss these issues with their religious representative when necessary. Before dealing with potentially sensitive issues, the nurse should establish rapport with the client and family by gaining their trust and confidence in less sensitive areas.
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BOX 13.1 Methods of Assessing Spiritual Needs in Culturally Diverse Clients Environment
• Does the client have religious objects in the environment? • Does the client wear outer garments or undergarments that have religious significance? • Are get-well greeting cards religious in nature or from a representative of the client’s religious
institution? • Does the client receive flowers or bulletins from a church or other religious institution?
Behavior
• Does the client appear to pray at certain times of the day or before meals? • Does the client make special dietary requests (e.g., kosher diet; vegetarian diet; or diet free
from caffeine, pork, shellfish, or other specific food items)? • Does the client read religious magazines or books?
Verbalization
• Does the client mention a Supreme Being (e.g., God, Allah, Buddha, or Yahweh), prayer, faith, church, or religious topics?
• Does the client request a visit by a clergy member or other religious representative? • Does the client express anxiety or fear about pain, suffering, or death?
Interpersonal Relationships
• Who visits the client? How does the client respond to visitors? • Does a church representative visit? • How does the client relate to nursing staff and roommates? • Does the client prefer to interact with others or remain alone?
Data from Andrews MM, Boyle JS, editors: Transcultural concepts in nursing care, ed 7, Philadelphia, PA, 2016, Wolters Kluwer.
TABLE 13.3
Shared Beliefs Among Various Religions: The “Golden Rule”
Religion Scripture Source Buddhism “Hurt not others in ways that you yourself would find hurtful.” Udana-varga 5:18
Christianity “Whatsoever you would that men should do to you, do you even so to them.” Matthew 7:12
Confucianism “Do not do to others what you do not want them to do to you.” Analects 15:23
Hinduism “One should not behave towards others in a way which is disagreeable tooneself.” Mahabharata 5:1517; Mencius Vii.A.4
Islam “Not one of you is a believer until he loves for his brother what he loves forhimself.” Number 13 of Al-Nawawi’s FortyHadiths Judaism “Thou shalt love thy neighbor as thyself.” Leviticus 19:18
Taoism “Regard your neighbor’s gain as your own gain and your neighbor’s loss as yourown loss.” T’ai Shang Kan Ying P’ien
Childhood and Spirituality
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Serious illness during childhood is especially difficult. Children have spiritual needs that vary according to the child’s developmental level and the religious climate that exists in the family. Parental perceptions about the illness of their child may be partially influenced by religious beliefs. For example, some parents may believe that a transgression against a religious law is responsible for a congenital anomaly in their offspring. Other parents may delay seeking medical care because they believe that prayer should be tried first. Certain types of treatment (e.g., administration of blood or medications containing caffeine or other prohibited substances and selected procedures) may be perceived as cultural taboos, which are to be avoided by children and adults.
Active Learning
1. Attend religious services at a church, temple, synagogue, or place of worship for a religion unfamiliar to you.
2. Interview an official representative (e.g., priest, elder, monk, or bishop) of a religion unfamiliar to you. Ask about health-related beliefs and practices, healing rituals, support network for the sick, and dietary practices.
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Culture and Aging Values held by the dominant U.S. culture, such as emphasis on independence, self-reliance, and productivity, influence aging members of society. Americans define people 65 years and older as “old” and limit their work. In some other cultures, people are first recognized as being unable to work and then identified as being old. In some cultures the wisdom, not the productivity, of the older adult is valued; the diminution of one’s activity level and the reduction of physical stamina associated with growing old are accepted more readily without loss of status among culture members. Retirement is also culturally defined, with some older adults working as long as physical health continues and others continuing to be active but assuming less physically demanding jobs.
The main task of older adults in the dominant culture is to achieve a sense of integrity in accepting responsibility for their own lives and having a sense of accomplishment. Individuals who achieve integrity consider aging a positive experience, make adjustments in their personal space and social relationships, maintain a sense of usefulness, and begin closure and life review. Not all cultures value accepting responsibility for an individual’s own life. For example, among Hispanics, Asians, Arabs, and other groups, older adults are often cared for by family members who welcome them into their homes when they are no longer able to live alone. The concept of placing an older family member in an institutional setting to be cared for by strangers is perceived as an uncaring, impersonal, and culturally unacceptable practice by many cultural groups (Andrews and Boyle, 2016; Giger, 2017).
Older adults may develop their own means of coping with illness through self-care, assistance from family members, and social group support systems. Some cultures have developed attitudes and specific behaviors for older adults that include humanistic care and identification of family members as care providers. Older adults may have special family responsibilities (e.g., the older Amish adults provide hospitality to visitors, and older Filipino adults spend considerable time teaching the youth skills learned during a lifetime of experience).
Older adult immigrants who have made major lifestyle adjustments in the move from their homeland to the United States or from a rural to an urban area, or vice versa, may need information about health care alternatives, preventive programs, health care benefits, and screening programs for which they are eligible. These individuals may also be in various stages of culture shock, the state of disorientation or inability to respond to the behavior of a different cultural group because it holds sudden strangeness, unfamiliarity, and incompatibility for the newcomer’s perceptions and expectations (Leininger and McFarland, 2002).
Several examples of how being an elderly immigrant influences health can be found in the nursing literature. Wilmoth and Chen (2003) studied living arrangements and symptoms of depression among middle-aged and older immigrants and concluded that immigrants had significantly more depressive symptoms than nonimmigrants. Furthermore, immigrants who lived alone or with family had more depressive symptoms than those who lived with a spouse.
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Cross-Cultural Communication Verbal communication and nonverbal communication are important in community health nursing and are influenced by the cultural background of the nurse and client. Cross-cultural, or intercultural, communication refers to the communication process between a nurse and a client with different cultural backgrounds as each attempts to understand the other’s point of view from a cultural perspective.
Nurse–Client Relationship From the introduction of the nurse to the client through termination of the relationship, communication is a continuous process for the community health nurse. First impressions are important in all human relationships; therefore cross-cultural considerations concerning introductions warrant a few brief remarks. To ensure a mutually respectful and trusting relationship, the nurse should introduce himself or herself and indicate how the client should refer to the nurse (i.e., by first name, last name, or title). Having done so, the nurse should ask the client to do the same. This enables the nurse to address the client in a manner that is culturally appropriate, thereby avoiding potential embarrassment. For example, some Asian and European cultures write the last name first; confusion can be avoided in an area of sensitivity (i.e., the client’s name).
Space, Distance, and Intimacy Sense of spatial distance is significant because culturally appropriate distance zones vary widely. For example, the nurse may back away from clients of Hispanic, East Indian, or Middle Eastern origin who invade personal space with regularity in an attempt to bring the nurse closer into the space that is comfortable to them. Although the nurse is uncomfortable with clients’ close physical proximity, clients are perplexed by the nurse’s distancing behaviors and may perceive the community health nurse as aloof and unfriendly. Table 13.4 summarizes the four distance zones identified for the functional use of space that are embraced by the dominant cultural group in the United States, including most nurses.
Overcoming Communication Barriers Nurses tend to have stereotypical expectations of the client’s behavior. In general, nurses expect behavior to consist of undemanding compliance, an attitude of respect for the health care provider, and cooperation with requested behavior throughout the examination. Although clients may ask a few questions for clarification, slight deference to recognized authority figures (e.g., health care providers) is expected. However, individuals from culturally diverse backgrounds may have significantly different perceptions about the appropriate role of the individual and family when seeking health care. If nurses find themselves becoming annoyed that a client is asking too many questions, assuming a defensive posture, or otherwise feeling uncomfortable, they may pause for a moment to examine the source of the conflict from a cross-cultural perspective.
During illness, culturally acceptable “sick-role” behavior may range from aggressive, demanding behavior to silent passivity (Cockerham, 2009). Complaining, demanding behavior during illness is may be rewarded with attention in some cultures, whereas others may promote quiet and compliance in clients during illness (Andrews and Boyle, 2016). Furthermore, during an interview, Asian clients may provide the nurse with the answers they think the nurse wants to hear, behavior that is consistent within their cultural value for harmonious relationships with others. The nurse should attempt to phrase questions or statements in a neutral manner that avoids foreshadowing an expected response. Appalachian clients may reject a community health nurse whom they perceive as prying or nosy because a cultural ethic of neutrality mandates that people mind their own business and avoid assertive or argumentative behavior (Giger, 2017).
TABLE 13.4
Functional Use of Space
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Zone Remarks
Intimate zone (0 to 1.5 feet) Visual distortion occurs. Best for assessing breath and other body odors.
Personal distance (1.5 to 4 feet) Perceived as an extension of the self, similar (1.5 to 4 feet) to a “bubble.” Voice is moderate. Body odors are inapparent. Visual distortion does not occur. Much of the physical assessment will occur at this distance.
Social distance (4 to 12 feet) Used for impersonal business transactions. Perceptual information is much less detailed. Much of the interview will occur at this distance.
Public distance (>12 feet) Interaction with others is impersonal. Speaker’s voice must be projected. Subtle facial expressions are imperceptible.
Data from Hall E: Proxemics: The study of man’s spatial relations. In Galdston I, editor, Man’s image in medicine and anthropology, New York, 1963, International Universities Press.
Nonverbal Communication Unless the nurse makes an effort to understand the client’s nonverbal behavior, he or she may overlook important information such as that conveyed by facial expressions, silence, eye contact, touch, and other body language. Communication patterns vary widely cross-culturally, even for seemingly “innocent” behaviors such as smiling and shaking hands. For example, among many Hispanic clients, smiling and shaking hands are considered an integral part of sincere interaction and essential to establishing trust, whereas a Russian client may perceive the same behavior from the nurse as insolent and frivolous (Giger, 2017).
Gender issues also become significant. For example, among some groups of Middle Eastern origin, men and women do not shake hands or touch each other in any manner outside the marital relationship. However, if the nurse and client are both female, a handshake is usually acceptable (Andrews and Boyle, 2016).
Wide cultural variation exists in the interpretation of silence. Some individuals find silence extremely uncomfortable and make every effort to fill conversational lags with words. In contrast, Native Americans consider silence essential to understanding and respecting the other person. A pause after a question signifies that what the speaker has asked is important enough to be given thoughtful consideration. In traditional Chinese and Japanese cultures, silence may mean that the speaker wishes the listener to consider the content of what has been said before continuing. The English and Arabs may use silence out of respect for another person’s privacy, whereas the French, Spanish, and Russians may interpret it as a sign of agreement. Asian cultures often use silence to demonstrate respect for elders (Giger, 2017).
Eye contact is among the most culturally variable nonverbal behaviors. Although most nurses have been taught to maintain eye contact while talking with clients, individuals from culturally diverse backgrounds may misconstrue this behavior. Asian, Native American, Indochinese, Arab, and Appalachian clients may consider direct eye contact impolite or aggressive, and they may avert their own eyes during the conversation. Native American clients often stare at the floor when the nurse is talking. This culturally appropriate behavior indicates that the listener is paying close attention to the speaker (Giger, 2017; Andrews and Boyle, 2016).
In some cultures, modesty for women is interrelated with eye contact. For a Muslim woman, modesty is achieved in part by avoiding eye contact with men, except for her husband, and keeping the eyes downcast when encountering members of the opposite sex in public situations. In many cultures, the only women who smile and establish eye contact with men in public are prostitutes (Giger, 2017). Hasidic Jewish men also have culturally based norms concerning eye contact with women. Such a man may avoid direct eye contact and turn his head in the opposite direction when walking past or speaking to a woman. It is important to understand that the preceding examples are intended to be illustrative and are not exhaustive, nor do they represent values, actions, and beliefs of all members of the cultural groups described.
Language To assess non–English-speaking clients, the nurse may need the help of an interpreter. Interviewing
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a non–English-speaking person requires a bilingual interpreter for full communication. Even the person from another culture or country who has a basic command of English may need an interpreter when faced with the anxiety-provoking situation of becoming ill; encountering a strange symptom; or discussing sensitive topics such as birth control, gynecological concerns, and urological problems. The nurse may be tempted to ask a relative or friend of another client to interpret because this person is readily available and is anxious to help. However, doing so is disadvantageous because it violates confidentiality for the client, who may not want personal information shared with another. Furthermore, the friend or relative, although fluent in ordinary language, is likely to be unfamiliar with medical terminology, clinical procedures, and medical ethics.
Whenever possible, the nurse should use a bilingual team member or trained medical interpreter. This person knows interpreting techniques, has a health care background, and understands clients’ rights. The trained interpreter is also knowledgeable about cultural beliefs and health practices, can help bridge the cultural gap, and can provide advice concerning the cultural appropriateness of recommendations.
Although the nurse is in charge of the client–nurse interaction, the interpreter is an important member of the health care team. Whenever feasible, the nurse should ask the interpreter to meet the client before the visit to establish rapport and learn about the client’s age, occupation, educational level, and attitude toward health care. This knowledge enables the interpreter to communicate on the client’s level.
The nurse should allow more time for visits with culturally diverse clients who require an interpreter. With the third person repeating everything, it can take considerably longer than interviewing English-speaking clients. The nurse will need to focus on the major points and prioritize data.
Line by line and summarization are interpretation styles. Translation line by line ensures accuracy, but it takes more time. The nurse and client should speak only a sentence or two and then allow the interpreter time to interpret. The nurse should use simple language, not medical jargon that the interpreter must simplify before translating. Summary translation is faster and useful for teaching relatively simple health techniques with which the interpreter is already familiar. The nurse should be alert for nonverbal cues as the client talks because they can give valuable data. A good interpreter will also note nonverbal messages and communicate those to the community health nurse. Box 13.2 summarizes suggestions for the selection and use of an interpreter.
Although use of an interpreter is ideal, the nurse may find himself or herself in a situation with a non–English-speaking client in which no interpreter is available. Box 13.3 provides some suggestions for overcoming language barriers when an interpreter is not available.
BOX 13.2 Overcoming Language Barriers : Use of an Interpreter
• Before locating an interpreter, the nurse should know what language the client speaks at home because it may be different from the language spoken publicly (e.g., French is sometimes spoken by aristocratic or well-educated people from certain Asian or Middle Eastern cultures).
• The nurse should avoid interpreters from a rival tribe, state, region, or nation (e.g., a Palestinian who knows Hebrew may not be the best interpreter for a Jewish client).
• The nurse should be aware of the gender difference between the interpreter and client to avoid violation of cultural mores related to modesty.
• The nurse should be aware of the age difference between the interpreter and client. • The nurse should be aware of socioeconomic differences between the interpreter and client. • The nurse should ask the interpreter to translate as closely to verbatim as possible. • An interpreter who is not a relative may seek compensation for services rendered.
BOX 13.3 Overcoming Language Barriers when an Interpreter is not Available
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• The nurse should be polite and formal. • The nurse should greet the client using his or her last or complete name. The nurse should
gesture to himself or herself and say his or her name. The nurse should offer a handshake, nod, or smile.
• The nurse should proceed in an unhurried manner. The nurse should pay attention to efforts by the client or family to communicate.
• The nurse should speak in a low, moderate voice. The nurse should remember that he or she may have a tendency to raise the volume and pitch of his or her voice when the listener appears not to understand, and the listener may perceive that the nurse is shouting or angry.
• The nurse should use words that he or she may know in the client’s language. Doing so indicates that the nurse is aware of and respects the client’s culture.
• The nurse should use simple words, such as “pain” instead of “discomfort.” The nurse should avoid medical jargon and slang. He or she should avoid using contractions such as “don’t,” “can’t,” and “won’t.” The nurse should use nouns repeatedly instead of pronouns. For example, the nurse should say, “Do you take medicine?” instead of “You have been taking your medicine, haven’t you?”
• The nurse should pantomime words and simple actions while verbalizing them. • The nurse should give instructions in the proper sequence. For example, he or she should say,
“First, wash the bottle. Second, rinse the bottle,” instead of “Before you rinse the bottle, sterilize it.”
• The nurse should discuss one topic at a time. He or she should avoid use of conjunctions. For example, the nurse should ask, “Are you cold [while pantomiming]?” and then “Are you in pain?” instead of, “Are you cold and in pain?”
• The nurse should determine whether the client understands by having the client repeat instructions, demonstrate the procedure, or act out the meaning.
• The nurse should write out several short sentences in English and determine the client’s ability to read them.
• The nurse should try a third language. Many Indo-Chinese people speak French. Europeans often know three or four languages. The nurse should try Latin words or phrases.
• The nurse should ask who among the client’s family and friends could serve as an interpreter. • The nurse should obtain phrase books from a library or bookstore, make or purchase flash
cards, contact hospitals for a list of interpreters, and use both formal and informal networking to locate suitable interpreters.
Touch Touching the client is a necessary component of a comprehensive assessment. Although benefits exist in establishing rapport with clients through touch, including the promotion of healing through therapeutic touch, physical contact with clients conveys various meanings cross-culturally. In many cultures (e.g., Arab and Hispanic), male health care providers may be prohibited from touching or examining all or certain parts of the female body. During pregnancy, the client may prefer female health care providers and may refuse to be examined by a man. The nurse should be aware that the client’s significant other also might exert pressure on health care providers by enforcing these culturally meaningful norms in the health care setting.
Touching children may also have variable meanings cross-culturally. For example, Hispanic clients may believe in mal ojo (evil eye), in which an individual becomes ill as a result of excessive admiration by another. Many Asians believe that personal strength resides in the head and consider touching the head disrespectful. The nurse should approach palpation of the fontanelle of an infant of Southeast Asian descent with sensitivity. The nurse may need to rely on alternative sources of information (e.g., assessing for clinical manifestations of increased intracranial pressure or signs of premature fontanelle closure). Although it is the least desirable option, the nurse may need to omit this part of the assessment (Giger, 2017).
Gender Violating norms related to appropriate male–female relationships among various cultures may
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jeopardize the therapeutic nurse–client relationship. Among Arab Americans, a man is never alone with a woman, except his wife, and is usually accompanied by one or more other men when interacting with women. This behavior is culturally significant, and failure to adhere to the cultural code (i.e., set of rules or norms of behavior used by a cultural group to guide their behavior and interpret situations) is viewed as a serious transgression, often one in which the lone male will be accused of sexual impropriety. The best way to ensure that cultural variables have been considered is to ask the client about culturally relevant aspects of male–female relationships, preferably at the beginning of the interaction before an opportunity arises to violate culturally based practices.
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Health-Related Beliefs and Practices One of the major aspects of a comprehensive cultural assessment concerns the collection of data related to culturally based beliefs and practices about health and illness. Before determining whether cultural practices are helpful, harmful, or neutral, the nurse must first understand the logic of the belief system underlying the practice and then be sure to grasp fully the nature and meaning of the practice from the client’s cultural perspective.
Health and Culture The first step in understanding the health care needs of clients is to understand personal culturally based values, beliefs, attitudes, and practices. Sometimes this step requires considerable introspection and may necessitate that the nurse confront his or her own biases, preconceptions, and prejudices about specific racial, ethnic, religious, sexual, or socioeconomic groups. The next step is to identify the meaning of health to the client, remembering that concepts are derived, in part, from the way in which members of their cultural group define health.
Considerable research has been conducted on the various definitions of health that may be held by various groups. For example, Jamaicans define health as having a good appetite, feeling strong and energetic, performing activities of daily living without difficulty, and being sexually active and fertile. For traditional Italian women, health means the ability to interact socially and perform routine tasks such as cooking, cleaning, and caring for oneself and others. Individuals may define themselves or others in their group as healthy even though the nurse identifies symptoms of disease (Spector, 2017).
Cross-Cultural Perspectives on Causes of Illness For clients, symptom labeling and diagnosis depend on the extent of the difference between the individual’s behaviors and those the group defines as normal. Other issues that the nurse should consider include the client’s beliefs about the causation of illness, level of stigma attached to a particular set of symptoms, prevalence of the disease, and meaning of the illness to the individual and family.
Throughout history, humankind has attempted to understand the cause of illness and disease. Theories of causation have been formulated on the basis of religious beliefs, social circumstances, philosophical perspectives, and level of knowledge. Disease causation may be viewed from the following three major perspectives: biomedical (i.e., sometimes used synonymously with the term scientific), naturalistic (i.e., sometimes used synonymously with the term holistic), and magicoreligious (i.e., metaphysical or supernatural belief).
Biomedical Perspective The biomedical (i.e., scientific) theory of illness causation is based on the following beliefs:
1. All events in life have a cause and effect. 2. The human body functions more or less mechanically (i.e., the functioning of the human
body is analogous to the functioning of an automobile). 3. All life can be reduced or divided into smaller parts (e.g., the human person can be reduced
into body, mind, and spirit). 4. All of reality can be observed and measured (e.g., with intelligence tests and psychometric
measures of behavior).
Among the biomedical explanations for disease is the germ theory, which posits that microscopic organisms such as bacteria and viruses are responsible for many specific disease conditions. Most educational programs for nurses and other health care providers embrace biomedical, or scientific, theories that explain the causes of physical and psychological illnesses.
Naturalistic Perspective
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Another way in which clients may explain the cause of illness is from the naturalistic (i.e., holistic) perspective. This viewpoint is found most frequently among Native Americans, Asians, and others who believe that human life is only one aspect of nature and a part of the general order of the cosmos. Individuals from these groups believe that the forces of nature must be kept in natural balance or harmony to maintain health and well-being. A combination of worldviews is possible, and many clients are likely to offer more than one explanation for the cause of their illness. As a profession, nursing largely embraces the biomedical-scientific worldview, but some aspects of holism have begun to gain popularity. These include a wide variety of techniques for management of chronic pain (e.g., hypnosis, therapeutic touch, and biofeedback). Many nurses hold a belief in spiritual power and readily credit supernatural forces with various unexplained phenomena related to clients’ health and illness states.
Numerous Asians subscribe to the yin-yang theory, in which health is believed to exist when all aspects of the person are in perfect balance. Rooted in the ancient Chinese philosophy of Tao, the yin-yang theory states that all organisms and objects in the universe consist of yin or yang energy forces. The origin of the energy forces is within the autonomic nervous system, where balance between the opposing forces is maintained during health. Yin energy represents the female and negative forces (e.g., emptiness, darkness, and cold), whereas yang forces are male and positive, emitting fullness, light, and warmth. Foods are classified as hot and cold in this theory and are transformed into yin and yang energy when metabolized by the body. Yin foods are cold, and yang foods are hot. Cold foods are eaten when one has a hot illness, and hot foods are eaten when one has a cold illness. The yin-yang theory is the basis for Eastern or Chinese medicine.
The naturalistic perspective posits that the laws of nature create imbalance, chaos, and disease. Individuals embracing the naturalistic view use metaphors such as the healing power of nature, and they may call the earth “Mother.” For example, from the perspective of the Chinese, illness is seen not as an intruding agent but rather as a part of life’s rhythmic course and an outward sign of the disharmony that exists within.
Many Hispanic, Arab, African American, and Asian groups embrace a hot-cold theory of health and illness, an explanatory model with its origin in the ancient Greek humoral theory. Blood, phlegm, black bile, and yellow bile, the four humors of the body, regulate basic bodily functions and are described in terms of temperature, dryness, and moisture. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors.
Beverages, foods, herbs, medicines, and diseases are classified as hot or cold according to their perceived effects on the body, not on their physical characteristics. Illnesses believed to be caused by cold entering the body include earache, chest cramps, paralysis, gastrointestinal discomfort, rheumatism, and tuberculosis. Illnesses believed to be caused by overheating include abscessed teeth, sore throats, rashes, and kidney disorders.
According to the hot-cold theory, the individual as a whole, rather than a specific ailment, is significant. Those who embrace the hot-cold theory maintain that health consists of a positive state of total well-being, including physical, psychological, spiritual, and social aspects of the person. Paradoxically, the language used to describe this artificial dissection of the body into parts is a reflection of the biomedical-scientific perspective, not a naturalistic or holistic one.
Magicoreligious Perspective Another way in which people explain the causation of illness is from a magicoreligious perspective. The basic premise of this explanatory model is that the world is seen as an arena in which supernatural forces dominate. The fate of the world and those in it depends on the action of supernatural forces for good or evil. Examples of magical causes of illness include the belief in voodoo or witchcraft among some African Americans and others from circum-Caribbean countries. Faith healing is based on religious beliefs and is most prevalent among selected Christian religions, including Christian Scientists. Various healing rituals (prayer, anointing, exorcism, laying of hands, etc.) may be found in many religions—Roman Catholicism, Mormonism (i.e., Church of Jesus Christ of Latter-day Saints), and others (Hanson and Andrews, 2016).
Folk Healers All cultures have their own recognized symptoms of ill health, acceptable sick-role behavior, and treatments. In addition to seeking help from the nurse as a biomedical-scientific health care
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provider, clients from many groups may seek help from folk or religious healers. Numerous types of folk healers exist, each with a unique scope of practice. Hispanic clients may
turn to a curandero (male folk healer) or curandera (female folk healer), spiritualist, yerbo (herbalist), or sabador (healer who manipulates muscles and bones). In many instances, people from diverse cultures combine folk healing and biomedicine. Among the main reasons for seeking care from folk healers is the perception that biomedical practitioners (e.g., physicians and nurses) fail to provide holistic care and use medicines that are not natural (Andrews and Boyle 2016).
Some African American clients may mention having received assistance from a hougan (voodoo priest or priestess), spiritualist, or “old lady” (an older woman who has successfully raised a family and specializes in child care and folk remedies). Likewise, Native American clients may seek assistance from a shaman or a medicine man or woman. Clients of Asian descent may mention that they have visited herbalists, acupuncturists, or bone setters (Giger, 2017).
Each culture has its own healers, most of whom speak the native tongue of the client, make house calls, and cost significantly less than healers practicing in the biomedical-scientific health care system. In addition to folk healers, many cultures rely on lay midwives (e.g., parteras for Hispanic women) or other health care providers to meet the needs of pregnant women.
In some religions, spiritual healers may be found among the ranks of the ordained or official religious hierarchy ranks and are called priest, bishop, elder, deacon, rabbi, brother, or sister. Other religions have a separate category of healer (e.g., Christian Science “nurses” [not licensed by states] or practitioners) (Hanson and Andrews, 2016).
A comprehensive discussion of the variety of healing beliefs and practices used by the numerous cultural groups is beyond the scope of this chapter. However, the nurse should be aware of alternative practices and folk healers that are used by the groups for which they care. The nurse should also be aware that most indigenous healing practices are innocuous, regardless of whether they are effective.
Cultural Expressions of Illness A wide cultural variation exists in the manner in which certain symptoms and disease conditions are perceived, diagnosed, labeled, and treated. The disease that is grounds for social ostracism in one culture may be reason for increased status in another.
Bodily symptoms are also perceived and reported in a variety of ways. For example, individuals of Mediterranean descent tend to report common physical symptoms more often than people of Northern European or Asian heritage. To express emotion, East Asian clients sometimes somaticize their symptoms. For example, a client may complain of cardiac symptoms because the center of emotion in the Chinese culture is the heart. If the client has experienced a loss through death or divorce and is grieving, he or she may describe the loss in terms of a pain in the heart. Although some biomedical-scientific clinicians may refer to this pain as a psychosomatic illness, others will recognize it as a culturally acceptable somatic expression of emotional disharmony (Andrews and Boyle, 2016; Giger, 2017).
Cultural Expression of Pain Pain, an extensively studied symptom, is used here to illustrate the manner in which symptom expression may reflect the client’s cultural background. Pain is a universally recognized phenomenon and an important aspect of assessment for clients of various ages. It is also a private, subjective experience that is greatly influenced by cultural heritage. Expectations, manifestations, and pain management are all embedded in a cultural context. The definition of pain, like that of health or illness, is culturally determined.
The term pain is derived from the Greek word for penalty, a fact that helps explain the long association between pain and punishment in Judeo-Christian thought. The meaning of painful stimuli for individuals, the way people define their situation, and the influence of personal experience combine to determine the experience of pain.
Much cross-cultural research has been conducted on pain (Campbell and Edwards, 2012; Ludwig-Beymer, 2008; Zborowski, 1969). Pain has been found to be a highly personal experience that depends on cultural learning, the meaning of the situation, and other factors unique to the individual (Campbell and Edwards, 2012). Health care professionals have identified silent suffering as the most valued response to pain. The majority of nurses have been socialized to believe that in
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virtually any situation, self-control is better than open displays of strong feelings. Studies of health care providers’ attitudes toward pain reveal that the ethnic background of
clients is relevant to the assessment of physical and psychological pain (Campbell and Edwards, 2012). Nurses view Jewish and Spanish clients as experiencing suffering the most and Anglo-Saxon Germanic clients as experiencing suffering the least. In addition, nurses who infer relatively greater client pain tended to report their own experiences as more painful. In general, nurses with an Eastern or Southern European or African background tend to infer greater suffering than do nurses of Northern European background. Years of experience, current position, and area of clinical practice are unrelated to inferences of suffering (Ludwig-Beymer, 2008).
In addition to expecting variations in pain perception and tolerance, a nurse should expect variations in the expression of pain. Individuals turn to their social environments for validation and comparison. A first important comparison group is the family, which transmits cultural norms to its children.
Culture-Bound Syndromes Clients may have a condition that is culturally defined, known as a culture-bound syndrome. Some of these conditions have no equal from a biomedical or scientific perspective, but others, such as anorexia nervosa and bulimia, are examples of health problems found primarily among members of the dominant U.S. cultural group. Table 13.5 presents selected examples from among more than 150 culture-bound syndromes that have been documented by medical anthropologists.
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Management of Health Problems: A Cultural Perspective After a symptom is identified, the first effort at treatment is often self-care. In the United States, an estimated 70% to 90% of all illness episodes are treated first, or exclusively, through self-care, often with significant success. The availability of over-the-counter medications, a relatively high literacy level, and influence of the mass media/technology in communicating health-related information to the general population have contributed to the high percentage of self-treatment. Home treatments are attractive because of their accessibility in comparison with the inconvenience associated with traveling to a physician, nurse practitioner, and pharmacist, particularly for clients from rural or sparsely populated areas. Furthermore, home treatment may mobilize the client’s social support network and provide the sick individual with a caring environment in which to convalesce.
However, the nurse should be aware that not all home remedies are inexpensive. For example, urban African American populations in the Southeast sometimes use medicinal potions that cost much more than an equivalent treatment with a biomedical intervention.
Various nontraditional interventions are gaining the recognition of health care professionals in the biomedical-scientific health care system. Acupuncture, acupressure, therapeutic touch, massage, cupping, biofeedback, relaxation techniques, meditation, hypnosis, distraction, imagery, and herbal remedies are interventions that clients may use alone or in combination with other treatments.
Cultural Negotiation Cultural negotiation refers to the process in which messages, instructions, and belief systems are manipulated, linked, or processed between the professional and lay models of health problems and preferred treatment. In each act, the nurse gives attention to eliciting the client’s views regarding a health-related experience (e.g., pregnancy, complications of pregnancy, or illness of an infant).
TABLE 13.5
Selected Culture-Bound Syndromes
Group Disorder(S) Remarks Whites Anorexia nervosa Excessive preoccupation with thinness, self-imposed starvation
Bulimia Gross overeating, then vomiting or fasting African Americans Blackout Collapse, dizziness, or inability to move
Low blood Not enough blood or weakness of the blood that is often treated with diet High blood Blood that is too rich in certain components from ingesting too much red meat or
rich foods Thin blood In women, children, and the elderly; renders the individual more susceptible to
illness in general Diseases of hex, witchcraft, or conjuring
Sense of being doomed by a spell, part of voodoo beliefs
Chinese or Southeast Asians
Koro Intense anxiety that the penis is retracting into the body
Greeks Hysteria Bizarre complaints and behavior because the uterus leaves the pelvis and goes to another part of the body
Hispanics Empacho Food forms into a ball and clings to the stomach or intestines, causing pain and cramping
Fatigue Asthmalike symptoms Mal ojo (evil eye) Fitful sleep, crying, and diarrhea in children caused by a stranger’s attention;
sudden onset Susto Anxiety, trembling, and phobias from sudden fright
Native Americans Ghost Terror, hallucinations, and sense of danger Japanese Wagamama Apathetic childish behavior with emotional outbursts
Katon and Kleinman (1981) describe negotiation as a bilateral arrangement in which two principal parties attempt to work out a solution. The goal of negotiation is to reduce conflict in a way that promotes cooperation. Cultural negotiation is used when conceptual differences exist between the client and the nurse, a situation that may occur for one or more of the following reasons:
• The nurse and client may be using the same words but applying different meanings to them.
• The nurse and client may apply the same term to the same phenomenon but have different
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notions of its causation. • The nurse and client may have different memories or emotions associated with the term
and its use.
In cultural negotiation, the nurse provides scientific information while acknowledging that the client may hold different views. If the client’s perspective indicates that behaviors would be helpful, positive, adaptive, or neutral in effect, the nurse should include them in the plan of care. However, if the client’s perspective would result in behaviors that may be harmful, negative, or nonadaptive, the nurse should attempt to shift the client’s perspective to that of the practitioner (Spector, 2008).
Pregnancy and childbirth are social, cultural, and physiological experiences; therefore an approach to culturally sensitive nursing care of childbearing women and their families must focus on the interaction between cultural meaning and biological functions. Childbirth is a time of transition and social celebration that is of central importance in any society; it signals realignment of existing cultural roles and responsibilities, psychological and biological states, and social relationships. Child rearing is also a period during which culturally bound values, attitudes, beliefs, and practices permeate virtually all aspects of life for the parents and child (Andrews and Boyle, 2016). Careful assessment and attention to culturally based practices are particularly important during these occasions.
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Management of Health Problems in Culturally Diverse Populations The factors responsible for the health disparity between minority and white populations are complex and defy simplistic solutions. Health status is influenced by the interaction of physiological, cultural, psychological, and societal factors that are poorly understood for the general population and even less so for minorities. Despite the shared characteristic of economic disadvantage among minorities, common approaches for improving health are not recommended because of the variations in cultural beliefs and practices that exist among the different minority populations. Rather, solving problems among minorities necessitates activities, programs, and data collection that are tailored to meet the unique health care needs of many different subgroups. Solutions to health care problems among culturally diverse populations include the following recommendations that are the cornerstone of public health nursing (Keller et al., 2011):
• Focus on the health of entire populations • Reflect community priorities and needs • Establish caring relationships with the communities, families, and individuals that make up
the population • Remain grounded in social justice, having compassion and respect for the worth of all
people, especially the vulnerable • Provide care for the whole person: mental, physical, emotional, social, spiritual, and
environmental aspects • Promote health through strategies based on epidemiological evidence (evidence-based
practice) • Collaborate with community resources to reach health care goals
Providing Health Information and Education Minority populations need more information about their health risks and treatment options. This is demonstrated by the following facts (American Cancer Society, 2016; CDC, 2016):
• African Americans have the highest mortality rate and shortest survival rate for many cancers.
• African Americans receive less information about cancer and heart disease than nonminority groups.
• African Americans tend to underestimate the prevalence of cancer, give less credence to the warning signs, obtain fewer screening tests, and receive a diagnosis at later stages of cancer than whites.
• Mexican Americans have a higher incidence of overweight and obesity than non-Hispanic whites, but non-Hispanic Blacks have the highest rates of obesity.
Programs to increase public awareness about health problems have been well received in several areas. For example, the Healthy Mothers, Healthy Babies Coalition, which provides an education program in both English and Spanish, has contributed to greater awareness of measures to improve the health status of mothers and infants. In addition, increased knowledge among African Americans of hypertension as a serious health problem is one of the accomplishments of the National High Blood Pressure Education program. The success of these efforts indicates that carefully planned programs have a beneficial effect, but efforts must continue and must expand to reach even more of the target population and focus on additional health problems.
Planning Health Information Campaigns Sensitivity to cultural factors is often lacking in the health care of minorities. Key concepts for the nurse to consider in designing a health information campaign include meeting the language and cultural needs of each identified minority group, using minority-specific community resources to tailor educational approaches, and developing materials and methods of presentation that are
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commensurate with the educational level of the target population. Furthermore, the powerful influences of cultural factors over a lifetime in shaping people’s attitudes, values, beliefs, and practices concerning health require health information programs to be sustained over a long period. The following are examples of ways in which the nurse can interweave these concepts into health promotion efforts:
• The nurse should involve local community leaders who are members of the targeted cultural group to promote acceptance and reinforcement of the central themes of health promotion messages.
• Health messages are more readily accepted if they do not conflict with existing cultural beliefs and practices. Where appropriate, messages should acknowledge existing cultural beliefs.
• The nurse should involve families, churches, employers, and community organizations as a support system to facilitate and sustain behavioral change to a more healthful lifestyle. For example, although hypertension control in African Americans depends on appropriate treatment (e.g., medication), blood pressure can be improved and maintained by family and community support of activities such as proper diet and exercise.
• Language barriers, cultural differences, and lack of adequate information on access to care complicate prenatal care for Hispanic and Asian women who have recently arrived in the United States. Through the use of lay volunteers to organize community support networks, programs have been developed to disseminate culturally appropriate health information.
Health Education Although printed materials and other audiovisual aids contribute to the educational process, client education is inherently interpersonal. The success of educational efforts is often determined by the credibility of the source and is highly dependent on the skill and sensitivity of the nurse in communicating information in a culturally appropriate manner. Education programs are particularly critical and necessary for several health problems with the greatest influence on minority health, such as hypertension, obesity, and diabetes. For example, if patients with diabetes could improve their self-management skills through education, a significant number of complications (e.g., ketoacidosis, blindness, and amputations) could be avoided, saving human misery and health care dollars.
Delivering and Financing Health Services Innovative models for delivering and financing health services for minority populations are needed. According to community health experts, models should increase flexibility of health care delivery, facilitate minorities’ access to services, and improve efficiency of service and payment systems. One of the most commonly used indicators of the adequacy of health services for a population is the distribution of health care providers; however, this is an inadequate measurement. The following observations exemplify the problems associated with health services for minorities:
• The disparities in death rates between minorities and whites remain despite overall increases in health care access and use (AHRQ, 2014).
• Language problems hinder refugees and immigrants when they seek health care. • African Americans with cancer postpone seeking diagnosis of their symptoms longer than
whites and delay initiation of treatment once diagnosed (American Cancer Society, 2016). • The infant mortality rate among African American women is more than twice as high as the
infant mortality rate among white women (CDC, 2015).
Models of Health Promotion In most health models, SES is assumed to affect health status through environmental or behavioral factors. These models posit that poor families may not have the economic, social, or community resources needed to remain in good health. For example, poverty is thought to affect children’s well-being by affecting health and nutrition, the home environment, caregiver interactions with children, caregiver mental health, and neighborhood conditions. The deficits associated with
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poverty may lead to an inadequate diet, which results in poor growth and delayed development. Likewise, poor housing raises the risk for exposure to many illnesses and infections; overcrowding results in increased risk for infectious diseases such as tuberculosis, meningitis, influenza, and related conditions; and community violence threatens the safety and well-being of children. The combined effect of these stressors is thought to provide the foundation for a cycle of hopelessness and depression among family members, who in turn may engage in risky health behaviors (e.g., smoking, substance abuse, and poor dietary habits resulting in obesity and high cholesterol levels) and unfavorable family interactions.
Although many Latino children live in poverty, they enjoy relatively good health in comparison with children in other low socioeconomic groups. This finding has been called an epidemiological paradox. The assumption is that if the family promotes beneficial health behaviors among its members, these behaviors will become integrated into the culture. Healthy lifestyle behaviors become an integral component of the family identity, traditions, and history.
Continuity of Care Continuity of care is associated with improved health outcomes and is presumably greater when a client is able to establish an ongoing relationship with a care provider. Many of the leading causes of death among minorities (e.g., cancer, cardiovascular disease, and diabetes) are chronic rather than acute problems; therefore they require extended treatment regimens. Consider the following:
• Refugees are eligible for special medical assistance during their first 18 months in the United States. However, after this period, refugees who cannot afford private health insurance and are ineligible for Medicaid or state medical assistance may become medically indigent.
• Illegal immigrants are ineligible for Medicare and Medicaid. They are medically indigent. • Many Native Americans and Alaska Natives live in areas where the availability of health
care providers is half the national average.
Health Care Financing Problems As mentioned previously, problems associated with financing health care tend to be more common in minority groups than in the dominant cultural group. Consider the following (National Center for Health Statistics, 2008):
• Economic inequalities cause members of minority groups to rely disproportionately on Medicaid for their health care needs.
• Older minority people are less likely than whites to supplement Medicare with additional private insurance.
• Proportionately, three times as many Native Americans, African Americans, Hispanics, and certain Asian and Pacific Islander groups as whites live in poverty.
• In 2015, 19.4% of Hispanics lacked insurance coverage, compared with 9.9% of African Americans and 6.2% of whites (Ward et al., 2016).
To better manage health problems and reduce the disparity in health indicators, these issues of financing must be addressed. Failure to address them will result not only in continued inequity in access to services but also in continued poor health among minority groups.
Developing Health Professionals from Minority Groups The need to increase the number of health professionals from minority groups has been recognized for decades. With few exceptions, minorities are underrepresented as students and practitioners of the health professions. Although the number of minority nursing students has been steadily increasing, there still are proportionately more white nursing students.
Differences in the availability of health personnel resources in minority communities are apparent, regardless of the minority group being considered. Communities located in urban- metropolitan areas have significantly more professional resources. Among the factors that contribute to the imbalances in minority representation in health professions are the size of a
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minority population, number of cultural subgroups, and demographic features. Efforts to encourage more students from minority groups are ongoing, and government and private foundations offer grants, scholarships, and low-cost loans to recruit and retain students from underserved minority groups in nursing and other health care professions. Minority and nonminority health professional organizations, academic institutions, state governments, health departments, and other organizations from the public and private sectors should work together to develop strategies to improve the availability and accessibility of health care professionals to minority communities (Sullivan Commission, 2014).
Enhancing Cooperative Efforts with the Nonfederal Sector Activities to improve minority health should involve participation of organizations at all levels (i.e., community, municipal, state, and national). Community involvement in developing health promotion activities can contribute to their success by providing credibility and visibility to the activities and facilitating their acceptance. Changes in health behavior frequently depend on personal initiative and are most likely to be triggered by efforts from locally based sources.
However, not all minority communities have the ability to identify their own health problems and initiate activities to address them. Support from the state and federal governments and private- sector assistance are needed to assist with identifying and solving health-related problems afflicting the minority community. Assistance may be provided to minority communities in the following ways:
1. The use of technical assistance to identify high-risk groups 2. Assistance with planning, implementing, and evaluating programs to address identified
needs 3. Specialized community services (e.g., federally funded projects for infants and frail older
adults) 4. Programs supported by businesses and industries (e.g., health promotion programs
organized by unions)
The private sector can also serve as an effective channel for programs targeted to minority health projects. National organizations concerned with minorities, such as the National Urban League and the National Alliance for Hispanic Health, include health-related issues in their national agendas and are actively seeking effective ways to improve the health of minorities. Organizations such as these have a powerful potential for effecting change among their constituencies because they have strong community-level, grassroots support.
Promoting a Research Agenda on Minority Health Issues The National Center on Minority Health and Health Disparities was developed in 2000 and redesignated in 2010 as the National Institute on Minority Health and Health Disparities (NIMHD) (http://www.nimhd.nih.gov) to assist in the investigation of factors affecting minority health (NIMHD, 2016). Its mission is to lead scientific research to improve minority health and to ultimately eliminate health disparities (NIMHD, 2016). The NIMHD conducts and supports research that examines risk factor prevalence and treatment services. It also reviews health education interventions, preventive services interventions, and sociocultural factors that influence health and outcomes of care.
For further information on current research related to culture and community health nursing, the reader should search library databases for reports of completed studies. Electronic bulletin boards also may be valuable when one is searching for research in progress and for communicating with researchers studying a particular phenomenon of interest. An example of recent nursing research related to culturally competent care is described in the Research Highlights box.
Research Highlights
Nutritional Patterns of Recent Immigrants
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Edmonds (2005) examined the nutritional patterns of 23 women who had recently emigrated from Honduras to assist in understanding health-related nutritional issues in this Hispanic subgroup. She determined that the Honduran women had made both positive and negative changes in their diets since coming to the United States. Rice, beans, natural fruit juices, tortillas, bananas, beef, and eggs were reported as the typical foods eaten every day in Honduras. Positive changes in diets included eating a greater variety of fruits and vegetables, cooking with less grease, baking more frequently than frying, and using vegetable oil rather than lard. The women also ate more meat and dairy products. Negative changes noted were more skipped meals and eating foods high in fat and calories (e.g., fast foods). Research suggests that classes be taught in Women, Infants, and Children programs and other venues that would support the Hondurans’ traditional diet and focus on how to eat nutritionally in fast-food restaurants, eat a balanced diet, plan meals and cook ahead, and read food labels. Data from Edmonds VM: The nutritional patterns of recently immigrated Honduran women, Journal of Transcultural Nursing, 16(3):226–235, 2005.
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Role of the Community Health Nurse in Improving Health for Culturally Diverse People This chapter provides data detailing the health care problems of culturally diverse individuals, families, groups, and communities. Given the complexity of the problems and the wide variation in incidence and distribution of these problems within specific subgroups, no simple method exists for providing culturally sensitive community health nursing care to all clients. However, the following strategies may assist the community health nurse when working with culturally diverse clients:
• Conduct a “culturological” assessment. • Conduct a cultural self-assessment. • Seek knowledge about local cultures. • Recognize the political issues of culturally diverse groups. • Provide culturally competent care. • Recognize culturally based health problems.
Culturological Assessment All nursing care is based on a systematic, comprehensive assessment of the client; therefore the community health nurse must gather cultural data on clients from racially and ethnically diverse backgrounds. A culturological assessment refers to a systematic appraisal or examination of individuals, groups, and communities regarding their cultural beliefs, values, and practices to determine explicit nursing needs and intervention practices within the cultural context of the people being evaluated (Leininger, 1995). The term culturological is a descriptive reference to cultural phenomena in their broadest sense.
Culturological assessments are as vital as physical and psychological assessments. Culturological assessments tend to be broad and comprehensive because they deal with cultural values, belief systems, and ways of living now and in the recent past. In conducting a culturological assessment, the community health nurse should be involved in determining and appraising the traits, characteristics, or smallest units of cultural behavior as a guide to nursing care. The following sections summarize major data categories pertaining to the culture of clients and offer suggested questions that the nurse may ask to elicit needed information.
Brief History of Ethnic and Racial Origins of the Cultural Group with Which the Client Identifies
• With what ethnic group or groups does the client report affiliation (e.g., Hispanic, Polish, Navajo, or a combination)? To what degree does the client identify with the cultural group (e.g., “we” concept of solidarity or a fringe member)?
• Where has the client lived (i.e., country and city) and when (i.e., during what years)? If the client has recently relocated to the United States, knowledge of prevalent diseases in the country of origin may be helpful.
Values Orientation
• What are the client’s attitudes, values, and beliefs about birth, death, health, illness, and health care providers?
• Does culture influence the manner in which the client relates to body image change resulting from illness or surgery (e.g., importance of appearance, beauty, strength, and roles in the cultural group)?
• How does the client view work, leisure, and education? • How does the client perceive change? • How does the client value privacy; courtesy; touch; and relationships with individuals of
different ages, of different social class, or caste, and of the opposite sex? • How does the client relate to people in a different cultural group (e.g., withdrawal, verbal
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or nonverbal expression, or negative or positive attitude)?
Cultural Sanctions and Restrictions
• How does the client’s cultural group regard expression of emotion and feelings, spirituality, and religious beliefs? How are dying, death, and grieving expressed in a culturally appropriate manner?
• How is modesty expressed by men and women in the client’s cultural group? Does the client’s cultural group have culturally defined expectations about male–female relationships, including the nurse–client relationship?
• Does the client have restrictions related to sexuality, exposure of body parts, or certain types of surgery (e.g., amputation, vasectomy, or hysterectomy)?
• Does the client have restrictions against discussion of dead relatives or fears related to the unknown?
Communication
• What language does the client speak at home? What other language does the client speak or read? In what language would the client prefer to communicate with you?
• What is the written and spoken English fluency level of the client? Remember that the stress of illness may cause clients to use a more familiar language and temporarily forget some English.
• Does the client need an interpreter? If so, make sure to use an interpreter who is fluent in medical language and is not a relative or friend of the client.
• What are the rules (i.e., linguistics) and modes (i.e., style) of communication? • Is it necessary to vary the technique of communication during the interview and
examination to accommodate the client’s cultural background (e.g., tempo of conversation, eye contact, sensitivity to topical taboos, norms of confidentiality, and style of explanation)?
• How does the client’s nonverbal communication compare with that of individuals from other cultural backgrounds? How does it affect the client’s relationship with the nurse and with other members of the health care team?
• How does the client feel about health care providers who are not of the same cultural background (e.g., African American, middle-class nurse, or Hispanic of a different social class)? Does the client prefer to receive care from a nurse of the same cultural background, sex, or age?
Ethical Insights Disclosure of HIV/AIDS Status Ortiz (2005) examined the experiences of 19 Latinas who disclosed they were living with HIV/AIDS. She described how the women decided to disclose their HIV status to partners, family members, friends, and employers. Four categories emerged: timing of the disclosure, the need to disclose, controlling disclosure, and supportive disclosing. These factors were influenced by the Latinas’ relationship with others, the perceived risks to the women and others, the need to disclose, the wish to give support to themselves or others, and the desire to control who should know and when. Ortiz concluded that nurses should be knowledgeable of the realities of Latinas’ lives and be able to incorporate that knowledge into comprehensive care plans that will help them maximize the utilization of appropriate resources. Data from Ortiz CE: Disclosing concerns of Latinas living with HIV/AIDS. Journal of Transcultural Nursing, 16(3):210–217, 2005.
Health-Related Beliefs and Practices
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• To what cause(s) does the client attribute illness and disease (e.g., divine wrath, imbalance in hot-cold or yin-yang, punishment for moral transgressions, hex, or soul loss)?
• What does the client believe promotes health (e.g., eating certain foods, wearing amulets to bring good luck, exercise, prayer, ancestors, saints, or intermediate deities)?
• What is the client’s religious affiliation (e.g., Judaism, Islam, Pentecostalism, West African voodooism, Seventh-Day Adventism, Catholicism, or Mormonism)?
• Does the client rely on cultural healers (e.g., curandero, shaman, spiritualist, priest, minister, or monk)? Who determines when the client is sick and when the client is healthy? Who determines the type of healer and treatment that should be sought?
• In what types of cultural healing practices does the client engage (e.g., herbal remedies, potions, massage, wearing talismans or charms to discourage evil spirits, healing rituals, incantations, or prayers)?
• How does the client perceive biomedical-scientific health care providers? How do the client and family perceive nurses? What are the expectations of nurses and nursing care?
• What constitutes appropriate “sick-role” behavior? Who determines what symptoms constitute disease and illness? Who decides when the client is no longer sick? Who cares for the client at home?
• How does the client’s cultural group view mental disorders? Do they show differences in acceptable behaviors for physical versus psychological illnesses?
Nutrition
• What nutritional factors are influenced by the client’s cultural background? • What meanings does the client attach to food and eating? With whom does the client
usually eat? What types of foods does the client usually eat? What does the client define as food? What does the client believe defines a “healthy” versus an “unhealthy” diet?
• How does the client prepare foods at home (e.g., type of food preparation; cooking oils used; length of time foods, especially vegetables, are cooked; amount and type of seasoning added to various foods during preparation)?
• Do religious beliefs and practices influence the client’s diet (e.g., amount, type, preparation, or delineation of acceptable food combinations, such as kosher diets)? Does the client abstain from certain foods at regular intervals, on specific dates determined by the religious calendar, or at other times?
• If the client’s religion mandates or encourages fasting, what does the term fast mean to the client (e.g., refraining from certain types or quantities of foods, eating only during certain times of the day)? For what period of time is the client expected to fast? Does the religion allow exemption from fasting during illness, and, if so, is the client believed to have an exemption?
Socioeconomic Considerations
• Who constitutes the client’s social network (i.e., family, peers, and healers)? How do they influence the client’s health or illness status?
• How do members of the client’s social support network define caring (e.g., being continuously present, doing things for the client, or looking after the client’s family)? What are the roles of various family members during health and illness?
• How does the client’s family participate in the client’s nursing care (e.g., bathing, feeding, touching, and being present)?
• Does the cultural family structure influence the client’s response to health or illness (e.g., beliefs, strengths, weaknesses, and social class)? Does a key family member have a role that is significant in health-related decisions (e.g., grandmother in many African American families or eldest adult son in Asian families)?
• Who is the principal wage earner in the client’s family? What is the total annual income? This is a potentially sensitive question that should be asked only if necessary. Does the family have more than one wage earner? Does the family have other sources of financial support (e.g., extended family or investments)?
• What influence does economic status have on lifestyle, place of residence, living conditions,
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ability to obtain health care, and discharge planning?
Organizations Providing Cultural Support
• What influence do ethnic and cultural organizations have on the client’s receiving health care (e.g., National Association for the Advancement of Colored People, African American Political Caucus, churches, schools, Urban League, and community-based health care programs and clinics)?
Educational Background
• What is the highest educational level the client has obtained? Does the client’s educational background affect the client’s knowledge level concerning the health care delivery system, how to obtain the care needed, teaching and learning skills, and written material that is distributed in the health care setting (e.g., insurance forms, educational literature, information about diagnostic procedures and laboratory tests, and admissions forms)?
• Can the client read and write English, or does he or she prefer another language? If English is the client’s second language, are materials available in the client’s primary language?
• What learning style is most comfortable or familiar? Does the client prefer to learn through written materials, oral explanation, or demonstration?
Religious Affiliation
• How does the client’s religious affiliation influence health and illness (e.g., death, chronic illness, body image alteration, and cause and effect of illness)?
• What is the role of the client’s religious beliefs and practices during health and illness? • What is the role of significant religious representatives during health and illness? Does the
client have recognized religious healers (e.g., Islamic imams, Christian Scientist practitioners or nurses, Catholic priests, Mormon elders, and Buddhist monks)?
Cultural Aspects of Disease Incidence
• Does the client have specific genetic or acquired conditions that are more prevalent in a specific cultural group (e.g., hypertension, sickle cell anemia, Tay-Sachs disease, or lactose intolerance)?
• Are any socioenvironmental diseases more prevalent among the client’s specific cultural group (e.g., lead poisoning, alcoholism, AIDS, drug abuse, or ear infections)?
• Do diseases exist against which the client has an increased resistance (e.g., skin cancer in a darkly pigmented individual)?
Biocultural Variations
• Does the client have distinctive physical features that are characteristic of a particular racial group (e.g., skin color or hair texture)? Does the client have variations in anatomy that are characteristic of a particular racial or ethnic group (e.g., body structure, height, weight, facial shape and structure [nose, eye shape, and facial contour], or upper and lower extremity shape)?
• How do anatomical and racial variations affect the assessment?
Developmental Considerations
• Does the client have distinct growth and development characteristics that vary with his or her cultural background (e.g., bone density, psychomotor patterns of development, or fat folds)?
• What factors are significant in assessing children from the newborn period through
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adolescence (e.g., expected growth on standard grid, culturally acceptable age for toilet training, introduction of various types of foods, sex differences, discipline, and socialization to adult roles)?
• What is the cultural perception of aging (e.g., is youthfulness or the wisdom of old age more highly valued)?
• How are older people handled culturally (e.g., cared for in the home of adult children or placed in institutions for care)? What are culturally acceptable roles for older adults?
• Does the older adult expect family members to provide care, including nurturance and other humanistic aspects of care?
• Is the older adult isolated from culturally relevant supportive people or enmeshed in a caring network of relatives and friends?
• Has a culturally appropriate network replaced family members in performing some caring functions for older adults?
Cultural Self-Assessment Community health nurses can engage in a cultural self-assessment. Through identification of health-related attitudes, values, beliefs, and practices that are part of the personal cultural meaning brought to the nurse–client interaction, the nurse can better understand the cultural aspects of health care from the perspective of the client, family, group, or community. Everyone has ethnocentric tendencies that must be brought to a level of conscious awareness so that efforts can be made to temper ethnocentrism and view reality from the perspective of the client.
Knowledge About Local Cultures Community health nurses can learn about the cultural diversity characteristics of the subgroup or subgroups that are most prevalent within their communities. The nurse cannot know about all health-related beliefs and practices of the diverse groups served, but he or she can study select ones. The nurse can accomplish this cultural study through a review of nursing, anthropology, sociology, and related literature on culturally diverse groups; in-service programs held at community health agencies, educational institutions in the community, or organizations serving minority groups; enrollment in courses on transcultural or cross-cultural nursing and medical anthropology; and interviews with key members of the subgroups of interest, such as clergy members, nurses, and physicians, to obtain information about the influence of culture on health-related beliefs and practices.
Recognition of Political Issues of Culturally Diverse Groups Awareness of the political aspects of health care for culturally diverse groups and communities can help community health nurses influence legislation and funding priorities aimed at improving health care for specific populations. Recognized for their leadership role in community health matters involving culturally diverse groups, community health nurses may be invited by political leaders to participate in political decision making that affects the health of a targeted subgroup. Community health nurses should also be active politically, both individually and collectively, to influence legislation affecting culturally diverse individuals, groups, and communities, and they should offer to serve on key community committees, boards, and advisory councils that affect the health of culturally diverse groups.
Providing Culturally Competent Care When caring for individuals and families from culturally diverse backgrounds, the community health nurse can assess, diagnose, implement, and evaluate nursing care in a manner that is culturally congruent, competent, relevant, and appropriate. To provide this culturally appropriate nursing care, the nurse must create a relationship of mutual respect by becoming aware of the cultural similarities and differences between herself or himself and the client. A guideline for gathering cultural data has been presented, and the nurse may use this guideline or a similar one to identify significant areas in which the nurse and client differ. Knowledge about biocultural variations in health and illness is particularly important when the nurse is conducting cultural
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assessments.
Recognition of Culturally Based Health Practices As discussed previously, the community health nurse should attempt to understand the nature and meaning of culturally based health practices of clients, groups, and communities. Once the practices are understood, the nurse can make a determination regarding their appropriateness in a particular context. Generally, the nurse should decide whether a cultural practice is useful, neutral, or harmful to the client, group, or community. The nurse should encourage or “tolerate” helpful and neutral practices, whereas he or she should discourage harmful practices.
However, the classification of some cultural healing practices is not so easily determined. For example, many Southeast Asians practice coining, which is the rubbing of a coin over body surfaces to expel “bad winds” that are believed to cause illness (Berg, Morphew and Tran, 2016; Vitale and Prashad, 2017). Community health nurses are faced with an ethical dilemma when coining is practiced on young children, because it leaves abrasions on the skin and may be viewed by some as child abuse. This practice is not useful, so the nurse must make the decision whether it is neutral or harmful. An argument for the practice’s being neutral is that abrasions usually heal quickly, so no harm is done to the child as a result. Furthermore, the practice is meaningful to parents who have much confidence in the healing powers associated with coining (Giger, 2017; Vitale and Prashad, 2017).
The argument can also be made that the practice is harmful. The red marks and skin abrasions caused by the coining place the child at increased risk for skin infection. Given that the child may require antibiotics or other medication for a respiratory disorder, encouragement of coining as the only treatment may prevent the child from receiving needed medical intervention and may delay medical treatment. As a solution, the community health nurse may suggest that parents combine traditional treatment with Western biomedicine (i.e., they can use coining in conjunction with a biomedical intervention). Therefore the healing will occur in a manner that has involved the use of both folk and professional health care systems (Giger, 2017; Vitale and Prashad, 2017).
Active Learning
1. Select a client from a racially or ethnically diverse background, and conduct a cultural assessment.
2. Interview someone from a racial or ethnic background different from your own to determine beliefs about illness causation, use of the lay and professional health care delivery systems, and culturally based treatments.
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Resources for Minority Health Community health nurses will find federal resources for improving the health care of the federally defined minority populations through the USDHHS. Within the USDHHS, the Office of Minority Health (OMH) and the Indian Health Service (IHS) divisions are concerned with health promotion, disease prevention, service delivery, and research for minority groups.
Office of Minority Health The OMH coordinates federal efforts to improve the health status of racial and ethnic minority populations (i.e., African Americans, Hispanics, Native Americans and Alaska Natives, and Asians and Pacific Islanders). Directed by the deputy assistant secretary for minority health, the OMH was established by the Disadvantaged Minority Health Improvement Act of 1990 (PL 101-527), which was signed by President George H. W. Bush on November 6, 1990. Under the directives of the act, the OMH is charged with duties to:
TABLE 13.6
Federally Sponsored Initiatives to Improve the Health of Minority Groups
Initiative Description Racial and Ethnic Approaches to Community Health (REACH 2010)
This program was launched in 1999 to eliminate health disparities in six priority areas: cardiovascular diseases, immunizations, breast and cervical cancer screening and management, diabetes, HIV/AIDS, and infant mortality. REACH 2010 supports community coalitions in designing, implementing, and evaluating community-driven strategies to eliminate health disparities.
National Breast and Cervical Cancer Early Detection Program (NBCCEDP)
NBCCEDP provides breast and cervical cancer screening, diagnosis, and treatment to low-income, medically underserved, and uninsured women (emphasizing recruitment of minority women).
Ryan White Comprehensive AIDS Resources Emergency (CARE) Act B
Ryan White CARE Act provides services to persons living with HIV disease, primarily racial and ethnic minorities.
National Institute on Minority Health and Health Disparities (NIMHD)
NIMHD mission is to lead scientific research to improve minority health and reduce disparity.
• Establish short- and long-range goals and objectives relating to disease prevention, health promotion, service delivery, and research on the health of minority people
• Promote increased participation of disadvantaged people, including minorities, in health service and health promotion programs
• Create a national minority health resource center • Support research, demonstrations, and evaluations of new and innovative models that
increase understanding of disease risk factors and support better information dissemination, education, prevention, and service delivery to minority communities
• Promote minority health–related activities in the corporate and voluntary sectors • Develop minority-focused health information and health promotion materials and teaching
programs • Assist providers of primary care and preventive services in obtaining assistance of
bilingual health professionals when appropriate
As the focal point for minority health efforts, the OMH plays a key role in major initiatives launched by the secretary of the USDHHS. Table 13.6 lists some of these initiatives.
Indian Health Service The IHS is responsible for providing federal health services to Native Americans and Alaska Natives. Federal Indian health services are based on a special government-to-government relationship and laws that Congress has passed pursuant to its authority to regulate commerce with the Indian Nations as specified in the Constitution and other documents.
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The primary responsibility of the IHS is to elevate the health status of Native Americans and Alaska Natives to the highest level possible. The mission is to ensure quality, availability, and accessibility of a comprehensive, high-quality health care delivery system, providing maximum involvement of Native Americans and Alaska Natives in defining their health needs, setting health priorities for their local areas, and managing and controlling their health programs.
The IHS also acts as the principal federal health advocate for Native Americans by ensuring that they have knowledge of, and access to, all federal, state, and local health programs to which they are entitled as American citizens. The IHS carried out its responsibilities through development and operation of a health services delivery system designed to provide a broad-spectrum program of preventive, curative, rehabilitative, and environmental services. This system integrates health services delivered directly through IHS facilities and staff with those purchased by IHS through contractual arrangements. Tribes are also actively involved in program implementation.
The 1975 Indian Self-Determination Act (PL 93-638), as amended, builds on IHS policy by giving tribes the option of staffing and managing IHS programs in their communities and provides funding for improvement of tribal capability to contract under the act. The 1976 Indian Health Care Improvement Act (PL 94-437), as amended, was intended to elevate the health care status of Native Americans and Alaska Natives to a level equal to that of the general population through a program of authorized, higher-resource levels in the IHS budget. Appropriated resources were used to expand health services, build and renovate medical facilities, and step up the construction of safe drinking water and sanitary disposal facilities. It also established programs designed to increase the number of Native American health professionals for Native American needs and to improve health care access for Native Americans living in urban areas.
The operation of the IHS health care delivery system is managed through local administrative units called service units. A service unit is the basic health organization for a geographic area served by the IHS program, just as a county or city health department is the basic health organization in a state health department. These are defined areas usually centered on a single federal reservation in the continental United States or a population concentration in Alaska. The IHS serves approximately 50% of the total Native American and Alaska Native population in the United States, primarily those residing on reservations.
Case Study Application of the Nursing Process Asian Family and Cultural Practices Community health nurse Maria Gonzales visited the home of 5-year-old Nguyen Van Nghi, who was discharged from the hospital on the previous day. The pediatrician had diagnosed pneumonia and “suspected failure to thrive” in the child because the child’s growth fell below the third percentile on a standard growth chart for height and weight, and he performed poorly on a screening test used to identify developmental delays for a 5-year-old child.
Residing in the home were the child’s parents, four siblings, grandmother, aunt, uncle, and three cousins. Although the child’s father and uncle spoke some English, other members of the household communicated in a language unfamiliar to Maria, which “sounded like Chinese.” When Maria approached the child, he did not look at her or speak to her, even when she called him Nguyen (pronounced “we’en”). Assessment In a brief survey of the Nguyens’ home, Maria noted that the home and furnishings were modest but very clean. The pantry held a considerable amount of food, including rice and dried noodles. The small refrigerator smelled of fish and contained some vegetables that Maria did not recognize. She did not see any green vegetables, milk, or other dairy products.
During her initial assessment of Nghi, Maria observed multiple tender, ecchymotic areas with petechiae between the ribs on the front and back of the body, resembling strap marks. Suspecting child abuse, Maria told the family that she would return later in the day with an interpreter. She located an interpreter who spoke Mandarin Chinese and briefed him about her concerns with child abuse. When Maria and the interpreter returned to the client’s home, she instructed the interpreter to ask the parents for an explanation of the bruises. The interpreter told Maria that the family was Vietnamese and could not understand his Chinese dialect. Both the interpreter and the child’s
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father knew a little French and awkwardly managed to communicate. The interpreter advised the nurse that in the Vietnamese culture, the person’s family name is
given first, followed by the middle name and then the first name. Only a few different family names exist among the Vietnamese; therefore it is common practice to call people by their given first name. At this point, Maria also learned that the child was actually 4 years old, because the Vietnamese consider a newborn to be 1 year old at birth.
The interpreter explained that a Vietnamese healer performed cao gio, or coining, to exude the “bad wind” from Nghi. Cao gio is performed by applying a special menthol oil to the painful or symptomatic part of the body and then rubbing a coin over the area with firm, downward strokes. When Nghi’s condition seemed to worsen after his hospital discharge, his grandmother persuaded his parents that Western biomedicine had failed and that their son required the stronger power of folk healing. Diagnosis
• Maria must set priorities and focus on selected cultural data categories because they seem most relevant for the Nguyen family at present.
Individual
• High risk for Nghi’s pneumonia to worsen • Potential for child abuse/neglect • Possible physical and/or developmental delay (low weight/height for age)
Family
• Increased risk for poor health outcomes related to distrust of Western health care practices • Increased risk for nutritional deficits
Community
• Potential for poor health of area Vietnamese immigrants related to limited knowledge of good nutritional practices and general health promotion
Planning Individual Short-Term Goals
• Nghi’s pneumonia will resolve. • Nghi will show no more evidence of the practice of “coining.”
Long-Term Goal
• Nghi’s height and weight will increase proportionally to at least the 50th percentile for age.
Family Short-Term Goals
• Family members will cease the practice of “coining.” • Caregivers will recognize the importance of completing the antibiotic therapy as prescribed.
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Long-Term Goal
• A family nutritional assessment will be completed, and adjustments will be made to their diet to provide needed nutrients.
Community Long-Term Goal
• Leaders of the area’s Vietnamese community will work with area health care providers to promote good nutritional practices.
Intervention Individual Through the interpreter, Maria was able to communicate with the Nguyen family that it was vital for Nghi to take all of the prescribed antibiotics. She also attempted to convey the potentially harmful effect of the practice of coining and suggested that that procedure be stopped. She set a follow-up appointment for the next day. Family Maria was able to bring a Vietnamese interpreter for the follow-up appointment. So in addition to reiterating the importance of taking the medications, she was able to teach about basic nutritional principles and perform additional nutritional assessments. Although Nghi was not as small as initially thought, he was still below the 50th percentile for his age. Maria gave nutritional pamphlets written in Vietnamese to the parents and provided them with information on where to find low-cost foods in the neighborhood. Community Working with the health department’s social worker and the Vietnamese interpreter, Maria visited several area markets to gather information on diet and nutritional practices of Vietnamese immigrants. They decided that they would seek a small grant to develop more teaching materials on nutrition for this population. Evaluation Individual By the third follow-up visit, Maria determined that although Nghi still had a residual cough, his chest was clearing. In addition, there was no evidence of coining. Furthermore, Maria was shown that the family’s refrigerator now contained whole milk and some leafy green vegetables. It was decided that she would return in 6 weeks for a follow-up visit to weigh and measure Nghi. Family The presence of the interpreter who spoke Vietnamese and who was familiar with the culture was vital. And by the third visit, most of the family members appeared to be at ease with Maria. Mrs. Nguyen asked a number of questions about nutrition and other health issues and requested that Maria monitor the heights and weights of the other children. Community The health department’s social worker was able to identify a small grant to develop and purchase teaching materials for the Vietnamese population. The nurse and social worker applied for the funds and are eagerly waiting to hear the outcome. Levels of Prevention The following are examples of three levels of prevention as applied to the case study. Primary Prevention
• Nutritional education for the Nguyen family • Health education targeted at developing comfort with the U.S. health care system and
Western medicine
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• Education related to potentially harmful practices (e.g., coining)
Secondary Prevention Monitoring the height and weight of Nghi and his siblings Tertiary Prevention Evaluation of resolution of pneumonia
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Summary To provide community health nursing for individuals, groups, and communities representing the hundreds of different cultures and subcultures found in the United States, the nurse should include cultural considerations in nursing care. Guidelines for gathering data from clients of culturally diverse backgrounds have been suggested in this chapter and are interwoven throughout the text. Knowledge about culture-specific and culture-universal nursing care is foundational and is an integral component of community health nursing.
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Evolve Website http://evolve.elsevier.com/Nies/community
• NCLEX Review Questions • Case Studies
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Zborowski M. People in pain. San Francisco: Jossey-Bass; 1969.
∗ The author would like to acknowledge the contribution of Carrie L. Buch, who wrote this chapter for the previous edition.
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Environmental Health
Tamara Rose∗
OUTLINE
A Critical Theory Approach to Environmental Health Areas of Environmental Health
The Built Environment Work-Related Exposures Outdoor Air Quality Healthy Homes Water Quality Food Safety Waste Management
Effects of Environmental Hazards Efforts to Control Environmental Health Problems Emerging Issues in Environmental Health
Nursing Actions Approaching Environmental Health at the Population Level Critical Environmental Health Nursing Practice
Taking a Stand: Advocating for Change Asking Critical Questions Facilitating Community Involvement Forming Coalitions Using Collective Strategies
OBJECTIVES
Upon completion of this chapter, the reader will be able to do the following: 1. Describe areas of environmental health, environmental health problems, and related human
health risks. 2. Apply the basic concepts of critical theory to environmental health nursing problems. 3. Describe the importance of air, water, and food quality as a determinant of health. 4. Identify social, cultural, economic, and political factors that contribute to pollution and affect
environmental problems. 5. Develop an understanding of the risk assessment and risk management role of nurses. 6. Explain laws and regulations relevant to environmental health and how government agencies
use them to address environmental issues.
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KEY TERMS air quality index biosolids built environment climate change critical theory environmental health environmental justice environmental risks to health food desert food safety global warming Healthy Home outdoor air quality participatory action research population sick building syndrome social capital waste management water quality work-related exposures The World Health Organization (WHO) (2016) defines environmental health as “all the physical, chemical, and biological factors external to a person, and all related behavior, but excluding those natural environments that cannot reasonably be modified.” “As a fundamental component of a comprehensive public health system, environmental health works to advance policies and programs to reduce chemical and other environmental exposures in air, water, soil, and food to protect residents and provide communities with healthier environments” (National Environmental Health Association, 2016). Fig. 14.1, from the U.S. Department of Health and Human Services Healthy People 2020 program, demonstrates these factors.
Environmental health experts believe that the purpose of environmental health is to assure the conditions of human health and provide healthy environments for people to live, work, and play. This can be accomplished through risk assessment, prevention, and intervention.
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FIG. 14.1 Healthy People 2020: Elements of environmental health. From U.S. Department of Health and Human Services: Healthy People 2010, ed 2, Washington, DC,
2000, U.S. Government Printing Office.
Efforts are made to reduce and eliminate contaminant and contagion threats to human health from air, water, food, and the built environment (Lindland and Kendall-Taylor, 2011). Maintaining a healthy environment is vitally important to promoting the health of populations—particular groups or types of people. A healthy environment improves quality of life and increases years of healthy living. Accumulated evidence shows that the environmental changes of the past few decades have profoundly influenced the status of public health. Globally, environmental risk factors, including air, water and soil pollution, exposure to chemicals, radiation, and climate changes, contribute to nearly 25% of all deaths and increase disease burden (WHO, 2016). The safety, beauty, and life-sustaining capacity of the physical environment are unquestionably of global consequence. Since the beginning of the twenty-first century, it has become apparent that the world must address urgent environmental difficulties, including extinction of some species, diminishing rainforests, proliferation of toxic waste dumps, progressive destruction of the ozone layer, shortage of landfill sites, consequences of climate change, threats of terrorism, development of deadly chemical and ballistic weapons, adulteration of food by pesticides and herbicides, oceanic contamination through toxic dumping and petroleum spills, overcrowding of urban areas, and
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traffic congestion. This chapter uses critical theory to explore the health of communities in relation to the
environment. Critical theory is particularly useful in examining environmental health because it offers a framework for discussion and a basis for describing community health nursing practice (Martins and Burbank, 2011; Stevens and Hall, 1992). Applying critical theory is a way of thinking upstream (see Chapter 3). Critical theory is an approach that raises questions about oppressive situations, involves community members in the definition and solution of problems, and facilitates interventions that reduce health-damaging effects of environments. By applying the nursing process in a critical fashion, nurses can be dynamically involved in the design of interventions that alter the precursors of poor health.
Recognition of the gravity and pervasiveness of environmental hazards can be overwhelming. Looking beyond the individual to recognize the environmental determinants of health can be complicated and alarming. Intervening to improve the quality of air, water, housing, food, and waste disposal and reducing the risks of harmful exposures to environmental toxins require individual, social, economic, and political changes. Nurses are powerful change agents who use their assessment, management, and communication skills to promote environmental health locally and nationally. Nurses are becoming increasingly active in efforts to address environmental health issues and to increase awareness of the effects of the environment on well-being.
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A Critical Theory Approach to Environmental Health Critical theory suggests that nurses must be aware of environmental threats or factors that might detrimentally affect the safety and well-being of particular populations or deprive them of access to resources necessary in the pursuit of health. This awareness may include recognizing, supporting, and maintaining positive environmental influences. For instance, a nurse must consider the effects of having access to a safe place to walk on one’s ability to maintain healthy levels of physical activity. Research studies indicate that access to recreation facilities is an important correlate of physical activity (Troped et al., 2011; Tsunoda et al., 2012). Nurses can help individuals adopt healthy behaviors by considering not only individual-level issues but also those issues in the environment that facilitate or create barriers to healthy living.
Nurses need to ask critical questions about their clients’ environments to help discern the contributions of specific hazards to their health. Occupational exposure to environmental hazardous can cause harm to workers as well as their families. For example, farm workers and pesticide applicators who accumulate agricultural chemicals on their skin and clothing take these substances home with them, increasing their children’s exposure to toxicants (Thompson et al., 2008). Nurses must provide answers to farm workers who ask questions such as “What do I do if I’m exposed to a pesticide? How long should I wait until after a pesticide application to go back into the field? How do I find out how toxic a certain pesticide is? Where can I get information on a specific pesticide?” Nurses can take an environmental health history. An environmental health history can benefit the client in the following ways:
• Increase awareness of environmental health concerns • Improve timelines and accuracy of diagnosis • Prevent disease and aggravation of conditions • Identify potential environmental hazards
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FIG. 14.2 Environmental history assessment.
Environmental health histories should be obtained for both adults and children, although the relationship between the environment and children’s health is frequently overlooked. Fig. 14.2 demonstrates common assessment items of an environmental history. When looking at the community from a critical perspective, nurses have the opportunity to promote population health. In identifying environmental sources of health problems, nurses must be involved with the affected communities. Rather than impose their views of the problem, nurses should share their ideas and dialogue with community members. For example, nurses should listen to what the community believes is problematic, help raise consciousness about environmental dangers, and help bring about change. If nurses become involved in conducting community assessments and analyses, they can learn how the community members perceive themselves, their health, and their environmental influences.
From a critical standpoint, helping communities become more aware of the environmental effects on health and helping them make needed changes in their environment are legitimate nursing actions. Collective actions have been instrumental in accomplishing positive environmental changes since the 1980s. Some of the mechanisms have included strategic organization, litigation, public hearing testimony, letter-writing campaigns, legislative lobbying, mass demonstrations, and fundraising. Fundraising for environmental causes such as the 2012 storms that devastated the Northeast United States and the 2010 earthquake in Haiti facilitated rapid availability of resources,
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minimized loss of life, and helped restore basic necessities such as clean water and shelter. Public response to “acute” environmental disasters needs to be extended to an ongoing, consistent pressure to ensure day-to-day environmental integrity; hence “chronic” environmental problems need to be addressed more effectively.
A critical perspective can help nurses plan and implement population-level interventions by emphasizing collective strategies for change. Acting collectively can empower nurses to affect environmental health. Assessing environmental health problems, planning and implementing interventions, and evaluating the effectiveness of community-based actions need to be based on a wide lens. Community health nurses should be familiar with physical surroundings and their mutual interaction with cultural realities, social relations, economic circumstances, and political conditions of communities, applying a critical perspective to community health.
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Areas of Environmental Health Environmental health hazards are ubiquitous in communities across the United States and place people at risk for disease or injury. This chapter divides the vast field of environmental health into the following subcategories: the built environment, work-related exposures, outdoor air quality, healthy homes, water quality, food safety, and waste management (Table 14.1). A brief discussion introduces nurses to these seven areas of environmental health, describes how they affect health, and demonstrates basic strategies nurses can use to address them. Table 14.2 provides examples of health problems within each area of environmental health.
TABLE 14.1
Areas of Environmental Health
Area Definition Built environment
Buildings, spaces, and products that are created or modified by people, including homes, schools, workplaces, parks/recreation areas, greenways, business areas, and transportation systems.
Work-related exposure
Occupational exposure to environmental hazards that can cause illness or injury.
Outdoor air quality
The protectiveness of the atmospheric layers, the risks of severe weather, and the purity of the air for breathing purposes.
Healthy home The availability, safety, structural strength, cleanliness, and location of shelter, including public facilities and family dwellings. This includes indoor air quality.
Water quality The availability of and accessibility to a clean water supply, the mineral content levels, pollution by toxic chemicals, and the presence of pathogenic microorganisms.
Food safety The availability, relative costs, variety, safety, and health of animal and plant food sources. Waste management
The management of waste materials resulting from industrial and municipal processes, human consumption, and efforts to minimize waste production.
It should be noted that a critical perspective does not separate the idea of a safe social environment from a safe physical environment. For example, interpersonal violence is a significant and growing risk, with consequences ranging from bodily injury to psychiatric aftereffects that may last for decades in some individuals. Intergenerational patterns of abuse, hate crimes toward marginalized groups, sexual predators, and hazards of combat might be considered from an environmental health perspective. Issues of violence are discussed in more depth in Chapter 27.
Finally, we must be prepared for the public health effects of terrorism. Terrorism is a word that evokes many images and a range of reactions from rage to grief and loss. Acts of terrorism have drawn the public and political focus to establishing environmental security. Bioterrorism and homeland security are new areas where nurses will have an impact. A critical perspective is needed now more than ever, because security issues are linked to religious imperatives, moral stances, values, profit motives, health care systems and information, and cultural differences. These issues are also clearly within the scope of community health nursing and are discussed in more detail in Chapter 28.
TABLE 14.2
Examples of Environmental Health Problems
Area Problems Built environment Drunk driving
Secondhand smoke Noise exposure Urban crowding Technological hazards
Work-related exposure Asbestos exposure Agricultural accidents Excessive exposure to x-rays
Outdoor air quality Gaseous pollutants Greenhouse effect Destruction of the ozone layer Aerial spraying of herbicides and pesticides Acid rain Nuclear facility emissions
Healthy home Homelessness Rodent and insect infestation Presence of lead-based paint Sick building syndrome
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Unsafe neighborhoods Radon gas seepage in homes and schools
Water quality Contamination of drinking supply by human waste Oil spills in the world’s waterways Pesticide or herbicide infiltration of groundwater Aquifer contamination by industrial pollutants Heavy metal poisoning of fish
Food safety Malnutrition Bacterial food poisoning Food adulteration Disruption of food chains by ecosystem destruction Carcinogenic chemical food additives
Waste management Use of nonbiodegradable plastics Poorly designed solid-waste dumps Inadequate sewage systems Transport and storage of hazardous waste Illegal industrial dumping Radioactive hazardous wastes
The Built Environment The built environment consists of the connections among people, communities, and their surrounding environments that affect health behaviors and habits, interpersonal relationships, cultural values, and customs. There is growing evidence that the built environment directly and indirectly affects health outcomes and disease rates (Table 14.3). One review of the literature found that neighborhoods that are more walkable are associated with increased physical activity, increased social capital, lower overweight, lower reports of depression, and less reported alcohol abuse (Renalds et al., 2009). Social capital refers to networks and the associated norms and expected collective benefits derived from cooperation between individuals and groups. Structural characteristics of the built environment, such as street condition, neighborhood deterioration, and the proportion of parks and playgrounds, affect levels of physical activity and obesity (Schulz et al., 2013; Kerr et al. 2010) found that women are more likely to increase physical activity if they live in a walkable community compared with men, indicating safety to be an attributing factor. Simply put, having a safe, intact place to walk may encourage exercise among adults.
TABLE 14.3
A Conceptual Model of How the Built Environment Affects Health
Developed by Fan Y, Song Y: Is sprawl associated with a widening urban–suburban mortality gap? J Urban Health 86(5):708–728, 2009; adapted from a conceptual model by Klitzman S., Matte TD, Kass DE: The urban physical environment and its effects on health. In Freudenberg N, Galea S, Vlahov D, editors: Cities and the health of the public, Nashville, TN, 2006, Vanderbilt University Press, p 364.
Many people live within areas that require almost daily contact with potential health risks and threats. These include intoxicated or impaired drivers, secondhand smoke, urban crowding, noise exposure, unabated traffic, and the stress of increased mechanization. The type of area one lives in can greatly affect one’s health. For example, a research study found that adolescents living in rural working-class or mixed-race urban neighborhoods were more likely to be overweight than peers in newer suburbs, regardless of their socioeconomic status, age, or race/ethnicity (Nelson et al., 2006). In another study investigating the role of neighborhood characteristics and childhood obesity,
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neighborhood socioeconomic status (SES) was found to be a greater mediator of childhood obesity than racial or ethnic disparities (Sharifi et al., 2016). Access to equipment and facilities, neighborhood pattern (e.g. rural, exurban, suburban), walkability, and urban sprawl are also associated with obesity outcomes in adolescents (Ding et al., 2011; Dunton et al., 2009).
Urban sprawl has been defined as the conversion of land to nonagricultural or nonnatural uses at a faster rate than the population growth (Environmental Protection Agency [EPA], 2002). The sprawling development often occurs more rapidly than the expansion of the infrastructure (e.g., schools, sewer systems, water lines) needed for support. The urban sprawl is characterized by four dimensions: “low residential density; rigidly separated homes, shops, and workplaces; roads with large blocks and poor access; and lack of well-defined activity centers” (James et al., 2016, p. 369). Consequences of sprawl include air and water pollution, floods, infrastructure expenses, and a decrease in natural areas and forests (EPA, 2002).
One unfortunately common problem associated with living patterns relates to residing near hazardous facilities (e.g., waste incinerators, sewage treatment plants, landfills, refineries, and some correctional facilities). Molitor and colleagues (2011) found that higher levels of pollutants are generally associated with higher poverty. Discriminatory land use ensures that many impoverished and marginalized groups, especially minorities, live in close proximity to industrial contamination (Collins, 2011; Nweke, 2011). People who live near such environmental hazards are in danger of becoming victims of illness and injury related to violence, poisonings and exposures, fires, and malignant and nonmalignant diseases. Clinical Example 14.1 provides an example. Though historically outdoor pollution and hazards have been considered the major contributors affecting environmental quality, one must also consider the influence of indoor residential environmental hazards, such as radon, asbestos, lead, insect and pet allergens, chemicals, and other consumer products, as well as secondhand smoke and fungi (Adamkiewicz et al., 2011).
Many communities lack sufficient resources to respond when urban development and technological advances jeopardize the health and well-being of families in affected areas. The environmental movement of the 1960s and 1970s succeeded in building political power capable of passing monumental environmental reforms; however, charges that poor and minority communities are dumping grounds for environmental hazards have been substantiated by governmental agencies (EPA, 2004, 2013c).
Difficulties in alerting state and federal officials about environmental health dangers, as well as in obtaining compensation for environmental toxin–causing disease and death, often result in resident revictimization. Tightly knit social structures and a lack of low-cost housing may hinder the mobility of residents and perpetuate the exposure to health hazards. Residents may be unwilling to disrupt family ties and cultural roots to start over elsewhere, or they may be unable to afford a move. These residents may live with uncertainty and conflict. Long-term, community-wide effects of division, animosity, distrust, cynicism, and despair can abound in these situations, negatively affecting social capital.
In the 1990s, the central issues of equity and justice emerged in environmental health policy. In 1994, President Clinton signed Executive Order (EO) 12898, which required all federal agencies to develop comprehensive strategies for achieving environmental justice. This directive has served to increase public participation and access to information as well as provision of education about multiple risks and cumulative exposures (EPA, 2005, 2013c) (Box 14.1). A recent investigation of the impact of EO 12898 determined the order failed to address an important contributor to environmental justice: poor economic growth in low-income minority communities. In 2008, President Obama signed a memorandum of understanding in regard to EO 12898 to identify and address environmental justice at the program, policy, and initiative level (Geltman et al., 2016). Nurses are part of the interdisciplinary team made up of urban planners, public health practitioners, and policy makers needed to understand and address issues of the built environment that are critical to establishing health equity.
Examples of Environmental Health Issues Affecting Communities
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Water pollution from local industry.
Motor vehicle emissions (primary mobile source of air pollutants).
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Air pollution from local industry.
Sidewalks in disrepair.
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Food safety meat inspection.
Clinical Example 14.1 In an urban city in the south, the health department is becomingly increasingly concerned about the overweight and obesity rates of young school-age children. At health fairs held around the city, nurses are seeing more children with acanthosis nigricans, elevated blood pressure, high body mass index (BMI), and hypercholesterolemia. Though the public health nurse diligently counsels patients on the benefits of exercise, his patients do not increase their physical activity. When the nurse drives around the neighborhood where many of his patients reside, he realizes there are no recreational parks nearby, the sidewalks are in disrepair, the smokestacks cloud the air, and there
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appears to be gang-related activity. The nurse considers the impact of the built environment on the ability of his patients to be physically active. In partnership with the school board and neighborhood watch group, the nurse and community members successfully petition for a park to be built within walking distance of the school. Additionally, the partnership is able to establish a “walking school bus,” a program where students walk in a group to or from school, as a way for children to increase their physical activity.
BOX 14.1 Landmark Federal Environmental Legislation
Year Legislation 1970 Clean Air Act
Poison Prevention Packaging Act National Environmental Policy Act
1971 Lead-Based Paint Poisoning Prevention Act 1972 Federal Water Pollution Control Act Amendments
Noise Control Act Clean Water Act
1973 Endangered Species Act 1974 Safe Drinking Water Act 1975 Hazardous Materials Transportation Act 1976 Resource Conservation and Recovery Act
Toxic Substances Control Act Surface Mining Control and Reclamation Act
1980 Low-Level Radiation Waste Policy Act Comprehensive Environmental Response, Compensation, and Liability Act (i.e., Superfund)
1990 Oil Pollution Act Clean Air Act
2003 Healthy Forests Restoration Act 2016 Fuel Economy Standards raised (original legislation: 1975)
Work-Related Exposures Work-related exposures can happen as a result of poor working conditions and can lead to potential injury or illness. Environmental health problems posed by work-related exposures include such issues as occupational toxic poisoning, machine-operation hazards (e.g., falls, crushing injuries, burns), electrical hazards, repetitive motion injuries, carcinogenic particulate inhalation (e.g., of asbestos, coal dust), and heavy metal poisoning (Centers for Disease Control and Prevention [CDC], 2013; Krieger et al., 2008). Prevention of work-related health problems requires integrated action to improve job safety and the working environment. Occupational and environmental health nurses often collaborate on initiatives to reduce and eliminate work-related exposures, illnesses, and injuries. Nurses can be sure that workers are aware of and know where to access the safety data sheets relevant to their workplace. The U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) (2013) requires chemical manufacturers, distributors, and importers to provide safety data sheets that communicate the hazards of chemical products.
According to the Bureau of Labor Statistics (2016) approximately 2.9 million nonfatal workplace injuries and illnesses were reported by private industry employers in 2015. This rate continues a pattern of decline annually for the past 13 years, apart from 2012, where there was either equal or more days away from work because of injury compared with the previous year (Bureau of Labor and Statistics, 2016). The EPA estimates that 10,000 to 20,000 physician-diagnosed pesticide poisonings occur each year among the approximately 2 million U.S. agricultural workers (EPA, 2013). In one year (2010), 476 farm workers died from work-related injuries, with tractor overturns being the leading cause of death (CDC, 2013).
These statistics do not reflect unreported health problems. For example, a clerical worker leaves the office every day with back strain and a headache because of ventilation problems in the building. After 5 years on a repetitive hand-movement job task, an employee is diagnosed with carpal tunnel syndrome. An operating room nurse has a miscarriage and recalls that many of her coworkers have also been unable to carry their babies to term. A dry cleaner often leaves work feeling light-headed and dizzy from inhaling solvents at the shop, and one day she has a car
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accident on her way home. Collective problems related to employment or occupation are often perceived as individualized injuries, and no one “connects the dots.” Research is ongoing to determine the outcomes of work-related environmental exposures. For example, the GuLF STUDY (Gulf Long Term Follow-Up Study) is a health study, sponsored by the National Institutes of Health (NIH), for individuals who helped with oil spill clean-up after the 2010 Deepwater Horizon disaster in the Gulf of Mexico (NIH, 2014). Clinical Example 14.2 illustrates another case of work-related exposure.
Clinical Example 14.2 Sanitation workers in an urban area experienced a rising incidence of puncture injuries while transporting hazardous wastes from the public medical center; these puncture injuries caused several cases of hepatitis. When the story became public, members of the city health commission contacted community health nurses and instructed them to politically support the interests of the city and the medical center “at all costs.” Subsequently, the sanitation workers’ union contacted the community health nursing office and requested information about procedures for safely packaging medical wastes. They also requested that a nurse speak to their membership about immediate measures for preventing further injuries on the job.
The nurses met to resolve the conflict. Most agreed that the sanitation workers had pressing needs for education and support. Despite the city’s demand for loyalty, they decided to “choose sides” with the workers and respond to their requests. They collectively drafted a letter to the city health commission and arranged a meeting with the commissioners to discuss their plan to assist the sanitation workers. The health commission held a press conference, which depicted the nurses’ actions as mediational efforts that benefited the union and the city. Eventually, the nurses and the commission developed a new medical waste disposal plan, and injured workers received reasonable compensation through an out-of-court settlement.
Outdoor Air Quality Outdoor air quality refers to the purity of the air and the presence of air pollution. The EPA (2012b) has classified six common air pollutants (Table 14.4). WHO estimates that air pollution is the thirteenth leading cause of mortality worldwide, contributing to approximately 800,000 premature deaths annually. Particulate matter, one common pollutant, causes worsening respiratory symptoms, more frequent asthma-related medication use, decreased lung function, recurrent health care utilization, and increased mortality (Anderson et al., 2012).
TABLE 14.4
Major Air Pollutants
Pollutant Sources Effects Ozone: A colorless gas that is the major constituent of smog at the earth’s surface
Ozone is formed in the lower atmosphere as the result of chemical reactions among oxygen, volatile organic compounds, and nitrogen oxides in the presence of sunlight, particularly during hot weather. Sources of this harmful pollutant include vehicles, factories, landfills, lawn equipment, farm equipment, and industrial solvents.
Ozone can irritate the respiratory tract; impair lung function; and cause throat irritation, chest pain, cough, and susceptibility to lung infection. Individuals with asthma and other existing respiratory conditions are particularly vulnerable. Ozone can also reduce agricultural yields and injure forests and other vegetation.
Carbon monoxide: A colorless and odorless gas that is emitted in the exhaust of motor vehicles and other kinds of engines during combustion of fossil fuels
Carbon monoxide is emitted from the engines of cars, buses, trucks, and other small engines and from some industrial processes. High concentrations can be found in confined spaces (e.g., parking garages, poorly ventilated tunnels, or along roadsides during periods of heavy traffic).
Carbon monoxide reduces the ability of the blood to deliver oxygen to vital tissues, affecting primarily the cardiovascular and nervous systems. Lower concentrations have been shown to adversely affect individuals with heart disease and to affect exercise performance. Higher concentrations can cause symptoms such as dizziness, headaches, and fatigue.
Nitrogen dioxides : A light-brown gas at lower concentrations; in higher concentrations, a significant component of brown urban haze
Nitrogen dioxide forms from the burning of fuels in utilities, industrial boilers, and the engines of cars and trucks.
Nitrogen dioxide is a major component of smog and acid rain. When concentrations are high, it can increase respiratory illnesses (e.g., chest colds and coughing) in children. For asthmatic people, it may exacerbate breathing difficulty.
Sulfur dioxide: A colorless gas, odorless at
Sulfur dioxide is emitted from industrial, institutional, utility, and apartment-house furnaces and boilers as
Sulfur dioxide is one of the major components of smog. At high concentrations, it can harm humans; asthmatic people
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low concentrations but pungent at very high concentrations
well as petroleum refineries, smelters, paper mills, and chemical plants.
are particularly vulnerable. It can also harm vegetation and metals and acidify lakes and streams.
Particulate matter: Droplets from smoke, dust, ash, and condensing vapors that can be suspended in the air for long periods
Particulates are emitted from industrial processes, vehicles, wood smoke, dust from paved and unpaved roads, construction, and agriculture.
Particulates can affect breathing and elicit respiratory symptoms, causing increased respiratory disease and lung damage. Children, elders, and people with heart or lung disease are especially at risk. They can also damage paint, soil, and clothing and reduce visibility.
Lead: A metal found in nature as well as a by- product of industry; can contaminate substances (e.g., soil, dust) that can be directly inhaled
Metals processing is the major source of lead emissions into the air today. Lead is generally found near lead smelters, waste incinerators, utilities, and lead-acid battery manufacturers.
Lead can adversely affect mental development and performance, kidney function, and blood chemistry. Young children are particularly at risk to its effects.
From Environmental Protection Agency: What are the six common air pollutants? Retrieved January 26, 2018 from https://www.epa.gov/criteria-air-pollutants /
Air pollution originates from industry (dry cleaning, factories, oil refineries, coal-burning power plants), modes of transportation (cars, buses, trucks, and planes), and naturally occurring events (volcanic eruptions and windstorms). Tornadoes, electrical storms, smog, gaseous pollutants (e.g., carbon monoxide), excessive hydrocarbon levels, aerial herbicide spraying, and acid rain all contribute to air pollution. Under provisions of the Clean Air Act, the EPA sets the national ambient air quality standards for pollutants considered harmful to humans or the environment.
Ozone is the most common pollutant in the United States and is the primary component of smog. Ozone is formed when nitrogen oxides (created by the burning of fossil fuels in power plants, automobiles, and factories) react with oxygen and sunlight (EPA, 2013f). Ozone, along with other hazardous atmospheric pollutants, causes and/or contributes to asthma, allergic reactions, bronchitis, lung cancer, chronic respiratory disease, and death and harms animal and plant species (Ciencewicki et al., 2008; Sheffield et al., 2011). Furthermore, sulfur dioxide, a by-product of burning coal and other fossil fuels, contributes to acid rain, which affects terrestrial ecosystems by increasing soil acidity, reducing nutrient availability, mobilizing toxic metals, leaching soil chemicals, and altering species composition (EPA, 2012c).Two significant issues related to outdoor air quality are of global concern. First, the amount of protection in the atmospheric layers is diminishing (EPA, 2013e). Chemicals such as chlorofluorocarbons, halons, and carbon tetrachloride, which have been in widespread use for refrigeration, air conditioning, and aerosol propellants, remain in the atmosphere. These molecules cause depletion of the atmosphere’s protective ozone layer. The resulting “holes” in the ozone layer allow excess ultraviolet radiation to penetrate, which has harmful effects on many organisms. Long-term problems include increases in rates of skin cancer and cataracts, suppression of immune response, and environmental damage.
Second, there is a disruption in the key processes that break down atmospheric carbon dioxide. The ongoing deforestation of the earth’s surface, especially the diminishing of tropical rainforests, not only releases the carbon stored in the biomass but also eliminates sources of photosynthesis (i.e., the process by which plants absorb carbon dioxide and release oxygen). The loss of carbon dioxide– consuming resources increases carbon dioxide and traps part of the heat reemitted by the earth. As a result, the earth’s surface temperature is rising (i.e., the “greenhouse effect”), with potentially catastrophic ecological consequences. Global climate change, including evidence that glaciers are shrinking, ice on rivers and lakes is breaking up earlier than usual, and a shift in plant and animal ranges, has already been observed (NASA, 2014).
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FIG. 14.3 Environmental Protection Agency air quality index. From AirNow: Local air conditions and forecasts, n.d. Retrieved from www.airnow.gov
In 1968, the National Air Pollution Control Administration developed the air quality index (AQI) to increase public awareness of air pollution (Fig. 14.3). The AQI is a number used by government agencies to communicate current and forecasted air pollution conditions to the public. As the AQI rises, a larger percentage of the population, particularly vulnerable populations, may experience adverse health effects. The AQI fluctuates on the basis of the dilution of air pollutants. Air stagnation can lead to high concentrations of pollutants and haze. Although most air contaminants do not have an associated AQI, many countries monitor ground-level ozone, particulates, sulfur dioxide, carbon monoxide, and nitrogen dioxide to calculate the air quality index (EPA, 2013g). Nurses need to be aware of the AQI and the corresponding recommendations for the public to limit exposure to outdoor air during peak times of high AQI (Clinical Example 14.3). Additionally, nurses must consider the AQI when making recommendations for physical activity, particularly for asthmatic patients. One study suggests that population-level health benefits from increased physical activity in high-walkability neighborhoods may be offset by the adverse effects of exposure to air pollution (Hankey et al., 2012). A recent study on the effects of particulate matter for individuals who walk or cycle to work found that the health benefits of active travel far outweighed the health risks from air pollution (Tainio et al., 2016).
Clinical Example 14.3 During a recent summer, a sudden increase occurred in the number of clinic visits from residents of a particular urban neighborhood. The patients were elderly men and women who felt ill after going for a walk and asthmatic children with worsening respiratory symptoms. A nurse at the federally qualified health clinic in the neighborhood suspected that air pollution might be contributing to the increase in health concerns.
The nurse went online to the site www.airnow.gov and searched for the air quality index for the region. She discovered that the region was experiencing a very unhealthy level of outdoor air pollution. She immediately alerted the health care staff that people with heart or lung disease, older adults, and children should avoid all physical activity outdoors and that everyone should avoid prolonged or heavy exertion outdoors. The nurse contacted the local summer camps and nursing homes in the area to alert them of the recommendation. The clinic quickly decided to move their regularly scheduled outdoor picnic to an indoor venue. One week later, the nurse noticed a
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drop in the number of patients complaining of respiratory distress.
Healthy Homes A Healthy Home refers to the availability, safety, structural strength, cleanliness, location, and indoor air quality of shelter. According to the EPA (2017), many of the health concerns related to indoor living are a result of exposure to radon, carbon monoxide, molds and dust, secondhand smoke, cooking vapors, lead paint, and rodents. The CDC and surgeon general have developed a Healthy Home checklist that nurses can use with patients to guide a thorough assessment and develop a care plan to help patients improve the quality of their homes and their indoor air quality (CDC, 2011).
Radon causes an estimated 21,000 lung cancer deaths in the United States every year. It is the second leading cause of lung cancer, after active smoking, and the leading cause among nonsmokers (EPA, 2013f). Nine federal agencies are currently working on an initiative to reduce radon exposures and illnesses (EPA, 2013d). Carbon monoxide is an odorless, colorless, toxic gas. It can cause mild flulike effects such as headaches, dizziness, disorientation, nausea, and fatigue at lower levels of exposure and death at higher levels (EPA, 2012d). Molds, dust, and secondhand smoke exposure can often exacerbate asthma symptoms.
Other health problems related to housing include fire hazards; lack of accommodations for people with disabilities; illnesses caused by overcrowding; psychological effects of architectural design (e.g., low-cost, high-rise housing projects); injuries sustained from collapsed building structures; and exposure deaths from inadequate indoor heating or cooling (Clinical Example 14.4). Poor housing conditions can contribute to the spread of infectious disease (EPA, 2012e) as well as cardiovascular and respiratory disorders, cancers, allergies, and mental illnesses (Barton et al., 2007; Jones-Rounds et al., 2013; Rauh et al., 2008). The term sick building syndrome describes a phenomenon in which public structures and homes cause occupants to experience a variety of symptoms, such as headache, fatigue, and exacerbation of allergies. It typically results from poor ventilation and building operations, hazardous building materials, furniture and carpeting substances, and cleaning agents (EPA, 1991). Additionally, volatile organic compounds (VOCs) have been found in soil and soil vapor as a result of industrial spills that contaminate indoor air. One such spill in Endicott, New York, has been linked to congenital cardiac defects, low birth weight, and fetal growth restriction (Farand et al., 2012).
Other problems may arise related to building structures, composition, and settings. For example, commercial buildings with offices near underground parking garages may cause workers to have carbon monoxide intoxication. Formaldehyde, asbestos, and VOCs—which are common components of thermal insulation, cement, flooring, furnishings, and household consumer products —have carcinogenic properties. Additionally, “toxic mold” arising from chronically damp wood and improperly sealed areas in homes and offices has been recognized as contributing to respiratory irritation, allergies, and infections in susceptible individuals (EPA, 2012e).
Clinical Example 14.4 In a large, northeastern U.S. city, an economic recession led to large company layoffs, leaving many unemployed or underemployed. Because of the loss of income, many families faced tough decisions during the upcoming winter months. Temperatures often went below zero, requiring constant heating. Unfortunately, many people did not have the money to continue to pay their heating bill, fix leaky windows and doors, or buy warm clothes. Some families began to use space heaters and burned scraps of wood that were discarded. Often, this wood came from old abandoned buildings and homes. Other families took to sleeping in their cars.
Soon, hospitals began to see an uptick in patients presenting with respiratory illnesses, carbon monoxide exposure, and burns. The community health nurses in the area met with struggling families to assess their needs and determine a plan to meet their immediate needs. The nurses met with local politicians and church groups to find ways to supply healthy wood for heating, help financially with home utility bills, provide warm clothes for families, and find shelters for homeless families. Within a few months, the local hospitals began to see a decline in home-related injuries and illnesses.
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Water Quality Water quality refers to the water supply’s availability, volume, mineral content levels, toxic chemical pollution, and pathogenic microorganism levels. Water quality consists of the balance between water contaminants and the existing capabilities to purify water for human use and plant and wildlife sustenance. Water quality problems include experiencing droughts, dousing reservoirs with chemicals to reduce algae, contaminating aquifers with pesticides and fertilizers (Clinical Example 14.5), leaching lead from water pipes, and oil spilling from transport tankers or leaking offshore wells. Other sources of water pollution are microbial contamination from poorly managed or maintained septic or sewage systems and animal feedlot wastes (EPA, 2013b). Water pollution can be from point sources (a well-defined source, e.g., factory wastewater discharge) or nonpoint sources (urban runoff, domestic lawn care, and air-to-water transfer).
Advances in water treatment technologies in industrialized countries have controlled many water-related diseases, such as cholera, typhoid, dysentery, and hepatitis A. Nevertheless, disease outbreaks resulting from contamination by untreated groundwater and inadequate chlorination are increasing in both urban and rural areas. In addition, more than 45 million Americans (15%) obtain their drinking water from private water supplies (e.g., wells) that have no treatment or monitoring guidelines (CDC, 2011). Other potential water contaminants include accelerated soil erosion caused by construction, agriculture, and deforestation, which can contribute to high sediment levels in drinking water supplies.
Heavy metal and toxic chemical pollution may also occur during the water treatment process or in the drinking water distribution system. The EPA monitors drinking water for more than 90 organic and inorganic pollutants that have potential health effects in humans, including those who are most vulnerable, such as children and people with weakened immune systems (EPA, 2016). Pesticides, herbicides, and carcinogenic industrial waste infiltrate an increasing amount of groundwater, the underground source of half the U.S. population’s drinking water (U.S. Geological Survey, 2005). Additionally, commonly used medications and personal care products that contain endocrine disruptors have been found in water supplies (Wu et al., 2012). This development is particularly tragic because groundwater is uniquely susceptible to long-term contamination. Unlike river or lake water, once groundwater becomes contaminated, it is impossible to cleanse.
Clinical Example 14.5 In a Midwestern farm community, there is growing concern about seepage of agricultural pesticides and herbicides into groundwater. Families obtain water from private wells rather than a central municipal source. The families had heard about potential long-term carcinogenic effects of the chemicals, such as pesticides and herbicides, commonly used on the farms in the community. Although family farmers decreased their use of these chemicals, the large-scale agribusiness companies continued to use large amounts of these chemicals.
A community health nurse from the county health department lobbied local officials to begin a comprehensive program to monitor groundwater pollutants and enforce standards for herbicide and pesticide use. However, the powerful agribusiness companies pressured these officials to stand back. Together, some county farmers and nurses organized grassroots information and support groups for the rural families. The families and nurses, in coalition with environmental activist groups in the state, established several projects. These projects included collecting and testing samples from each family well, forming a local organization called “Water Watch” to coordinate actions and communications, and implementing a research project with a local university to track water contamination and health problems of local residents. The organization also disseminated an emergency plan to families whose wells were found to have toxic levels of pesticides, herbicides, or other pollutants.
Food Safety Food safety refers to availability, accessibility, and relative cost of healthy food free of contamination by harmful herbicides, pesticides, and bacteria. Food safety concerns include malnutrition, bacterial food poisoning (Clinical Example 14.6), carcinogenic chemical additives (e.g., nitrites, dyes, and cyclamate), improper or fraudulent meat inspection or food labeling, microbial
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epidemics among livestock (e.g., Escherichia coli), food products from diseased animal sources, and disruption of vital natural food chains by ecosystem destruction. Increased mobility and globalized trade also contribute to global contamination of the food supply. Finally, there are significant disparities in access to healthy and fresh food supplies, with poor minority families being more likely to live in a food desert—a neighborhood with little to no access to healthy foods (Institute of Medicine [IOM], 2009).
Annually, nearly 60 to 70 million Americans contract gastrointestinal illnesses, accounting for about 10% of all hospitalizations and 15% of in-patient hospital procedures for the treatment of digestive diseases (National Institute of Health [NIH], 2009). Potential microbial contaminants of foods include bacteria (e.g., Shigella salmonella, E. coli, Campylobacter, Listeria), parasites (e.g., Balantidium coli, Cryptosporidium parvum, Entamoeba histolytica Giardia intestinalis), and viruses (e.g., calicivirus, rotavirus, hepatitis A virus, enterovirus) (FoodSafety.gov, 2016). The federal government utilizes meat inspectors to prevent misbranded meat and meat products from being sold as food and ensure that meat animals are slaughtered and meat products processed under sanitary and humane conditions. The United States currently depends on the Foodborne Diseases Active Surveillance Network (FoodNet) of the CDC’s Emerging Infections Program to collect data on diseases caused by enteric pathogens transmitted through food (CDC, 2010). Public health nurses play a key role in foodborne illness investigations.
Food can also be contaminated by agrichemicals, such as pesticides and fertilizers; materials from mechanical handling devices; detergents; and organic packaging materials. Toxic chemicals from farming and ranching may be introduced into the food chain, increasing risk of reproductive and mutagenic effects in humans (Driehuis et al., 2008; Knobeloch et al., 2009). For instance, farmers spray dioxin-containing weed killers on rangeland. Beef cattle graze on the land, herbicide accumulates in their fatty tissue, and the contaminated meat is sold in markets. The complexity of transfer of these contaminants makes for difficulty in establishing causality and tracing accountability for these health risks.
FIG. 14.4 Steps to food safety. From FoodSafety.gov: Keep food safe, n.d. Retrieved from
http://www.foodsafety.gov/keep/basics/index.html
Unsuitable handling, storage, processing, and transport techniques can damage food and make it unsuitable for consumption. Nurses can council patients on the proper handling of food (Fig. 14.4). Furthermore, additives are often used to improve food properties. For example, vitamins and minerals are used to enhance nutritional content; salt, sugars, and monosodium glutamate are used to improve flavor; dyes are used to enhance color; leavening agents, gums, or thickening agents are used to improve consistency; and various preservatives are used to increase shelf life. Many of these additives are not nutritious, and some may be harmful. Additionally, residues from the overuse of antibiotics in animal husbandry remain in meat and milk products, causing consumers to develop resistance, thus rendering these antibiotics ineffective in treating human infections (Hurd and Malladi, 2008).
Another potential threat related to food quality involves “genetically modified” (GM) or genetically engineered foods. GM foods, which have been in existence since the early 1970s, are created by a process in which scientists splice plant or animal genes with particular traits into the DNA of other organisms. This technology has contributed to crops and livestock that grow faster, are more resistant to disease and insects, and produce higher yields and greater nutritive value. Often GM crops require less water and fertilizer. There is concern that genetic alteration of food is
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growing despite the fact that the long-term health effects of eating GM food are unknown. Some believe that allergies and other immunity problems may proliferate because unique antigens are present on GM proteins, and GM foods have unpredictable metabolic processes in animals, humans, and plants (Whitney et al., 2004). Although the U.S. Department of Agriculture and the U.S. Food and Drug Administration set policy for foods produced from new plant varieties and breeding, a number of groups and organizations have called for greater public awareness of the potential risks of genetically engineered foods and are working to require more stringent testing of them. The American Nurses Association was among several professional groups that developed principles of a healthy and sustainable food system (Box 14.2) (American Planning Association, 2010).
Clinical Example 14.6 A southwestern U.S. town with a population of 10,000 has three elementary schools. School nurses at all three schools had an influx of children into their offices one afternoon with complaints of gastrointestinal symptoms. After verifying that this was happening at all three schools, the nurses called the county health department to report possible foodborne illness outbreak. The county health nurse came out to the schools that afternoon to investigate the foodborne outbreak. She interviewed the school nurses, the affected and unaffected students, and the cafeteria staff.
BOX 14.2 Healthy and Sustainable Food Systems
Health-Promoting
• Supports the physical and mental health of all farmers, workers, and eaters • Accounts for the public health impacts throughout the entire lifecycle of how food is
produced, processed, packaged, labeled, distributed, marketed, consumed, and disposed
Sustainable
• Conserves, protects, and regenerates natural resources, landscapes, and biodiversity • Meets our current food and nutrition needs without compromising the ability of the system to
meet the needs of future generations
Resilient
• Thrives in the face of challenges, such as unpredictable climate, increased pest resistance, and declining, increasingly expensive water and energy supplies
Diverse In
• Size and scale—includes a variable range of food production, transformation, distribution, marketing, consumption, and disposal practices, occurring at different scales, from local and regional to national and global
• Geography—considers geographic differences in natural resources, climate, customs, and heritage
• Culture—appreciates and supports a diversity of cultures, sociodemographics, and lifestyles • Choice—provides a variety of health-promoting food choices for all
Fair
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• Supports fair and just communities and conditions for all farmers, workers, and eaters • Provides equitable physical access to affordable food that is health promoting and culturally
appropriate
Economically Balanced
• Provides economic opportunities that are balanced across geographic regions of the country and at different scales of activity, from local to global, for a diverse range of food system stakeholders
• Affords farmers and workers in all sectors of the system a living wage
Transparent
• Provides opportunities for farmers, workers, and eaters to gain the knowledge necessary to understand how food is produced, transformed, distributed, marketed, consumed, and disposed
• Empowers farmers, workers, and eaters to actively participate in decision making in all sectors of the system
After having all students in the school fill out a form describing what they had eaten for lunch, the county nurse was able to determine that the chicken salad was the likely source of contamination. The nurses sent the chicken salad as well as samples of all the ingredients in the salad for laboratory testing. Within 2 days, the nurse received confirmation that the chicken salad had been the source of the illness, related to the use of contaminated celery. The nurse then alerted federal officials. A warning was issued on www.foodsafety.gov to alert officials across the nation. Food inspectors were sent to the factory that prepared and sold the celery. The source of contamination was isolated to three of the five machines used to slice the prepackaged celery. The factory was temporarily shut down for thorough disinfection. The school and county nurses worked together to assess the outbreak, alert the appropriate officials, and stop the outbreak from spreading. They undoubtedly saved thousands from illness and possibly death.
Waste Management Waste management entails the handling of waste materials resulting from industry, municipal processes, and human consumption as well as efforts to minimize waste production. Environmental health problems related to waste management include nonbiodegradable plastics, inefficient recycling programs, unlicensed waste dumps, inadequate sewage systems for growing populations, unsafe dumping of industrial toxins, exportation of radioactive medical wastes, illicit dumping (Clinical Example 14.7), and nonenforcement of environmental regulations.
American consumers’ increasing trash production and the improper treatment, storage, transport, and disposal of waste are a significant concern. Routinely, commercial and institutional wastes are dumped with household waste in the same municipal incinerator, landfill, or sewer system. These commercial enterprises are generally exempt from the strict waste regulation applied to industry, although they often generate the same hazardous materials. Small businesses such as dry cleaners, photography laboratories, pesticide formulators, construction sites, and car repair shops discard a variety of substances that can cause serious public health problems.
Traditionally, U.S. economic development has produced optimal wealth with the assumption that the environmental health consequences would be minor. This notion of sustainable development has proved inadequate, and cumulative hazardous episodes necessitate tough pollution control technologies. The sustainability paradigm has led to a shift from disposing to recycling of biosolids. Biosolids refers to sewage sludge that has been treated for pathogens to meet the regulatory requirements for land application. This has been a cost-effective practice, but more research needs to be conducted on human health risks of biosolid distribution in the ecosystem.
A number of potential health problems are associated with waste management. For example, solid waste landfills accumulate methane gas, a by-product of decomposing organic wastes.
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Without proper venting, this volatile gas can move through soil and cause fires and explosions in nearby areas. Waste incineration causes particulate air pollution and is ineffective in the combustion of many materials. Improper design, operation, or location of a waste site causes hazardous substances to spread through air, soil, and water to poison humans, animals, and plant life. Alarmingly, only a small percentage of hazardous waste actually reaches the designated waste sites; much is disposed of in open pits and in bodies of water, with dangerously uncertain long-term effects. New methods are being developed to estimate long-term rates of leaching of materials in various types of waste sites, based on probability principles (Sanchez and Kosson, 2005).
In 1980, Congress passed the Environmental Response Compensation and Liability Act, which established a revolving fund called the Superfund to clean up several hundred of the worst abandoned chemical waste disposal sites. One of the most notorious sites is the Love Canal in Niagara Falls, New York. For 40 years before the 1960s, more than 80 different types of chemicals, including benzene, dioxin, trichloroethylene, toluene, and chloroform, were dumped in an abandoned canal. Afterward, the covered area became the site for a school and several hundred homes. In the winters of 1976 and 1977, heavy snowfall and rain caused toxic wastes to reach the surface. Subsequently, the inhabitants experienced elevated miscarriage rates, blood and liver abnormalities, birth defects, and chromosome damage.
Clinical Example 14.7 In a city on the Mississippi River, an outbreak of shigellosis was traced to a group of high school students who had been swimming in a particular area of the river. The local meatpacking plant was releasing waste material, including human and animal feces, directly into the river. After intervening to contain the Shigella outbreak, the local community health nurses began to assess the situation. Their research indicated that the meatpacking facility had been in violation of waste control laws for some time. City officials imposed fines, which the company paid, but the dumping continued. Signage placed along the riverbanks prohibited swimming. Frustrated by their attempts to negotiate with the city and the plant, the nurses wrote a letter to the state capital newspaper, which had a large state readership. In the letter, they voiced concern about the community’s health and the river’s ecological integrity. The paper published their commentary, prompting responses from two local environmental groups, several activist groups, and a national organization concerned with clean water. These groups provided legal support and brought a collective suit against the meatpacking company. Subsequently, the company improved its waste treatment process to avoid legal ramifications.
Genetics in Public Health
The Built Environment Obesity is a preventable condition yet worldwide has nearly tripled in the past four decades (World Health Organization, 2017). Obesity and weight gain is linked to genetic disposition but not as an isolated factor (Trasande et al., 2009). Lifestyle interactions with the built and natural environments are implicated in obesity risk where access to safe and walkable surroundings is not available (Hruby et al., 2016). Integrating environmental information with genetic characteristics allows for developing better understanding about health outcomes and health behavior (Population Reference Bureau) and identifying risk predictors for obesity and other human conditions (Liu et al., 2012).
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FIG. 14.5 Degrees of health effects from environmental exposures. From Environmental Protection Agency: Air pollution and health risk, 1991. Retrieved from
http://www.epa.gov/ttnatw01/3_90_022.html
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Effects of Environmental Hazards Environmental hazards are ubiquitous, and their effects on the public’s health are complex and generally interconnected. Nurses must understand the multiple and complex sequences leading to health concerns (Fig. 14.5). For example, nuclear power plant emissions may contaminate water and air supplies, affecting water quality, atmospheric quality, and radiation risk. Overcrowded housing may exacerbate problems in managing human waste, which may taint foodstuffs and contribute to the spread of communicable disease. Climate change continues to affect humans, the food chain, vegetation, and wildlife.
Effects of environmental hazards may be general or specific. For example, the ramifications of high unemployment, drought, and extensive smog cover affect the public generally. Other environmental health concerns, such as the housing needs of elderly people who use walkers or canes, the occupational risks of electrical line repair workers, and the mentally incapacitating effects of elevated blood lead values in children, affect the public more specifically.
Environmental health effects can be immediate, long-term, or intergenerational. Burns, gunshot wounds, hurricane damage, and outbreaks of gastrointestinal distress among cafeteria customers are examples of immediate effects from health-damaging environments. Examples of long-term health effects include gradual occupational hearing loss, “black lung” in coal miners, and increased rates of thyroid cancer among young victims of the Chernobyl nuclear reactor accident (Ron, 2007). Intergenerational effects will likely occur with climate change by affecting women of childbearing age.
Certain environmental exposures have been found to have a direct relationship with the development of some cancers, chronic diseases, and other health-related problems (Boyd and Genuis, 2008; Crouse et al., 2015). Furthermore, oppressive environments may affect health directly. In one case, an American company dumped dangerous waste material in Mexico rather than pay for proper disposal (Schrieberg, 1991). Poor children who lived nearby and scavenged for food in the dump picked up and played with the shiny, brightly colored radioactive medical waste. The severe burns they suffered and the wine-colored spots on their skin were direct effects of the illegally dumped toxic waste.
Effects of environmental risks may also be indirect, such as in the case of global warming (Akhtar et al., 2009; Pan and Kao, 2009). Global warming is the gradual increase in the average temperature of Earth’s near-surface air and oceans since the mid-twentieth century and its projected continuation (Easterling, 2011). Rising global temperatures may enhance the quantity and distribution of parasites, insects, and other disease vectors, potentially increasing the prevalence of a variety of infectious diseases. For example, global warming contributed to the entry and propagation of the West Nile virus in the United States (Epstein, 2001) and is suspected in facilitating the rapid spread of the Zika virus (Chan et al., 2016). Higher air and water temperatures facilitate the spread of vectorborne diseases transmitted by mosquitoes (e.g., West Nile virus). As a result, 2012 saw more cases of West Nile virus infection (5387) than any year since 2003, with a higher proportion of deaths (243) (CDC, 2012); however, between 2012 and 2015 there has been an annual consecutive reduction in both the number of cases and deaths related to West Nile Virus (CDC, 2016).
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Efforts to Control Environmental Health Problems The 1970s were the decade of environmental concern. Cynicism toward institutions grew during the years of U.S. involvement in Vietnam, and legislative activism for environmental preservation exploded (Burger, 1989). During the 1970s, Congress created new agencies to regulate environmental conditions on a national level, including the EPA, the Occupational Safety and Health Administration, and the Nuclear Regulatory Commission. The EPA has enormous responsibilities for protecting the environment and minimizing risks to human health. Among its roles are health surveillance and monitoring; setting standards for air and water quality; evaluating environmental risks; acquiring information; screening new chemicals; performing basic research and training; and establishing, evaluating, and enforcing regulatory efforts.
The legislative activism of the 1970s was aimed toward a comprehensive national environmental policy. For example, stricter automobile fuel and emissions standards created improvements in air quality, which caused lead levels in urban air to decrease dramatically over the next decade. The momentum to control environmental pollution in the United States slowed in the 1980s and 1990s, with several policy reversals and the defunding of regulatory mechanisms. In recent years, administrative and legislative activity related to the environment has focused on such issues as climate change, oil spills, hazardous waste, and toxic exposures.
Frequently, laws and regulatory structures are weak or nonexistent with regard to environmental health problems. For example, federal mandates for recycling do not exist, although local communities have made great strides in this area. Comprehensive groundwater legislation, similar to adopted measures to preserve marine and surface waters, also does not exist. Additionally, the EPA tends to set priorities for the reduction of environmental problems but does not allocate the resources necessary to accomplish these goals.
Research Highlights
I PREPARE: Development and Clinical Utility of an Environmental Exposure History Mnemonic The I PREPARE environmental exposure history mnemonic is a quick reference tool created by Paranzino and colleagues (2005) for primary care providers. A total of 159 health care providers, both students and professionals, were asked to evaluate a prototype of the mnemonic, to suggest new health history questions, and to propose the deletion of less relevant questions. The prototype was formatted as a pocket guide. The goal of this evaluation was to create a practical and clinically relevant mnemonic rather than to obtain quantitative estimates of its validity. This mnemonic is meant to serve as a mental cue to facilitate the collection and documentation of health information in a systematic manner:
I—Investigate Potential Exposures P—Present Work R—Residence E—Environmental Concerns P—Past Work A—Activities R—Referrals and Resources E—Educate
Questions to ask are presented for each letter in the mnemonic, except for Referrals and Resources, which provides sources of additional information. A checklist of strategies to prevent or minimize exposures can be used by the health care provider to help clients identify potential exposures. The sequence of I PREPARE makes intuitive sense by cueing the provider to ask specific questions and then provide educational materials to the client. The final version was reprinted on heavy laminated material. The I PREPARE mnemonic increases the repertoire of tools clinicians have available to elicit an appropriate health history. The national improvements in the quality of
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environmental exposure history are predicated, in part, on the creation of simple and convenient tools for use in clinical practice. Data from Paranzino GK, Butterfield P, Nastoff T, Ranger C: I PREPARE: Development and clinical utility of an environmental exposure history mnemonic, J American Association Occupational Health Nurses 53(1):37–42, 2005.
Most of the U.S. environmental health efforts have aimed for short-term results rather than anticipating future issues and problems. A crucial need exists in the development of human resources in the area of environmental health. Nurses in all areas of practice should be aware of the implications of the environment for their clients and their health. It is for this reason that nurses need to take and record an environmental health history for every client.
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Emerging Issues in Environmental Health Within the past decade, we are beginning to recognize that our environmental public health infrastructure is quite weak and that the United States is susceptible to many of the same problems that burden the rest of the world. For example, the illegal use of pesticides, medical waste incineration, and the increased incidence of asthma related to air pollution are just a few of the challenges facing the United States today. The manufacturing of methamphetamine in home-based and mobile laboratories continues to rise, and the “cooking process” emits dangerous levels of toxic chemicals into the air. Similarly, the abandoned labs also pose a threat (Grant et al., 2010). Finally, natural disasters and climate change affect the entire world.
Natural disasters can disrupt and oftentimes overwhelm private and public health systems. Natural disasters, such as the tsunami that struck the coast of Indonesia in December 2004, Hurricane Katrina in August 2005, the devastating earthquakes in the Sichuan Province of China in 2008 and in Haiti in 2010, and superstorm Sandy in 2012, require mobilization of disaster relief units that offer substantial assistance and expertise. Natural disasters such as hurricanes, tornados, and earthquakes frequently receive notable publicity, but other, more insidious disasters, such as droughts, floods, heat waves, and extreme cold, also pose major public health concerns. All of the aforementioned threats can cause significant mortality and morbidity and therefore have the potential to burden the health care delivery system.
Global warming is part of a larger issue called climate change that poses significant health hazards. Climate change is the change in weather over a certain period. Weather patterns are greatly affected by atmospheric and oceanic temperature rises. Climate change projections suggest that heat waves and hot weather are likely to increase in frequency, with the overall temperature distribution shifting away from extreme cold (O’Neill and Ebi, 2009). Climate change can have severe adverse health effects, such as health-related illness and death; increases in air pollution; water-, food-, vector-, and rodent-borne diseases; malnutrition; contaminated water supply; and injuries and deaths related to extreme weather and storm surges (Balbus, 2011; Sheffield et al., 2011). There are regional differences in the effects of climate change, although vulnerable populations will be affected the most. For instance, climate change will raise the risks of infant and maternal mortality, birth complications, and poorer reproductive health, especially in developing countries (Rylander et al., 2013).
Nursing Actions Nurses must work with the public to promote more stringent and actively enforced environmental legislation and regulations. In the twenty-first century, actions must include not only national but also worldwide environmental policies. Ozone depletion, climate change, fossil fuel burning, marine dumping, abandonment of active land mines in war-torn areas, and destruction of tropical rainforests are among the key global environmental health concerns.
Environmental concerns for clean air, clean water, and freedom from noxious chemicals must become nursing concerns. Community health nurses can be catalysts to neighborhood efforts to produce safe living environments. Community health nursing must expand its theory and practice to incorporate the fact that individual and community health ultimately depends on global environmental integrity. Many organizations work to preserve and protect the environment and could benefit from the active involvement and support of nurses. Box 14.3 lists some of these organizations. Nursing must include an environmental perspective by committing to environmental health promotion initiatives that promote social justice and environmental responsibility.
BOX 14.3 Nongovernmental Environmental Organizations
• Alliance of Nurses for Healthy Environments (http://envirn.org/) • American Farmland Trust (http://www.farmland.org/) • Citizens for a Better Environment (http://www.cbezambia.org/)
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• Clean Water Action (http://www.cleanwateraction.org/) • Green America (http://www.greenamerica.org/) • Environmental Defense Fund (http://www.edf.org/) • Environmental Working Group (http://www.ewg.org/) • Greenpeace (http://www.greenpeace.org/usa/en/) • International Rivers Network (http://www.internationalrivers.org/) • National Audubon Society (http://www.audubon.org/) • National Environmental Law Center (http://www.nelconline.org/) • National Geographic Society (http://www.nationalgeographic.com/about/) • Natural Resources Defense Council (http://www.nrdc.org/) • National Wildlife Federation (http://www.nwf.org/) • Ocean Alliance (http://www.oceanalliance.org/) • Pesticide Action Network (http://www.panna.org/) • Rainforest Action Network (http://ran.org/) • Sierra Club (http://www.sierraclub.org/) • The Nature Conservatory (http://www.nature.org/) • Trust for Public Land (http://www.tpl.org/) • Wilderness Society (http://wilderness.org/) • World Wildlife Fund (http://worldwildlife.org/)
For further information, see the report by the Institute of Medicine Committee on Enhancing Environmental Health Content in Nursing Practice: Nursing, health, and the environment, Washington, DC, 1995, National Academies Press.
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Approaching Environmental Health at the Population Level In the United States, personal independence and individual responsibility for success and failure are valued. These values can lead nurses to overlook environmental hazards and instead blame individual clients for their health problems. Placing responsibility for the cause and cure of health problems exclusively on the individual reinforces the belief that all individuals are free to exert meaningful control over the quality and length of their lives. Such a perspective absolves society, government, industry, and business from accountability.
Research suggests that changing individual behaviors does not lead to significant reductions in overall morbidity and mortality in the absence of basic social, economic, and political changes (Bhatia and Wernham, 2008). Emphasizing only interventions that address deleterious personal habits through exercise programs, weight loss regimens, smoking cessation classes, and stress reduction tactics fails to take into account the broader environmental origins of disease, injury, and ecological degradation. An attempt to approach health at the aggregate level is the Healthy People 2020 initiative (USDHHS, 2013). The Healthy People 2020 box lists selected environmental health objectives of the Healthy People 2020 initiative.
Healthy People 2020
Selected Objectives for Environmental Health
EH–2: Increase use of alternative modes of transportation for work EH–3: Reduce air toxic emissions to decrease the risk of adverse health effects caused by
mobile, area, and major sources of airborne toxins EH–4: Increase the proportion of persons served by community water systems who receive a
supply that meets the regulations of the Safe Drinking Water Act EH–5: Reduce waterborne disease outbreaks arising from water intended for drinking among
persons served by community water systems EH–8.1: Eliminate elevated blood lead levels in children EH–12: Increase recycling of municipal solid waste EH–14: Increase the proportion of persons living in homes at risk that have an operating
radon mitigation system
From U.S. Department of Health and Human Services. (n.d.) Environmental health. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=12
Ethical Insights Protecting Vulnerable Aggregates Community health nurses have a mandate to assist vulnerable aggregates who have fewer options in protecting themselves from pollution, inadequate housing, toxic poisoning, unsafe products, and other hazards. Non–English-speaking individuals, children, very low-income women and families, undocumented manual laborers, and people from racial and ethnic minorities are just some of the groups in the United States who hold minimal influence with industry, government, business, and other large institutions for environmental changes and compensations for harm from environmental hazards.
Interventions designed for individuals must consider the environmental determinants of behavior and health outcomes (Bartholomew et al., 2011; Coughenour et al., 2014). Community health nurses who base their practices on theory and evidence are better prepared to respond to collective challenges. These nurses can facilitate community participation in identifying and solving environmental health problems and bringing about changes that improve environments
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and eliminate hazards.
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Critical Environmental Health Nursing Practice The National Center for Environmental Health, the CDC, and the American Public Health Association has established three core competencies for environmental health professionals: assessment, management, and communication (Box 14.4). Several clinical examples throughout the chapter illustrate how nurses can focus their efforts by organizing groups of people, taking a stand, and acting as advocates for change. The nurses ask critical questions, stay engaged with the communities they serve, form coalitions, and use various collective strategies. The American Nurses Association highlights 10 critical environmental health principles. In the interest of educating future practitioners about the critical practice of environmental community health nursing, the following sections discuss each of these interventions.
Taking a Stand: Advocating for Change Nurses must make individual and collective decisions about which interests they want to serve with their specialized knowledge and skills. Nurses may choose to work with vulnerable people or those disproportionally experiencing the consequences of environmental hazards. Vulnerable groups are exposed to more health-damaging effects than less vulnerable groups (Chakraborty and Zandbergen, 2007; EPA, 2013c). Nurses can work toward health equity through the decisions they make, the positions they accept, and the interventions they undertake. Environmental problems are clearly intertwined with social, political, and economic policies; resource barriers; and the interests of those in positions of control. Nurses need to connect the immediate and long-term health problems experienced by particular communities to this larger sphere of influence.
BOX 14.4 Core Environmental Health Competencies
Assessment
Research: The capacity to identify and compile relevant information to solve a problem and the knowledge of where to go to obtain the relevant information
Data analysis and interpretation: The capacity to analyze data, recognize meaningful test results, interpret findings, and present the results in a meaningful way to different types of audiences
Evaluation: The capacity to evaluate the effectiveness or performance of procedures, interventions, and programs
Management
Problem solving: The capacity to understand and solve problems. Economic and political issues: The capacity to understand and appropriately utilize information
concerning the economic and political implications of decisions. Organizational knowledge and behavior: The capacity to function effectively within the culture of
the organization and to be an effective team player. Managing work: The capacity to plan, implement, and maintain fiscally responsible
programs/projects using appropriate skills and to prioritize projects across the employee’s entire workload.
Computer/information technology (IT): The capacity to utilize information technology as needed to produce work products.
Reporting, documentation, and record keeping: The capacity to produce reports that document actions, keep records, and inform appropriate parties.
Partnering: The capacity to form partnerships and alliances with other individuals and organizations in order to enhance performance on the job.
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Communication
Education: The capacity to use the environmental health practitioner’s front-line role to effectively educate the public on environmental health issues.
Communication: The capacity to effectively communicate risk and exchange information with colleagues, other practitioners, clients, policy makers, interest groups, media, and the public through public speaking, print and electronic media, and interpersonal relations.
Conflict resolution: The capacity to facilitate the resolution of conflicts within the agency, in the community, and with regulated parties.
Marketing environmental/public health as a service: The ability to articulate basic concepts of environmental health and public health and convey an understanding of their value and importance to clients and the public.
Data from American Public Health Association: Environmental Health Competency Project: Draft recommendations for non-technical competencies at the local level, 2013. Retrieved from http://www.apha.org/programs/standards/healthcompproject/corenontechnicalcompetencies.htm.
BOX 14.5 Critical Questions About Environmental Health Problems
• What is the problem? • Who is defining the problem? • In what terms is the problem described? • How are others in the situation viewing the problem? • What is the history of the problem? • How did things get the way they are? • What other situations does this problem directly affect? • Who does the problem affect? • Whose health is damaged because things are this way? • Who benefits from the way things are? • Whose interests do current solutions serve? • What are the economic inequities in the situation? • Who has political power in the situation? • Who knows about the problem? • Who needs to know more about the problem? • How effective are current programs, strategies, and policies? • What are the barriers to solving the problem? • What strategies may alleviate the problem? • How successful have these strategies been? • What existing groups might deal with this problem? • What resources are needed to solve the problem? • How accessible are the resources? • How can nurses evaluate potential solutions?
Asking Critical Questions Community health nurses must also consider the relationships between nonhealth policies and health policies. They should ask how policies concerning ecological preservation, energy, housing, immigration, civil rights, crime, nutrition, minimum wage, occupational safety, and defense might affect the health and well-being of people. Addressing critical questions such as who has access to resources in this country and whose interests are served in the existing system provides a way to include social, political, and economic factors in environmental nursing assessments. Box 14.5
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provides a sample set of questions that are useful in this endeavor. Nurses can ask these critical questions when approaching environmental health problems.
Facilitating Community Involvement Approaching community health from a critical perspective requires working to improve health conditions and creating the context in which people can identify health-damaging problems in their environments. One important nursing goal is to help people learn from their own experiences and analyze the world with an intention to change it. It is essential that the affected people participate in the process of identifying and working to solve environmental problems (White et al., 2014). To foster community-based, active participation, nurses must be prepared to take leadership positions and join in mutual exchanges with community members that consider each person’s experience. The nurse’s role changes from presenting solutions and directing lifestyle changes to providing support, information, and expertise to assist in meeting the group goals. Using critical questions, community health nurses can help community members look beyond immediate environmental problems and explore social, cultural, economic, and political circumstances that contribute to them. Nurses can share their knowledge about the scientific basis for health problems, their insights about the historical origins of particular environmental hazards, their technical skills, and their expertise in communicating and organizing. By addressing people’s everyday concerns and targeting the problems they identify, nurses situate their efforts in community struggles.
Forming Coalitions Another very important nursing task that arises from approaching environmental health from a critical perspective involves forming coalitions to produce social change. By initiating dialogue and building a strong base of collective support, nurses join with communities to eliminate hazards and improve public health. Nurses can approach existing community organizations, churches, and family and friendship networks to help mobilize aggregate members who have not previously socialized or acted together. Nurses can then discuss environmental concerns, assess needs, plan actions, secure appropriate resources, and advocate for legislative changes.
Nurses can be instrumental in these efforts by helping community groups make connections with larger, more powerful organizations. Nurses can organize forums whereby community groups meet with scientific experts who can help them gather evidence about health threats, with business managers whose actions impinge on the economic life of the community, with industry leaders whose companies create ecological hazards, and with legislators who can bring community concerns to lawmaking bodies. Using available institutional resources, skills, and knowledge, nurses can also explore what is happening elsewhere. Making connections with groups in other locales who are struggling for similar environmental changes can enhance collective strength and solidarity. Press releases, media events, interviews, television spots, speeches, newsletters, and leaflets are important means of calling attention to a situation and raising awareness among communities.
Using Collective Strategies Nurses can use a variety of strategies to intervene at the population level and facilitate improvement in a community’s health. Nurses can organize people to change health-damaging environments through combinations of strategies, including building coalitions, providing educational forums, facilitating a community needs assessment, disseminating research, and lobbying for legislative changes.
One collective strategy that is an effective population-level community health nursing intervention is participatory action research. This form of research calls for nurses, community members, and other resource people to work together in identifying health problems, designing the studies, collecting and analyzing the data, disseminating the results, and posing solutions to the problems (Garwick et al., 2010; Li et al., 2011). In PAR applied to environmental health, community health nurses and community members would gather information on suspected environmental hazards, determine their effects on health, and devise a plan of action to mitigate the threat.
Although nurses have not traditionally used all of these collective strategies to intervene in community health matters, environmental hazards are multiplying geometrically, pushing nurses
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to expand their skills repertoire. Pioneers such as Hollie Shaner, RN, have embraced that concept and are blazing the path to environmental awareness (Sattler, 2003). In the 1990s, Shaner frequently left her home, where she avidly separated and recycled, to work at a Vermont hospital, where none of the waste was recycled. Shaner was not comfortable throwing everything into a “red bag” and decided that there must be a way to change the environmental unfriendliness of her place of employment. She began voluntarily recycling the hospital’s cardboard and then began to recycle the newspapers, glass, and plastics. In addition, she received a grant from the state of Vermont to maximize her efforts in medical waste reduction. The efforts and savings did not go unnoticed by the hospital, as Shaner received a new job title of clinical waste reduction coordinator and saved the hospital $175,000 per year.
Shaner also wrote a book for the American Hospital Association on medical waste management. She quickly realized the negative impact the health care industry was having on the environmental health of the communities served. Mercury was being released into the streams from medical waste, and dioxins were being released into the air from medical waste incineration. From this realization, in 1996, Shaner and a small group of other health professionals launched a campaign to lead the health care industry toward environmental stewardship. This campaign, supported by the American Nurses Association, was named Health Care Without Harm. “The goal of the campaign was to reduce the environmental health risks that were being created by the health care industry” (Sattler, 2003, p. 8). The campaign still exists and is building momentum; today there are 433 participating organizations in 52 different countries (Health Care Without Harm, 2013). In 2015 the 2020 Health Care Climate Challenge was launched, aiming to reduce the health care carbon footprint, respond with resiliency to the changing patterns of disease, and lead the way for creating a healthier climate (Global Green and Healthy Hospitals, 2015).
Research Highlights
Participatory Action Research Asthma is a significant public health problem that disproportionately affects preschool-age, low- income children. Indeed, children from low-income families have significantly higher asthma prevalence rates, hospitalization rates, and emergency department visits than children from middle-income and wealthier families. This problem is even more pronounced among children in urban areas.
A team of public health nurses led by Garwick (2010) used participatory action research (PAR) techniques in working with teachers in an urban Head Start program with multiple sites to address asthma management among the children at their sites. In this project, teachers and managers from 16 Head Start centers were identified to participate in three focus groups. During the focus groups, participants identified asthma management issues and challenges, including undiagnosed and unreported asthma, coordination of asthma care with parents, medication administration issues, and variability among asthma action plans. As a result of the PAR, a standardized, comprehensive Head Start asthma action plan was developed that outlined strategies the teachers could use to better manage the problem of asthma among the children. Data from Garwick AW, Seppelt A, Riesgraf M: Addressing asthma management challenges in a multisite, urban Head Start Program, Public Health Nurs, 27(4): 329–336, 2010.
Case StudyApplication of the Nursing Process Air Pollution In July 2001, the Metro Pulse newspaper reported an extensive air pollution problem in the city of Knoxville, Tennessee (Tarr, 2001). The American Lung Association had recently named Knoxville the ninth most polluted city in the country on the basis of the ozone contamination in the air. The following case study expands on some of the reported facts of the situation to construct hypothetical nursing interventions.
Knoxville’s community health nurses and the public health department were aware of increasing rates of asthma in particular neighborhoods. In the wake of alarming newspaper and research
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articles about the dangerous incidence of air pollution and related asthma, the nurses decided to make the health issues a priority. The community health nurses and several nursing students assigned to their department researched the topics and uncovered the following information.
Asthma has long been recognized as a condition in which an acute respiratory response may follow inhalation of a material to which a person is sensitized. Scientists now know that air pollution can lead to nonspecific generalized inflammation. One study found strong evidence that ozone can cause, as well as exacerbate, asthma (Sheffield, et.al, 2011). The study found that days with worse AQI values resulted in significantly higher school absences due to respiratory illness, and asthma was more likely to develop in children living in high-ozone communities who actively participated in several outdoor sports than in children in communities not participating in sports.
Indeed, the nation’s leading group of pediatricians, the American Academy of Pediatrics (AAP), revised its policy statement on outdoor air pollution and the health hazards to children (Schwartz, 2004). The AAP’s Committee on Environmental Health strengthened its warning about the dangers that air pollution poses to children because of the recent studies correlating air pollution with asthma and negative lung growth and function. Estimates are that more than 25 million Americans have asthma (Asthma and Allergy Foundation, 2013).
An economically depressed neighborhood in Knoxville, hypothetically called Trent Park, is situated near numerous railways, freeways, and industrial yards. High numbers of African American, Latino, and Southeast Asian residents live in the older homes that line the streets of Trent Park. Isolated by language and economic circumstances, many Trent Park residents do not know they are exposed to these environmental health hazards. Assessment Elena Garcia, an 8-year-old girl who lives in Trent Park, presented to the pediatric primary clinic at the health department at 8 AM in November. Elena had been diagnosed with asthma 2 months ago and was now in mild respiratory distress. Elena explained to the nurse that she had gone trick-or- treating the night before in her neighborhood. It had turned cold that weekend, and she had also played outside in her neighborhood with friends the day before. In addition, the child’s mother explained that Elena had recently had a respiratory virus. The nurse realized that Elena and her mother both mentioned several factors, such as her playing outside on a cold afternoon/evening in a polluted neighborhood and a respiratory virus, that could have exacerbated her asthma.
At the clinic visit, the nurse assessed the following:
• Elena’s heart rate and cardiovascular status • Elena’s pattern of breathing, which includes rate, rhythm, and effort • Elena’s asthma medication history • Evidence of diaphoresis, papillary dilation, and fear, which are all features of the adrenergic
response to hypoxia • Elena’s global central nervous system function, such as alertness, cooperation, and motor
activity • Elena’s environmental health assessment
Diagnosis Individual
• Ineffective respirations related to environmental exposure to air pollution • Insufficient knowledge related to precipitating factors that can cause/worsen an asthma attack • Stress related to ongoing fear of daughter’s illness
Family
• Risk for family crisis related to instability caused by the illness • Insufficient knowledge related to factors that can cause/worsen an asthma attack
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Community
• Risk for increased incidence of asthma due to air pollution • Inadequate programs for asthma screening
Planning A plan of care was developed at the individual, family, and community levels. Mutual goal setting and contracting are essential if the outcome is to be optimal. Individual Long-Term Goals
• Client will modify outdoor time daily according to the AQI • Client will reduce exposure to allergy triggers • Client will avoid secondhand tobacco smoke • Client will keep pets out of the bedroom • Client will experience successful maintenance of asthma
Short-Term Goals
• Client will report reduced outdoor time on days with poor AQI values • Client will keep an asthma diary and identify which allergy triggers are problematic • Client will remain free of acute asthma attacks
Family Long-Term Goals
• Family will follow the city’s daily AQI • Family will encourage child to stay indoors on days with high pollution levels • Family will remove as many allergy triggers from home as possible • Family will enforce the pets-out-of-the-bedroom policy • Family will cope effectively with daughter’s asthma
Short-Term Goals
• Family will provide encouragement for client to keep an asthma diary
Community Long-Term Goals
• Citizens will be involved in decision-making process about proposed activities that could pose an environmental hazard
• Citizens will encourage utility companies, government, and industries to reduce air pollution • Citizens will be encouraged to use mass transit and carpools to reduce vehicle emissions
Short-Term Goals
• Citizens will be alerted about the air pollution problem in the area • Citizens will be educated about the AQI and its implications for outdoor activity
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Intervention Individual
• Identify Trent Park children with asthma and plan follow-up home visits to provide education on basic pathophysiology, symptoms of distress, and environmental controls needed for successful asthma management
• Add environmental health assessments to child health assessment protocol • Coordinate with school nurses to ensure they incorporate similar changes into their health
assessment protocols • Prepare and distribute an educational pamphlet with members of Trent Park that details Trent
Park residents’ air pollution and asthma risks • Prepare translations of the pamphlet in languages and reading levels appropriate for Trent
Park residents, and mail it to individual households.
Family
• Facilitate the formation of a support group for families with children who have asthma
Community
• Initiate an asthma awareness program for Trent Park community members. • Coordinate with school nurses to implement an asthma awareness program in Trent Park
schools. • Develop an asthma action team consisting of Trent Park community members. • Participate in the action team’s development of an intervention to reduce asthma-related
illness in Trent Park. • Encourage nursing students and community health nursing faculty from the local university
and college programs to participate. • Lobby state legislatures, municipal officials, local medical associations, local hospitals, and city
clinics regarding the project. • Form broader coalitions with Knoxville churches, the local nurses association, several
preschool and day care centers, and the Knoxville School Board to design a comprehensive, nonduplicative, cost-effective asthma screening program.
• Train action team members on how to conduct Healthy Home assessments. • Contact state environmental groups for advice on local efforts, and join in their fight for
stricter regulation of air pollutants and toxic wastes. • Contact local media (e.g., television, radio, and newspaper) about running a series of stories
about Knoxville air pollutants and related asthma risks; supply information and contacts for interviews and photographs.
Evaluation Individual
• Evaluate the child’s and mother’s understanding of asthma treatments at follow-up home visits.
• Facilitate the evaluation of ongoing interventions. • Track the number of asthma screening tests that Trent Park children receive and their rates of
asthma to determine the effectiveness of their efforts in these areas. • Keep close contact with the school nurses, and organize an after-school educational and
screening program at schools that are understaffed. • Ask school nurses to report on the educational sessions’ success.
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Family
• Document participation levels at educational programs and family training sessions. • Document ongoing participation in referrals and support groups.
Community The action team was able to get funding to provide Healthy Home assessments and asthma screening to at-risk youth in Trent Park. Levels of Prevention Primary Prevention Educating the community regarding air pollution and its relationship to asthma Secondary Prevention Screening at-risk populations for asthma Tertiary Prevention Follow-up treatment for people with asthma and reduction of air pollutants in the community environment
Active Learning
1. Identify a health-related problem associated with some aspect of the environment. It may be a problem in a nearby community, a problem publicized in the media, or a difficulty experienced by a family. Examine the problem using the sample series of critical questions listed in Box 14.5. Without sharing the results, present the problem to the group and ask them to discuss it by responding to the same questions. Were there differences or similarities in the initial results and the group’s answers? On what points did everyone agree? Why? What questions caused the most disagreement? Why? Now repeat the entire activity by involving people other than nursing students in the group discussion. How did this discussion compare with the previous discussion and responses?
2. Attend meetings that hold environmental hazard discussions. If meetings or public forums are not available in the vicinity, write for information about the state’s actions to fight environmental hazards. The reference librarians at colleges or public libraries can suggest ways of contacting sources and will supply addresses. Organizations that are likely to sponsor forums and provide information include those listed in Box 14.3, the Environmental Protection Agency, the National Institute for Occupational Safety and Health, state and municipal agencies for environmental protection and occupational health, environmental caucuses of political parties, the American Public Health Association, the local public health department, farmers’ organizations, and labor unions.
3. This chapter described how to use participatory research as an intervention in dealing with ecological hazards. In a group, brainstorm about possibilities for participatory action research projects in the area. Try to identify examples from a variety of environmental health areas. Be creative in planning. How might a nurse mobilize community support and participation in the research? What groups would be approachable? What critical questions might facilitate dialogue about the problem? What kinds of data could be collected, and how could they be used? How could research results be publicized? What ramifications could the completed study have for community members, other communities in the state, and community health nurses in other locales?
4. Nurses may have to supplement their knowledge of collective strategies by reading books about political action and by learning from community members who are experienced in political organizing. Visit a college or public library to investigate books and journal articles outside the nursing literature. Compile a list of references related to one of these political strategies (e.g., grassroots organizing, legislative lobbying, community education, policy analysis, use of the media, coalition building, citizen surveys, public protest, letter-writing
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campaigns, or consciousness-raising groups). Exchange reference lists with peers to benefit from their efforts. Then choose one or two books of interest and read them.
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Summary This chapter provided a glimpse into the complex world of environmental health from a critical community health nursing perspective. The case study and clinical examples illustrate that nurses must evaluate the broader picture in assessing the environmental health status of communities and the vulnerable aggregates within them. In preventing, minimizing, and resolving environmental health problems, nurses must recognize patterns, detect subtle changes, identify underlying issues, and work collaboratively with a variety of individuals and groups. In the past, environmental threats to health were usually suspected only when other possible causes of illness were ruled out. Nurses can expect this pattern to change dramatically in the twenty-first century as environmental health moves increasingly to the forefront of the public health agenda.
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Evolve Website http://evolve.elsevier.com/Nies/community
• NCLEX Review Questions • Case Studies
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∗ The author would like to acknowledge the contribution of Diane Santa Maria, who wrote this chapter for the previous edition.
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Health in the Global Community Julie Cowan Novak
OUTLINE
Population Characteristics Environmental Factors Patterns of Health and Disease International Agencies and Organizations International Health Care Delivery Systems
The Role of the Community Health Nurse in International Health Care Research in International Health
OBJECTIVES
Upon completion of this chapter, the reader will be able to do the following: 1. Describe globalization and international patterns of health and disease. 2. Discuss the World Health Organization’s concepts of “health for all” and primary health care. 3. Identify international health care organizations and how they collaborate to improve global
nursing and health care. 4. Describe the role of the community or public health nurse in international health. 5. Discuss key elements and effective models for successful international service learning
community health projects, including the International Community Assessment Model, the Furco service learning framework, and the Integrated Model of Sustainability and Innovation
KEY TERMS Bill & Melinda Gates Foundation Carter Center Centers for Disease Control and Prevention Declaration of Alma-Ata globalization health for all by the year 2000 Integrated Model of Sustainability and Innovation International Council of Nurses (ICN) Millennium Development Goals nongovernmental organizations Pan American Health Organization
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primary care primary health care United Nations United Nations International Children’s Emergency Fund (UNICEF) U.S. Department of Health and Human Services World Bank World Health Organization Health care and health care reform are subjects of critical political, social, moral, and ethical debate throughout the world. Human health and its influence on every aspect of life are central to the global agenda. Nurses, as first responders; expert care providers; and leaders in international health care assessment, planning, evaluation, and policy development promote and restore health to individuals, families, and communities across settings and geographic boundaries. Nurses must study models of health promotion, community assessment, community empowerment, service learning, and sustainability to improve health care access and efficient and effective delivery. Community public health nurses must also be aware of forces that threaten health in the global community. Our global society, the Internet, and reduction in travel time provide access that was unimaginable even a decade ago. Globalization—the process of increasing social and economic dependence and integration as capital, goods, persons, concepts, images, ideas, and values cross state boundaries—is inextricably linked to the benefits and challenges of our time.
This chapter highlights population characteristics; international patterns of health and disease; social, cultural, and economic factors; international health care agencies and organizations; health care providers; health care delivery systems and models; and the community public health nurse’s role as a leader in the global community. The chapter presents an International Community Assessment Model (ICAM; see Case Study 15.1 later in chapter); the Furco service learning framework (Furco, 2002) for faculty and student discovery, learning, reflection, engagement, policy, and system design; and the Integrated Model of Sustainability and Innovation (IMSI).
Population characteristics, including patterns of growth, demographics, and pandemics, are among the many health issues that merit attention and study because they have global effects that threaten human life. This chapter explores these issues and other environmental factors, including identified stressors and patterns of health and disease.
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Population Characteristics More than 1 billion people entered the twenty-first century without benefiting from the health care revolution. Population growth presents a threat to the health and the economy of many nations. The exponential nature of world population growth is evident. In 1804, after 2 to 5 million years of human existence, the world population exceeded 1 billion. Between 1804 and 1927, the population reached 2 billion, and between 1927 and 1960, 3 billion. The population soared to 4 billion between 1960 and 1974 and to 5 billion between 1974 and 1987. In 1999, the world population was about 6 billion; by 2016 it had grown to 7.4 billion. The population is projected to reach 8 billion by 2025, 9.8 billion by 2050, and 11.2 billion by 2100 (United Nations, 2017). One concern is that 99% of the growth is expected to occur in resource-poor countries (Population Reference Bureau [PRB], 2015).
In any society, large populations create pressure. For example, feeding a population becomes problematic in developing countries when famine, international trade problems, and war occur. Malnutrition, disease, or death may be the outcome. Pressures from population growth are also felt in industrialized nations. Although food may be plentiful, overcrowding leads to pollution, stress, disease, and violence. Each of these challenges represents a major barrier to economic growth. The poor suffer this burden of excess mortality and morbidity disproportionately. Thus health promotion, effective health care delivery systems, and the enhancement of the environmental infrastructure will address the origins of poverty and ultimately increase productivity and improve quality of life (QOL).
World population distribution is uneven. More than 50% of the population lives in just four countries: China (1.38 billion), India (1.32 billion), the United States (324 million), and Indonesia (261 million) (World Bank, 2016). In 2013, 26.1% of the world’s population consisted of children 0 to 14 and only 8.3% over 65 years of age (World Bank, 2016). In developed countries, life expectancy is increasing; however, in countries severely affected by the HIV/AIDS epidemic, life expectancy dropped to 35 to 40 years, although it has significantly improved over the last decade. Today, a girl born in Zambia can expect to live 64.7 years, whereas a girl born in Japan can expect to live 86.8 years (WHO, 2015.) Of note, 56% of the deaths in Africa are due to communicable, maternal, perinatal or nutritional conditions (WHO, 2015). Malcolm Potts (1994), a world-renowned population theorist, predicted that “the world may end up divided not into political or economic groups but by demographic structure,” in which countries will be classified into slow-growth or fast-growth countries instead of rich or poor countries. This will eventually further divide the rich and poor.
Active Learning
Discuss population characteristics and the threat of population growth to health and health care systems.
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Environmental Factors The relationship between humans and their environment is an important component of individual, family, and global health. The fields of environmental health and sustainable resource development have exploded over the past three decades. Environmental stressors are categorized into five types. First, stressors such as lead poisoning and air pollution directly assault human health. Second, stressors such as the effects of air pollution on products and structures damage society’s goods and services. Third, stressors such as noise and litter affect QOL. Fourth, stressors such as global warming interfere with the ecological balance. Finally, natural disasters, terrorism, and war affect all aspects of life.
Air pollution, water pollution, and land pollution are among the consequences of environmental stressors. For example, 50% of the worldwide air pollution problem is attributable to the chemical carbon monoxide. Other primary pollutants, such as nitrogen monoxide, sulfur oxides, particulate matter, and hydrocarbons, combine with carbon monoxide to create 90% of the world’s pollution. According to joint WHO and United Nations Children’s’ Fund (UNICEF) data, 36% of the world’s population lack access to basic sanitation facilities, and 768 million people regularly go without clean drinking water. Inadequate access to sanitation and clean water contributes to the deaths of 4000 vulnerable children each day. Without clean water sanitation and hygiene, efficient and sustainable development is unattainable (Borgen Project, 2014).
Agricultural, industrial, residential, and commercial wastes increase land pollution. For example, chemical fertilizers have displaced natural fertilizers; synthetic pesticides have displaced natural means of pest control; and petrochemical products, such as detergents, synthetic fiber, and plastics, have replaced soap, cotton, and paper. Disposable goods have replaced reusable goods, resulting in increased waste. Production technologies are contributing to worldwide environmental and ecological stress.
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Patterns of Health and Disease Lifestyles, health and cultural beliefs, infrastructure, economics, and politics affect existing illnesses and society’s commitment to prevention. Disease patterns vary throughout the world; therefore primary causes of death differ in developed and developing countries. Racial, ethnic, and access disparities exist within and between countries. For example, of the 56.4 million deaths worldwide in 2015, 54% were due to ischemic heart disease and stroke. This was followed by pneumonia, chronic obstructive pulmonary disease, lung tracheal and bronchial cancers, and diabetes. Deaths from Alzheimer and other dementias doubled between 2000 and 2015, making dementias the seventh leading cause of death globally. In contrast, deaths from diarrheal diseases halved between 2000 and 2015. Finally, deaths from tuberculosis rounded out the top 10, and notably, HIV/AIDS is no longer among the world’s top 10 causes of death (WHO, 2017). Once plagued with high rates of infectious disease, developed countries significantly reduced such rates through improved sanitation, nutrition, immunization, and improved health care. Most developed countries have a more stable economy and a wide range of industrial and technological development. These countries experience an epidemiological transition. For example, the morbidity and mortality profile of a country changes from a lesser developed one to a developed one. Many developed countries experienced an epidemiological transition from having an infectious disease profile to having a chronic disease profile and are now plagued by chronic diseases such as cardiovascular disease, respiratory disease, and cancer secondary to air pollution and the tobacco use pandemic. This altered profile has created a demographic transition from traditional societies, in which almost everyone is young, to societies with rapidly growing numbers of middle-aged and elderly people.
Among the infectious diseases that contribute to higher mortality rates in developing countries are AIDS, tuberculosis (TB), malaria, hepatitis B, rheumatic heart disease, parasitic infection, and dengue fever. Although these diseases claim the lives of millions, it is estimated they could be reduced by up to 50% through effective public health interventions. It is hoped that many of these diseases could join smallpox as a disease known only to history through the development and implementation of immunization programs. Immunization is the most powerful and cost-effective strategy at our disposal for many infectious diseases. Efforts to reduce the incidence of TB were included in the “Commission for Africa” report, which called for wealthy nations to double their aid to Africa in order to rebuild systems to deliver public health services, provide staff training, develop new medicines, and provide better sexual and reproductive health services. The bacille Calmette-Guérin vaccine series, for example, induces active immunity to TB, but it does not reduce the transmission of infectious types of TB. At least one third of the world’s population harbors the TB pathogen, Mycobacterium tuberculosis. Other WHO programs, including Zika: Then, Today, Tomorrow; Roll Back Malaria; Unite to End TB; HIV/AIDS Control; Tobacco Free Initiative; and Avian Influenza Pandemic Preparedness, target key infectious and chronic disease issues of the twenty-first century.
Although significant progress has been made, AIDS continues to be a global concern. In 2015, 1 in 25 adults was estimated to be living with HIV in sub-Saharan Africa and 36.7 million adults and children were thought to be doing so worldwide. Sadly, the total number of AIDS deaths from 1981 to 2015 exceeds 35 million (WHO, 2015).
Rates of HIV infection vary demographically in different parts of the world. For example, the estimated male-to-female ratio of HIV infections in North America is 5:2, whereas in Africa the ratio is 1:1 (WHO, 2015). Urbanization and within-country migration play a role in the spread of AIDS. For instance, in Rwanda the HIV seroprevalence is 14 to 20 times higher in urban areas than in rural areas. Annually, HIV threatens more lives as more people migrate to the world’s largest cities. In 2015, 50% of the developing world lived in cities. This is an increase from 25% in 1970. Over the past three decades, significant progress has been made in HIV education, prevention, treatment, social policy, and legislation; however, stigma against people living with HIV persists.
Malaria is a life-threatening parasitic disease transmitted by mosquitoes. Today approximately 40% of the world’s population is at risk for malaria; however, because of improved public health efforts, malaria rates fell 21% between 2010 and 2015. Malaria is found throughout the tropical and subtropical regions of the world and causes more than 212 million acute illnesses and at least 429,000 deaths annually (WHO, 2015). Effective low-cost strategies are available for its prevention, treatment, and control, including insecticide-treated nets and new-generation medications.
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Successful administration of antimalarial medications has included a challenge of evolving drug- resistant parasites and the search for new drug formulations. Indeed, resistance to chloroquine has rendered the drug ineffective in many regions (CDC, 2016; Mayo Clinic, 2016). Of note, the first malaria vaccine was approved in 2015 and reports an efficacy of 25% to 50%.
With approximately 5 million deaths annually worldwide due to the use of tobacco, tobacco control is a critical component of the international health care agenda. Including deaths from secondhand smoke, by 2020, an estimated one in seven deaths will be tobacco related. Since 1990, tobacco control and secondhand smoke policies have been implemented at various political levels in the United States and abroad. The magnitude and consequences of the tobacco pandemic were unexpected. Smoking prevention and cessation programs, state and federal mandates, tobacco taxation, the 1998 Tobacco Master Settlement Agreement, antitobacco media campaigns, strict licensing of tobacco retailers, the elimination of tobacco vending machines and point-of-sale advertising, and the elimination of tobacco sales by pharmacies have had an impact on tobacco sales in the United States. Because of health concerns and cost, 29 countries, from Ireland to New Zealand, have developed tobacco-free policies and banned all forms of tobacco advertising, promotion, and sponsorship. Although American adults have enrolled in cessation programs, the tobacco industry has targeted youth and dramatically increased international exports. A global commitment to tobacco control can avert millions of premature deaths in the next half-century.
In 2003, the first global public health treaty was adopted at the World Framework Convention on Tobacco Control. The treaty was designed to reduce tobacco-related deaths and diseases around the world. In 2008, the WHO introduced MPower, which stands for Monitor tobacco use and prevention policies; Protect people from tobacco use; Offer help to quit tobacco use; Warn about the dangers of tobacco; Enforce bans on tobacco advertising, promotion and sponsorship; and Raise taxes on tobacco (WHO, 2018).
The global approach to tobacco control can guide the development of effective interventions based on best evidence and best practice. Countering potential threats to health resulting from economic crises, unhealthful environments, or risky behavior is critical. Promotion of a healthy lifestyle underpins a proactive strategy for risk reduction, tobacco use prevention and cessation, immunization provision, cleaner air and water, adequate sanitation, healthful diets, fitness and exercise programs, and safe transportation.
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International Agencies and Organizations Promoting worldwide health is humankind’s greatest challenge. Several global agencies, such as the WHO, the Pan American Health Organization (PAHO), the United Nations, UNICEF, the World Bank, the Centers for Disease Control (CDC), and nongovernmental organizations such as foundations, play important roles in improving the health of all nations. Founded on April 7, 1948 (now celebrated as World Health Day), the World Health Organization is an international health agency of the United Nations. With six regional offices in the United States, Congo, Denmark, Egypt, India, and the Philippines, the WHO’s primary role is to direct and coordinate international health efforts, disseminate global health standards and guidelines, and help countries address public health concerns within the United Nations system. The main areas of work include health systems, promoting health through the life course, noncommunicable diseases, communicable diseases, corporate services, preparedness, surveillance, and response. The WHO’s goal of “health for all by the year 2000” was framed at the conference in Alma-Ata, the former USSR (now known as Almaty, Kazakhstan), in 1978. The conference defined “health for all” as “the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life” (WHO, 1999, p. 65). Not being met, the target year for achievement was extended first to 2010 and now to 2020.
The Alma-Ata conference on primary health care expressed the need for urgent action by all governments. The WHO’s statement of beliefs, goals, and objectives is outlined in the Declaration of Alma-Ata, which is presented in Box 15.1. The concept of primary health care stresses health as a fundamental human right for individuals, families, and communities; the unacceptability of the gross inequalities and disparities in health status; the importance of community involvement; and the active role of all sectors.
Primary health care seeks to obtain the highest level of health care for all people. The program promotes seven elements of primary health care: health education regarding disease prevention and cure, proper food supply and nutrition, adequate supply of safe drinking water and sanitation, maternal and child health care, immunizations, control of endemic diseases, and the provision of essential drugs. According to the declaration, a primary health care system should provide the entire population with universal coverage; relevant, acceptable, affordable, and effective services; a spectrum of comprehensive services that provide for primary, secondary, and tertiary care and prevention; active community involvement in the planning and delivery of services; and integration of health services with development activities to ensure that complete nutritional, educational, occupational, environmental, and safe housing needs are met.
The year 2010, the tenth anniversary of the adoption of the WHO Global Strategy on Diet, Physical Activity, and Health, presented a time for reflection and evaluation of progress. The WHO created an action plan depicting 2020 targets related to the prevalence of unhealthy diets, inactivity, tobacco use, and alcohol. Soft drink and candy taxes were promoted and have been implemented in some areas.
The Pan American Health Organization (PAHO) is an international public health agency with nearly a century of experience in working to improve the health and living standards of the Americas. It serves as the regional office of WHO and is recognized as part of the United Nations system.
Founded in 1945 after World War II, the United Nations (UN) now comprises 193 member nations committed to world peace and security through international cooperation. The UN attempts to resolve global conflicts and formulates policies that affect all nations. Regardless of size, wealth, or political system, all member nations have an equal vote in the decision-making process. UN decisions seek to reflect world opinion and the moral authority of the community of nations (United Nations, 2018). In 2000, the Millennium Development Goals were developed to coordinate and strengthen global efforts to meet the needs of the poorest of the poor. Governments throughout the world and leading global development agencies agreed on the following goals (United Nations, 2000):
1. Eradicate extreme hunger and poverty. 2. Achieve universal primary education. 3. Promote gender equality and empower women.
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4. Reduce child mortality. 5. Improve maternal health. 6. Combat HIV/AIDS, malaria, and other infectious diseases. 7. Ensure environmental sustainability. 8. Develop global partnerships.
Collaborating with the UN are nongovernmental organizations (NGOs) such as the Carter Center and the Bill & Melinda Gates Foundation. Founded in 1982, the Carter Center is a nonprofit NGO founded by former President Jimmy Carter and First Lady Rosalynn Carter and based in Atlanta, Georgia. The Carter Center’s objectives include (1) to prevent and resolve conflicts, (2) to enhance freedom and democracy, and (3) to improve health and quality of life.
The bond of our common humanity is stronger than the divisiveness of our fears and prejudices. God gives us the capacity for choice. We can choose to alleviate suffering. We can choose to work together for peace. We can make these changes—and we must.
(Jimmy Carter, Nobel Laureate, Carter Center, 2016)
Founded in 2000, the Bill & Melinda Gates Foundation has local, national, and global objectives. Globally, the foundation focuses on reducing hunger and poverty, improving health through harnessing advances in science and technology to save lives in developing countries, and to improve U.S. high school and postsecondary education and support vulnerable children and families (Gates Foundation, 2017). Within Africa, the foundation has had a profound effect on improving access to antiretroviral medications and prevention and treatment for HIV, TB, and malaria.
BOX 15.1 Declaration of Alma-Ata The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth day of September in the year Nineteen hundred and seventy-eight, expressing the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world, hereby makes the following Declaration:
• The Conference strongly reaffirms that health, which is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important worldwide social goal, whose realization requires the action of many other social and economic sectors in addition to the health sector.
• The existing gross inequality in the health status of the people, particularly between developed and developing countries and within countries, is politically, socially, and economically unacceptable and is therefore of common concern to all countries.
• Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of developing and developed countries. The promotion and protection of the health of the people are essential to sustained economic and social development and contribute to a better quality of life and to world peace.
• The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.
• Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. In the coming decades, a main social target of governments, international organizations, and the whole world community should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to attaining this target as part of development in the spirit of social justice.
• Primary health care is essential health care based on practical, scientifically sound, and
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socially acceptable methods and 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 primary health care is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact for individuals, the family, and the community with the national health system bringing health care as close as possible to where people live and work and it constitutes the first element of a continuing health care process.
• Primary health care: • reflects and evolves from the economic conditions and sociocultural and political
characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical, and health services research and public health experience;
• addresses the main health problems in the community, providing promotive, preventive, curative, and rehabilitative services accordingly;
• includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs;
• involves, in addition to health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food industry, education, housing, public works, communication, and other sectors; and demands the coordinated efforts of all those sectors;
• requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation, and control of primary health care making fullest use of local, national, and other available resources; and to this end, develops through appropriate education the ability of communities to participate;
• should be sustained by integrated, functional, and mutually supportive systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need;
• relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries, and community workers, as applicable, and on traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.
• All governments should formulate national policies, strategies, and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors. To this end, it will be necessary to exercise political will, to mobilize the country’s resources, and to use available external resources rationally.
• All countries should cooperate in a spirit of partnership and service to ensure primary health care for all people because the attainment of health by people in any one country directly concerns and benefits every other country. In this context the joint WHO-UNICEF report on primary health care constitutes a solid basis for the further development and operation of primary health care through the world.
• An acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of the world’s resources, a considerable part of which is now spent on armaments and military conflicts. A genuine policy of independence, peace, détente, and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share.
The International Conference on Primary Health Care calls for urgent and effective national and international action to develop and implement primary health care throughout the world and particularly in developing countries in a spirit of technical cooperation and in keeping with a New
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International Economic Order. It urges governments, WHO and UNICEF, and other international organizations, and multilateral and bilateral agencies, nongovernmental organizations, funding agencies, all health workers and the whole world community to support national and international commitment to primary health care and to channel increased technical and financial support to it, particularly in developing countries. The Conference calls on all the to collaborate in introducing, developing and maintaining primary health care in accordance with the spirit and content of this Declaration. Reprinted by permission from Alma-Ata 1978: Primary health care, report of the international conference on primary health care, Alma Ata, USSR, 6–12 September, 1978 (Health for All Series, 1, 2–6), Geneva, 1978, World Health Organization.UNICEF, United Nations International Children’s Emergency Fund; WHO, World Health Organization.
Created in 1946, the United Nations International Children’s Emergency Fund (UNICEF) was founded to assist millions of sick and hungry children in war-ravaged Europe and China. In 1950, the UNICEF mandate was expanded to address the needs of children and women throughout the world. UNICEF works for children’s survival, development, and protection by developing and implementing community-based programs with well-documented achievements in child health, nutrition, education, water, sanitation, and women’s rights. In 1953 the name was shortened to the UN Children’s Fund; however, the UNICEF acronym was retained (WHO, 2015).
Within a dramatically changing world economy, the major goal of the World Bank is to improve the health status of individuals living in areas that lack economic development. The World Bank was established in 1945 to provide low-interest loans and grants to developing countries for education, health initiatives such as education of health care providers, disease prevention and control, infrastructure, agriculture, communications, environmental protection, and economic and institutional development (World Bank, 2017). Since 1970, the World Bank has become more focused on health-related initiatives to promote sustainable economic growth. Projects range from alleviation of poverty to safe water to effective sanitation to affordable housing The largest shareholder countries are the United States (17.25%), Japan (7.42%), China (4.78%), Germany (4.33%), France (4.06%), and the United Kingdom(4.06%) (World Bank, 2016). Since 1963, the World Bank has provided $61 billion in loans and credits, and funds educational, health, nutrition, and population projects (World Bank, 2017).
The Centers for Disease Control and Prevention, located in Atlanta, Georgia, is one of the 13 major operating components of the U.S. Department of Health and Human Services (USDHHS, also called HHS). The principal agency in the U.S. government for protecting the health and safety of all Americans and for providing essential human services, the CDC was founded in 1946 to help control malaria. The agency has remained at the forefront of public health efforts to prevent and control infectious and chronic diseases, injuries, workplace hazards, disabilities, and environmental health threats and to protect the health of international travelers through advisories and immunization and vaccine recommendations. The CDC is globally recognized for conducting research and investigations and for its action-oriented approach. It applies research and findings to improve people’s daily lives and responds to health emergencies—a feature that distinguishes the CDC from many of its peer agencies. The CDC is committed to achieving evidence-based health improvements. The agency is defining specific health-impact goals to prioritize and focus its work and investments, to measure progress, and to work toward attainment of its National Public Health Performance Standards (CDC, 2017). In one example of their efforts, over the past three years the CDC has broadened its focus on the Zika virus. Zika was first discovered in 1947. In 1952 the first human cases were detected. Before 2007, 14 cases were documented. Zika spreads primarily through the bite of an infected mosquito, through sexual contact with an infected partner, and from an infected pregnant woman to her fetus. Most cases of microcephaly, other fetal malformations, and Guillain-Barré syndrome have been reported in Brazil (1046 cases). Cabo Verde, Colombia, French Polynesia, Martinique, and Panama have also reported cases. Other cases have been linked to a stay in Brazil (WHO, 2016).
Founded in 1899 and representing 16 million nurses in 130 national nurses associations, the International Council of Nurses (ICN) works to ensure quality nursing care for all; sound health policies; the advancement of nursing knowledge; and the presence of a respected, competent, and satisfied nursing workforce worldwide. Nursing research, advanced practice registered nursing (APRN), doctoral education, socioeconomic welfare, first responders, disaster preparedness, mass
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casualties, policy, and advocacy have received increased emphasis over the past three decades. The ICN has five core values: visionary leadership, inclusiveness, flexibility, partnership, and achievement. The ICN Code for Nurses is the foundation for ethical nursing practice throughout the world (ICN, 2015). ICN, WHO, the UN, the World Bank, the International Labor Organization, and a wide range of NGOs are attempting to address the global shortage of nurses and other health care providers and complex global health care challenges.
The U.S. Department of Health and Human Services (USDHHS) created a program titled Healthy People that serves as the foundation for efforts throughout the HHS to create a healthier Nation. Healthy People 2020 is based on the accomplishments of the following four previous Healthy People initiatives: (1) 1979 Surgeon General’s Report, Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention; (2) Healthy People 1990: Promoting Health/Preventing Disease: Objectives for the Nation; (3) Healthy People 2000: National Health Promotion and Disease Prevention Objectives; and (4) Healthy People 2010: Objectives for Improving Health. Healthy People provides science-based, 10-year national objectives for improving the health of all Americans. Healthy People 2020 is the result of a multiyear process that reflects input from a diverse group of individuals and organizations. The vision of Healthy People is a society in which all people live long, healthy lives. The overarching goals of Healthy People are to:
• Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; achieve health equity; eliminate disparities; and improve the health of all groups
• Create social and physical environments that promote good health for all • Promote quality of life, healthy development, and healthy behaviors across all life stages
Four foundation health measures that serve as an indicator of progress toward achieving these goals are general health status, health-related QOL and well-being, determinants of health, and disparities.
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International Health Care Delivery Systems In the comparison of health care systems, developed and developing countries can learn much from one another. Although transferring specialized medical technologies from developed to developing countries may not always be appropriate, developing countries are currently learning from health care reform policies and the technological revolution in developed countries. Likewise, developed countries have much to learn about low-technology initiatives, such as oral rehydration therapy for the treatment of diarrhea and the delivery of primary health care as defined by the WHO. Participatory approaches to health care delivery, such as community involvement in health and education and maternal-newborn interventions such as delayed cord clamping, are also essential. This exchange is important given the state of the current health care policy in developed countries, many of which have made health care inaccessible to portions of their general public.
Even in countries with socialized medicine, medical costs rise annually and citizens are faced with paying supplemental medical fees or copayment. There is a need to expand the knowledge base that made the twentieth-century health care revolution possible. In the twenty-first century, it is critical to provide research and development that are relevant to the infectious diseases that overwhelmingly affect the poor. In addition, it is necessary to systematically generate an information base that countries can use to shape the future of their health care systems (WHO, 2015).
The Lalonde Report (1974) on the health of Canadian citizens proposed the “health field concept” as a useful way to consider the determinants of health such as biology, lifestyle, environment, and health services. This report emphasized lifestyle and environment as determinants of health outside the traditional medical sphere. It became the basis for rethinking new paradigms for health care delivery. The report signified the early beginnings of a health care paradigm shift from the traditional medical model to a more holistic system–environment perspective (Boothroyd and Eberle, 1990).
In the 1980s, 1990s, and early 2000s, the rising costs of health care were a major catalyst for change, focusing attention on the need to provide alternative models of care. Over the past three decades, population-based approaches to health promotion and disease prevention and new nursing degrees such as the doctor of nursing practice (DNP) have been developed to address system access, quality, efficiency, effectiveness, and value-based care (Porter, 2016; Wall et al., 2005). Birthing centers, same-day surgery, outpatient and ambulatory services, home care, nurse-managed clinics, and wellness centers provide alternatives to hospital-based care. In each of these areas, the nurse plays a prominent role and has the potential to bring a needed dimension of health promotion and disease prevention to individuals, families, and communities attempting to navigate a complex health care system. An emphasis of the integration of research/discovery, teaching/learning, and practice/service/engagement with nurse-led innovation led to the development of the Integrated Model of Sustainability and Innovation (IMSI) presented in Fig. 15.1.
The key components of the IMSI include effective communication, collaboration, community partnership, and a mosaic of support or a diverse portfolio of funding sources to promote long-term sustainability of local to global community-based projects. Conversely, unsustainable projects lack clear communication, mutual respect, and community and administrative partnership and are often dependent on only one or two sources of support (Novak, 2016).
Nurses must think more broadly about potential collaborators in solving the problems of the health care delivery system. Disciplines such as industrial engineering have much to offer nursing and other health care professionals, because engineering principles are applied to information technology; system design; patient safety; medication administration and reconciliation; simulation; chronic disease management; and hospital and clinic development, design, and renovation. The DNP was developed by nursing leaders and endorsed by the American Association of Colleges of Nursing to reengineer health care (Wall et al., 2005). Since 2000 this revolution in nursing education has grown to more than 289 programs, with many more programs in the developmental phase (AACN, 2016).
In 2015, U.S. expenditures for health care were 17.8% of the gross domestic product (GDP) and are expected to grow to 19.9% GDP by 2025 (Centers for Medicaid and Medicare Services [CMS], 2016). A market-based, developed country such as the United States treats health care as a market commodity; therefore it focuses on curative medicine rather than preventive medicine because
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doing so creates more capital. A market-based health care system could lead to a goal opposite that of health for all. Theoretically, the advent of the managed care system in the United States proposed a capitated model to cut health care costs. The Affordable Care Act was to address the problem of the large number of uninsured Americans, but since its implementation in 2010 is slowly being unraveled by both states and insurers, leaving a gap that will need to be filled. This may be accomplished through changes as moving to a single-payer system, expanding Medicare, removing barriers to APRN practice, and other diverse proposals.
Given the two basic health care systems, market based and population based, and the fact that countries at different levels of development need to learn from one another, it is evident that a single model of health care delivery is not appropriate for every country. For example, in 1985, Cuba was recognized for reaching WHO’s goal of “health for all.” Cuba began to demonstrate to the world that health care could be provided as a basic human right rather than a privilege. In another example, Canada developed a universal health care system, and Canadian community health nurses (CHNs) created innovative models for practice. A 1986 report by the Canadian Minister of National Health and Welfare, entitled Achieving Health for All, offered a health promotion framework that involves fostering public participation in decisions that affect health, strengthening community health service networks with the disadvantaged communities they serve, and coordinating public health policy efforts (Epp, 1986).
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FIG. 15.1 Integrated Model of Sustainability and Innovation (IMSI) Novak JC: Interdisciplinary and interprofessional collaboration. In Dreher HM and Glasgow EMS, editors,
Role development for doctoral advanced nursing practice, New York, 2016, Springer, pp 397–414
The pressure for change provides the opportunity for reform, and the broad goal of health for all should guide this reform. Effective health care delivery systems must increase access and efficiency, improve health status through health promotion and disease prevention, eliminate health disparities, and protect individuals and families from financial loss due to catastrophic illness. One lesson learned from Canada’s experience is that a narrow focus on individual responsibility and biology with acute interventions does not ensure the overall health of a country. Thirty years after the start of the “Health for All” programs, inequity in health in Canada is still linked to socioeconomic status. This suggests that a collective responsibility or population-based focus must be established with less emphasis on the individual. Collective mandates, such as required physical education classes in elementary and middle schools, may be instrumental in changing the social and economic environments in which people live. Health promotion and wellness programs are the first line in reducing disease by providing education on healthy lifestyle (Low, 2008). McKinley argued that treatment of disease is akin to standing downstream and pulling people out of the river after they have fallen in (Low, 2008). In contrast, health promotion stresses prevention, taking into account how social structure produces ill health and the economic framework of a society shapes lifestyle decisions. They are thus analogous to upstream activities by which people are prevented from falling into the river in the first place (Low, 2008).
The Role of the Community Health Nurse in International Health Care
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In a rapidly changing health care environment, the nursing role is becoming less traditional. The traditional structure of provider roles is challenged as professional disciplines are recruited to provide expanded and diverse health care services. The nursing role is reciprocal and interdependent with clients and families, physicians, and other health care professionals. The nurse’s role expectations and societal expectations influence the formation of behavior patterns specific to the professional nursing role. These expectations provide the basis for the role of the community and public health nurse in global health care.
Health Initiatives Taking Place Throughout the World
Home health visit, San Luis, Xochimilco, Mexico. Courtesy Dr. Julie Novak.
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Community home health visits, Cape Town, South Africa. Courtesy Dr. Julie Novak.
Nurse-managed clinics in San Luis, Xochimilco, and Mexico City. Courtesy Dr. Julie Novak.
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Nurse-managed public health clinic, Universidad Nacional Autonomo de Mexico, San Luis, Xochimilco, Mexico.
Courtesy Dr. Julie Novak.
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Cape Town, South Africa, school inauguration and health fair. Courtesy Dr. Julie Novak.
Florence Nightingale was the first nurse to establish international linkages and networks that moved from her own country of England to nurses throughout the world. As the first woman and first nurse inducted into the Royal Statistics Society, she recognized the importance of evidence- based nursing and health care. Every obstacle to health and wellness confronted her. She overcame obstacles systematically, developing the foundation and legacy for modern nursing and for community and public health nursing. Nightingale channeled her energies into all aspects of health from the care of wounded soldiers at Scutari in the Crimea to the broad public policies that affected health in her time.
CHNs seek to ensure the attainment of health for all in a cost-effective, efficient, accessible health care system. They must be involved in research, community assessment, planning, implementation, management, evaluation, health services delivery, disaster preparedness and emergency response, health policy, advocacy, and legislation. Nurses in all countries coordinate their work with other health care personnel, as well as informal and formal community leaders. Health for all requires attitudes, levels of competence, knowledge, and skills that differ substantially from those required in traditional nursing or medicine. The changes in the health environment, such as technological advancements, changes in the morbidity and mortality patterns of the population, and social and political changes, all form the basis for the nursing role and system redesign.
With the development of the nurse practitioner (NP) role over the past 50 years in the United States and over the past 30 years abroad, nurses with advanced degrees and areas of specialization have strengthened the community-based health care system. The development of the DNP degree in the United States and PhDs in nursing in many countries further elevates the knowledge and skill base for nursing’s role in reengineering health care (Wall et al., 2005).
Because primary health care and primary care may be practiced differently in other countries, the NP and the CHN face multiple challenges. Primary health care refers to essential services that support a healthy life. It involves access, availability, service delivery, community participation, and the citizen’s right to health care. In contrast, primary care refers to first-line or point-of-access medical and nursing care controlled by providers and focused on the individual. Primary care may not be the norm, particularly in communities in developing or less developed countries that have overwhelming needs for basic necessities such as safe drinking water, sanitation, and basic hygiene. The needs of the group outweigh the needs of the individual.
Nurses can make a difference in helping solve the existing and emerging health problems in
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countries throughout the world. The advent of technology has enhanced global communication and facilitated travel. It is important that nurses throughout the world understand and learn from one another. With 3.3 million nurses in the United States and over 25 million worldwide, nurses are the largest cadre of health care professional. Community public health nurses improve access to care for the most vulnerable and hard-to-reach groups. The future demands evidence-based education, practice, engagement, service, growth in information technology/health informatics, and local to global health policy and advocacy. Population-based nursing experts are critical to solving the challenges of the fragmented, mismanaged, expensive, ineffective, inefficient health care delivery system that exists in many parts of our global community.
Active Learning
1. Compare and contrast the scientific progress for HIV, TB, and malaria over the past two decades. Discuss methods of prevention.
2. Describe the status of Zika in the Americas. What are the best methods of prevention? 3. Conduct research and compare the rates of infant mortality and life expectancy in Africa,
Mexico, Japan, and the United States. What factors might account for the similarities and differences in rates between the developing and the developed countries?
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Research in International Health Since 1990, international nursing research has focused predominantly on the following areas: (1) multiple aspects of student and faculty educational exchange programs, (2) diverse clinical conditions and experiences, (3) maternal-child health, and (4) the global development of home care or transition from hospital to home.
WHO collaborating centers in nursing and midwifery development provide a framework for research, education, practice, and service delivery partnerships in 44 institutions from the six WHO regions. Purdue University and the University of Virginia, both affiliates of Case Western Reserve University and the University of Mexico WHO Collaborating Centers, contributed to a partnership for educational programming, clinical practice, and research for graduate students in primary health care nursing and community health. Team Reach Out South Africa, one of the resulting programs, is presented in Case Study 15.2.
U.S. models of home health care are developing in many countries. These models provide a variety of services to bridge the gap between the hospital and community-based care. Sources of home care include home visits by nurses from official government public health agencies, nonprofit voluntary agencies, and for-profit home care agencies. Examples of home care services include assistance with activities of daily living, treatment, rehabilitation, transportation, and respite for caregivers. Home care service providers in the United States and abroad face many challenges. Estimating financial implications and calculating potential caseloads are complex factors in the design of effective delivery systems.
Case Study Application of the International Community Assessment A Collaborative Model for Community Assessment, Education, and Health Care Delivery In Mexico and South Africa, the provision of equitable health care services to populations that are geographically and educationally disparate is both economically and logistically challenging. Both countries are further challenged by a lack of infrastructure necessary for health promotion, protection, and maintenance. South Africa is challenged by extreme poverty and staggering rates of HIV and TB. In planning interventions, nurses need a globally diverse assessment tool and methodology to empower communities to achieve health care goals and reduce health care costs. U.S. nursing students gaining international health care experience in a community in rural Mexico and urban South Africa can implement the International Community Assessment Model (ICAM) (Fig. 15.2) before planning targeted programs with local community leaders. The ICAM, tested in rural Mexico and as a component of Team Reach Out South Africa (see Case Study 15.2), is part of an ongoing project. U.S. nursing students compare and contrast practices in various countries using the ICAM and Furco Service Learning Model (Fig. 15.3). Service learning is discipline specific, experiential, and embedded in course objectives and relies heavily on reflection and journaling. The Model Community Empowerment A critical element of designing and implementing global health care projects is community empowerment. If a community is not fully engaged, the project will be unsustainable. In community empowerment, the community identifies its problems and a plan of action, and nurses remain as partners, consultants, and team members. Working with communities is a dance, and the community leads the dance. This mutually respectful, shared decision-making process helps the community develop interventions that are culturally acceptable, breaking down cultural barriers. In developing countries, health promotion programs that do not involve community participation and education often fail after the so-called experts leave the community.
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FIG. 15.2 International Community Assessment Model. Courtesy J. C. Novak.
Assessment During the assessment phase, the nurse identifies key influential community members and leaders and encourages them to join a board of community partners with the goal of assessing community health. The community partners may choose to use the ICAM for the purpose of providing a globally diverse assessment framework and for data gathering. Assessment of community culture helps identify potential cultural barriers to nursing interventions. The center of the model assesses the heart of the community’s culture by identifying individual, family, and community characteristics, including their history, demographics, values, beliefs, rituals, and the effect of these characteristics on social and economic conditions.
The ICAM assesses the following:
Recreation: Community cardiovascular fitness; stress management; energy renewal; and relaxation through sports, hobbies, games, fun run walks, 5Ks, yoga, and tai chi.
Perceptions: Community perceptions of health, including community members’ physical, social, and mental balance and lifestyle choices.
Spirituality: The community’s religious beliefs and practices. Support systems: Family support systems, including parental support of children and adult
children, adult children’s support of their parents, and support among extended family members. (Family is defined as a group of individuals who have common experiences and goals and are often linked together by genetics, marriage, living situation, or a common emotional bond.)
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The physical environment encompasses the community’s infrastructure, including homes, water sources, waste disposal sites, roadways, buildings for businesses and shops, factories, power lines, and considerations related to occupational health (e.g., nurses must seek new collaborators in solving the complex problems of the health care delivery system).
The ICAM also assesses the following:
Education: The concept of education reflects the community’s knowledge, skills, level of schooling or training, and literacy rate.
Transportation: Defined as how community members travel from point A to point B. Safety: Evaluation of the community’s safety includes examining both the potential dangers in
the community that could lead to injury or death and the safety measures and plans developed by the community to prevent these problems.
Government and politics: How the community is governed or ruled. Economy: The efficacy of economic resources is analyzed in terms of production, dispersal,
and expenditure of resources.
FIG. 15.3 Distinction among service programs. Furco A: Service learning: A balanced approach to experiential education. In Expanding
boundaries: Service and learning, Washington, DC, 1996, Corporation for National Service, pp 2–6.
Communication: Communication is evaluated by examining face-to-face and community- wide information exchange through speech, body language, writing, and drawings. Key components of the community’s communication are native languages and forms of communication, such as letters, telephone, computer networks, electronic health records, the Internet, fax machines, television, billboards, signs, magazines, newspapers, and telegrams.
Access: Electricity, public sanitation, public water systems, radio, television, technology, computers, the Internet, fax machines, libraries, industrial machinery, and agricultural practices must be examined.
The ICAM encourages the partners to examine all the public health threats to the community and additional barriers to an effective cultural awareness, sensitivity, proficiency, and humility. It also reflects the importance of assessing the country of origin and global effects on the community. When assessing a community, the nurse must consider the external factors affecting the community. For example, the economy depends on vendors and international purchasing of their main exports.
After the community assessment, the collaborative team should develop an educational program that identifies potential challenges to an educational program or intervention. This program should motivate community partners to identify these problems and then search for effective solutions. As partners become further aware of the health care barriers or health hazards, resources should be provided that will aid in their response.
Next, partners should be assisted in completing a survey and offering focus groups related to needs assessment and attitudes.
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The nursing team, local experts, key community informants, and partners need to establish the root cause of problems in a collaborative manner in order to develop effective interventions. Planning and Intervention The board and community identify central issues, challenges, and barriers. The board then enters the planning phase of the intervention campaign. Community board members can collaborate with environmental experts and the nurse to identify individual, family, and community educational and service learning goals, strategies, and interventions based on best evidence and practice.
The collaborative team subsequently analyzes possible interventions. This body of knowledge allows the community partners to determine which, if any, of the proposed interventions would be relevant and appropriate for their community. In addition, they may be able to apply these ideas in creating their own interventions. When the community partners have selected or developed an intervention for their project, they can be encouraged to create strategies to educate the community. Implementation Before the project is implemented, the outcome of the community-needs assessment must be clarified. The community must be given the opportunity to provide feedback to all collaborators regarding proposed interventions. The partners must be willing to compromise to meet the community’s needs. After community-wide education has occurred and necessary consensus and compromise have been achieved, the project can be implemented. At this point, the community members understand ways to sustain the project. Once the implementation is completed, evaluation of the project can begin to ensure that the goals and objectives of the board and the community are met. Evaluation The collaborative team should evaluate the project in a formative and summative manner. In addition, the nurse should conduct community surveys to determine whether members continue to recognize the need to maintain the project; to provide feedback related to progress, facilitators, and barriers; and to identify necessary modifications or innovations. Applications The ICAM was tested in rural Mexico and South Africa as part of the Team Reach Out project. The targeted communities have a high incidence of poverty. As a result, 80% of the communities reside in crowded living conditions. Many factors in the community pose serious health threats, including infectious disease, chronic conditions, tobacco use, secondhand smoke, farm chemicals, and air pollution. Field workers are often powerless and have minimal recourse when exposed to unhealthy environmental contaminants causing increased morbidity and mortality.
In rural Mexico, the top causes of mortality in the communities are cardiac disorders, diabetes, automobile accidents, and dramatic increases in violence, particularly in urban Mexico and border communities. The leading causes of morbidity are respiratory infections, diabetes, hypertension, and gastrointestinal illnesses. The community’s high rate of gastrointestinal illness is related to limited access to potable water. The community historians, community political leaders, key employers, full-time staff at nurse-run public health clinics, local community health faculty, and the pasantes (nursing graduates who have completed 1 year of community service at nurse-run clinics and public health agencies) are critical to the success of the project.
A multidisciplinary team of key influential community members, environmental experts, and nurses will further assess the community using the ICAM model. The goal of this assessment is to assist the community members in further diagnosing the community’s health care needs and other issues as they are identified. Nurses collaborate with community partners to develop culturally proficient interventions. After the interventions are developed, the local partners, clinic staff, and pasantes continue to evaluate the effectiveness of these interventions, promoting a sense of ownership of the project in the community and helping ensure improvements in health care long after the multidisciplinary team leaves the community (see Case Study 15.2).
Case Study Application of the International Community Assessment
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Team Reach Out South Africa Team Reach Out started as a student-initiated service learning project with the goal of providing ongoing assistance to the victims of Hurricane Katrina. Four years after Hurricane Katrina, Team Reach Out refocused its efforts in Cape Town, South Africa. Four senior nursing students and one premed science student integrated their leadership skills with the application of public health knowledge, compassion, and concern as they worked in partnership with several international health agencies. This case reviews the service learning framework (Furco, 1996, course planning, implementation, and evaluation.
Service learning is a reciprocal partnership that bridges the gap between professional education and society. It is a powerful teaching and learning strategy that engages students in learning while helping communities help themselves (Poirrier, 2001). Service learning provides an experiential, collaborative, discipline-based relationship between students and community members for a reciprocal learning experience and allows an opportunity for reflection. Service learning sets the stage for a lifelong commitment to the development of civic duty, social awareness, and engagement while providing unique learning experiences that focus on building citizenship, cultural diversity, community partnerships, knowledge of community resources, critical thinking skills, and mutual respect .
Both students and the community benefit from service learning. Students benefit from the exposure to real-life dilemmas and firsthand experience of joint team efforts. Communities benefit from the knowledge and creativity available from academia (Richards et al., 2009).
The faculty team leader/advisor completed an exploratory trip to Johannesburg and Cape Town, South Africa, meeting with prospective community partners. Each of the local health care leaders invited the development of a collaboration. Because of the richness of each setting and the overwhelming need for human and financial resources, the choice was extremely difficult. Cape Town was selected as the city site through a comprehensive assessment using the ICAM (Richards, et al., 2009; Richards and Novak, 2010). Health care and educational partners within the city were selected in collaboration with the school nurse, faculty, and staff of Christel House Academy in Cape Town. Subsequently, students from the School of Nursing and College of Science were invited to apply through notification in their respective student newsletters. Selection was based on the clarity of the student’s goals and understanding of cultural humility and service learning. After selection, each student wrote an additional travel grant application to the university’s Office of Engagement. Following is a description of the partners involved in this project and the experiences each provided. Partners Christel House International is a 501(c)(3) public charity that operates learning centers in impoverished neighborhoods with the goal of creating sustainable social and educational impact, breaking the cycle of poverty through a comprehensive holistic approach that transforms the child, family, and community. Between 1999 and 2015, Christel House opened nine learning centers in Mexico, South Africa, India, Venezuela, and the United States. Currently, Christel House serves more than 5000 students, their families, and communities. Christel House K-12 Academy in Cape Town helps children around the world break the cycle of poverty, realize their hopes and dreams, and become self-sufficient, contributing members of society. The academy invited the students to participate in the inaugural celebration of a new school facility and campus. Weekend cultural experiences included a trip to Robben Island, an ecological and historical heritage site where Nelson Mandela was imprisoned from 1963 to 1990; Table Mountain, a protected natural habitat with 1500 plant species; and a game and nature preserve.
The Themba Care Orphanage provides a safe and compassionate environment for approximately 20 children who are HIV positive. In the majority of cases their parents have died of AIDS; however, some children are placed in the setting by their parents to avoid stigma within their respective communities. The orphanage is run by an executive director, two registered nurses/“sisters,” a teacher, a staff of five nursing assistants, and local volunteers. Team Reach Out worked with volunteers from three different U.S. universities on site. In addition to one older child, 95% of the children at the orphanage ranged in age from 18 months to 4 years. Students were able to complete Denver Developmental Screenings and health assessments and to work with the sisters in medication dispensation and reconciliation. The majority of the children demonstrated global developmental delay on the screenings. Students played with, fed, and cared for the children in this warm, caring, inviting preschool environment. The students reflected on their difficulty in
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saying goodbye to the children. The Gatesville Medical Center is a multispecialty large private Indian hospital located in Cape
Town. Team Reach Out students were able to care for pediatric patients and effectively compare and contrast this South African state-of-the-art private hospital with other health care settings. Diagnoses included respiratory syncytial virus, pneumonia, asthma, gastroenteritis/dehydration, and meningitis.
The Tafelsig Community Health Center provides care to approximately 9000 low-income patients each month. Patients receive health promotion visits throughout the lifespan. Tafelsig treats one of the largest TB and HIV patient populations in Cape Town. Students were able to complete health assessments and immunize patients under the supervision of South African RN specialty clinic coordinators and their faculty advisor.
The students’ week of clinical experiences culminated with a presentation of a health fair at the Christel House Academy. The health fair focused on school and family health promotion; prenatal and newborn care and parenting; prevention of TB, HIV, and malaria; health care careers; science experiments (with the premed student); and health screenings, including measurements of height, weight, blood pressure, glucose, and cholesterol. The academy ran special bus routes from the school to and from area informal settlements to bring parents and other community members to the school health fair. The students worked with the WHO, the CDC, Johnson & Johnson, and local Cape Town universities to ensure culturally appropriate materials for the health fair. The Christel House Academy Health Fair was attended by 600 children and 200 parents. Student Responses Team Reach Out South Africa students provided poignant and insightful reflections about their experiences. Community partners indicated that the students were very professional and were able to provide much-needed support. Summary Students felt strongly that service learning enhanced their community public health experience while building relationships with community service organizations. Students reported encountering minimal barriers to the implementation of this project and also were not reluctant to participate in these activities. Students also agreed that they would continue to participate in service-learning activities in the near future. Table 15.1 includes more student reflections on their experiences. Table 15.2 and Box 15.2 highlight students’ feelings about service learning in general (Richards and Novak, 2010).
TABLE 15.1
Student Reflections on Team Reach Out Projects
Reflections from Team Reach Out Biloxi “It was a wonderful experience to be able to meet so many interesting people and use our knowledge of health care to provide support to
this community.” “Every student was thinking about their neighbor in terms of their needs.” “Everyone expressed appreciation and hope.” “My most meaningful memory is the incredible impression each patient made on me. It was amazing to me that through all of the tragedy,
devastation, and loss, their hospitality and gentleness was still very much alive.” Reflections from Team Reach Out South Africa “We were so fortunate to see the health care extremes, from the poorest of the poor clinics to the private hospitals. It was such a diverse
spectrum to work in.” “Traveling to South Africa was an eye-opening experience in so many ways. I’ll never forget the striking beauty of the country contrasted
with the devastating poverty that runs rampant; I was both impressed and surprised by the resourcefulness of their health care system.” “The trip was incredible. So much poverty and beauty and riches in the same area. The people touched my life and I hope that I did the
same for some of them.”
TABLE 15.2
Student and Provider Responses to Service Learning Questionnaire
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BOX 15.2 Student Responses: What is the Definition of Service Learning? Service learning is:
• Providing services to those in need while at the same time learning in your field of interest and having the ability to work with those less fortunate. It is a hands-on learning experience that, for me, was life changing and eye opening.
• Volunteering with doing something that you are in the field of doing or obtaining a degree in. • A unique way of learning in and about a community and providing services for the
betterment of a community. Service projects provide communities with people who are able to use their time, resources, and expertise in order to improve or help the community in which they are serving. At the same time, the people involved in the service project are learning from their experiences with the project.
• A volunteering project that is done to help the community in some positive way while the volunteer has the opportunity to broaden their own horizons by learning something new.
• Utilizing skills and knowledge acquired in the classroom as a means to enhance the community.
Modified from Richards E, Novak J: From Biloxi to Cape Town: Curricular integration of service learning. Journal of Community Health Nursing, 27(1):46–50, 2010.
Active Learning
1. Compare population-focused nursing in a developing country with community health nursing in the community. How are they the same, and how do they differ?
2. Test the ICAM in a community. Evaluate its effectiveness. 3. Describe the Furco Service Learning Model and its potential application in local to global
projects in your university. 4. Describe the key elements of an effective health care delivery system. Will the focus of future
health care services reflect downstream thinking, or will the team create innovative, sustainable models of health promotion, disease prevention, and early intervention?
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Summary Community public health nurses face many exciting challenges in health care reform and the design of effective systems of health care delivery. These include being responsive to emerging needs and health issues in the population, developing multidisciplinary practice models that adhere to the principles of primary health care in the context of a reengineered health care system, and mobilizing research dissemination and practice implementation strategies to ensure evidence-based practice as the norm rather than the exception. Using evidence-based models as a framework for local to global community public health partnerships and projects should be tested and evaluated. There is still much to be done to meet the challenge of WHO’s goal of “health for all.” Studying the progress achieved in other countries is critical; however, success will ultimately depend on societal commitment to addressing complex issues of poverty, disparity, and health care inaccessibility.
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Evolve Website http://evolve.elsevier.com/Nies/community
• NCLEX Review Questions • Case Studies
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us>. Epp J. Achieving health for all: a framework for health promotion. Ottawa: Health and Welfare
Canada; 1986. Furco A. Service learning: a balanced approach to experiential
education. In: Raybuck J, Taylor B, eds. Expanding boundaries: serving and learning. Washington, DC: Corporation for National Service; 1996 Accessed from:. https://digitalcommons.unomaha.edu/cgi/viewcontent.cgi?article=1104&context=slceslgen.
Gates Foundation. who we are. www.gates foundation.org, 2017. International Council of Nurses. About ICN Available from:. <www.icn.ch/abouticn.htm>, 2016. Lalonde M. A new perspective on the health of Canadians. Ottawa: Minister of Supply and
Services; 1974. Low J, Theriault L. Health promotion policy in Canada: lessons forgotten, lessons still to
learn. Health Promot Int. 2008;23(2):200–206. Novak J.C. Interdisciplinary and interprofessional collaboration. In: Dreyer and Glasgow: Role
development for doctoral advanced practice nursing. New York: Springer; 2016. Population Reference Bureau. World population data sheet Available
from:. http://www.prb.org/Publications/Datasheets/201506/201506WorldPopulationDataSheet.aspx Poirrier G: Service learning: curricular applications in nursing, New York, 2001, National League for
Nursing. Porter M.E. Value based healthcare delivery. Harvard University School of Business; 2016. Potts M. Common sense prevailing at population conference. Lancet. 1994;344:809. Richards E, Novak J. From Biloxi to Cape Town: curricular integration of service learning. J
Community Health Nurs. 2010;27(1):46–50. Richards E, Novak J, Davis L. Disaster response after Hurricane Katrina: a model for an academic-
community partnership in Mississippi. J Community Health Nurs. 2009;26(3):114–120. United Nations. News: World Population. 2017 Available
from. https://www.un.org/development/desa/en/news/population/world-population-prospects- 2017.html.
United Nations. Resolution adopted by the general assembly: United Nations millennium declaration. New York: The Author; 2000.
United Nations. About the UN; 2018 Available from:. http://www.un.org/en/about- un/index.html, 2018.
Wall B, Novak J, Wilkerson S. The doctor of nursing practice: reengineering healthcare. J Nurs Educ. 2005;44(9):396–403.
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sheet. Geneva: Author; 2005. <www.who.int/malaria/docs/Basicfacts.pdf>. World Health Organization. Unite to End TB. Author; 2016. World Health Organization. Tobacco free initiative. 2018 Available
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from. <http://www.who.int/tobacco/en/>. World Health Organization. Global health atlas database. Author; 2015. World Health Organization. The top 10 causes of death worldwide. Author; 2017.
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UNIT 4 Aggregates in the Community
OUTLINE
16. Child and Adolescent Health
17. Women’s Health
18. Men’s Health
19. Senior Health
20. Family Health
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Child and Adolescent Health
Melissa Domingeaux Ethington∗
OUTLINE
Issues of Pregnancy and Infancy Infant Mortality Preterm Birth and Low Birth Weight Preconception Health Prenatal Care Prenatal Substance Use Breast-feeding Sudden Unexplained Infant Death
Childhood Health Issues Accidental Injuries Unhealthy Weight Immunization Environmental Concerns Child Maltreatment Children With Special Health Care Needs
Adolescent Health Issues Sexual Risk Behavior Violence Tobacco, Alcohol, and Drug Use
Factors Affecting Child and Adolescent Health Poverty Racial and Ethnic Disparities Health Care Use
Strategies to Improve Child and Adolescent Health Monitoring and Tracking Healthy People 2020: Child and Adolescent Health Health Promotion and Disease Prevention
Public Health Programs Targeted to Children and Adolescents Health Care Coverage Programs Direct Health Care Delivery Programs
Sharing Responsibility for Improving Child and Adolescent Health Parents’ Role Community’s Role Employer’s Role Government’s Role Community/Public Health Nurse’s Role
Legal and Ethical Issues in Child and Adolescent Health
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Ethical Issues
OBJECTIVES
Upon completion of this chapter, the reader will be able to do the following: 1. Identify major indicators of child and adolescent health status. 2. Describe social determinants of child and adolescent health. 3. Discuss the individual and societal costs of poor child health status. 4. Discuss public programs and prevention strategies targeted to children’s health. 5. Apply knowledge of child and adolescent health needs in planning appropriate, comprehensive
care at the individual, family, and community levels.
KEY TERMS child maltreatment childbirth educator childhood immunization Children’s Health Insurance Program (CHIP) Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) fetal alcohol spectrum disorders (FASD) infant mortality lactation consultant late preterm birth lead poisoning low birth weight Medicaid preconception health prenatal care preterm birth Safe to Sleep Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) teen childbearing teen dating violence WIC A nation’s destiny lies with the health, education, and well-being of its children. The United States has made tremendous progress over the past century toward improving children’s lives. Advancements in public health measures—such as sanitation, infectious disease control, environmental regulation, health screening, and education—and remarkable strides in medical care have all contributed to the good health status that most children enjoy. However, these improvements have not equally benefited children of all races and ethnic groups, children at all income levels, or children in all geographic areas of the country. For example, significant disparities persist in the health status of white children versus children of color. Children living in suburban areas and most outer urban areas experience access to health care services superior to that of children living in rural areas and inner cities, especially if they are poor.
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Although most of the nation’s children are healthy and succeed in school, many are not enjoying optimal health and well-being and are not reaching their full potential as contributing members of society. Despite improvements, the mortality and morbidity rates for U.S. children in all age groups are unacceptably high. Consider the following facts (Jiang, Granja, and Koball, 2017; Khan et al., 2016; Kochanek et al., 2016):
• Each year about 23,000 to 25,000 infants die before reaching their first birthday. Black infants are more than twice as likely to die as white infants.
• Nearly one-half million babies are born prematurely each year. Prematurity is the leading cause of infant death and long-term neurological disabilities.
• Twenty-two percent of children aged 0 to 18 years live in poverty. • Every day, five children die as the result of child abuse; most are younger than 4 years. • More than 249,000 girls aged 15 to 19 years give birth each year. • An average of 22% of twelfth graders are cigarette smokers and nearly 28% smoke
marijuana. • Well over half of children currently residing in the United States will be affected by
violence, crime, abuse, or psychological trauma this year.
The health of a child has long-term implications. Health habits adopted by children and youth will profoundly influence their potential to lead healthy, productive lives. The physical and emotional health experienced by a child plays a pivotal role in his or her overall development and the well-being of the entire family. Children who go to school sick or hungry, who cannot see well enough to read, who cannot hear the teacher, who have learning disabilities, who are troubled by abusive parents or disruptive living circumstances, or who fear for their safety at home or in school often do not perform on the level of their counterparts who are healthy, well nourished, well cared for at home, and safe and secure in their world. From fetal life onward, the health and well-being of individuals has a substantial impact on their futures.
In 2015 there were 73.7 million U.S. children younger than 18 years. Children represent about 24% of the country’s population, down from a peak of 36% at the end of the mid-1960s baby boom. The birth rate for children of all races has declined in recent years, and the racial and ethnic diversity of children is changing rapidly. For example, by 2050, Hispanic children are expected to account for 32% of the population, up from 25% in 2015. The percentage of children who are Hispanic has increased faster than that of any other racial or ethnic group (Federal Interagency Forum on Child and Family Statistics, 2016) (Fig. 16.1).
Children are a dependent population and rely primarily on parents or other adults to protect and promote their health and well-being. Community health nurses can learn more about this important population group and the positive and negative factors that influence their health. Nurses can use this information to help improve the chances that children will grow up to be healthy, both physically and emotionally.
This chapter focuses on the health status of children and adolescents and the medical, socioeconomic, cultural, environmental, educational, safety, and public health factors that community health nurses must address to improve child and adolescent health. The chapter also discusses the individual and societal costs of poor child health, public programs targeted to children’s health, and strategies to improve child and adolescent health at the individual, family, and community levels.
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Issues of Pregnancy and Infancy The health of the mother before, during, and after pregnancy has a direct impact on the health and well-being of her child. The conditions that surround a child’s fetal development and early years shape his or her life. Adapting healthy lifestyles and obtaining regular medical care before becoming pregnant can help ensure a healthy pregnancy. Unfortunately, many women face barriers to good health throughout their lives, including racism, violence, poverty, and lack of access to health care. A comprehensive approach that helps women identify and treat potential risks and overcome barriers to good health before, between, and beyond their pregnancies will help protect and promote the health of women and children and can help ensure the health of future generations (Moos, 2010; Moos et al., 2010). Consider the following findings:
FIG. 16.1 Percentage distribution of U.S. children by race/ethnicity, 2016. From Federal Interagency Forum on Child and Family Statistics: America’s children in brief: Key national
indicators of well-being, 2016. Retrieved from https://www.childstats.gov/pdf/ac2016/ac_16.pdf
1. Women who are not in optimal health before becoming pregnant are at increased risk for poor pregnancy outcomes.
2. Babies whose mothers have uncontrolled medical conditions, such as infections, diabetes, hypertension, and obesity, are more likely to be born at low birth weights and with serious medical conditions.
3. A fetus exposed to maternal drug, alcohol, or tobacco exposure or poor nutrition is more likely to have chronic conditions that affect health and well-being.
4. Infants exposed to unsafe environmental conditions, such as secondhand smoke and lead- based paint, are more likely to have chronic conditions throughout childhood and, in some cases, through adolescence and adulthood.
5. Children who do not receive preventive health care and do not obtain all necessary immunizations are more likely to have preventable diseases or chronic conditions that could have been prevented or minimized and controlled.
Infant Mortality Infant mortality, the deaths of children during the first year of life, is a critical gauge of children’s health status. It is an important marker because it is related to several factors, including maternal health, medical care quality and access, socioeconomic conditions, and public health practices. Infant mortality reflects the health and welfare of an entire community and is used as a broad indicator of health care and health status. Box 16.1 lists some terms and definitions associated with infant health and mortality. The five leading causes of infant death are congenital defects; disorders related to short gestation or low birth weight; maternal complications of pregnancy; sudden infant death syndrome (SIDS; see later in the chapter); and accidents such as suffocation. These five factors
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account for close to 60% of all infant deaths. The order of the top five leading causes changed slightly from 2012 to 2013. In 2012, SIDS was the third leading cause, followed by maternal complications, whereas in 2013, maternal complications was third and SIDS was fourth (Mathews et al., 2015). Box 16.2 lists sources of vital statistics birth data.
BOX 16.1 Infant Health Definitions
Infant death: Death of an infant before his or her first birthday. Infant mortality rate: Number of infant deaths per 1000 live births. Preterm birth: Birth before 37 completed weeks of gestation. Very preterm birth: Birth before 32 completed weeks of gestation. Late preterm birth: Birth from 34 to 36 completed weeks of gestation. Term birth: Birth from 37 to 41 completed weeks of gestation.
From MacDorman MF, Mathews TJ: Understanding racial and ethnic disparities in U.S. infant mortality rates, NCHS data brief, no 74. Hyattsville, MD, 2011, National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db74.pdf
BOX 16.2 Sources of Vital Statistics Data for Children In the United States, laws require birth certificates to be completed for all babies born. Information concerning an infant’s birth, including the total number of the mother’s prenatal care visits; the mother’s and father’s ages and race; mother’s marital status and education; and the infant’s weight, gestational age, and birth date, appears on a baby’s birth certificate.
Information concerning an infant’s death, such as the cause(s), date, and other details, appears on the death certificate. In each state, the vital statistics office in the state health department stores these certificates. This agency collects and regularly reports the aggregated data and forwards them to the National Center for Health Statistics.
The National Center for Health Statistics collects, analyzes, and publishes numerous reports on the health and well-being of the nation’s infants. These data sources are very important in tracking the health of infants as well as of other population groups; they help determine necessary interventions from various perspectives (e.g., clinical, public health, public policy, and environmental). From National Institute of Child Health & Human Development: Safe to sleep public education campaign, 2012. https://www1.nichd.nih.gov/ sts/Pages/default.aspx
Surprisingly, the United States ranks a dismal nineteenth in infant mortality, behind most other industrialized nations, including South Korea, Sweden, Spain, Israel, Italy, France, and Australia (Table 16.1). Fifty years ago, the United States ranked twelfth (Organisation for Economic Co- operation and Development [OECD], 2012). The gap in infant mortality between the United States and other nations has occurred in spite of the United States’ comparatively high per capita spending on health care and technological advancements.
Despite a poor ranking among other nations in the world, the infant mortality rate in the United States has declined every year since 1940 with the exception of 2002 (Fig. 16.2). The 2016 figure, 5.8 deaths per 1000 live births (Central Intelligence Agency, 2017), was the lowest infant mortality rate ever recorded in this country. This drop can be attributed largely to public health measures and improved standard of living (e.g., better sanitation, a clean milk supply, immunizations against deadly childhood diseases, the increased availability of nutritious food, and enhanced access to maternal health care). Technological advances in neonatal care—for example, the introduction of synthetic lung surfactant—have also contributed to reductions in infant mortality.
TABLE 16.1
International Comparisons of Infant Mortality Rates∗ for Selected Countries and Territories (2015)
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∗ Infant mortality rate represents infant deaths per 1000 live births.
From Organisation for Economic Co-operation and Development: Health: Key tables from OECD, No. 14: Infant mortality, 2015. Retrieved from https://data.oecd.org/healthstat/infant-mortality-rates.htm; Centers for Disease Control and Prevention: Deaths final data 2015, 2016. Retrieved from https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_04.pdf
Declines in infant mortality have stagnated during the past decade, however, and the gap between black and white infant mortality rates remains stubbornly high, with black infants dying at a rate of approximately 2.2 times higher than that of white infants. Identifying and remedying the causes of higher infant mortality rates among certain population subgroups remains a vexing societal problem that must be addressed (Fig. 16.3).
The first year of life is the most hazardous a person faces until he or she reaches 65 years.
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Therefore it is particularly important for women to be as healthy as possible before becoming pregnant and to receive prenatal care and adopt healthy lifestyle choices, and for infants to receive primary health care to maintain health and prevent or minimize serious, long-lasting health problems.
Preterm Birth and Low Birth Weight Preterm birth (birth before 37 completed weeks of gestation) and low birth weight (weighing less than 5.5 pounds at birth) are the most important predictors of infant health. In 2014, 9.57% of babies in the United States were born preterm; the percentage of low-birth-weight babies was essentially unchanged in 2014 over the previous year. Black women are more likely than white women to have a preterm birth and about twice as likely to have babies born at low birth weight (Hamilton et al., 2017).
Infants born preterm or at a low birth weight have a far greater risk of death as well as of mental and physical disabilities such as cerebral palsy, visual problems such as retinopathy of prematurity, feeding problems, and hearing loss than infants born at term with normal weight. Even babies born late preterm (34 to 36 completed weeks of gestation) carry a risk for physical problems and developmental delay that is much higher than for babies born at full term. Important growth and development occur even in the last few days of a pregnancy. Factors associated with preterm birth and low birth weight include the following:
1. Minority status 2. Chronic stress 3. Maternal age less than 17 years or more than 35 years 4. Chronic health problems such as diabetes mellitus, hypertension, and some infections 5. Lack of prenatal care 6. Multiple births 7. Certain problems with the uterus or cervix 8. Low socioeconomic status 9. Unhealthy maternal habits (e.g., poor nutrition, obesity, alcohol and drug use, and cigarette
smoking) 10. Induced labor before 39 weeks of pregnancy without a medical indication 11. Elective cesarean birth
One reason that infant mortality has declined so slowly in recent years is that the preterm rate rose very quickly from 1990 to 2006. A portion of this rise was due to increases in multiple births, which in turn was due in part to childbearing in later years, which increases the likelihood of multiple conceptions. Also there was an increase in the rate of multiples that resulted from assisted reproductive technology. Yet the rate of preterm births among singleton births also rose during this time. Further, medical management of pregnancy has increased the numbers of labor inductions and elective cesarean births and has helped push the rate of late preterm births upward (Martin et al., 2017). Success stories of tiny survivors are sensationalized in the news, but the long-term consequences of babies born even a few weeks early are not well publicized. Consequences of preterm and late preterm birth can be long-lasting and costly (Engle and Kominiarek, 2008; Morse et al., 2009; Petrini et al., 2009; Ramachandrappa and Jain, 2009). Because late preterm births account for the majority of preterm births, it is imperative that all possible measures are taken to decrease elective births before 39 weeks of gestation (Oshiro et al., 2009).
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FIG. 16.2 Infant, neonatal, and postneonatal mortality rates: United States, 1940–2014. Rates are infant (under 1 year), neonatal (under 28 days), and postneonatal (28 days–11 months) deaths per 1000 live
births in specified group. From National Center for Health Statistics: Deaths: Final data for 2014. National Vital Statistics Report,
65[4], 2016. Retrieved from https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_04.pdf
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FIG. 16.3 Infant mortality rates by race and ethnicity of mother, 2005–2014. From National Center for Health Statistics: Trends in infant mortality in the United States, 2005–2014,
2017. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db279.htm
Preventing the occurrence of prematurity and low birth weight is a high priority for clinical and public health research and policy. Nurses can play important roles in preventing prematurity through the provision of evidence-based primary care, research, screening, counseling, education, advocacy, referral, and implementation of interventions to reduce risk among target population groups.
Preconception Health Developing fetal organ systems are highly vulnerable to the effects of poor maternal nutrition, drugs, alcohol, tobacco, chronic maternal diseases, environmental toxins, and other exposures. The fetus can suffer damage very early in pregnancy (3 days after a missed period), even before a woman knows she is pregnant. Because approximately half of the pregnancies in the United States are unintended (Finer and Zolna, 2011), achieving good health for all women throughout their reproductive years—preconception health—can help ensure optimal fetal health and development should pregnancy occur. Healthy lifestyle measures for women (regardless of their intent to become pregnant) include maintaining a healthy weight and good nutrition; tending to chronic medical problems such as diabetes and hypertension; being up to date on vaccinations; avoiding environmental toxins; decreasing stress and eliminating abusive relationships; and avoiding illicit drugs, tobacco, and alcohol. Effective contraception can help women avoid unintended pregnancies and lengthen pregnancy spacing. Close pregnancy spacing (less than 18 months apart) may increase the likelihood of low birth weight, preterm birth, and placental problems (Conde-Agudelo et al., 2006). Preconception health focuses on taking steps in the present to ensure the health of future children and considering effective contraception if pregnancy is not desired.
Simple measures such as consuming 400 micrograms of the B vitamin folic acid every day for at least a month before becoming pregnant and during pregnancy can help decrease the likelihood of defects of the brain and spine, known as neural tube defects, by 50% to 70% (Wolff et al., 2009). Some foods, such as leafy vegetables, bananas, and beans, are naturally high in folic acid. Other foods, including breads, cereals, flours, cornmeal, pastas, rice, and select grain products, are enriched with folic acid as required by the U.S. Food and Drug Administration.
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Prenatal Care Obtaining early and regular prenatal care enhances a woman’s chance of delivering a healthy, term baby. Prenatal care includes client education, risk identification, and monitoring and treatment of symptoms. It also includes referral to health, nutrition, childbirth education, and social service programs that can help a woman optimize her chances for a healthy pregnancy. Until the late twentieth century, prenatal care was seen as the best solution for improving birth outcomes. But even with expansions in the Medicaid program to cover health care for increasing numbers of low- income pregnant women and infants and significant federal, state, and local investments, poor pregnancy outcomes have persisted, especially for non-Hispanic black, American Indian, and Puerto Rican women.
Although prenatal care is not the only solution to reducing infant mortality, comprehensive prenatal care can improve the identification of specific and treatable causes of infant morbidity and mortality, such as maternal anemia, diabetes, hypertension, urinary tract infections, sexually transmitted infections, and poor nutrition. Ideally, such counseling and treatment of chronic health conditions should begin before a woman becomes pregnant. Optimal health throughout her life, including treatment of chronic health conditions and the adaptation of a healthy lifestyle, will have far more of an impact on healthy pregnancy than prenatal care alone.
Prenatal Substance Use Tobacco, alcohol, and illicit drug use are social factors that affect the health of women and their children. During pregnancy, substance use profoundly affects the neurological and physical development of the fetus. The use of these substances, in any combination, is dangerous to a woman’s health and worsens infant health and development outcomes.
Tobacco Smoking tobacco during pregnancy is one of the most preventable causes of infant morbidity and mortality. The adverse health effects of tobacco use during pregnancy are well documented; they include low birth weight, prematurity, stillbirth, intrauterine growth retardation, premature rupture of membranes, placenta previa, placental abruption, neurodevelopmental impairment, and SIDS (USDHHS, 2010). Cigarette smoke contains more than 2500 chemicals. The fetal effects of most of these chemicals are unknown. What is known, however, is that when a pregnant woman inhales cigarette smoke, the oxygen supply to her fetus is disrupted by nicotine and carbon monoxide. Nicotine crosses the placenta and becomes concentrated in fetal blood and amniotic fluid. Nicotine concentrations in the fetus of a smoking woman can be as much as 15% higher than maternal levels. Secondhand smoke exposure also is dangerous to the fetus and newborn. It is linked to SIDS, decreased respiratory functioning, and childhood asthma. Pregnant women who are exposed to secondhand smoke have higher odds of giving birth to low-birth-weight babies than women who are not exposed to secondhand smoke during pregnancy (CDC, 2016a).
An estimated 10% of women report smoking during the last 3 months of pregnancy. Teenagers and young women have the highest rates of maternal smoking (Curtin and Mathews, 2016). The elimination of tobacco use among pregnant women would significantly reduce the rates of low- birth-weight infants, preterm delivery, intrauterine growth restriction, and infant mortality. Quitting is very difficult because the nicotine in tobacco is addictive, but quitting is best. Merely reducing cigarette use during pregnancy may not be enough to benefit the fetus because women who cut back tend to inhale more deeply or take more puffs to get an equivalent amount of nicotine.
The need for widespread implementation of smoking cessation programs for women in the childbearing years is clear. Many smoking cessation programs have been developed and implemented by national, state, and local governments and organizations. Because pregnant women who have received even brief smoking cessation counseling are more likely to quit smoking, the nurse should offer evidence-based smoking cessation interventions to the pregnant smoker at the first prenatal visit and throughout the pregnancy (Lumley et al., 2009; Tong et al., 2008).
Alcohol and Illicit Drugs The use of alcohol and illicit drugs is a major risk factor for poor infant outcomes. Alcohol exposure
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during pregnancy can lead to fetal alcohol syndrome and other fetal alcohol spectrum disorders (FASDs). FASDs range from mild, subtle learning disabilities to severe learning disabilities. Children with FASDs are at risk for psychiatric problems, criminal behavior, unemployment, and incomplete education. Many children with FASDs also have physical abnormalities, growth deficiencies, and central nervous system disorders. No level of alcohol intake has been determined to be safe during pregnancy, and there is no safe time to drink during pregnancy. Women who are pregnant or who may become pregnant should abstain from drinking alcohol (CDC, 2018).
An estimated 10.2% of pregnant women drink during their pregnancies. Binge drinking, which is defined for women as four or more drinks on an occasion in the past 30 days, is especially harmful to fetal development. About 3.1% of pregnant women report binge drinking (CDC, 2015a). There is a compelling need for research on intervention strategies that can help prevent alcohol-exposed pregnancies.
Like alcohol, illicit drugs can cause permanent harm to an unborn baby. Current illicit drug use, including marijuana/hashish, cocaine (including crack), heroin, hallucinogens, and inhalants or prescription-type psychotherapeutics used nonmedically among pregnant women has remained constant at 5.9% despite efforts of prevention and education programs (Substance Abuse and Mental Health Services Administration [SAMHSA], 2013). Risks to the baby include prematurity, low birth weight, birth defects, newborn withdrawal symptoms, and learning and behavioral problems. Substance use is often a sign of more complex psychosocial problems, such as depression, poverty, abuse, and violence. Illicit drug use often goes hand in hand with other maternal risks, including tobacco and alcohol use, poor nutrition, intimate partner violence, and risk of sexually transmitted infections. Surveys now indicate that many pregnant women do understand the negative impact of substance use during pregnancy and cut back or stop use but then rapidly resume use after pregnancy. Evidence-based public health measures are needed to further reduce substance use during pregnancy and to prevent postpartum resumption.
Because of serious potential risks to the developing fetus, women who are pregnant or who could become pregnant should be asked about substance use and counseled to abstain from alcohol, tobacco, and the use of illicit drugs, through the use of evidence-based practices. For women who already use alcohol, tobacco, and illicit drugs, a comprehensive and long-lasting approach to treatment is required.
Breast-feeding Breastfeeding is a natural and beneficial source of nutrition and provides the healthiest start for an infant. In addition to the nutritional benefits, breastfeeding promotes a unique and emotional connection between mother and baby.
(American Academy of Pediatrics, 2012)
The American Academy of Pediatrics (AAP) recommends exclusive breast-feeding for about the first 6 months of a baby’s life, followed by breast-feeding in combination with the introduction of complementary foods until at least 12 months of age, and continuation of breast-feeding for as long as mutually desired by mother and baby. Breast-feeding has many advantages for the mother, for the baby, and for society. The cells, hormones, and antibodies in breast milk protect babies from illness such as infections and lower the childhood risk of asthma, obesity, diabetes, and SIDS. For mothers, breast-feeding is linked to a lower risk of breast and ovarian cancer and type 2 diabetes (Chowdhury et al., 2015). Breast-feeding can save more than $1500 per year in formula and supplies, and even more in the costs of infant illness (Womenshealth.gov, n.d.).
Initiation of breast-feeding occurs in about 77% of hospital births. Maternity practices that discourage separation of mothers and their babies have helped boost these rates, but more attention is required to meet AAP recommendations. The breast-feeding initiation rate for Hispanic infants is 80% compared with 75% for white infants and 60% for black infants. Only about 24% of infants are being breast-fed by 12 months. The prevalence is 12% for black infants. Black infants have the lowest rates of breast-feeding initiation and duration (CDC, 2013). This gap points to the need to understand and act upon barriers to breast-feeding that are unique to black women.
The 2011 Surgeon General’s Call to Action to Support Breastfeeding suggests actions aimed at increasing societal support for breast-feeding women. These suggestions call on communities,
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employers, health care providers, governments, and nonprofit organizations to implement strategies to support breast-feeding (U.S. Department of Health and Human Services [USDHHS], Office of the Surgeon General, 2011). There are many community sources of support for breast- feeding mothers, and nurses can play a key role in linking breast-feeding mothers with help if it is needed. In addition to nurses, health professionals such as lactation consultants, childbirth educators, physicians, trained home visitors, and doulas can provide assistance. Peer support groups such as La Leche League and breast-feeding centers can also be helpful. The federally supported Women, Infants, and Children (WIC) program also provides counseling and support for breast-feeding mothers.
Sudden Unexplained Infant Death Sudden unexplained infant death (SUID) is defined as death in an infant less than 1 year of age that occurs suddenly and unexpectedly, the cause of which is not immediately obvious before investigation. About 4500 infants die each year from SUID. Later investigation may reveal death in infants with SUID to be from poisoning, metabolic disorders, hyperthermia or hypothermia, neglect and homicide, and suffocation. About half of the infants who die from SUID die from SIDS, defined as the sudden death of an infant less than 1 year of age that cannot be explained after a thorough investigation is conducted, including a complete autopsy, examination of the death scene, and review of the clinical history. SIDS is the third leading cause of infant mortality. Non-Hispanic black and American Indian/Alaska Native infants are far more likely to die from SIDS than infants of other races (CDC, 2017a).
In 1994, with the recognition that placing infants on their backs for sleep lowered SIDS rates, the federal government, along with private entities, launched the successful Back to Sleep Campaign to heighten awareness of the safety of positioning infants on their backs for sleep. Since 1994, SIDS deaths have declined by more than 50% (CDC, 2017a) (Box 16.3). More has been learned about other factors that can lower the risk of SIDS. In 2012, the AAP released new guidelines for safe sleeping environments (AAP, 2011). Drawing from the success of Back to Sleep, the Safe to Sleep campaign was launched to educate parents, caregivers, and health care providers about ways to reduce the risk of infant death from SIDS as well as death from known sleep-related causes, such as suffocation.
BOX 16.3 “Safe to Sleep” Public Education Campaign Recommendations to reduce the risk of sudden infant death syndrome (SIDS) and sleep-related causes of infant death: Always place a baby on his or her back to sleep, both for naps and at night.
• Use a firm sleep surface, covered by a fitted sheet. • Your baby should not sleep in an adult bed, on a couch, or on a chair alone, with you, or with
anyone else. • Keep soft objects, toys, and loose bedding out of your baby’s sleep area. • Do not smoke during pregnancy, and do not smoke or allow smoking around your baby. • Breast-feed your baby. • Do not let your baby get too hot during sleep. • Follow health care provider guidance on your baby’s vaccines and regular health checkups. • Avoid products that claim to reduce the risk of SIDS and other sleep-related causes of infant
death. • Get regular health care during pregnancy, and do not smoke, drink alcohol, or use illegal
drugs during pregnancy or after the baby is born.
From National Institute of Child Health & Human Development: Safe sleep for your baby (NIH Pub. No. 12-7040), 2013. Retrieved from https://www.nichd.nih.gov/publications/pubs/Documents/STS_SafeSleepForYourBaby_General_2013.pdf
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Active Learning
1. Examine infant mortality statistics in the community, and compare the rates with state and national averages. Is infant mortality higher for any particular racial or ethnic group within the community?
2. Determine how a non–English-speaking immigrant without finances or available transportation would obtain prenatal care.
3. Accompany a pregnant woman to a local department of social services and observe as she tries to establish Medicaid eligibility for herself and her unborn child.
4. Survey businesses in the community to determine whether they offer maternity health insurance benefits, paid or unpaid maternity or paternity leave, and leave for prenatal care appointments. Is there a location within each worksite where women can pump breast milk? Use this information to develop a strategy to encourage family-friendly policies and practices in the business community.
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Childhood Health Issues At all ages, appropriate and timely medical care plays an important role in children’s health status. However, other factors, including parental influences, nutrition, environment, community safety, and the overall quality of home life, exert even stronger influences over a child’s well-being. Childhood is generally a healthy time of life, as evidenced by the improvement in many indicators of child health status over the past century. For example, the incidence of childhood disease has diminished because the majority of children receive a full complement of immunizations during infancy and toddlerhood.
The causes of childhood death vary with age. Parents and the community have important responsibilities in promoting healthy lifestyles, creating safe environments, and ensuring access to medical care. They must take steps to protect children from the leading threats to children’s health (i.e., accidental injury and exposure to environmental toxins, abuse, and violence).
Newborn Screening
Newborn screening checks for rare but serious health conditions shortly after birth. Often babies with certain health disorders appear healthy at birth; thus all babies are tested for selected conditions that can be treated if they are identified early. Babies can be screened for blood, heart, and hearing conditions.
Screening can be conducted in three ways. Blood screening is conducted by collecting a few drops of blood from the newborn’s heel. This sample is tested at a laboratory, and parents are notified of abnormalities. Hearing screening requires that a tiny, soft speaker be placed in the baby’s ear to see how the baby responds to sound. Heart screening uses pulse oximetry to evaluate the baby for congenital heart disease.
Newborn screening is state based, and the number of conditions that babies are screened for varies from state to state. All U.S. states and territories currently test for 26 health conditions, including phenylketonuria, galactosemia, congenital hypothyroidism, and sickle cell disease. Modified from March of Dimes: Newborn screening, n.d.Retrieved from https://www.marchofdimes.org/baby/newborn-screening-tests-for-your- baby.aspx http://www.marchofdimes.com/baby/newborn-screening.aspx.
Community Health Visit
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This clinic provides services through the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program, which was developed to provide health care for children in low-income families receiving Medicaid.
The nurse has an opportunity to observe the client and the family as they register and wait for their appointment. The parent registers the 5-year-old daughter for a school entry health physical examination. Medicaid insurance is verified for the physical.
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Trust can be established in a short time. The nurse can begin by explaining the steps in the clinic process so that the client knows what is expected. The nurse should always listen to the client attentively and should allow enough time for the client to reflect and respond to questions.
Reviewing immunization records is an important primary prevention role for the community health nurse. This is a teachable opportunity for the nurse to stress the importance of maintaining immunizations for the child. In California parents are provided with a yellow state immunization record for the child, which they should use to record all immunizations and to show proof of immunizations when needed.
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The nurse discusses any concerns about the client with the practitioner before the examination.
The practitioner performs the physical examination of the child with the help of the parent. The practitioner discusses the result of the vision test with the parent and the need for a follow-up appointment with an ophthalmologist. The child has not undergone a blood lead measurement and requires booster immunizations. The practitioner orders laboratory tests, immunizations, and a referral to an ophthalmologist.
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The clinic staff performs the laboratory work: hematocrit, urinary analysis, and lead measurement. The immunization consent forms have been signed by the parent. The nurse administers the immunizations and takes this opportunity to reinforce the importance of immunizations for both children.
The nurse also offers suggestions to relieve the common side effects of immunizations.
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The parent asks about an ophthalmologist who takes Medicaid and about day care facilities in the area for the younger child. The parent also asks about family planning services in the community.
The community health nurse gives the parent a business card with the nurse’s name and the agency’s address and phone number. The nurse advises the parent to call the nurse if there is anything else that the family may need.
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The nurse searches for resources for an ophthalmologist and a family planning clinic that accept Medicaid and a resource for day care providers. The nurse obtains phone numbers for a couple of ophthalmologists, a family planning clinic, and a day care consortium service.
The nurse calls the family with the referrals for an ophthalmologist and a phone number to obtain a list of day care providers. Story by Leonard Kaku, RN, MSN. Photography by George Draper.
Accidental Injuries Infants and young children are at great risk for accidental injuries. They are curious and eager to explore their environments, but they often lack the coordination and cognitive abilities to keep themselves safe from harm. Their small size and developing bones and muscles make them especially susceptible to injury. The leading cause of injury death for children younger than 1 year
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is accidental suffocation due to choking or strangulation. Unintentional injury is the leading cause of death for children ages 1 to 14. For children younger than 5, drowning is the leading cause of death. From 5 to 14 years, motor vehicle–related injuries are the cause of most deaths. Low-income and minority children suffer disproportionately from accidental injuries. They are more likely to sustain injuries and more likely to die from their injuries. For example, Native American children are more than twice as likely to experience accidental injury as their white counterparts (Safe Kids USA, 2013).
Many accidents can be avoided by improving the safety of a child’s environment. Ensuring a child’s safety in a motor vehicle is critical. The most important steps that a parent can take to ensure a child’s safety in a motor vehicle is to correctly secure the child into a car seat based on the child’s age and size. The safest place for all children younger than 13 years to ride is in the back seat, regardless of weight and height (National Highway Traffic Safety Administration, 2013). Leaving children unattended in a motor vehicle is another safety concern. In only a few minutes a car can become hot enough to cause heat stroke in a youngster. Children can also become entrapped in a car trunk or locked in a car. They should never be left alone in a car.
Smoke alarms should be installed on every level of the home and in bedrooms. Escape plans should be practiced often. Small children can drown in as little as an inch of water. Toilets, buckets, bathtubs, and pools are all potential drowning hazards. Storage of medications and hazardous substances and playground safety are also important safety education topics.
Finally, head injury from cycling and other wheeled sports, such as skateboarding, is a leading cause of child death and disability. Without proper head protection, a fall from as little as 2 feet can cause traumatic brain injury. The use of helmets and proper protective equipment can substantially reduce the risk of injuries. Box 16.4 discusses how toys can be another threat to small children.
Low-income parents may have difficulty affording safety equipment such as safety latches for cabinets, smoke alarms, car seats, and helmets. The grassroots coalition Safe Kids USA can help link parents and professionals to child injury prevention advocacy and events in local communities (Safe Kids USA, 2013).
Unhealthy Weight Childhood obesity has become a health crisis in the United States. The rate of obesity has more than doubled in children and tripled in adolescents since the 1970s, but has leveled off in the past decade. An estimated one-third of children are overweight or obese Ogden et al., 2014). Children who are overweight are more likely to experience cardiovascular disease, diabetes, bone and joint disease, and sleep apnea and to face social discrimination that can lead to poor self-esteem and depression.
BOX 16.4 Toy-Related Injuries Although most toys are safe, children are at risk for toy-related injuries and death. Approximately 168,000 children younger than 14 years are treated in hospital emergency departments for toy- related injuries. Though the majority of toy-related injuries are minor, permanent disability can occur. Riding toys, such as nonmotorized scooters and tricycles, are associated with more injuries than any other toy group.
Laws and regulations have been put into place to protect children from toy injuries. An example is the Federal Hazardous Substances Act, which bans children’s toys that contain any hazardous substance, such as lead. The Child Safety Protection Act of 1994 was designed to reduce toy-related choking and requires manufacturers to place choking hazard warning labels on balloons, marbles, small balls, and games with small parts intended for use only by children 3 years and older. The act also requires manufacturers, importers, distributors, and retailers to report choking incidents involving such products to the Consumer Product Safety Commission. The U.S. Department of Commerce requires toy guns to be distinguished from real guns. In addition, the toy industry has established voluntary safety standards to minimize risk of injury.
Although regulations and laws are helpful, parents and caretakers must also provide adequate supervision of children and must adopt strategies recommended to prevent toy-related injuries, as follows: use only age-appropriate toys; use Mylar balloons instead of latex (which can cause children to choke or suffocate); purchase a “small parts” tester to determine whether small toys
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pose choking hazards; check the website of the U.S. Consumer Product Safety Commission (www.cpsc.gov) to obtain information on toy recalls; follow age and safety recommendations on toy labels; and ensure that toys are used in a safe and proper environment. Data from Safe Kids USA: Preventing accidental injury: Toy safety. Retrieved from https://www.safekids.org/safetytips/field_risks/toy-safe ty? gclid=EAIaIQobChMI16TRze7I2AIVVyOBCh1HPQyXEAAYAiAAEgI WQfD_BwE /
Obesity prevalence is higher among Hispanic (21.9%) and non-Hispanic black (19.5%) children and adolescents than among non-Hispanic white children (14.7%) (Ogden et al., 2015). Minority groups, those with less income, and those with lower education levels are more likely to be overweight. The higher cost and unavailability of healthy foods, food insecurity, and the lack of access to safe places to exercise contribute to obesity in lower-income communities (Widome et al., 2009).
The body mass index (BMI) is a screening tool calculated from a person’s weight and height that can be used to determine whether the person is underweight, of normal weight, overweight, or obese. BMI can be calculated in children from as young as 2 years to teenage with the use of age- and sex-specific growth charts. BMI does not calculate actual body fat percentage, but it is an easy and inexpensive method that can identify weight problems (CDC, 2015c).
A number of factors contribute to childhood obesity. The typical American diet, which is both high in fat and calories and low in nutrients, has resulted in an increase in obesity. Widely available fast food, increasing portion sizes, the presence of vending machines in schools, availability of sugar-sweetened drinks, and the eating of fewer meals at home have contributed to the trend. Modern technologies such as electronic games and television, a lack of safe convenient outdoor exercise areas, and readily accessible transportation have also led to more sedentary lifestyles.
In some urban neighborhoods where high concentrations of people living in poverty are prevalent, there may be little to no access to fresh, nutritious, affordable foods, which also contributes to obesity. Such neighborhoods are called food deserts. Residents are limited to obtaining food from convenience stores and fast-food restaurants rather than from grocery stores and fresh food markets; nutritious foods are not available.
Nurses can play a leading role in generating public awareness of factors that contribute to obesity and can focus on preventive measures such as healthy lifestyles and physical activity. For example, breast-feeding provides some protection against later obesity. At least 60 minutes of moderately strenuous exercise is recommended for children most days of the week. Nurses can design and implement nutrition, healthy eating, and physical activities policies and standards in schools; take part in initiatives that make fresh, healthy foods available to all; and challenge policy makers and industry leaders such as fast-food restaurants to mobilize resources for good nutrition and fitness.
Immunization Childhood immunization is a benchmark of child health. Maintaining appropriate immunization protects all members of the community, especially immune-compromised individuals and pregnant women, who are particularly vulnerable to certain infectious diseases. Adequate immunization protects children against several diseases that kill or disable many children. Poliomyelitis, a crippling disease of the past, has been eliminated in the United States thanks to the public health effort that made the polio vaccine accessible and affordable. Over the ensuing decades, new vaccines have been developed, and children can now be protected from more than 14 vaccine- preventable diseases. State laws requiring proof of vaccination before entry to school or child care have helped ensure high vaccination levels in the population.
Vaccine-preventable disease levels are at or near record lows, but many children and adolescents remain underimmunized. Concerns about the frequency and timing of vaccines and widespread fears that childhood vaccines are linked to autism have prevented some parents from vaccinating their children (Institute of Medicine, 2013). In 2009, however, the U.S. Court of Federal Claims ruled that childhood vaccines do not cause autism. This ruling was consistent with 18 major scientific studies that failed to show a link between vaccines and autism (U.S. Court of Federal Claims, n.d.). Nurses can help educate community members about the safety of vaccines and recommended vaccination schedules and about the consequences of undervaccination. The following vaccines are recommended for children and adolescents (CDC, 2017b):
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• Tetanus, diphtheria, acellular pertussis • Inactivated polio • Rotavirus • Influenza • Measles, mumps, and rubella vaccine • Hepatitis A vaccine • Hepatitis B vaccine • Varicella (chickenpox) vaccine • Haemophilus influenzae type b (Hib) • Pneumococcal conjugate • Human papillomavirus vaccine (males and females) • Meningococcal conjugate
Most insurance plans cover the cost of childhood vaccines, and the Affordable Care Act (ACA) required new insurance plans to eliminate copays and deductibles for preventive services such as vaccinations. Another source of assistance is the Vaccines For Children program, a federally funded program that provides vaccines at no cost to children who might not otherwise be vaccinated because of inability to pay.
Environmental Concerns Potential threats to the health of children sometimes exist in their living environments. Threats can be found in the air, in the water, and from toxic exposures to chemicals. For example, air pollution, poor indoor air quality, and secondhand smoke can cause or trigger childhood asthma. Asthma is one of the most common chronic childhood disorders, affecting an estimated 6.3 million (8.6%) children in 2014 (CDC, 2017). Lead—a neurotoxin that can sometimes be found in drinking water (often from lead pipes and fittings), in old paint dust or chips that crumble from walls on older housing units, and in contaminated soil—is a cause of cognitive and behavioral problems, decreased growth, and neurological disabilities. The reduction of childhood blood lead levels is among the greatest public health stories of the latter half of the twentieth century, but unfortunately lead is still a threat. Although lead is banned from the manufacture of paint, many millions of housing units in the United States still contain lead-based paint. Most of these units are located in poor, inner-city neighborhoods. Despite dramatic declines in blood lead levels for most U.S. populations, levels remain high among children in low-income families who live in older housing with lead-based paint. Treatment for children with elevated blood lead values is long and difficult and carries risks. Better prevention, elimination of risks in the environment (particularly in older housing units), more efficient tracking, and education of the public are essential to further reduce the menace of lead poisoning.
Exposure to toxic cleaning products, pesticides, medicines, and herbicides is another area of concern. Simple steps can help protect children from accidental exposures, including child-resistant packaging, cabinet safety latches, and careful supervision.
Child Maltreatment Child maltreatment refers to all types of abuse and neglect of a child under age 18 by a parent, caregiver, or another person in a custodial role (Leeb et al., 2008), and is another indicator of children’s physical and emotional health status. Almost five children die every day in the United States from child abuse and neglect. The reported number of child deaths from abuse and neglect increased to 1670 in 2017 from 1580 in 2014. Of note, nearly 50% of child abuse victims are under 1 year of age (USDHHS Administration for Children and Families, 2017).
Child abuse may be physical, sexual, or emotional. Neglect is by far the most prevalent form of child maltreatment. Child neglect is the failure to provide for a child’s basic physical, medical, emotional, or educational needs or to protect a child from harm or potential harm. It may include failure to provide affection, warmth, understanding, and supervision adequate for healthy development (USDHHS, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau, 2017).
Child maltreatment affects children of all races, ages, and ethnicities. Factors that place children at a higher risk for maltreatment include living in a family that is stressed by drug and alcohol
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abuse, poverty, chronic health problems, violence in the community or at home, and social isolation (USDHHS Administration for Children and Families, 2017).
There are many long-term effects of child abuse and neglect. The effects may be physical, such as brain damage in shaken baby syndrome; emotional, such as depression and low self-esteem; and behavioral, such as delinquency, promiscuity, eating disorders, poor academic achievement, and drug abuse. Extreme stress caused by abuse and neglect interferes with normal brain development, harming the basic architecture of the brain. Healthy brain development relies on consistent, reciprocal, and appropriate interactions between young children and their caretakers. Chronic deprivation of healthy, reciprocal interactions can lead to the persistent activation of the stress response, leading to poor academic achievement, low self-esteem, depression, promiscuity, drug abuse, and chronic health problems (Center on the Developing Child at Harvard University, 2012).
Often, the perpetrators of maltreatment are parents, who themselves were victims, forming a cycle of abuse. The two dominant characteristics of abusive parents are a history of substance abuse and abuse from their own parents. Often, caretakers do not intend to hurt their children. They may be stressed by poverty, illness, or disability, and they may lack social support systems or coping skills. Young and inexperienced parents may not understand the physical, emotional, and behavioral needs of their children.
Children are never responsible for the harm done to them by others, and yet they may feel guilty for causing it. Many professionals, including nurses, social service workers, and teachers, are required by law to report child abuse. Nurses in the community must understand their ethical and legal obligations to report child maltreatment. They can also help create a climate that supports families and provides parents with alternatives to abusive behavior. Programs for parents can take many different forms. Positive parenting skills are at the core of such programs. Positive parenting skills include responsiveness to the emotional and physical needs of children, good communication, and appropriate discipline. This education may occur in parents’ homes, in schools, in medical or mental health clinics, or in other community settings. Nurse home visitors can be key in providing education. The ultimate goal is to prevent child maltreatment before it starts.
Children With Special Health Care Needs Children and youth with special health care needs are those who are at risk or have chronic physical, developmental, behavioral, or emotional conditions that necessitate health and related services beyond those required by children generally. These conditions include developmental disorders such as Down syndrome and autism spectrum disorder, mental health disorders such as depression and anxiety, seizures, allergies, asthma, and attention-deficit/hyperactivity disorder (Child and Adolescent Health Measurement Initiative, 2012). Chronic conditions are those expected to last 12 months or more. Often children with special health care needs experience two or more chronic conditions (USDHHS, Health Resources and Services Administration, 2015).
Children with special health care needs frequently have multiple service needs, including public health; physical and mental health care; specialized diagnostic services; social services; and educational, vocational, and sometimes corrective services. Families trying to obtain care for children with special needs face challenges in dealing with differing eligibility criteria; duplication and gaps in services; inflexible funding sources; geographic, cultural, and financial barriers; and poor coordination of care. Children with special needs can benefit from a coordinated, comprehensive, integrated system of care—often called a medical home. A medical home is not a place, but, rather, an approach to providing care. Having a medical home strengthens the ability of children with multiple service needs to receive comprehensive care for complex conditions (Box 16.5).
The Individuals with Disabilities Education Act (IDEA), enacted by Congress in 1975, is intended to ensure that children with disabilities receive a free, appropriate public education. The law has been amended many times and addresses the needs of babies through school-age children. IDEA is known as the nation’s “special education law” and is administered through the U.S. Department of Education (n.d.).
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Adolescent Health Issues Adolescence is a time of generally good health. It is a period when preteens and teens form lifelong health habits, including dietary and exercise habits and emotional health skills such as problem solving and coping strategies. Typically, adolescents do not use health services unless they have an underlying chronic condition or an acute illness. They rarely use preventive health services.
BOX 16.5 The Patient-Centered Medical Home The American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and the American Osteopathic Association have long endorsed the concept of a “medical home.” This ideal suggests that every child, including special needs children, should have “accessible, continuous, comprehensive, family-centered, coordinated, culturally effective and compassionate” health care (AAP, 1992).
A medical home should be within a community-based system that has coordinated networks designed to promote the healthy development and well-being of children as they move from adolescence to adulthood. Such a system requires appropriate financing to support and sustain quality care, optimal outcomes, family satisfaction, and cost-efficiency (AAP, 1992, n.d.).
In their struggle to gain independence, many adolescents engage in risk-taking behaviors, including alcohol and drug abuse, tobacco use, early and unprotected sexual activity, unsafe driving, and participation in delinquent and violent activities that threaten their health. Such behaviors are influenced by peers, the family, and characteristics of communities in which they live. Risk taking among adolescents is greatly influenced by their ability to control their impulses at this stage of brain development. The part of the brain that is responsible for executive functioning, the prefrontal cortex, is not fully mature until near age 25. Even though a teen may understand that a behavior is risky, he or she may have difficulty “putting on the brakes” because of the immaturity of brain development and connections (USDHHS, Office of Population Affairs, 2013).
Traditional approaches to improving adolescent health have focused on specific risks; however, a collaborative, multipartner approach that centers on the strengths of the whole person in the community, rather than focusing on individual risks, may be more effective in helping adolescents avoid risks and develop social competence. The community health nurse can help parents and communities understand the nonmedical, public health nature of risky behaviors and can assist in the development of community-wide strategies to effectively deal with them. The Youth Risk Behavior Surveillance System (YRBSS), administered by the CDC’s Division of Adolescent and School Health, monitors health risk behaviors in ninth through twelfth graders that lead to morbidity and mortality (Khann et al., 2016).
Sexual Risk Behavior One of many risk-taking adolescent behaviors is sexual intercourse. Adolescent sexual activity is often unprotected and can result in unintended pregnancy, infection with HIV, and other sexually transmitted infections (STIs).
Among students surveyed in 2015, about 41.2% had ever had sexual intercourse. Nearly 30.1% had engaged in sexual intercourse during the 3 months preceding the survey. Of these, 56.9% reported that either they or their partner had used a condom during last sexual intercourse. Another 26.8% used another form of birth control, such as birth control pills, an injectable form of birth control, a birth control ring, an implant, or an intrauterine device to prevent pregnancy. Nearly 14% used no method of birth control during the last sexual intercourse. Of consequence, 20.6% had used alcohol or drugs before last sexual intercourse (Khann et al., 2016).
Research Highlights
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Does a Satisfactory Relationship With Her Mother Influence When a 16-Year-Old Female Begins to Have Sex? A prospective panel study of more than 1500 female adolescents (not randomly selected) examined whether the dimensions within the mother–daughter relationship during young adolescence influenced sexual initiation prior to age 16 years. Researchers found that three dimensions within the relationship were associated with delayed sexual initiation: positive cohesion, communication, and satisfaction with time spent together. The researchers concluded that efforts in delaying sexual initiation in young adolescents need to be directed toward promoting positive mother–daughter relationships. Data from Kovar C, Salsberry P: Does a satisfactory relationship with her mother influence when a 16-year-old begins to have sex? MCN Am J Matern Child Nurs 37(2):122–129, 2012.
Teen childbearing has been on the decline since the late 1950s, reaching a historic low at 22.3 births per 1000 women aged 15 to 19 years (Martin et al., 2017). In recent years, teens seem to be less sexually active, and more of those who are sexually active seem to be using birth control than in previous years (Martinez and Abma, 2015). Despite the declines in teen childbearing, the U.S. adolescent birth rate remains one of the highest among industrialized nations (Ventura et al., 2014). Large disparities exist among racial and ethnic groups. The teen pregnancy rate is lowest among Asian and Pacific Islanders and highest among Hispanic teenagers (Hamilton et al., 2015).
The consequences of early childbearing on mothers, children, and society are significant. Teen childbearing contributes greatly to high school dropout rates. Only half of teen mothers receive a high school diploma by 22 years of age, compared with approximately 90% of girls who did not give birth during adolescence (Perper et al., 2010). For the infant, having a teenage mother poses serious health risks, including death, prematurity, low birth weight, and social risks, such as lower school achievement, incarceration, teen pregnancy, and adult unemployment. Children born to teenage parents have lower school achievement and are more likely to drop out of high school. They are more likely to be incarcerated at some time during adolescence, father children as teenagers, require public assistance, and face unemployment as young adults. According to an analysis by the National Campaign to Prevent Teen Pregnancy, the estimated national cost of teen childbearing in the United States for taxpayers (federal, state, and local) is at least $9.4 billion per year (National Campaign to Prevent Teen and Unplanned Pregnancy, 2015).
STIs are another consequence of sexual risk behavior. These include human papillomavirus (HPV), Chlamydia trachomatis, herpes simplex virus type 2, HIV/AIDS, hepatitis B, gonorrhea, syphilis, and vaginal trichomoniasis. Teenagers are more likely than adults to acquire STIs (CDC, 2016b). For some infections, such as C. trachomatis, the difference may be due to a physiological susceptibility. Barriers to health care such as lack of transportation, concerns about confidentiality, and lack of access to preventive health services also contribute to a higher prevalence of STIs among teens. STIs may be asymptomatic in both males and females. Although many STIs clear on their own, others can persist over time, putting women at high risk for cervical cancer, pelvic inflammatory disease, ectopic pregnancy, and infertility. Not only is a woman’s health affected, especially if the infections go untreated, but the infant born to a woman with an STI is at risk of infection and can suffer long-term consequences. Routine counseling and voluntary testing for sexually active teens and pregnant women is recommended. The HPV vaccination can protect against related disease and is the best way to prevent many types of cancer. The HPV vaccine is recommended for preteen girls and boys at age 11 or 12 years (CDC, 2015b).
The causes and effects of risky sexual behaviors are complex, and the solutions are multifaceted. One survey found that most parents feel they play an important role in providing guidance to their children about healthy sexual behavior, yet half of children are uncomfortable with these conversations. Parents who were surveyed overwhelmingly support school-based sex education programs, including information about birth control (Planned Parenthood, 2012).
Abstinence from vaginal, anal, and oral intercourse is the only 100% effective way to prevent HIV, other STIs, and pregnancy. Primary prevention models are most successful when they are evidence based and tailored to the community’s individual needs. Components of such programs can include the following:
• Abstinence promotion • Education about contraception and its availability
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• Sex education • Character development • Problem-solving skill development • Peer counseling programs • Strategies for ensuring teenagers’ school success • Job training
Such efforts are more likely to succeed when there are partnerships among parents, adolescents, and agencies for health, education, religion, social service, and government. Nurses working within such organizations can play leadership roles in developing community programs for prevention of adolescent sexual risk behaviors.
Violence Youth violence can be seen as a reflection of how well parents, schools, and the community are able to supervise and channel youth behavior in positive ways. Children and adolescents can be victims of, aggressors in, or witnesses to violence. For the victims, violence can cause both emotional and physical harm. For too many of the nation’s youth, violence is a way of life, a way of coping with challenging and difficult situations, and a significant public health problem.
The rate of serious violent crime against youth ages 12 to 17 years declined 77% between 1994 and 2010. In 2010, male (14.3 victimizations per 1000) and female (13.7 per 1000) youth were equally likely to experience serious violent crime—rape or sexual assault, robbery, and aggravated assault. Black males are the racial group most likely to be victimized (White and Lauritsen, 2012). Homicide is the third leading cause of death for young people ages 15 to 24 years. Of victims in 2014, 86% were killed with a firearm (CDC, 2016c). Handguns are readily accessible to America’s youth. Federal law prohibits anyone under age 21 years from purchasing a handgun from a licensed dealer, but it does not prohibit anyone under age 21 years from purchasing a handgun from a nonlicensed dealer (Law Center to Prevent Gun Violence, n.d.).
Teen dating violence consists of physical, sexual, or psychological/emotional violence (including stalking) within a dating relationship. In the 2015 Youth Risk Behavior Survey, 9.6% of high school students reported having been hit, slapped, or physically hurt on purpose by their boyfriend or girlfriend in the preceding 12 months (Khann et al., 2016). Teen dating violence can be emotionally and physically traumatizing and can lead to victimization and unhealthy relationships in the future.
Violence among youth is a complex public health problem with multifaceted risk factors. Risk factors include individual factors; influences by families and peers; and social, political, and cultural factors. The home environment is a key to the development of violent behavior in young people. Poor supervision of children and harsh physical punishment are associated with youth violence. Also linked to youth violence is associating with delinquent peers. At the social level, gang involvement, access to firearms, and drug use are more likely to increase youth violence (World Health Organization, 2016).
Teen violence does not have simple remedies. Solutions require community and neighborhood efforts to help young people diffuse anger and frustration before they escalate; to help parents, religious organizations, and schools assist their youth in managing anger and resolving conflicts; and to work with children and teenagers to assure them that they are loved, appreciated, and accepted for who they are. Reducing children’s unsupervised exposure to guns, engaging communities in strengthening law enforcement, modifying the design of guns, and limiting the flow of illegal guns to youth are also strategies to reduce youth gun violence (Reich, 2002).
Tobacco, Alcohol, and Drug Use The use of tobacco, alcohol, and illicit drugs has serious and long-lasting consequences for adolescents and for society. The YRBSS (Khann et al., 2016) provides a snapshot of behavioral trends. In 2015, the survey revealed the following:
• 10.8% of students had smoked cigarettes in the 30 days before the survey. • 32.3% of students had ever tried cigarette smoking. • 24.1% of students had used electronic vapor products in the 30 days before the survey.
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• 44.9% of students had ever used electronic vapor products. • 32.8% of students had had at least one drink of alcohol in the 30 days before the survey. • 17.7% of students had had five or more drinks of alcohol in a row (i.e., within a couple of
hours—also known as binge drinking) in the 30 days before the survey. • 63.2% of students had had at least one drink of alcohol on at least 1 day during their lives
(i.e., had ever drunk alcohol). • 20.7% of students had taken prescription drugs (e.g., OxyContin, Percocet, Vicodin,
codeine, Adderall, Ritalin, or Xanax) without a doctor’s prescription one or more times during their lives (i.e., had ever taken prescription drugs without a doctor’s prescription).
• 38.6% of students had used marijuana one or more times during their lives (i.e., had ever used marijuana).
• 21.7% of students had used marijuana one or more times during the 30 days before the survey (i.e., current marijuana use).
• 9.2% of students had used synthetic marijuana one or more times during their lives. • 21.7% of students had been offered, sold, or given an illegal drug by someone on school
property during the 12 months before the survey.
Among the findings of the latest YRBSS survey are that smoking rates among teens have continued to decline since peaking in the mid-1990s. In contrast, illicit drug use by youths is constantly evolving as new drugs in new forms are introduced. “Designer drugs” or synthetic cannabinoids (aka “Spice” or “K2”) have been banned in most states, but minor changes to the chemical makeup of these substances result in new substances that allow law breakers to circumvent existing drug laws (National Conference of State Legislatures, 2012; Sacco and Finklea, 2016). Also, prescription drugs used outside of medical supervision—for example, OxyContin, Ritalin, and steroids—have become more popular. Vaping prevalence grew rapidly from near-zero prevalence in 2011 to one of the most common forms of adolescent substance use. Despite a decline in 2016, the prevalence of vaping remains substantially higher than the use of any other tobacco product, including cigarettes (Johnston et al., 2017).
According to the Monitoring the Future Project of the University of Michigan, rumors of the supposed benefits of using a drug usually spread much faster than information about the adverse consequences. It generally takes much longer for evidence of adverse consequences, such as death, disease, overdose, and addictive potential, to become widely known, thus contributing to the widespread use of both legal and illegal drugs (Johnston et al, 2010).
Adolescence is a critical time to prevent substance addiction. Drugs change brains, and early use of drugs increases a person’s chances of more serious drug abuse and addiction (National Institute on Drug Abuse, 2014). Broad evidence-based prevention efforts, including addressing the issues of housing, poverty, and crime, are needed.
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Factors Affecting Child and Adolescent Health As in other age groups, social, nonmedical factors largely determine children’s health. Children depend on their families or caregivers for their health and well-being; therefore the following factors significantly affect children’s physical health, mental health, and overall well-being:
• Parents’ or caregivers’ income, education, and stability • Security and safety of the home • Nutritional and environmental issues • Health care access and use
Poverty Poverty is the greatest threat to child health. Child poverty in the United States is higher than in most other industrialized countries, and the rate is rising (National Center for Children in Poverty, 2017). About 15 million (21%) of the nation’s children live below the federal poverty level (Jiang et al., 2017). The official poverty level is calculated by using poverty thresholds that are issued each year by the U.S. Census Bureau. The thresholds represent the annual amount of cash income minimally required to support families of various sizes. The 2017 poverty guideline for a family of three in the 48 contiguous states and the District of Columbia was $24,600 (USDHHS, 2017b). Many more children (about 43%) live in low-income families that are close to the poverty level and unable to meet basic living expenses. Children are far more likely than adults to live in poverty. Poverty rates are highest for black, Hispanic, and American Indian children (Jiang et al., 2017).
Factors associated with poverty include parental education, employment, and single parenting. Eighty-five percent of children whose parents do not have a high school education live in low- income families. Even if parents have full-time employment, low education levels make their children susceptible to poverty. Likewise, children in households headed by a single parent (usually the mother) are far more likely to live in poverty and thus to have more health risks; 68% of all children with single parents live in low-income families (Jiang et al., 2017).
Poverty by itself does not always put a child at risk; however, poor children face the following health and socioeconomic risks that can compound the burdensome influence of poverty (Federal Interagency Forum on Child and Family Statistics, 2016):
• Children in poverty have less access to nutritious food, shelter, and health care. • Poor children are often deprived of advantages such as good schools, libraries, and other
community resources. • Deaths from unintended injuries, child maltreatment, homicide, STIs, and infectious
diseases are more common among poor children. • Many poor children live in substandard housing, have stressful home lives, may live
surrounded by drugs and crime, and lack positive and nurturing adult role models. • Poor children may feel hopeless about the future. • Poor children often suffer from low birth weight, asthma, dental decay, high blood lead
levels, learning disabilities, and teenage unmarried childbearing. • Poor children are more likely to move frequently. Residential instability and extreme living
conditions of poor children who are homeless or migrants usually compound their health problems.
These social and economic burdens can be overwhelming to parents or caregivers and may cause them to neglect other matters, such as providing a nutritious breakfast before school, taking a child for a well-child appointment, and getting his or her immunizations completed on schedule. They can create a sense of despair and hopelessness among parents and children, which greatly hinders healthy behavior. These factors clearly increase a child’s physical and emotional health risks.
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FIG. 16.4 Birth rates for women aged 15 to 19 years by race and Hispanic origin: United States, 1991, 2007, 2013, and 2014.
From National Center for Health Statistics: Births United States, 2014, 2015. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db216.htm
Racial and Ethnic Disparities Although children in the United States are healthier now than in any other time in our nation’s history, overall improvements in health mask the poor health of some racial and ethnic subgroups (Fig. 16.4). For example, as mentioned previously, the infant mortality rate has plunged over the past century, yet infants born to non-Hispanic black women are 2.5 times more likely to die in the first year of life than babies born to non-Hispanic white mothers. Native Americans and African Americans account for a disproportionate share of disabilities and deaths due to fetal alcohol exposure. African American youth are at higher risk for gun violence than white youth and are more than four times as likely to die from asthma as non-Hispanic white children. Childhood obesity affects racial and ethnic minority children at much higher rates than non-Hispanic whites, driving up rates of associated diabetes.
Eliminating health disparities is an important national health priority. Healthy People 2020 (USDHHS, 2018; see later) targets persistent differences in health among children of varying racial and ethnic groups and calls for the elimination of disparities in health. Social determinants of health —the circumstances into which children are born—exert a strong and persistent influence over their lifelong health. A child’s ability to be healthy and productive in life is negatively affected by poverty, violence, and a family history of poor health along with systemic inequities such as limited access to quality health care, education, and job opportunities.
Community health nurses can develop an understanding of differences in health based on race, ethnicity, and economic circumstances. They can translate experiences in the field into evidence- based intervention strategies that incorporate social programs such as education, employment, and housing into solutions for addressing health disparities.
Health Care Use Children grow and develop rapidly between infancy and adolescence; therefore they are extremely vulnerable to the effects of illness and of environmental factors that influence physical and emotional health. Preventive health and dental care offer children and parents a chance to periodically meet with a health care provider to do the following:
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• Discuss the child’s physical and emotional growth and development. • Learn about good nutrition. • Address safety issues, such as the use of car seats and seatbelts. • Receive immunizations and vision and hearing screening. • Learn about potential environmental threats to the child’s health. • Begin prompt treatment for a condition discovered during the examination. • Ask other questions or obtain a referral if necessary.
Access to a regular health care source can facilitate prompt attention to acute medical problems, which can help prevent chronic, disabling conditions. For example, untreated ear infections can cause hearing loss, which can lead to learning disabilities, school problems, and even school dropout. Resulting low self-esteem can increase the likelihood of depression, behavior problems, early sexual activity, STIs, and unplanned pregnancy. Comprehensive, regular health care helps all children achieve their potential.
BOX 16.6 Resources: Monitoring the Health and Well-Being of Children
Centers for Disease Control and Prevention (CDC): Monitors many health and disease prevention efforts, including the Youth Risk Behavior Surveillance System, which monitors youth tobacco, alcohol, and drug use; dietary behaviors; and sexual behaviors contributing to unintended pregnancy and sexually transmitted infections. (www.cdc.gov.)
Federal Interagency Forum on Child and Family Statistics: On an annual basis, produces America’s Children: Key National Indicators of Well-Being, a report containing detailed information on a set of key indicators of child well-being. (www.childstats.gov.)
National Center for Education Statistics (NCES): The primary federal agency for collecting and analyzing data related to education in the United States. (www.nces.ed.gov.)
National Center for Health Statistics (NCHS): Provides birth and death data, including birth certificate information. (www.cdc.gov/nchs.)
U.S. Bureau of Justice Statistics: Collects information about juvenile offenders. (www.ojp.usdoj.gov/bjs.)
U.S. Bureau of Labor Statistics: Provides a variety of employment data. (http://www.bls.gov/) U.S. Census BureProvides current census figures and analysis. (www.census.gov.) U.S. Department of Health and Human Services (USDHHS): Program Healthy People 2020 is a
framework of goals and objectives for the nation’s health. (www.healthypeople.gov.)
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Strategies to Improve Child and Adolescent Health One of the most important ways to ensure the success and well-being of future generations is for each child to start life healthy and maintain his or her physical and emotional health status throughout childhood and adolescence. Since the beginning of the twentieth century, the nation has made remarkable progress in many areas of child and adolescent health, but the results are mixed. Fortunately, scientific, medical, environmental, parenting, and other knowledge can lessen or eliminate many of the problems. It is a matter of making these concerns a priority and taking the necessary steps to elicit change. Box 16.6 lists several resources for monitoring the health and well- being of children.
Monitoring and Tracking Federal, state, and local governments and many national organizations collect and analyze data to track the well-being of children and adolescents. For example, the Maternal and Child Health Bureau of the USDHHS (2015) generates a yearly report, Child Health USA, on child population characteristics, health status, and health care utilization. Such data are readily accessible online to citizens, health professionals, policy makers, and the media. A number of key indicators are tracked on a regular basis by the federal statistical system so that trends are revealed. State and local data also are used to track the well-being of children.
Healthy People 2020: Child and Adolescent Health Many professions establish goals and set measurable objectives. Educators use these techniques to organize their teaching materials, measure their students’ progress, and evaluate the effectiveness of their teaching strategies and plans. Health care professionals use them for similar purposes in client care. The individual community health nurse uses them in working with a family to ensure that the nurse and family are organized and are guided by common purposes. Goals and objectives help the nurse and family evaluate progress and make necessary midcourse corrections.
These strategies are also important at the macro level and the programmatic level, where multiple players must collaborate to address complicated statewide or nationwide problems. In 1979, the surgeon general of the United States embarked on an ambitious task of convening hundreds of public health experts, health care researchers, health professional organizations, and others to develop the first health goals and objectives for the nation. At each of the intervening decades, these groups have developed a new set of goals and objectives to help bring clear focus to the health concerns of the nation and to set measurable and attainable goals for different age groups and issues across the country.
Healthy People 2020 (USDHHS, 2018) sets broad national health goals for the first decade of the twenty-first century. This initiative, like its predecessors, helps define the nation’s health agenda and guides policy development. Healthy People 2020 addresses many challenges facing the country and helps the public and private sectors understand the nation’s leading health problems, helps the two sectors develop strategic plans for addressing them, and collaborates to reach common goals. The Healthy People box lists selected objectives from Healthy People 2020 related to child and adolescent health.
Since the inception of the Healthy People initiative in 1979, child and adolescent health has improved. For instance, there have been improvements in infant, child, and adolescent mortality; adolescent smoking; pregnancy; and violence.
Healthy People 2020
Selected Objectives for Child and Adolescent Health
AH 2020-1: Increase the proportion of adolescents who have had a wellness checkup in the past 12 months.
AH HP2020–2: Increase the percentage of adolescents who participate in extracurricular and
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out-of-school activities. EMC HP2020–1: (Developmental) Increase the proportion 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.
EMC HP2020–3: Increase the proportion of elementary, middle, and senior high schools that require school health education.
EH HP2020-3: Reduce air toxic emissions to decrease the risk of adverse health effects caused by mobile, area, and major sources of airborne toxics.
FP HP2020–8: Reduce pregnancies among adolescent females. FP HP2020–12: Increase the proportion of adolescents who received formal instruction on
reproductive health topics before they were 18 years old. NWS HP2020-10: Reduce the proportion of children and adolescents who are considered
obese. IID HP2020–1: Reduce chronic hepatitis B virus infections in infants and young children
(perinatal infections). IID HP2020–14: Reduce or eliminate or maintain elimination of cases of vaccine-preventable
disease. IVP HP2020–16: Increase age-appropriate vehicle restraint system use in children. IVP HP2020–28: Increase the proportion of public and private schools that require students to
wear appropriate protective gear when engaged in school-sponsored physical activities. MICH HP2020–1: Reduce the rate of child deaths. MICH HP2020– 9: Reduce preterm birth. MICH-HP2020-16: Increase the proportion of women delivering a live birth who received
preconception care services and practiced key recommended preconception health behaviors.
OH HP2020–4: Increase the proportion of low-income children and adolescents who received any preventive dental service during the past year.
PA HP2020–8: Increase the proportion of children and adolescents who do not exceed recommended limits for screen time.
SA HP2020–3: Increase the proportion of adolescents who disapprove of substance abuse. TU HP2020–3: Reduce the initiation of tobacco use among children, adolescents, and young
adults.
From U.S. Department of Health and Human Services: Healthy People 2020, Washington, DC, 2018, U.S. Government Printing Office. Retrieved from http://www.healthypeople.gov/2020/default.asp
Health Promotion and Disease Prevention Health promotion and disease prevention are more significant and cost effective for children than for any other age group. Primary health care and early intervention for children and families can help prevent costly problems, suffering, and lost human potential. The following examples illustrate this point:
1. Preterm birth, the leading cause of infant death and long-term neurological disabilities in children, costs the U.S. health care system more than $26 billion each year (CDC, 2013b).
2. Preventing pregnancy among teenagers can reduce the rates of school dropout, welfare dependency, low birth weight, and infant mortality. It has been estimated that teen childbearing costs taxpayers billions of dollars every year in expenses associated with health and foster care, criminal justice, and public assistance (National Campaign to Prevent Teen and Unplanned Pregnancy, 2015).
Health promotion and disease prevention strategies for improving child and adolescent health come in many forms and originate in research institutions, public agencies, private businesses, and community-based organizations. They can include the following:
1. Clinical interventions 2. Public health efforts that identify trends and develop population-based, community-wide,
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or individual strategies to affect them 3. Philanthropic endeavors that fund initiatives at the community, state, and regional levels 4. Public policy initiatives that create or improve public programs or provide incentives for
nongovernmental entities to address identified problems
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Public Health Programs Targeted to Children and Adolescents A number of public programs address the health needs of children, and many target medically underserved or low-income individuals and families. In addition, local and state public health and social service agencies aim to protect the health of an entire community or state through programs such as water fluoridation, sanitation, and infectious disease control. Furthermore, broad-based strategies such as lead-based paint elimination, mandatory child safety seats in automobiles, bicycle helmet laws, teen pregnancy prevention programs, comprehensive school health clinics, and drug and violence prevention programs serve to improve the health of children using community-wide approaches.
Health Care Coverage Programs Approximately 9.4% of American children under 18 years of age do not have health insurance. Hispanic children are far more likely than children of other races to be uninsured (Fig. 16.5). Those who do not have health insurance are more likely to lack a source of health care, to have unmet health needs, and to experience worse health outcomes than children with insurance. Efforts to expand health care coverage for pregnant women and children have been successful, and provisions of the ACA helped further ensure affordable preventive services and health care coverage.
Among other provisions, for pregnant women, the ACA expanded options for health care insurance. Job-based health plans and new insurance plans are not allowed to deny or exclude coverage for pregnant women or children on the basis of a preexisting condition, including a disability. The ACA mandated certain preventive services at no cost, such as vaccinations for children and breast-feeding support. Teens and adults younger than 26 years can stay insured under their parent’s insurance plan if the plan allows dependent coverage.
Medicaid and the Children’s Health Insurance Program The ability to pay for health care greatly influences whether a parent takes a child to see a health care provider. Medicaid (Title XIX of the Social Security Act) is a health insurance program for poor and low-income people. It is a federal/state entitlement program that plays an important role in providing health coverage for low-income women and children. The federal government sets the minimum guidelines for Medicaid eligibility, and states can chose to expand eligibility through the Children’s Health Insurance Program (CHIP). Depending on the state, the average CHIP income eligibility level for children is 200% to 250% of the federal poverty level (FPL). Together, Medicaid and CHIP serve about half of all low-income children (Centers for Medicare and Medicaid Services, 2017).
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FIG. 16.5 Children less than 18 years of age and lacking health insurance by race, 2015. Data from U.S. Census Bureau Current Population Reports: Health insurance coverage in the United
States: 2015 current population reports, 2016. Retrieved from https://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-257.pdf
Within broad national guidelines, each state establishes eligibility standards based on a family’s income in comparison with the FPL, determines the type and scope of services, and administers its own Medicaid and CHIP programs. States have some discretion in determining which population groups their programs will cover. Thus a pregnant woman or child who is eligible for the program in one state may not be eligible in another.
Through the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, a child covered by Medicaid can receive a range of health and health-related services beginning in infancy. The program is designed to assure availability and accessibility of health care resources and to help Medicaid recipients and their parents effectively use them. The program’s services far exceed those usually covered by private insurance and include the following:
• Health, developmental, and nutritional screening • Physical examinations • Immunizations • Vision and hearing screening • Certain laboratory tests • Dental services
Expansions in public health care insurance programs have helped many children achieve insurance coverage, but many children still lack insurance or other health care coverage like Medicaid or CHIP for many reasons, some of which are as follows:
• Insurance is too expensive. • Medicaid has a welfare stigma, and parents do not want to be associated with it. • Medicaid application forms and processes can be complex and burdensome and can
intrude on a family’s privacy. • Parents may be concerned that their illegal immigration status may be revealed. • Parents may not consider the importance of health insurance. • Parents may not know their child is eligible for programs such as Medicaid and CHIP. • Applications and other information may not be available in the family’s language.
Although insurance gives a child financial access to health care, some children may not obtain the health care they need for other reasons. Numerous health care or family barriers can still stand in
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the way. They include the following (Angier et al., 2014; World Health Organization, n.d.):
• Lack of transportation • Language barriers • Lack of knowledge and awareness • Inconveniences associated with provider’s office (clinic or office hours that conflict with
work or school schedules; overcrowded clinics with delays in the waiting room) • Competing family or personal priorities that reduce the importance of obtaining care • Providers’ unwillingness to see Medicaid or low-income clients • Parent’s concerns that care providers are either unresponsive to their medical needs or
interpersonally disrespectful • Lack of affordability, such as cost of deductibles, copayments, medications
To successfully meet the health needs of children and adolescents, especially those with known risk factors, the community health nurse must be cognizant of health care access issues, family and neighborhood influences, and other social concerns in a child’s life. The nurse must be prepared to help the family solve problems, to be their health care system advocate, and to address the child’s health needs in a culturally competent manner.
Direct Health Care Delivery Programs Although Medicaid and CHIP finance health care for their enrollees like private insurance, several other public programs deliver health care services directly to underserved populations. Most underserved aggregates live in inner cities or rural areas with few health care providers and facilities. Some have Medicaid, CHIP, or other insurance coverage, but many are uninsured.
Maternal and Child Health Block Grant The Maternal and Child Health (MCH) Block Grant program (also called Title V, because it is the fifth section, or title, of the Social Security Act) allocates federal funds to the states, and the states must contribute their own funds for maternal and child health services. It is administered by the Maternal and Child Health Bureau as a part of the USDHHS’s Health Resources and Services Administration. Established in 1935, the Title V MCH Block Grant has provided a foundation of health care services for mothers, children (including those with special health care needs), and families over the years. States must match every four dollars of federal Title V money with three dollars of state and/or local funding to help ensure the delivery of basic health care to pregnant women and children and help deliver additional services to children with special health care needs. Agencies in state health departments also monitor the health status of mothers and children throughout their respective states and work with other state agencies to develop programs to improve the health of this population.
The Consolidated Health Centers Program, managed by the Health Services Administration (HRSA) within the Department of Health and Human Services (HHS), provides funding to more than 9000 primary health care clinics in geographically isolated and economically distressed areas.
These health centers provide comprehensive, culturally competent, primary, and preventive health care to a diverse population, including individuals who are low income, uninsured, and experiencing homelessness. Services are provided to all residents of the service area without regard to an individual’s ability to pay. This successful program provides primary care services, including health, dental, mental health, and pharmacy, as well as services that promote access to health care such as language interpretation, case management, and transportation.
School-Based Health Centers Adolescents are the least likely aggregate to use health care services, especially preventive services. Their adolescent health care needs are different from their childhood needs, and they may be uncomfortable seeing a pediatrician or their childhood provider. Furthermore, they may or may not be able to discuss sensitive topics such as sexuality, substance use, and peer relationships with their parents. Some may not want their parents to know they have a health problem; therefore they may not want to see the family’s health care provider out of concern about privacy and confidentiality. As a result, their health care needs may go unmet.
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School-based health centers typically provide a combination of screening and preventive services, primary care, mental health and substance abuse counseling, dental health, nutrition education, and other health promotion activities. State dollars, mostly from general funds and the MCH Block Grant, are the primary sources of funding for school-based health care. A growing number of health centers participate in the Medicaid and CHIP programs, and some provide services within a managed care network. Expansion of school-based health centers has been made possible under the ACA.
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Although it is not a health program exclusively, WIC gives federal grants to states for the purpose of serving nutritionally at-risk, low-income, pregnant and postpartum women, and their children up to 5 years of age. WIC programs provide highly nutritious foods, nutrition education and counseling, and screening and referral to needed services. To be eligible, women and children must meet income guidelines established by each state, and a health professional must determine they are at “nutritional risk.” Women and children who participate in Medicaid, the food stamp program, or the Temporary Assistance for Needy Families program are automatically eligible for WIC. Fifty-three percent of all infants born in the United States are served by WIC (U.S. Department of Agriculture Food and Nutrition Service, 2017).
WIC clinics operate in a number of sites, including health clinics, hospitals, schools, public housing sites, and mobile clinics. Women participating in the program are encouraged to obtain prenatal care if they are pregnant. They are also encouraged to maintain healthy diets and obtain preventive health care for themselves and their children, including childhood immunizations.
Established in 1972, WIC is one of the most successful, popular, and cost-effective public health programs. Some of the many benefits attributed to WIC include the following:
• Improvements in birth outcomes and health care cost savings • Improved infant feeding practices, better low-birth-weight rate, and more regular primary
care • Lower rates of childhood obesity
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Sharing Responsibility for Improving Child and Adolescent Health Most children in the United States are born healthy and remain healthy throughout childhood. However, the protective factors operating in the lives of healthy children and the interventions they receive are not available to all children. Although public-sector programs have attempted to provide a “safety net” for children, these interventions cannot address all the needs of children. For example, the health care system may provide emergency care to a 9-year-old child injured by gunfire in a drive-by shooting, but it cannot address the community conditions that perpetuate violence.
Child health is affected by many factors; therefore the responsibility for improving children’s health rests with the entire community. This responsibility begins with parents and includes health care professionals, community groups, businesses, and the public sector. When a child is older, he or she can be responsible for practicing healthy behaviors and obtaining proper health care.
BOX 16.7 Breast-Feeding: The Feeding Method of Choice Breast-feeding is uniquely superior for infant feeding. The practice imparts many health benefits for mothers and babies.
Benefits for children include the following:
• Decreased incidence and severity of a wide range of infectious diseases • Decreased infant mortality • Decreased risk of sudden infant death syndrome • Reduction in the incidence of diabetes, respiratory infections, and some cancers • Lower risk of overweight and obesity • Enhanced cognitive development
Benefits of breast-feeding for mothers include the following:
• Decreased postpartum bleeding • Earlier return to prepregnancy weight • Decreased risk of breast and ovarian cancer
The American Academy of Pediatrics (AAP) and many other health organizations recommend exclusive breast-feeding for the first 6 months of life with continuation of breast-feeding for 1 year or longer as mutually desired by mother and infant (AAP, 2012).
Parents’ Role Even before conception, a woman can help ensure the health of her fetus by practicing healthy behaviors herself. Reproductive life planning can help a woman set personal goals and priorities and design strategies to meet these goals. This planning may entail avoiding unwanted pregnancy and/or learning about specific actions she can take to increase her chances for having a healthy baby should she desire a child in the future. If pregnancy is desired, a woman can learn to manage chronic health conditions and to develop healthy behaviors, including proper nutrition with folic acid supplementation and avoidance of tobacco, alcohol, drugs, and other behaviors that could harm a developing baby. It is also important for the mother to receive prenatal care early in pregnancy.
Starting with breast-feeding, parents must give their children nutritious food and ensure that they are immunized, receive needed health care services, and acquire healthful lifestyles. Breast- feeding provides many health benefits for mothers and their children (Box 16.7).
Another important task for parents is to ensure that their children have a safe environment at
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home, in the neighborhood, and at school. They must protect their children from injury, violence, abuse, and neglect. Parents must learn how to nurture, guide, and protect their children effectively through the developmental stages of childhood and adolescence.
Community’s Role Families need support from their community and society to fulfill their roles and responsibilities. This is particularly true for families who live in poverty and for parents who are isolated and disenfranchised. Ensuring access to health care is an important community role, but communities are also responsible for promoting well-being, which goes far beyond the provision of traditional medical care.
Communities should work to create safe neighborhoods and support the development of community-based comprehensive health, education, housing, and social service programs. Collaborative, multipartner approaches that concentrate on helping children and adolescents avoid risks and develop social competence are more likely to be effective than fragmented programs focusing on individual risks, such as teen drug use. Communities are well situated to facilitate the integration of health, education, and social services; to eliminate fragmentation and duplication of services; to provide culturally competent care; and to better organize more comprehensive and streamlined systems of care. Although many health and social service programs exist, they can be poorly coordinated with one another, with little collaboration among the professional disciplines.
The media are part of the community at large and should be involved in promoting child and adolescent health. The media significantly influence children’s lives, their perceptions of the world, and their self-images. From developing informational campaigns about prenatal care and immunizations to discouraging violence and explicit sex in advertising and popular television programs, the media can have a profound effect on improving children’s health and well-being.
Employer’s Role Business and industry have an enormous stake in the health of the nation’s children. A strong, productive workforce is ensured only when the health, social, and educational needs of the next generation of workers are met. Furthermore, health risks cost employers in lost productivity and increased health care costs.
The private sector can play a role in improving the health of individual children or the community in general. An employer can make health care more accessible to families with children by offering affordable health insurance that covers employees and dependents. The provision of insurance plans that offer full pregnancy and well-child health care benefits is essential to employee health promotion. Employers can meet the requirements of the U.S. Department of Labor (2015) by supporting nursing mothers in the workplace. This includes providing reasonable break time to express milk and a private space other than a bathroom in which to do so.
Maintaining a workplace that allows flexible leave for prenatal and pediatric health care and allows time off to care for newborn and sick children can also contribute to child health improvements. In 1993, the Family and Medical Leave Act (FMLA) mandated that employers with 50 or more employees must allow a total of 12 work weeks of unpaid leave during any 12-month period for the birth, adoption, or foster care of a child or for the care of a seriously ill family member or the employee himself or herself. The Department of Labor issued a Final Rule on February 25, 2015, revising the definition of spouse under the FMLA of 1993. Revision of the definition ensures same-sex married spouses the same ability as all spouses to fully exercise their FMLA rights (U.S. Department of Labor, 2015).
In addition, employers can sponsor education opportunities for employees about topics such as healthy diets, healthy pregnancies, substance abuse, and stress management. Businesses can also offer onsite child care and can work with community leaders and public officials to initiate community-wide health promotion projects targeted to children. Finally, employers can be catalysts in their communities for linking health, education, and social services for children.
Government’s Role In the United States, government’s role in promoting or ensuring children’s health is more limited than in many other countries. Other countries often have defined policies on children’s health; the
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United States does not. Such policies not only indicate that children are a priority of the citizenry but also help shape the operation of programs and their funding.
As discussed earlier, U.S. state and federal governments have several public health programs that provide assistance to children, especially to those at risk from poverty or other disadvantages. Monitoring the health of children is also a governmental role. Although these programs are not a substitute for a family or caregiver’s care and concern, they are important in protecting and promoting health and delivering services to those who would otherwise go without. Programs with significant funding exist, but many children with health problems do not receive the services they need for reasons previously discussed.
Managers and front-line workers (e.g., community health nurses, social workers, physicians, and caseworkers) in effective community programs should be encouraged to collaborate and thereby assist children with problems that adversely affect their health. “One-stop shopping” (i.e., user- friendly, accessible services for children and families) is an important concept for public and community programs to embrace to ensure that children easily receive needed services. Outreach and referral efforts should be an integral part of health initiatives to provide children with the services they require. Community health nurses are often an essential part of these efforts.
Community/Public Health Nurse’s Role Public health nurses have always played pivotal roles in improving the health status of pregnant women, children, and adolescents. Within the community, the community health nurse is often most aware of children’s health status, any barriers that prevent children from receiving necessary care, and other factors that may adversely affect their health. Armed with this information and knowledge about available health resources in the community, the community health nurse is:
• An advocate for improved individual and community responses to children’s needs • A researcher for effective strategies to serve women and children • A participant in publicly funded programs • A promoter of social interventions that enhance the living situations of high-risk families • A partner with other professionals to improve service collaboration and coordination
One important role of the community health nurse is to help link local health and social services with the school system. Children must be healthy to learn; however, children may come to school with vision, hearing, and other health problems that appropriate education, screening, and treatment could have prevented or alleviated. When children pass the preschool years, the school health nurse is sometimes their only connection to the health care system. School health nurses can be important sources of primary health care and health information for students and their families.
Community health nurses can alert the health professional community, business leaders, religious groups, and voluntary organizations to children’s and adolescents’ needs and to the strategies that can improve their health. Community health nurses can influence the planning and implementation of necessary changes in the health care system to ensure improved children’s health and to achieve the national health goals for the year 2020. Also, they can promote commitment within their own institutions for comprehensive, culturally competent care.
Home visiting is a promising strategy that connects community health nurses, paraprofessionals, or lay home visitors to families in order to provide education, support, and referrals (Olds et al., 2010). One home visiting model, administered through the Nurse-Family Partnership, partners low- income, first-time mothers with maternal and child health nurses. Pregnant women develop trusting relationships with their nurse home visitors and receive the care and support needed for healthy pregnancy and parenting. Financial self-sufficiency is encouraged (http://www.nursefamilypartnership.org/).
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Legal and Ethical Issues in Child and Adolescent Health Every day, community health nurses are involved in making decisions. In each encounter with a client, the nurse’s decisions or the family’s choices have the potential to influence the health and well-being of the family or the community at large for better or for worse.
People often assume that health care professionals, particularly nurses, are by nature attuned to the ethical implications of their decisions. In addition, the community trusts that nurses are aware of the legal ramifications of their actions and decisions, of their clients’ decisions, and of the health care and legal systems’ decisions. In reality, the ever-changing pressures of serving the community’s health care needs leave little time to reflect on the ethical and moral implications of a given situation. In some cases, it may seem easier to avoid tough decisions. An ethical approach to decision making allows the community health nurse to evaluate a client’s or a population’s needs more honestly and completely and take appropriate action. Understanding the legal environment will help the nurse make informed decisions and effectively assist clients with their decision- making processes.
Ethical Issues The complex nature of public health and health care delivery environments often sets the stage for conflicts of interest and values. Meanwhile, nurses and other health professionals must work within the system to improve child and adolescent health in a country of great differences. Such differences exist between races and cultures, and there are great dichotomies, such as the affluence of some and the poverty of many others. For the perinatal nurse, for example, ethical dilemmas may arise because she is an advocate for two clients: the pregnant woman and her fetus. The scope of ethical and legal dilemmas is broad. The Ethical Insights box lists specific ethical issues related to child and adolescent health.
Ethical Insights Ethical Issues Related to Child and Adolescent Health
Allocation decisions: Given limited time and resources, what level of care should a nurse offer a child and his or her family?
Maternal-fetal conflict: Sometimes there are opposing ethical concerns for the pregnant woman and her fetus—for example, whether the benefits of prolonging a pregnancy justify the risk of complications for a pregnant woman or whether court-ordered treatment for a substance- abusing pregnant woman overrides the right to autonomy for a pregnant woman.
Client autonomy: In each specific case, who should make health care decisions for a young client, especially when opposing opinions arise? The client? The parents or guardian? The nurse or other health care professional? At what age does a child become mature enough to participate in such decision making? What laws does any given state have that affect adolescent client autonomy? What should the community health nurse do if he or she believes the client’s or parent’s decisions are not in the best interest of the client?
Privacy and confidentiality: Is an intervention appropriate if the community health nurse identifies gross noncompliance, neglect, or abuse? Is an intervention appropriate if in making it the nurse must break confidentiality? When and how should the nurse take action?
”Gaming the system”: When the health care system’s rules appear to impede the nurse’s ability to serve the client’s best interest, is it acceptable to circumvent the system? If so, what are the moral and legal costs?
Cultural competence: The United States will continue to experience huge demographic changes and greater diversity; nurses will face different cultural definitions of what is and what is not acceptable or ethical. How should the community health nurse respond to a client or population group that does not share the same cultural outlook on health? What is the
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nurse’s legal justification, if any, for responding in a certain way? Health disparities and access to care: What are the nurses’ responsibilities in ensuring that
women and children have access to health care? How can nurses influence policy decisions that affect community health care?
Prenatal diagnosis and newborn screening: What are potential long-term consequences of identifying genetic conditions? Are parents fully informed of negative consequences of genetic diagnoses, including stigmatization, discrimination, and psychological effects?
These issues invariably involve value judgments and challenge a nurse’s bounds of professional and personal duty. They also require the community health nurse to stay abreast of legislative changes at the local, state, and national levels and participate in professional activities that can help him or her stay current in these important matters. By recognizing the ethical implications of the care and advice they give or the actions they take, nurses can embrace their duty to promote the health and well-being of individual clients and the community more completely, protect their clients from harm, and strive for health care fairness and justice for all clients.
Recognizing the value of engaging in a shared dialogue with colleagues regarding ethical decision-making issues and understanding the possible legal implications of their decisions are equally important. The choices can be complex; therefore receiving the guidance of an ethics board or gaining a second opinion can be critical to making the right choices. On a broader scale, a community health nurse’s ethical perspective can enhance any discussion about individual client care and overall community health and also can affect the direction of the country’s public health policy.
Active Learning
1. Develop strategies to inform parents whose children are uninsured about the availability of CHIP.
2. Spend a day with a school health nurse and analyze what could help prevent or address the health problems and issues he or she encountered throughout the day.
3. Communicate with those in policy-making positions by writing letters or holding meetings about children’s needs.
4. Identify the public health and advocacy organizations in the community that are working to address children’s health needs and identify their strategies for promoting child health within the community.
5. If your community has a lay home visitor program, meet with a home visitor and, if possible, accompany him or her during home visits.
Case Study Application of the Nursing Process Pregnant Teenager By applying the principles of the nursing process to the individual, family, and community, the community health nurse can provide services to children and adolescents more systematically and effectively. Most communities offer a range of preventive services and other important programs that children need. The community health nurse must thoroughly understand the needs of the individual child and family and must be aware of available community resources to help meet the child’s health needs, as this case study illustrates.
Maria Martinez, a community health nurse working for the county health department, received a call from the high school nurse informing her that a 16-year-old high school student named Kaylah M. would come in that afternoon for a pregnancy test. Kaylah had already missed three menstrual periods and was afraid to talk about it with her family. She had a long discussion with the school nurse and asked her boyfriend, also aged 16, to take her to the health department clinic after school for the pregnancy test.
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Assessment Kaylah’s pregnancy test result was positive, and she was an estimated 3 months pregnant. She was upset and would not speak with Maria at the health department. With agreement from Kaylah, Maria arranged to make a home visit the next afternoon.
Knowing that she needed to address a number of issues at the first home visit, Maria prepared by developing a list of possible assessment areas that covered individual, family, and community concerns, as follows: Individual
• Medical risk factors • Emotional well-being, including concerns about community safety, domestic violence, and
sexual abuse • Cultural beliefs and attitudes toward pregnancy and medical care • Barriers to communication with providers, such as language, hearing, and sight • Understanding and acceptance of pregnancy • Health-promoting and risk-taking behaviors • Understanding the importance of obtaining preventive care services • Health insurance status • Access to transportation
Family
• Adequacy of housing structure • Safety of neighborhood • Ability of family members to provide emotional support • Ability of family to provide financial support • Ability and willingness of the father of the baby to provide support
Community
• Availability of affordable and culturally sensitive prenatal and pediatric care • Health and social services coordination • Emotional guidance and counseling • Educational opportunities for pregnant and parenting teenagers • Job training • Nutrition services such as WIC and food stamps • Pregnancy and parenting education • Child care availability
Assessment Data Individual
• Kaylah was already in the early second trimester of pregnancy and had not received prenatal care. She also engaged in risk-taking behaviors (i.e., smoking, alcohol use, unprotected sex, and poor eating habits) potentially detrimental to her baby.
• During the interview, Kaylah seemed quiet and reserved. She said she was excited to have a baby but feared labor and delivery.
• Her boyfriend wanted her to keep the baby but was not committed to supporting Kaylah or the baby. He did not want to involve his own parents.
• Kaylah said she did not think about prenatal care much but would probably visit a health
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clinic sometime before her delivery. Her family did not have health insurance, and she said they could not afford prenatal care.
• She wanted to keep the baby and remain in school, yet she did not have a realistic understanding of parental responsibilities.
Family
• When Kaylah told her parents she was pregnant, they expressed disappointment. Her mother voiced a willingness to provide emotional support, but her seemingly emotionally distant father expressed anger.
• Both parents expressed concern about how the family would manage financially. • After a brief review of the family’s financial situation, it appeared that Kaylah was eligible for
Medicaid and WIC. • Her parents wanted her to have no further contact with her boyfriend.
Community
• Maria determined that prenatal services were available, but only during school hours. Although the only clinic that accepted Medicaid clients was on the other side of town, a nearby obstetrical practice with a certified nurse-midwife on staff accepted clients with Medicaid coverage. However, their primary clientele consisted of middle-class, married women.
• Applying for Medicaid and the WIC program required Kaylah to go to the welfare office and apply during school hours. However, the hospital outpatient department could make a preliminary Medicaid eligibility determination, which might be more convenient.
• Although Medicaid would pay for some prenatal classes, those nearby were geared to older, married couples.
• Kaylah’s school encouraged her to remain in regular classes until her delivery date and participate in home study for a limited time thereafter.
• No parenting classes geared toward adolescents were available. • Child care was not available at the high school, making a return to school more difficult for
Kaylah. • Although the community has a lay home visitor program that matches mentors with pregnant
and parenting teens and provides health information and encouragement, the project does not serve Kaylah’s neighborhood.
Diagnosis Individual
• Unhealthy lifestyle choices related to the lack of prenatal care and the effect of poor nutrition, smoking, and alcohol use on fetal development
• Parenting issues related to unrealistic expectations about parenting responsibilities • Lack of knowledge related to infant and child safety issues, such as the use of child safety
seats, advantages of breast-feeding, safe sleep for infants, and use of preventive health care, including immunizations
Family
• Disrupted family dynamics related to anger and disappointment over daughter’s pregnancy • Altered financial status resulting from the addition of another dependent to the family
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Community
• Lack of coordinated, culturally sensitive, accessible prenatal and parenting services for adolescents
• Existing lay home visitor program not available
Planning To ensure the action plan is complete, realistic, and successfully implemented, Maria must thoroughly identify the factors affecting Kaylah’s health and well-being. In addition, Kaylah, her family, and Maria must set mutual goals. Individual Long-Term Goals
• Pregnancy outcome will be healthy for mother and infant. • Kaylah will demonstrate successful parenting behaviors. • Kaylah will complete high school.
Short-Term Goals
• Kaylah will obtain prenatal care. • Kaylah will understand the reasons to change nutrition and substance use habits. • Kaylah and the nurse will plan actions to change poor health habits. • Kaylah will remain in school throughout her pregnancy and will use the home study program
until she returns to school after her baby is born. • Kaylah will enroll in parenting class. If classes are not available, she will use age-appropriate
reading materials, films, CDs, Internet resources, opportunities for group discussion with other teens, or visits with experienced parents.
• Kaylah will breast-feed her baby. • Kaylah will speak with the community health educator to determine methods to protect the
health and safety of her newborn.
Family Long-Term Goal
• The family’s ability to handle crises will improve with their ability to discuss problems and engage in mutual problem solving.
Short-Term Goal
• Kaylah’s parents will display supportive behaviors, such as accompanying her to prenatal care appointments, helping her engage in healthy behaviors, and helping her arrange child care so she can remain in school.
Community Long-Term Goal
• Accessible, comprehensive, culturally sensitive prenatal and other health care services will be established, including home visiting and parenting classes targeted to adolescents.
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Short-Term Goals
• The health department clinic will extend evening hours to accommodate students and working families.
• A child care facility will open in or near the high school.
Intervention The nurse, family, and individual must address their immediate, mutual goals to help Kaylah achieve a healthy birth outcome and begin successful parenting. Interdisciplinary planning among Kaylah’s school health nurse, caseworker, community health nurse, primary pregnancy care provider, childbirth educator, and family planning nurse is critical. In addition, Maria must be an advocate for community-wide change to ensure that the community is meeting individuals’ needs. Individual Maria worked with the school nurse and other health professionals to help Kaylah obtain Medicaid and WIC; she was referred to an obstetrician who saw her regularly. Kaylah’s pregnancy was also monitored by the school nurse, who had her come to the clinic on a weekly basis to check her weight and blood pressure and to talk with her about pregnancy-related issues.
Working with the school nurse, Maria provided Kaylah with information on childbirth classes and nutrition as well as booklets detailing how to promote a healthy pregnancy. She was counseled to avoid tobacco, alcohol, and all drugs. Near the end of the pregnancy, Kaylah was encouraged to attend parenting classes with her boyfriend. Family Maria and the social worker referred Kaylah’s parents to other social service agencies that might be able to help financially. In particular, they focused on providers who could assist with utilities, job placement, and child care. The family was also referred to a family counselor who specialized in working with families with adolescent children. Community Maria worked with the maternal-child health division of the county health department to help facilitate offering parenting classes at an area high school, targeting the learning needs of pregnant teens. She and the school nurse also met with school district officials and community leaders to stimulate dialogue about the consequences of dropping out of high school and to facilitate action in policies such as child care for parenting teenagers to help them remain in school. Evaluation Evaluation strategies must involve both process and outcome measures on the individual, family, and community levels. Individual The school nurse was able to monitor Kaylah throughout her pregnancy and was aware that she finished classes for the term. Kaylah’s pregnancy was unremarkable, and she delivered a healthy boy. Their health care expenses were covered by Medicaid, and the baby was determined to also be eligible for CHIP. A home-based teacher was assigned to work with Kaylah for 1 month after delivery to ensure that she was able to keep up with her coursework. With the assistance of the social worker, Kaylah was able to place the baby in a subsidized day care facility, allowing her to finish school. Family Family counseling helped the family resolve some of their issues. Maria observed that Kaylah’s parents were proud of their grandson and eager to help with his care. Community With the help of the school nurse and other interested parties, Maria was able to initiate a collaborative program in which health department nurses and developmental specialists offered parenting classes in high schools on a regular basis. They were also planning on writing for a Maternal Child Health Block Grant to implement a school-based clinic focusing on the needs of pregnant teens and their infants. Levels of Prevention
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Primary
• Primary prevention depends largely on the child’s age. For the youngest children, strategies include encouraging healthy behaviors by girls and women.
• Primary prevention also includes the prevention of unwanted pregnancy, which is especially important for adolescents.
Secondary
• Once pregnant, the woman must receive early and adequate prenatal care, practice healthy behaviors, obtain necessary social and supportive services, and prepare herself for becoming a parent.
• It is incumbent on the community to ensure that adequate preventive health services, such as prenatal care, nutrition and dietary counseling, pregnancy and parent education, and social services, are available.
Tertiary
• Initiate programs and services that prevent future unwanted pregnancy among teenagers and help the parenting teenager provide the best possible care to the child.
• Establish programs such as parenting classes; support services to help adolescents complete their education; coordination of health and social services for the mother and her child; and well-child care, immunizations, and nutrition services.
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Summary Child and adolescent health status remains an important indicator of the nation’s health. The health of a child sets the foundation for school readiness and future success. Child and adolescent health problems are reflections of rapidly changing social conditions, not isolated events. Despite generally improving trends in health for most children, community health nurses must address discrepancies that exist between racial and ethnic groups. Poverty is the basis for many continuing health problems among children in this country, and nurses must recognize and treat it as such.
The best way to ensure the success and well-being of future generations is for each child to begin life healthy and maintain that health status throughout childhood. Any health problem (e.g., hunger and poor nutrition, asthma, poor vision or hearing, anemia, dental caries, mental health problems, illicit drug use, or teen pregnancy) can interfere with school attendance, academic success, normal growth and development, learning ability, and life success.
The prevention of health problems is most significant and cost effective for children. Each dollar spent on the prevention of physical and emotional problems in children is a sound investment. Primary health care and early intervention for children and families can help prevent costly problems, suffering, and the loss of human potential. Community health nurses can use their experience and “inside knowledge” of barriers to child health to educate others. Rather than limiting their approach to caring for the individual and family only, community health nurses can maximize their roles to collaborate and forge necessary alliances to solve children’s health problems. Nurses are authority figures in the least expected places. Working on health care’s front line is a powerful and very real position to members of Congress, state legislators, mayors, and other leaders. By creatively using this kind of power, community health nurses can contribute greatly to improving the health and well-being of all children.
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Evolve Website http://evolve.elsevier.com/Nies/community
• NCLEX Review Questions • Case Studies
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Substance Abuse and Mental Health Services Administration. Results from the 2012 national survey on drug use and health: summary of national findings. Rockville, MD: Administration, S. A. a. M. H. S; 2013.
Tong V.T, England L.J, Dietz P.M, et al. Smoking patterns and use of cessation interventions during pregnancy. Am J Prev Med. 2008;35(4):327–333.
U.S. Court of Federal Claims: Autism decisions and background information, n.d. Available from: <http://www.uscfc.uscourts.gov/omnibus-autism-proceeding>.
U.S. Department of Agriculture Food and Nutrition Service. Women, infants, and children (WIC) Available. https://www.fns.usda.gov/wic/women-infants-and-children-wic, 2017.
U.S. Department of Education. Building the legacy: IDEA 2004 n.d. Available from. <http://idea.ed.gov/explore/home>.
U.S. Department of Health & Human Services. Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child maltreatment 2015. 2017 Available from. http://www.acf.hhs.gov/programs/cb/research-data- technology/statistics-research/child-maltreatment.
U.S. Department of Health and Human Services. Healthy People 2020. Washington, DC: U.S. Government Printing Office; 2018. http://www.healthypeople.gov/2020/default.asp.
U.S. Department of Health and Human Services. A report of the surgeon general: how tobacco smoke causes disease: what it means to you. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2010.
U.S. Department of Health and Human Services. 2017 poverty guidelines. Fed Regist. 2017;82(19):8831–8832 Also available from Government publishing Office. https://www.gpo.gov/fdsys/pkg/FR-2017-01-31/pdf/2017-02076.pdf.
U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child maltreatment 2010 Available from. <http://www.acf.hhs.gov/programs/cb/resource/child-maltreatment- 2010>, 2011.
U.S. Department of Health and Human Services; Office of Population Affairs. Title X family Planning Annual Report: 2012 National Summary. https://www.hhs.gov/opa/title-x-family- planning/fp-annual-report/index.html, 2013.
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U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA. Rockville, Maryland: U.S. Department of Health and Human Services, 2015; 2014 Online at. http://mchb.hrsa.gov/chusa14/.
U.S. Department of Health and Human Services; Office of the Surgeon General. The surgeon general’s call to action to support breastfeeding. Washington, DC: Author; 2011. <http://www.surgeongeneral.gov/library/calls/breastfeeding/index.htm>.
U.S. Department of Labor, Wage and Hour Division. Break time for nursing mothers Available from. https://www.dol.gov/whd/nursingmothers/#Overview, 2013.
U.S. Department of Labor, Wage and Hour Division: Family and medical leave act, Final rule to amend the definition of spouse in the family and medical leave act regulations, revised February 2015. Available from: https://www.dol.gov/whd/fmla/spouse/.
Ventura S.J, Hamilton B.E, Mathews T.J. National and state patterns of teen births in the United States, 1940-2013 National Vital Statistics Reports vol. 63, no. 4. Hyattsville, MD: National Center for Health Statistics; 2014 Available from. https://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_04.pdf.
White N, Lauritsen J.L, Office of Justice Programs, Bureau of Justice Statistics, . Violent crime against youth, 1994-2010 U.S. Department of Justice. 2012 Available from: https://www.bjs.gov/content/pub/pdf/vcay9410.pdf.
Widome R, Neumark-Sztainer D, Hannan P.J, et al. Eating when there is not enough to eat: eating behaviors and perceptions of food among food-insecure youths. Am J Public Health. 2009;99:822– 828. .
Wolff T, Witkop C.T, Miller T, et al. Folic acid supplementation for the prevention of neural tube defects: an update of the evidence for the United States Preventive Services Task Force. Ann Intern Med. 2009;150:632–639.
Womenshealth.gov: Breastfeeding, n.d. Available from: <http://www.womenshealth.gov/breastfeeding/index.html>.
World Health Organization-Western Pacific Region. Barriers to access to child healthcare n.d. Available from:. www.wpro.who.int/publications.
World Health Organization. Media centre. Youth violence facts Available from. http://www.who.int/mediacentre/factsheets/fs356/en/, 2016.
∗ The author would like to acknowledge the contribution of Susan Rumsey Givens, who wrote this chapter for the previous edition.
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Women’s Health Lori A. Glenn
OUTLINE
Major Indicators of Health Life Expectancy
Mortality Rate Morbidity Rate
Social Factors Affecting Women’s Health Health Care Access Education and Work Employment and Wages
Working Women and Home Life Family Configuration and Marital Status
Health Promotion Strategies for Women Chronic Illness Reproductive Health Other Issues in Women’s Health
Major Legislation Affecting Women’s Health Public Health Service Act Civil Rights Act Social Security Act Occupational Safety and Health Act Family and Medical Leave Act
Health and Social Services to Promote the Health of Women Women’s Health Services Other Community Voluntary Services
Levels of Prevention and Women’s Health Primary Prevention Secondary Prevention Tertiary Prevention
Roles of the Community Health Nurse Direct Care Educator Counselor
Research in Women’s Health
OBJECTIVES
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Upon completion of this chapter, the reader will be able to do the following: 1. Identify the major indicators of women’s health. 2. Examine prominent health problems among women of all age groups (i.e., from adolescence
to old age). 3. Identify barriers to adequate health care for women. 4. Discuss issues related to reproductive health. 5. Explain the influence of public policy on women’s health. 6. Discuss issues and needs for increased research efforts focused on women’s health. 7. Apply the nursing process to women’s health concerns across all levels of prevention.
KEY TERMS breast cancer cesarean section Civil Rights Act cardiovascular disease ectopic pregnancy Family and Medical Leave Act Hypertension intimate partner violence life expectancy maternal mortality multiple family configurations osteoporosis pelvic inflammatory disease sexual harassment To achieve “health for all” in the twenty-first century, health care services must be affordable and available to all. Although adequate health care for women is a key to realizing this goal, a significant number of women and their families face tremendous barriers to health care access. Additionally, knowledge deficits related to health promotion and disease prevention activities prevent women of all educational and socioeconomic levels from assuming responsibility for their own health and well-being.
Beginning in the 1970s, the women’s movement called for the reform of systems affecting women’s health. Women were encouraged to become involved as consumers of health services and as establishers of health policy. More women entered health professions in which they were previously underrepresented, and those in traditionally female-dominated professions, such as nursing and teaching, became more assertive in their demands to gain recognition for their contributions to society. Health care for women has evolved from a focus on the pelvic area and breast to viewing the woman as a holistic being with specialized needs.
In “Preamble to a New Paradigm for Women’s Health,” Choi (1985) declared that collaboration and an interdisciplinary approach are necessary to meet the health care needs of women. She further stated, “[E]ssential to the development of health care for women are the concepts of health promotion, disease and accident prevention, education for self-care and responsibility, health risk identification and coordination for illness care when needed” (p. 14). To realize this paradigm, community-based health care focuses on health beyond the biophysical, disease-focused approach. Health from a social perspective considers the interaction of individual physiology along with work environment, living conditions, lifestyle choices, and health habits (Ruzek et al., 1997). Community health nurses must work with other health care professionals to formulate upstream strategies that modify the factors affecting women’s health. Many Healthy People 2020 objectives address health problems pertaining to women and include specific targets and strategies to improve the health of
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this aggregate. The Healthy People 2020 boxes in this chapter present a small selection of these objectives. This chapter examines the health of women from adolescence to old age. It explores the major indicators of health, including specific health problems and the socioeconomic, sociocultural, and health policy issues surrounding women’s health. The chapter also discusses identification of current and future research aimed at improving the health of women. An understanding of these points will enable community health nurses to appropriately apply this expertise in a community setting to help improve women’s health.
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Major Indicators of Health In the United States, data collected on major causes of death and illness appraise the health status of aggregates. These data are typically presented in terms of gender, age, or ethnicity and can help us interpret the levels of health in different groups. The primary indicators of health this chapter covers are life expectancy, mortality (i.e., death) rate, and morbidity (i.e., acute and chronic illness) rate.
Healthy People 2020
Selected Objectives for Women’s Health
∗ Reflects a change in practice guidelines: Through 2008, women >18 years old were recommended for routine Pap smear screening, but guidelines changed the age to 21 years old in 2008.
† Reflects a change in practice guidelines. Prior to 2008, the measurement was mammograms within the past 2 years for women older than 40 years.
Data from U.S. Department of Health and Human Services: Healthy People 2020, ed 3, Washington, DC, 2010, Author; and National Center for Health Statistics: Healthy People 2010 final review, 2012. http://www.cdc.gov/nchs/data/hpdata2010/hp2010_final_review.pdf Accessed 11-10, 17.
According to the Census Bureau (2017), there are an estimated 164 million women in the United States. Of these women, 11% are considered in fair to poor health and 12% have conditions that impair their daily functioning (Adams et al., 2011). Many factors that lead to death and illness among women are preventable or avoidable. If certain conditions receive early detection and treatment, a significant positive influence on longevity and the quality of life could ensue. Recognition of patterns demonstrated by these indicators can address problems preventively. This section presents an overview of these major indicators of health among women.
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Life Expectancy Except in a few countries, such as Bangladesh, Malawi, Niger, Pakistan, Qatar, and Zimbabwe, women typically experience greater longevity than their male counterparts (World Health Organization [WHO], 2013). For example, women born in the 1970s in the United States have an average life expectancy of 74.7 years, or 7.6 years longer than men born in the same year.
Life expectancy for Americans is at an all-time high, but the discrepancy between males and females remains. Males born in 2014 have a life expectancy of 76 years, compared with 81 years for females. This suggests a trend toward narrowing the gap between male and female life expectancies. Ethnic/racial disparities in life expectancy unfortunately continued into the twenty- first century, as there is considerable variation among races. For example, black females gained an additional 7.1 years, from 69.4 years for those born in 1970 to 78 years for those born beginning in 2005. Although that is a significant gain, it falls behind the 81 years of life expectancy for white females born in 2014 and has not changed since 2005 (Hoyert and Xu, 2012).
Mortality Rate Table 17.1 lists the six major causes of death among American women in 2009 by age group (Centers for Disease Control and Prevention [CDC], 2009, 2016). As age increases, the leading causes of death change. In the adolescent to early adulthood years, the leading cause is unintentional injuries (i.e., motor vehicle accidents, drug overdose). Changes since 2007 include (1) increased rate of suicide for 15- to 44-year olds, (2) increased proportion of deaths from chronic liver disease in 25- to 44-year-olds, and (3) stabilization or decrease in death from pregnancy complications in 20- to 34-year-olds. As middle age approaches, cancer becomes the number-one cause for women aged 35 to 85+ years, with the exception of the 75- to 84-year-olds who are more likely to die from heart disease.
Research Highlights
Nurse Researchers Study the Inclusion of Women in Research A group of nurse researchers (Crane et al., 2004) examined more than 1000 articles published in nursing journals between 1995 and 2001 to determine whether women had been included in research studies focusing on the leading causes of mortality. They found that 87% of the studies did include women participants. They also noted that there appeared to be a slight increase in inclusion of women from the earlier years to the later years.
TABLE 17.1
Six Leading Causes of Death Among American Women for All Races by Age Groups In 2009
Age Group (Years) Cause of Death (in Rank Order) 15–19 Unintentional injury or accidents (43.9%)
Suicide (9.1%) Homicide (8.1%) Cancer (8.1%) Heart disease (3.4%) Birth defects (3.1%)
20–24 Unintentional injury or accidents (36.8%) Suicide (9.1%) Homicide (8.1%) Cancer (7.8%) Heart disease (4.9%) Pregnancy complications (3.6%)
25–34 Unintentional injury or accidents (26.5%) Cancer (13.9%) Suicide (7.7%) Heart disease (7.6%) Homicide (5.6%) Pregnancy complications (3.0%)
35–44 Cancer (25.3%)
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Unintentional injuries (15.8%) Heart disease (11.9%) Suicide (5.5%) Stroke (3.1%) Chronic liver disease (3.0%)
45–54 Cancer (34.6%) Heart disease (14.4%) Unintentional injuries (9.0%) Stroke (3.8%) Chronic liver disease (3.6%) Chronic lower respiratory disease (3.3%)
55–64 Cancer (40.1%) Heart disease (26.6%) Chronic lower respiratory disease (5.7%) Stroke (3.8%) Diabetes mellitus (3.8%) Unintentional injuries (2.9%)
65–74 Cancer (36.5%) Heart disease (19.1%) Chronic obstructive pulmonary disease (8.9%) Stroke (4.7%) Diabetes mellitus (3.7%) Kidney disease (2.2%)
75–84 Heart disease (23.8%) Cancer (23.5%) Chronic obstructive pulmonary disease (8.0%) Stroke (7.0%) Alzheimer disease (4.6%) Diabetes mellitus (3.1%)
85+ Heart disease (31.1%) Cancer (10.5%) Stroke (8.0%) Alzheimer disease (8.0%) Chronic obstructive pulmonary disease (4.6%) Influenza and pneumonia (3.0%)
Data from Centers for Disease Control and Prevention: Leading cause of death by age group, all females – United States, 2009. http://www.cdc.gov/women/lcod/2009/index.htm.
Cardiovascular Disease About one in four Americans has one or more forms of cardiovascular disease (CVD) (e.g., high blood pressure, coronary heart disease, stroke, congenital defects, or rheumatic heart disease). For women in the United States, CVD accounts for one out of every four deaths, making it the leading cause of death (CDC, 2016b). One in ten women under age 60 has some form of CVD; the ratio increases to one in three after age 65. Black women are more likely to die from CVD than are white women. In 2011, the CVD death rate among white women was 230.4 per 100,000, compared with 319.7 per 100,000 for black women. Black women are also more likely to die from stroke than white women (60.7 per 100,000 and 44 per 100,000, respectively) (American Heart Association [AHA], 2013).
CVD continues to be the number-one overall killer of women. One out of every 7.5 deaths is from CVD, whereas 1 out of every 30 deaths is from breast cancer. Since 1984, CVD caused more deaths among females than males. In 2011 51% of deaths from CVD were in women (AHA, 2013). The overall number of deaths due to CVD decreased dramatically from 424.2 per 100,000 in 1950 to 236 per 100,000 in 2010, with significant differences between white women (190.4 per 100,000) and black women (267.9 per 100,000). (CDC, 2016a)
Disparities have improved for women in relation to prevention, diagnosis, and management of heart disease through public awareness campaigns such as “Go Red for Women” and research focusing more on the unique aspects of women and heart disease (AHA, 2017). Despite an increased focus, 64% of women do not recognize that heart disease is their number-one cause of death. The number of cardiovascular deaths has decreased, but women were still more likely to die from a first myocardial infarction than men. In part, this phenomenon is due to the subtle or absence of symptoms of coronary artery disease (CDC, 2016d). Women have smaller arteries and higher rates of metabolic syndrome, diabetes, heart failure, and other comorbidities. They tend to be older at their first cardiovascular event, with more urgent and emergency presentations (Jacobs, 2003).
Rates of CVD among women can decline further when individuals become more aware of risk factors and accept responsibility for managing their own health and well-being (Kuehn et al., 1999).
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Concerned and motivated providers must encourage women to practice heart-healthy behaviors. In 2002, the American Heart Association launched the “Go Red” campaign for women and “The Heart Truth” program for health care providers, which were designed to educate both groups about the unique features of women and heart disease.
Cancer Cancer is the second leading cause of death in the United States. One out of four deaths in the United States is due to cancer (Siegel et al., 2014). Cancer rates rose through the early 1990s for a number of reasons, including lifestyle choices (smoking, diet, sun exposure), increasing exposure to environmental carcinogens, and, probably most important, greater life expectancy. Because of improvements in early detection, screening, and treatment of the major cancers, incidence rates have leveled off and in some cases decreased. To illustrate, death rates from cancer among women have increased from 136 per 100,000 in 1960 to 167.3 per 100,000 in 2000 (CDC, 2004). Yet there was a decline in the cancer death rate from 2002 to 2004, about 2% per year, which was “large enough to overcome the impact of the growth and aging of the population” (ACS, 2013). In 2013, there were 277,319 deaths among women as a result of cancer.
According to the American Cancer Society (2017b) in 1987 lung cancer surpassed breast cancer as the leading cause of cancer deaths in women, and death rates from lung cancer increased sharply until about 1990. The percentage of cancer deaths due to lung cancer leveled off in 2005 to 26% and remained stable through 2013 at 25%. Breast cancer was the second most common cause, accounting for 14% of all cancer deaths. Colorectal cancer, the third most frequent cause of cancer deaths, accounts for 8% of such deaths.
Other female-specific cancers include ovarian cancer (fifth most common), uterine cancer (sixth most common), and cervical cancer. Cervical cancer, in particular, has received considerable attention of late because it has been determined that 90% of women with cervical cancer have evidence of cervical infection with human papillomavirus (HPV) (ACS, 2016a). In June 2006, the U.S. Food and Drug Administration (FDA) licensed Gardasil (Merck and Co, Inc.), the first vaccine to prevent HPV infection (CDC, 2015e). Through March 2013, 57 million doses have been given (CDC, 2017d). Gardasil has been shown to be highly effective in preventing the most common types of HPV infection and was approved for use in females between 9 and 26 years of age.
The good news is that healthy lifestyle changes and early detection and intervention have contributed to the decreases in mortality rates from some cancers. For example, the death rate for colorectal cancer has been dropping since the mid-1980s as a result of early detection and treatment (ACS, 2014). Lung cancer deaths are beginning to show a slight decline that parallels a lower incidence of smoking by women older than 18 years (ACS, 2017b).
Five-year survival rates vary according to the type of cancer and stage at diagnosis. For instance, the 5-year survival rate for all clients with lung cancer is 19%. For those with localized breast cancer, it is 91%, decreasing to 23% for those diagnosed with distant metastases. Of cancers related to the reproductive tract, ovarian cancer has the lowest survival rate, as only around 46% of women survive for 5 years (ACS, 2017c). The 5-year survival rate is 66% for women with colon cancer and 68% for those with rectal cancer; this rate improves significantly with early detection (ACS, 2014).
Early diagnosis and prompt treatment are major factors in surviving many types of cancer. Routine cervical cancer screening begins at age 21, at which time a Papanicolaou (Pap) smear should be done every 3 years. Colorectal cancer screenings include annual fecal occult blood tests along with sigmoidoscopy every 5 years or colonoscopy every 10 years (ACS, 2017c).
Certain health choices may reduce an individual’s risk of cancer. Women reduce their risk for cancer by never smoking or by quitting if they already use tobacco products. Eating a nutritious, plant-focused, high-fiber diet along with adopting a physically active lifestyle and maintaining a healthy body weight protect against both heart disease and many cancers. Nutrition guidelines include avoiding salt-cured, smoked, nitrite-containing, and charred foods; high-fat foods; and excessive alcohol. Obesity has been associated with an increased risk for cancers of the colon and rectum, endometrium, and breast (ACS, 2016b). Finally, the practice of safe sex has been shown to reduce the spread of cancer associated with sexually transmitted diseases (STDs) such as HPV, hepatitis B and C, and HIV (ACS, 2016c; CDC, 2016b).
Community health nurses must encourage all females (i.e., from childhood to old age) to adopt these healthy lifestyle choices and pursue early cancer detection. Community health nurses play a major role in providing cancer control services that should be culturally sensitive and appropriate
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to the targeted aggregate. If providers and clients applied everything known about cancer prevention, approximately two thirds of cancer cases would not occur.
Diabetes In 2014, the number of diabetics in the United States reached 29 million, 9.3% of the population. Of 86 million American adults over age 20, 37% are considered prediabetic, and 51% of those over age 60 are affected (CDC, 2014a). The CDC estimates that at the current rate, one third of adults will have diabetes by 2050 (CDC, 2016b).
Diabetes mellitus is a chronic disease that causes the premature death of many women and overall ranks sixth in mortality among that group, being highest after age 45. Diabetes is the fourth leading cause of death among several aggregates, including Native Americans, blacks, and Asians, and is fifth among Hispanics (National Center for Health Statistics, 2013). Women are more likely to be seriously affected by the complications of diabetes, including CVD, stroke, vision loss, and depression (USDHHS, 2017).
In addition to being a serious illness in itself, diabetes is a risk factor for the development of CVD; furthermore, it dramatically influences the severity and course of CVD. In death certificates from 2004 on which the cause of death was related to diabetes, 68% also listed CVD and 16% also listed stroke (CDC, 2009). When comparing men and women with diabetes, of those who suffer a myocardial infarction before age 65, women are more likely to die and suffer long-term health problems (Norhammar et al., 2009). The good news is that the number of women hospitalized for diabetes and its complications has dropped, indicating that better management with tighter control of blood glucose has decreased complications (CDC, 2014a). The community health nurse is an important resource for supporting the tight control of diabetes to prevent its complications. An upstream approach to this problem includes helping women maintain a desirable weight throughout life in an effort to avoid nutrition-related causes of death such as diabetes and CVD.
BOX 17.1 Centering Pregnancy: Model for Prenatal Care Developed in 1993, the Centering Pregnancy model uses a group approach to prenatal care. The prenatal visit occurs with women of similar gestational ages and includes an assessment with the provider along with group learning, facilitated discussion, and support among women. The group dynamic contributes to health-promoting behaviors and to normalizing attitudes to pregnancy. Women report high satisfaction with the care and go on to have fewer preterm births and babies of optimal weight (Centering Health Care, 2013; Manant and Dodgson, 2011).
Maternal Mortality According to the WHO (2012), 800 women die every day from complications of pregnancy and childbirth, which are the leading cause of disability and death among women worldwide between the ages of 14 and 49 years. Maternal mortality in developing countries is 240 per 100,000 live births, whereas it is 16 per 100,000 in developed countries. Forty percent of women experience complications during pregnancy, childbirth, and the postpartum period, 15% of which are life threatening. Reduction of maternal mortality is one of the Healthy People 2020 objectives for the United States. See Box 17.1 for information on a group approach to prenatal care.
The United States ranks seventeenth in maternal mortality among all nations. Beginning in the 1950s, maternal mortality rates began to decline in the United States due to the use of blood transfusions, the availability of antimicrobial drugs, and the maintenance of fluid and electrolyte balance during serious complications of pregnancy and birth. The development of obstetrical training programs and obstetrical anesthesia programs was also important.
However, since 1987 the rate of maternal death has increased from 7.2 per 100,000 pregnancies to 17.3 in 2013 (CDC, 2016b). Some of this change may be due to updated methods for data collection. Before 2003, in the United States, maternal mortality was defined as the deaths of women while pregnant or within 42 days after termination of pregnancy. The U.S. Standard Certificate of Death and the tenth revision of WHO’s International Statistical Classification of Diseases and Related Health Problems (ICD-10) revised this definition in 2003 to include late causes of maternal death, defined as occurring more than 42 days but less than 1 year after the end of the pregnancy (Hoyert and Xu, 2012; WHO, 2007). Although this change may explain the increase in the mid-2000s, the continued
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increase in the death rate is still without clear etiology. Researchers cite maternal obesity, older age, and chronic health conditions along with an increasing cesarean section rate as contributing factors (CDC, 2017; Kaiser Daily, 2009). In 2013 the leading cause of maternal death was CVD, followed by other medical conditions, infection/sepsis, cardiomyopathy, pulmonary embolism, and hypertensive disorders (CDC, 2017).
Beginning in the 1950s, maternal mortality rates began to decline in the United States due to the use of blood transfusions, the availability of antimicrobial drugs, and the maintenance of fluid and electrolyte balance during serious complications of pregnancy and birth. The development of obstetrical training programs and obstetrical anesthesia programs was also important.
TABLE 17.2
Maternal Mortality Rate Per 100,000 Live Births—Selected Years
Data from Berg CJ, Callaghan WM, Syverson C, Henderson Z: Pregnancy-related mortality in the United States, 1998 to 2005, Obstet Gynecol 116(6):1302–1309, 2010.
Racial discrepancy persists, however, in maternal mortality rates as in life expectancy. Table 17.2 illustrates how nonwhite women have a significantly higher incidence of death during pregnancy than white women. The gap in maternal mortality rates between black and white women has widened over the past several decades. Early in the twentieth century, black women were two times more likely to die of pregnancy-related complications than white women. Currently, black women are nearly four times more likely to die (CDC, 2017). Major risk factors for maternal death include lack of antepartum care and family planning services, inadequate health education, and poor nutrition. An additional risk factor, regardless of race, is advancing age. Women 40 years and older have more than three times the risk of dying from a pregnancy-related cause as women aged 30 to 39 years (National Center for Health Statistics, 2017). Intrinsic maternal factors, such as higher frequency of hypertension and greater likelihood of uterine hemorrhage, help explain this increase in the mortality rate among older mothers.
Death associated with legal surgical abortion is rare in the United States, with four cases reported in 2012 (Jatlaoui et al., 2016). Complications that result in death from legal abortion relate to the woman’s age, the type of procedure, the gestational age of the fetus, and general health problems at the time of the abortion (Cates et al., 2004).
A medical, or induced, method of abortion using mifepristone (i.e., RU-486), an antiprogestin medication, together with prostaglandins has been used in the United States since September 2000. This method is as effective as surgical abortion and is considered a safe alternative to surgical abortion in pregnancies of less than 49 days (7 weeks). In 2013, 22% of the legal abortions in the United States employed this method. Curettage is still the most widely used abortion procedure.
Abortion is a controversial issue for providers and for the women in their care. Abortion rates have fallen significantly from 820,151 in 2005 to 664,435 in 2013, as has the rate of complications from this procedure. (Jatlaoui et al., 2016). Access to free contraception through the Affordable Care Act (ACA) and multiple long-acting methods have contributed to the decreased use of abortion. Nurses must continue to keep abreast of all available pregnancy prevention and termination options to provide the best counsel for women.
Ectopic pregnancy is the leading cause of maternal death in the first trimester. Since the 1980s, the incidence of ectopic pregnancy has decreased from 1.15 to 0.50 per 100,000 live births, the cause of death being hemorrhage in 67% of cases. Racial discrepancy is evident, with rates 6.8 times higher in African Americans. Rates are also 3.5 times higher in women older than 35 years than in those younger than 25 years. The rates are possibly higher because STDs are diagnosed more frequently in this older population and may cause damage and scarring of fallopian tubes, raising
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the risk of ectopic pregnancy (CDC, 2016b; Creanga et al., 2011). The most significant risk for ectopic pregnancy is previous pelvic inflammatory disease (PID) or
salpingitis. Early diagnosis and treatment greatly lower the mortality rate. Prevention interventions for women at risk for acquiring STDs are critical in reducing a woman’s risk for an ectopic pregnancy. An important task of health care providers is to educate women and men about methods to reduce sexual health risk-taking behaviors. Additional risk factors for ectopic pregnancy include tubal pathology, previous ectopic pregnancy, tubal surgery, and the use of intrauterine contraceptive devices.
Morbidity Rate Hospitalizations The 2010 National Hospital Discharge Survey reported that more women than men are hospitalized each year in the United States (Hall et al., 2010). Pneumonia resulted in an average hospital stay of 5.0 days, which occurred most frequently among women aged 65 or older. Fractures accounted for an average 5.1 days, malignant neoplasms for an average 6.5 days, and diseases of the heart for an average 4.4 days. The primary reason for hospitalization was childbirth, followed by circulatory, digestive, and respiratory diseases, and finally injury or poisoning (DeFrances et al., 2008).
The prospective payment system for hospitalization resulted in a greater demand for skilled nursing services in the home. After community members have been hospitalized for any of several of these conditions, community health nurses may provide ongoing nursing care in the home by referral. Nurses practicing in home environments must be prepared to deliver “high-tech” and “high-touch” services. Chapter 33 discusses home health care in detail.
Chronic Conditions and Limitations Women are more likely than men to be disabled by chronic conditions. Arthritis and rheumatism, hypertension, and impairment of the back or spine decrease women’s activity level more often than they affect their male counterparts. In fact, twice as many women (24.3%) as men (11.5%) are limited in activity from arthritis and rheumatism. Women are more likely than men to have difficulty performing activities such as walking, bathing or showering, preparing meals, and doing housework (Arthritis Foundation, 2014; CDC, 2009b).
Functional limitations may require home health care that community health nurses supervise and deliver. Nurses plan and implement interventions on the basis of functional assessments. Each care plan facilitates optimal resumption of the individual’s independence in personal care activities.
Surgery Women are more likely than men to have surgery. Hysterectomy is the second most frequently performed major surgical procedure among women of reproductive age after cesarean section. Approximately 600,000 hysterectomies are performed each year (CDC, 2015d). Hysterectomy rates for women in the South are slightly higher than those in the Northeast (6.3 and 4.9 per 1000 women, respectively). Overall, rates of hysterectomy decreased from 5.4 to 5.1 per 1000 in the years 2000 through 2004 (Whiteman et al., 2008).
According to the CDC (2016b), the most common reason for hysterectomy is uterine fibroids or leiomyoma, which contributes to more than one-third of all such surgeries, but considerably more in blacks (68%) than in whites (33%). White women are more often diagnosed with endometriosis and uterine prolapse, which are the second and third most common reasons for hysterectomy. Hysterectomy rates are the highest in women aged 40 to 44 years CDC, 2015c).
Optional procedures are becoming available to women. Myomectomy—removal of only the tumors with repair of the uterus—uterine artery ablation, and the use of a gonadotropin-releasing hormone to shrink the tumors can decrease the need for hysterectomy, but women may not know about these alternatives. Community health nurses function as advocates for women and can provide health education programs related to alternatives to hysterectomy, indications for hysterectomy and oophorectomy (i.e., removal of ovaries), and information regarding the type of surgical approach and the purpose of a second opinion. Second opinions and higher levels of education tend to lower the rate of hysterectomies (Finkel and Finkel, 1990).
Birth by cesarean section (C-section) is the most prevalent surgical procedure experienced by women in the United States and accounts for 32% of births. Several factors contribute to the high
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rates of C-section, including physician fear of malpractice suits, routine use of early induction of labor, and epidural anesthesia. The technology of fetal monitoring has been shown to increase the C-section rate without improving neonatal outcomes.
Mental Health The most frequently occurring interruption in women’s mental health relates to depression. Well- controlled epidemiological studies consistently demonstrate that women experience depression at two to three times the rate of men (American Psychological Association [APA], 2005). Symptoms of depression include depressed mood, apathy, anxiety, irritability, and thoughts of death and suicide (Evans et al., 1999). Unique to women are atypical symptoms including anxiety, increased appetite, weight gain, and somatic complaints along with increased rates of comorbid conditions. Women are more likely to attempt suicide but less likely to be successful (Urbanic, 2014). Women with socioeconomic barriers, such as lower income and lower educational levels, racial/ethnic discrimination, unemployment, poor health, single parenthood, and high-stress jobs, are at greater risk for depression than women with higher educational levels or higher economic status. Other risk factors are childhood negligence and abuse, parental death, negligence, and alcoholism (Urbanic, 2009).
Nurses practicing in community health settings should be aware of the signs and symptoms of depression and should identify referral sources for professional help within the community. The community health nurse plays a vital role in identifying mothers who suffer from postpartum depression. The CDC (2008d) reports that up to 12% of women suffer postpartum depression that interferes with a woman’s ability to care for herself, baby, and family. The nurse needs to also be aware of the impact a mother’s depression may have on her child’s development and family functioning. A woman experiencing depression displays a variety of symptoms, including depressed mood, weight changes, sleep disturbances, and fatigue, among others, which can be found in the Diagnostic and Statistical Manual of Mental Disorders (APA, 2013).
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Social Factors Affecting Women’s Health Health Care Access In 2012, 18.2% of the U.S. population, or 48.2 million U.S. citizens, lacked health insurance coverage (NCHS, 2017). With the passing of the ACA in 2012, the number of uninsured citizens had dropped to 28.5 million by 2016 (NCHS, 2017). The ACA required all insurers to provide coverage for essential services to women, including preventive screenings (cervical and breast cancer), pregnancy care, breast-feeding support, and contraception (NCHS, 2017). Young adults (i.e., those between ages 16 and 24 years) previously made up approximately 50% of individuals without health insurance, but can now obtain coverage or stay on their parent’s insurance until the age of 26. Women who choose not to enroll in the ACA are not likely to seek health care until they or a family member is in acute distress. Others may rely on home remedies, over-the-counter drugs, or folk healers for health care. Older women on fixed incomes may have difficulty meeting copayments required by Medicare and paying for prescription medications. Many senior citizens have paid hospitalization insurance premiums for policies that fail to meet the gap.
Education and Work In the workplace, women traditionally predominated as secretaries, administrative assistants, registered nurses (RNs), teachers, cashiers, and retail sales people. However, in the 1980s, more women began to enter professions traditionally held by men (e.g., lawyers, physicians, and dentists), and in 2008, more than half (51%) of young professionals were women (U.S. Department of Labor, 2016). In 1970, 55.4% of all women aged 25 or older were high school graduates, compared with 81.6% in 1995 and 85% in 2003. Of this same age group in 2009, 35% had completed college, which was more than three times the 1970 rate of 8.1% (U.S. Census Bureau, 2012). A growing number of women have earned degrees in traditionally male-dominated professions. Table 17.3 reflects the changes occurring in percentages of women receiving degrees in medicine, dentistry, law, and theology.
Employment and Wages In 2016, 57% of the workforce were women. In addition, more than half (64%) of women with young children (younger than 6 years) were working outside the home (U.S. Department of Labor, 2017). In 1950, only 12% of women were combining these roles (Chadwick and Heaton, 1992).
Several questions concerning women’s health and well-being relate to employment issues. A review of female-dominated versus male-dominated jobs discloses inequalities in wage and salary scales; despite the diminishing gap between women’s and men’s incomes, there is still much room for improvement. Table 17.4 depicts median annual income by sex and ethnicity for both men and women (DeNavas-Walt et al., 2012). Disparities in income, based on sex and ethnicity, are clear.
Women heads of households and their children are the poorest aggregate in the United States. This phenomenon is labeled “the feminization of poverty.” In 2014, the poverty rate for single female heads of household was 38.9%, compared with 8.2% for single male heads of households (National Women’s Law Center [NWLC], 2017). Race is a factor in the poverty rate as follows:
• Asian American 28.9% • Black 45.6% • Hispanic 46.3% • Foreign born 44.8% • Native American 56.9 % • White 32.0%
The nurse working with impoverished families should be aware of social services, child care programs, emergency services, and other resources for families in need. The community health nurse often needs to act as case manager and advocate for families with social service agencies and other public entities.
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TABLE 17.3
Percentages of Degrees Received by Women
From U.S. Department of Education: Digest of education statistics, Washington, DC, 2008, Author.
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Working Women and Home Life Added to inequalities outside the home are inequalities within the home. A working woman is less likely to have a spouse or partner help with the home and children. Even when a spouse or partner is present, the burdens of housework and child care usually fall more heavily on the woman, regardless of ethnicity. Mothers generally spend more time than fathers preparing meals and training and disciplining their children. These multiple-role demands and conflicting expectations contribute to stress (American Academy of Pediatrics, 2003; Matthews and Power, 2002).
However, changes are occurring, as both younger and older men now report spending more time in family activities than middle-aged men. Black and Hispanic men tend to spend a little more time working at family tasks than white men. Books and articles encourage wives and husbands to make their needs known, encouraging greater communication between partners. Marriage enrichment programs, often offered through churches and synagogues, teach couples how to communicate more effectively with each other, fostering equality between partners.
Family Configuration and Marital Status Women are members of multiple family configurations (e.g., nuclear families, extended family units, single-parent units, families of group marriages, blended family units, adoptive family units, nonlegal heterosexual unions, and lesbian family units). This diversity causes changes in women’s roles within families. Whether or not they function in a traditional role, most women do whatever is necessary to maintain the integrity of their families. Early assessment of the strengths of family units by the community health nurse provides a database for positive nursing interventions established on upstream strategies to enhance each family’s level of health and well-being.
Many women are delaying marriage, and an increasing number are not marrying. Overall, marriage rates have remained stable, perhaps because the increasing number of remarriages balances the declining rate of first marriages. When a relationship ends in divorce or separation, more women than men have the responsibility of providing for themselves and their children. Single mothers are most often the head of a single-parent family. Even in the face of changing lifestyles, divorce, and increased mobility, which leads to long-distance relationships, most Americans report that they remain connected to their extended families through parents, grandparents, siblings, aunts, and uncles.
One contemporary family configuration involves single women with one or more adopted children. Single-parent adoptions are legal, and a growing number of single women are becoming adoptive parents. An often-ignored family structure is one headed by a lesbian parent. Since the Supreme Court made gay marriage a right in 2015, same-sex couples have made progress in establishing families. Lesbians who become parents have needs similar to those of all mothers. Many cities have lesbian-gay parent groups that provide support, anticipatory guidance, and strategies for coping in society. However, lesbian women often neglect their own health. This self- neglect may be traced to hostile and rejecting attitudes of health care providers (Zeidenstein, 2004). However, the parents or guardians must remain healthy to ensure the child’s well-being.
TABLE 17.4
Median Annual Earnings by Type of Household in 7 Years Between 1969 and 2011
From DeNavas-Walt C, Proctor D, Smith J: Income, poverty, and health insurance coverage in the United States: 2011 (U.S. Census Bureau Current Population Reports), 2012. http://www.census.gov/prod/2008pubs/p60-243.pdf.
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Active Learning
Review county or state health department statistics for leading causes of death among women of varying ethnic or racial groups.
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Health Promotion Strategies for Women A woman’s ability to carry out her important roles can affect her entire family; therefore women should receive services that promote health and detect disease at an early stage. Early detection and improved treatments for disease allow women to return to work or remain working throughout the course of an illness. Although work is essential to the economic and social well-being of many women’s families, the workplace itself creates physical and social stress. As more women enter the workforce and face many of the same risks and stressors as men do, it is not surprising that their formerly favorable mortality and morbidity rates have been declining.
Many women seek information that will allow them to be in control of their own health. Since the early 1970s, women have met in self-help groups to develop a better understanding of their own health needs. Some of the health behaviors that women learn in these groups are the importance of nutrition and exercise, health maintenance, pregnancy testing and contraceptive awareness; recognition of the early signs of vaginal infections and STDs; and awareness of the variations in female anatomy and physiology.
For women who desire to become more knowledgeable about their own health, books are available in bookstores, in public libraries, and among the holdings of traditional women’s groups such as sororities and federated women’s clubs. An excellent resource for women is the FDA Consumer (http://www.fda.gov/fdac/), the official consumer site of the FDA, which reports on studies that cover a variety of women’s health issues such as mammography standards, menopause, treatment for STDs, eating disorders, infertility, cosmetic safety, silicone breast implants, and osteoporosis. Another resource is the U.S. Department of Health and Human Services’ Office on Women’s Health (www.WomensHealth.gov), which highlights positive health behaviors for women and girls. The community health nurse can use models such as Pender’s Health Promotion Model in teaching health behaviors that lead to general health promotion among women. Pender notes that health-promoting behaviors are directed toward sustaining or increasing the level of well-being, self-actualization, and fulfillment of a given individual or group (Pender et al., 2006). However, because many models were developed for the middle class, they may not be useful to community health nurses working with low-income families.
Knowledge deficits related to body awareness prevail among all women, regardless of socioeconomic or educational level. For example, a woman may ask whether she will menstruate after a hysterectomy, whether she should perform a breast self-examination (BSE), or what she can do to prevent recurrent episodes of vaginitis. Nurses can play an instrumental role in helping women develop a greater sense of self-awareness. Furthermore, community health nurses can remove the mystery surrounding the woman’s body and encourage clients to ask previously unmentionable questions.
Chronic Illness Included among chronic diseases that may affect a woman during her life span are coronary vascular disease and metabolic syndrome, hypertension, diabetes, arthritis, osteoporosis, and cancer.
Coronary Vascular Disease and Metabolic Syndrome Evidence suggests that CVD and metabolic syndrome in most women are preventable. CVD is caused by atherosclerosis, which results in buildup of plaque that in turn narrows arteries, decreasing blood flow to the heart muscle. Metabolic syndrome is a group of risk factors that have been linked to an increased risk of cardiovascular events. These factors are abdominal obesity (waist circumference more than 35 inches in women), dyslipidemia (elevated triglyceride and low high-density lipoprotein cholesterol values), insulin resistance, and elevated blood pressure. The underlying etiology of metabolic syndrome is related to the combination of inactivity, obesity, and genetics.
At-risk women have nonmodifiable risk factors such as increasing age, race, gender, or family history of CVD and diabetes. Where the greatest impact can be made is with the modifiable risk factors, which are as follows (AHA, 2013):
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• Cigarette smoking • Obesity • Diet high in calories, total fats, cholesterol, refined carbohydrates, and sodium • Glucose intolerance • Elevated serum lipid values • Sedentary lifestyle • Personality type • Hypertension • Stress • Alcohol use
Education by community nurses can assist women in identifying their risk of CVD and metabolic syndrome along with health behaviors that decrease modifiable risk factors. Also important are evidence-based recommendations for high-risk women with existing CVD, including aspirin therapy and omega-3 fatty acid supplementation (Mosca, 2007).
Hypertension The latest report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure defines hypertension as blood pressure of 140/90 mm Hg or greater diastolic. If the client is over the age of 60, the threshold is 150/90 (James et al., 2014). Essential hypertension is the most common type of chronic hypertensive disorder in women. Approximately one third of hypertension cases occur during pregnancy as gestational hypertension or preeclampsia. Essential hypertension is the most common type of chronic hypertensive disorder in women, accounting for 85% of such cases. It is also responsible for approximately one third of all hypertension cases during pregnancy. Hypertension is more common in women than in men and affects more blacks than whites. Hypertension usually starts with an asymptomatic phase; therefore every woman should be screened on an average of every 2 years beginning in her teenage years. Diagnosis is crucial to prevent or modify possible complications of this disease.
Diabetes According to the CDC (2016b), 29 million people (9.3% of the population) have diabetes in the United States, and the number is growing every year. Furthermore, although an estimated 20.9 million have been diagnosed, some 8.1 million people are not aware they have the disease. In previous years, community health nurses have worked to educate women to assume responsibility in their management of diabetes mellitus. More recently, community health nurses have been actively involved in education and screening programs for groups at high risk. Included in these groups are individuals who have a family history of diabetes, those who are obese, and older adults. Nurses who design education programs need to be aware of the ethnic differences in the prevalence of diabetes. African American, Hispanic, American Indian, and Asian women are two to four times more likely to have diabetes than their non-Latino white counterparts (USHHS, 2011).
Pregnancy is potentially diabetogenic (Cunningham et al., 2010). Pregnancy may aggravate the condition, and clinical diabetes may appear in some women only during pregnancy. Consequently, screening for diabetes is routine in pregnancy. Annual screening for type 2 diabetes should occur beginning at age 45. Screening methods include the fasting blood glucose, hemoglobin A1C, or 2- hour oral glucose tolerance test (CDC, 2014a). The nurse is involved in explaining the purpose of the screening and how to prepare for the tests. In most public health settings, the nurse is responsible for explaining the results.
Arthritis In 2009, 50 million people in the United States, nearly one in five adults, were afflicted with arthritis. The incidence of arthritis is higher in women than in men: approximately 25.9 million women have the condition, compared with 18.3 million men (CDC, 2010).
Osteoarthritis (OA) is the most common form of the disease. It is characterized by degeneration of the joints and is more common with increasing age and in women. OA of the knee is the leading cause of disability in the United States. Modifiable risk factors for OA include excess body mass, joint injury, occupation, and estrogen deficiency (CDC, 2017a).
Rheumatoid arthritis (RA) can affect anyone, but for every man affected, 2.5 women have the
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disease. Onset usually occurs between 30 and 50 years of age. RA often goes into remission in a pregnant woman, although symptoms tend to increase in intensity after the baby is born, and RA develops more often than expected the year after giving birth. Although women are two to three times more likely to have RA than men, men tend to be more severely affected when they do have it (Arthritis Foundation, 2014).
Arthritis is the leading cause of disability in the United States (CDC, 2017b). Nursing interventions focus on prevention of joint deformity and modification of lifestyle if necessary.
Osteoporosis Osteoporosis is a major disorder affecting women, occurring in 25% to 50% of postmenopausal women. Although men may experience osteoporosis, it is four times more common among women. The National Osteoporosis Foundation (2014) estimates that of the 10 million Americans who have osteoporosis, 8 million are women and 2 million are men. An additional 34 million Americans have osteopenia. Half of all non-Hispanic white women in the United States will experience an osteoporosis-related fracture during their lifetimes. The most serious complication of osteoporosis is hip fracture, which is experienced by 280,000 Americans annually. Approximately 24% die within a year from complications of hip fracture.
Postmenopausal white women are at highest risk for osteoporosis. Loss of bone begins at an earlier age in women and proceeds twice as rapidly as in men. Guidelines issued by the National Osteoporosis Foundation recommend bone mineral density tests for selected postmenopausal women and the use of oral bisphosphonates as the first-line pharmacological treatment. In light of the results of the Women’s Health Initiative Study showing that nonestrogen therapies fail or cause intolerable side effects, hormone replacement therapy is currently considered second-line therapy for the disease (Wei et al., 2003). Osteoporosis has no cure; therefore prevention is especially important early in life. Prevention involves an awareness of dietary practices such as maintaining a correct balance of calcium, vitamin D, and protein throughout life, in addition to regular weight- bearing, muscle-strengthening, and aerobic exercise.
Nurses in ambulatory health practices should encourage women to become more knowledgeable of the strategies to prevent osteoporosis. For women diagnosed with this condition, nurses can assist in various aspects of management (e.g., education regarding prescribed medication, follow- up care, avoidance of complications, and dietary modifications as needed).
Breast Cancer The incidence of breast cancer has been rising since the 1950s. Currently, one out of every eight women will have breast cancer sometime in her life. The chance of dying from breast cancer is about 1 in 35. In 2013 230,815 women in the United States were diagnosed with breast cancer and 40,860 died from it (CDC, 2016b). Risk factors include aging, personal or family history (especially mother or sister) of breast cancer, early age at menarche, late age at menopause, never having children, and having a first child after age 30. Female gender and aging are the most significant risk factors for breast cancer (ACS, 2016b). An additional risk is a genetic mutation of tumor suppressor genes known as BRCA1 and BRCA2. The lifetime risk for women with this mutation to be diagnosed with breast cancer is 60%, compared with 12% for the general population. Additional risks are for ovarian cancer, with a 40% lifetime risk for those who inherit the gene, compared with 1.4% for the general population (NCI, 2013a). Genetic testing is available, and the rights of those tested is protected legally, so insurers and employers cannot use this information to discriminate against those testing positive (Genetic Information Nondiscrimination Act, 2008; NCI, 2013a, 2013d).
In 2009 the United States Preventive Services Task Force published recommendations based on a review of scientific evidence that women should not have routine mammography screening between ages 40 and 49 years but should have biennial screenings between the ages 50 and 74 years. This was a major shift from the recommendation of annual screening mammograms for women older than 40 years. The researchers cited the reason for this recommended change as improvements in mammography screening films that led to more accurate diagnosing. They also cited the high cost and harmful psychological effect of screening on women related to unnecessary diagnostic testing resulting from the high number of false-positive results. Despite that recommendation, the American Cancer Society (2012) continues to recommend annual mammograms after age 40, whereas the National Cancer Institute (NCI) (2013c) recommends
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screening every 1 to 2 years, except in women at higher risk, who should begin before age 40. Key to mammogram screening is a woman’s informed choice based on individual risk factors for development of breast cancer as well as the benefits (early detection and improved survival) and potential harms (false-positive results or missed cancer).
The current position of the U.S. Preventive Services Task Force is that there is insufficient evidence to recommend for or against the teaching of BSE (Thomas et al., 2002). The ACS (2016c) also no longer supports the routine use of self breat exam (SBE) or clinical breast examination (CBE) for screening because of this lack of evidence. Instead, women are encouraged to be familiar with the normal look and feel of their breasts and to report changes to a health care provider.
For women at low risk who are 40 years and older, the greatest potential to save lives from breast cancer is through early detection with mammography (ACS, 2016a). In addition to annual mammography and CBEs, breast cancer detection may involve ultrasound, MRI, positron emission tomography, and genetic testing for BRCA1 and BRCA2 (NCI, 2013a). Box 17.2 lists resources that provide information about breast cancer and early detection.
Research Highlights
Breast Cancer Study A study of the data collected in the U.S. National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program demonstrated an increase in the incidence of breast cancer with distant involvement in younger women. From 1976 to 2009 there was a 2.07% average compounded increase in this diagnosis in women 25 to 39 years old but not in older women. This increase was highest in Hispanic and African American women (Johnson, 2013).
The CDC looked at data from United States Cancer Statistics to determine whether race affected breast cancer outcomes. Black women had a lower incidence of breast cancer diagnosis than white women, yet cancers were diagnosed at more advanced stages and the death rate was 41% higher in the former group from 2005 through 2009 in the United States. Self-reports of mammogram frequency did not differ in the two groups. However, research shows that in black women, differences do exist in breast cancer screening, follow-up, and treatment after diagnosis, leading to greater mortality (Cronin et al., 2012).
Lung Cancer Although breast cancer is the most common cancer among women after skin cancer, cancer of the lung and bronchus is responsible for more cancer deaths. In 2013, 219,709 women were diagnosed with lung cancer. Lung cancer is responsible for more deaths yearly in U.S. women than breast cancer. From 2005 to 2009, 39.6 of every 100,000 women died from lung cancer, compared with 21 per 100,000 from breast cancer (U.S. Cancer Statistics Working Group [USCSWG], 2016). In fact, lung cancer kills more women annually than breast, ovarian, and uterine cancers combined (ACS, 2016c). Between 1990 and 2003, there was a 60% increase in the number of new cases of lung cancer in American women, whereas the number of men diagnosed with lung cancer remained stable (Patel, 2005). The rise in the incidence of lung cancer in women is due primarily to an increase in their tobacco use: 85% to 90% of all clients who have lung cancer have a history of cigarette smoking. Yet lung cancer develops in only 20% of cigarette smokers, suggesting that the cause of lung cancer is multifactorial.
Widely accepted risk factors for lung cancer include exposure to environmental tobacco smoke, certain occupational exposures (especially asbestos), genetic predisposition, sex, gender, diet, chronic lung disease, and a history of tobacco-related cancer (Rivera and Stover, 2004). Studies have shown that the risks for development of lung cancer are different in women and men and that lung cancer appears to be a biologically different disease in women. Women smokers are more likely than men to have adenocarcinoma of the lung, and women who have never smoked are more likely to have lung cancer than men who have never smoked. These differences are due to hormonal, genetic, and metabolic differences between the sexes (Patel, 2005).
Although medical treatment may be similar for men and women, the symptom distress, quality of life, and demands of illness experienced by women may be different from those in men, because the competing household, child care, and other role-related demands take a toll on many women
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(Sarna and McCorkle, 1996). Further, women with advanced lung cancer report more psychological symptoms than men (Hopwood and Stephens, 1995).
BOX 17.2 Resource Materials for Breast Cancer
BCCCP (Breast and Cervical Cancer Control Program)
Federally funded free breast and cervical cancer screening through state departments of community health
American Cancer Society Website
Breast Cancer: Early Detection (available from http://www.cancer.org/acs/groups/cid/documents/webcontent/003165-pdf.pdf)
Publications
Breast Cancer Awareness Information Packet ABC’s of Breast Health The Older You Get, the More You Need a Mammogram (pamphlet) Breast Health (card) How to Check Your Breasts (pamphlet) Let’s Talk About Mammograms (pamphlet)
For copies, call (800) ACS-2345. For more information, visit http://www.cancer.org/acs/groups/cid/documents/webcontent/003165-pdf.pdf. National Cancer Institute Website
General Information About Breast Cancer (available from http://www.cancer.gov/cancertopics/pdq/screening/breast/Patient/page2)
Publications and Videos
A Mammogram Once a Year … For a Lifetime (video) Smart Advice for Women 40 and Over: Have a Mammogram (pamphlet) Guidelines for Screening Mammography (pamphlet) A Mammogram Could Save Your Life∗ Take Care of Your Breasts
For copies, call (800) 4-CANCER. For more information, visit http://www.cancer.gov/cancertopics/pdq/screening/breast/Patient/page2. U.S. Department of Health and Human Services, and Health Care Financing Administration
Get a Mammogram: A Picture That Can Save Your Life (pamphlet) Medicare Covers Mammograms (pamphlet)
For copies and more information, call (800) 4-CANCER (breast cancer and mammograms) or
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(800) MEDICARE (Medicare coverage).
∗ Specifically designed for low-literacy audiences; some resources are available in Spanish and English.
Lung cancer is often a fatal illness because it is diagnosed most commonly at an advanced stage; early detection is difficult, and treatment for advanced disease is not as effective. Women appear to have a slight survival advantage over men: the 5-year survival rate is 15.6% for women with lung cancer and 12.4% for men (Patel, 2005).
The primary factor in preventing lung cancer is for individuals either to never start smoking or to quit smoking. Nurses must work with other health care providers to reverse the morbidity and mortality rates related to this disease. The Agency for Healthcare Research and Quality has developed a useful guideline for health care professionals to assist women and their families in smoking cessation efforts plus summaries of more than 400 guidelines on a wide variety of topics, which can be found on their website (http://www.ahrq.gov).
Gynecological Cancers About 20% of all malignant diseases in women occur in the genital tract. The incidence of invasive cervical cancer has declined dramatically as a result of regular Pap smears, which allow for identification of precancerous conditions. However, 4217 women died from the disease in 2013 (CDC, 2015c). Cervical cancer used to be the leading cause of cancer death, but the use of cytological screening has decreased the mortality rate. One major risk factor is infection with HPV, which is linked to nearly all cervical cancer cases. Other risk factors include coitus at an early age, multiple sexual partners, cigarette smoking, history of Chlamydia infection, long-term oral contraceptives, intrauterine device, multiple pregnancies, pregnancy at a young age, HIV, family history, and low socioeconomic status (ACS, 2016b). It is most commonly diagnosed in women between the ages of 30 and 50 years, because the cellular changes that lead to cancer are caused by chronic infection and inflammation. It is uncommon for women who undergo regular screening to be diagnosed with cancer.
Current guidelines recommend cervical cancer screening to begin at 21 years of age. Screening should then be performed every 3 years until age 65 using liquid-based Pap smear tests. After age 30, cotesting for HPV DNA (CDC, 2015b) is acceptable. Because HPV is a common virus affecting 80 million people, routine screening for HPV is not recommended in women younger than 30. HPV infection is responsible for the majority of these cancers: 90% anal, 70% vaginal and vulvar, 60% penile, and 70% throat (CDC, 2016a). Current recommendations are that girls and boys be vaccinated for HPV beginning at the age of 11 or 12 years. Between 2006 and 2016, 79 million doses of HPV vaccine had been administered without serious safety concerns (CDC, 2017d). Because of the ACA, vaccinations are covered by private insurers and through the Vaccines for Children Program for eligible children who would otherwise not have access (CDC, 2012).
According to the CDC (2017) and ACS (2017a), the incidence of endometrial cancer is highest among white women, but mortality is higher among black women, suggesting disparity in diagnosis and/or treatment. This cancer is commonly found in women during their sixth and seventh decades of life (i.e., 80% of women with this condition are postmenopausal). It is estimated that in 2017 61,380 women will be diagnosed with endometrial cancer and 10,920 will die. Factors related to its occurrence are obesity, low parity, diabetes mellitus, and conditions in which high circulating estrogen levels are not countered by adequate progesterone levels. The most common sign of endometrial cancer, occurring in 90% of women, is abnormal vaginal bleeding. Postmenopausal women experiencing vaginal bleeding should seek immediate gynecological evaluation.
Cancer of the ovary causes more deaths than any other pelvic malignancy, although the mortality rate has fallen 1.6% per year since 2001 (NCI, 2017). The lifetime risk of ovarian cancer is 1.38%. The incidence increases with age, peaking in women 75 to 79 years old at 56.7 per 100,000. Risk factors include increasing age, nulliparity, never having breast-fed, a history of breast cancer, postmenopausal use of hormone replacement therapy, obesity, a family history of breast and ovarian cancer, and testing positive for the BRCA mutation. Protective factors against ovarian
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cancer include use of oral contraceptives, having and breast-feeding children, tubal sterilization, hysterectomy, and prophylactic oophorectomy (NCI, 2017).
Ovarian cancer is a silent cancer. Early-stage detection is difficult; therefore it has usually reached an advanced stage when discovered. The health professional should be alert to ovarian enlargement on pelvic examination with suspicion that ovarian malignancy may be present, especially in a postmenopausal woman. The most common sign a woman experiences is abdominal enlargement. She may complain that her skirts and slacks are getting tighter in the waist. Any woman older than 40 years who experiences vague digestive complaints that persist and are not explained by another cause must have a thorough evaluation for ovarian cancer. According to the ACS (2017d), transvaginal ultrasound, MRI, or computed tomography scan along with a blood test for tumor marker CA-125 may assist in the diagnosis of ovarian cancer. These tests are not recommended for routine screening of all women, but are recommended for those with risk factors related to family history (strong family history of ovarian and breast cancer, positive for genetic mutations BRCA1 and BRCA2).
Mental Disorders and Stress Various circumstances and conditions influence the mental health of women. Women face stressful decisions about career and family, and many express anxieties about these decisions. A woman may feel pressured to make decisions regarding childbearing before she has fulfilled her career goals. Deciding to focus on a career may mean decreased authority and the suffering of stress in the workplace. More women are occupying middle-management positions, which are known for creating stress-related illnesses associated with high demands and little or no power. Women combining motherhood and a career have additional decisions, such as whether to work during pregnancy and choice of child care.
A woman’s emotional state can be influenced by ovarian function from the onset of menstruation to the cessation of menstrual periods. Depression may be triggered or worsened by premenstrual hormonal changes. Women with a history of depression are also at increased risk for a recurrent episode of depression during the postpartum period, and they also are at risk for depression during the perimenopausal transition (Blehar, 2003). Depression is more prevalent among women than among men. In all age groups from adolescents through the elderly, approximately two thirds of those affected with depression are women. According to Bhatia and Bhatia (1999), the higher prevalence of depression in women is most likely due to a combination of gender-related differences in cognitive styles, certain biological factors, and a higher incidence of psychosocial and economic stressors.
Mental disorders often go undiagnosed and untreated or undertreated despite the availability of effective treatments. Women may not recognize or correctly identify their symptoms, and even when they do, they may be reluctant to seek care because of stigma associated with mental illness (Blehar, 2003). Community health nurses are in a good position to assess women’s moods in diverse aggregates. Being familiar with the symptoms of common mental disorders, nurses can identify these problems and can help women seek and maintain continuity of care.
Reproductive Health Community health nurses provide a variety of services in the area of women’s reproductive health from menarche through postmenopause. Nurses, in collaboration with other health care professionals, have identified a persistent group of preventable and correctable problems related to maternal-child health. Healthy People 2020 (USDHHS, 2017) provides numerous recommendations for improving maternal and infant health, including reduction of cigarette smoking, reduction of alcohol and other drug use, optimal nutrition, improved socioeconomic opportunities (including education), and decreased environmental hazards.
For the Healthy People 2020 initiative, some of the family planning objectives demonstrated progress. Adolescent pregnancy rates decreased until the year 2005, but a 5% increase occurred between 2005 and 2007 (CDC, 2009). Adolescent pregnancy (ages 15–19) rates have decreased since 1991, from 61.8 per 1000 to 26.5 per 1000 in 2013 (CDC, 2015a). The improvements have been attributed to reduced sexual activity, low-cost and long-acting contraceptives, and condom use. Health disparities remain an issue for Hispanic and black populations. With Healthy People 2020 family planning objectives, the focus is on the positive that “all pregnancies should be intended.”
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Examples of Healthy People 2020 objectives related to family planning are shown in the Healthy People 2020 box (National Center for Health Statistics, 2012).
Dysmenorrhea is another reproductive health problem affecting approximately 50% to 80% of the female population between ages 15 and 24 years (Nelson, 2004). At least 10% to 20% of women with dysmenorrhea are incapacitated for 1 to 3 days each month. Dysmenorrhea is the greatest single cause of absenteeism from school and work among young women and causes the loss of approximately 140 million working hours annually; therefore the economic influence of this condition is significant.
Ethical Insights Working With Women’s Health Community health nurses working in the field of women’s health will be exposed to ethical dilemmas during their careers. For this reason, nurses must have a working knowledge of the principles of health care ethics. The commonly accepted principles include the following:
• Respect for autonomy • Beneficence • Nonmaleficence • Justice
Nursing care revolves around moral values such as compassion, empathy, honesty, trust, and respect. Most encounters will be nonproblematic. Occasionally, nurses may be exposed to clinical situations that challenge their values and beliefs. Clients and family members may, at times, also disagree with the nurse’s professional advice/plan. It is important for the nurse to keep his or her personal philosophy, politics, religion, and moral values out of clinical work with individuals and families.
Examples of potential ethical dilemmas related to women’s health care are emergency contraception, abortion, assisted reproductive technology, and end-of-life issues.
The average age of menopause in the United States is 51 years. Menopause is defined as the cessation of menses for at least 1 full year, but it is characterized by several years of symptoms as the hormonal shifts occur, called perimenopause (Schuiling and Likis, 2016). At this stage, women’s health concerns become focused on the symptoms associated with this transition. The most common complaints are related to vasomotor changes causing hot flushes, increased heart rate, insomnia, and night sweats; urogenital atrophy causing incontinence; vaginal dryness and dyspareunia; and mood alterations, including irritability, depression, and anxiety (Schmidt, 2012). Community health nurses can play a key role in helping women find resources to deal with symptoms and develop an understanding of the normal processes associated with menopause. Also, women in menopause need guidance in promoting a healthy lifestyle because they have an increased risk for development of chronic conditions such as osteoporosis, coronary heart disease, hypertension, and type 2 diabetes.
Nutrition One of the most important factors in a woman’s reproductive health is her total life nutritional experience from infancy through childhood and adolescence. Obesity has become a major public health concern. The community health nurse is in an advantageous position to provide nutritional counseling. The U.S. Department of Agriculture updates the dietary recommendations every 5 years on the basis of current scientific information. In 2011, the “My Plate” approach to healthy eating was unveiled. This approach is intended to encourage persons to be mindful of the foods they eat in terms of both portion size and proportion to other foods. One-half of the plate should consist of fruits and vegetables, with one-quarter each for meats/proteins and grains, preferably whole grains. Recommendations also include eating less sodium and fewer sugary foods (U.S. Department of Agriculture, 2013).
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Healthy People 2020
Selected Objectives for Family Planning
Data from U.S. Department of Health and Human Services: Healthy people 2020, ed 3, Washington, DC, 2010, Author.
Pregnancy may provide a motivational factor for developing an awareness of proper nutrition. During the nutritional assessment of a prenatal client, the community health nurse can take the opportunity to determine dietary habits and initiate a referral to the Special Supplemental Food Program for Women, Infants, and Children. This program provides food vouchers for pregnant or breastfeeding women, infants, and children who are at nutritional risk.
Good nutrition must include factors other than kinds and amounts of foods. Elements to consider include age, lifestyle, economic status, and culture. For example, when counseling a pregnant adolescent, the nurse can include the primary person responsible for meal preparation. The nurse should include the adolescent in the planning of her diet, asking her to identify foods that she likes from those recommended. The nurse should make the adolescent aware of the influence of her nutrition on fetal growth and development. This information must be balanced with the young woman’s individual needs.
Sexually Transmitted Diseases STDs are commonly found among U.S. women. Community health nurses and other health providers, including physicians, nurse practitioners (NPs), nurse midwives, and social workers, must be prepared to provide age-appropriate STD prevention, education, and counseling.
In 2016, the CDC reported STD rates were the highest ever, the most common was Chlamydia trachomatis (1,526,658 cases), followed by Neisseria gonorrhea (395,216 cases), gonorrhea (395,216), and syphilis (23,872). This was the largest number of Chlamydia cases ever reported. Chlamydia infection is diagnosed three times more in women than men, most likely because of the CDC’s recommendation for routine screening of any sexually active woman of childbearing age to prevent infertility. Gonorrhea is also diagnosed more often in women, but particularly in black women, who are diagnosed 15 times more often than white women. The Gonococcal Isolate Surveillance Project demonstrated that gonorrhea was becoming resistant to treatment with CDC-recommended fluoroquinolone drugs in 2007, prompting the CDC to revise treatment guidelines (CDC, 2017).
When rates of syphilis, another STD, dropped nearly 90% between 1990 and 2000, the CDC initiated the National Plan to Eliminate Syphilis. However, rates have increased yearly since 2001. Racial disparity in cases of syphilis has improved from 1999, when 29 times more blacks than whites were diagnosed, down to a rate that is now 7 times higher. The increase in syphilis began mostly among men, especially men having sex with men, and less in women (CDC, 2017b). In 2014– 2015, there was a 19% increase in cases of syphilis.
Treatments of STDs are outlined in the CDC guidelines, which are updated regularly and available online (www.cdc.gov/std/tg2015/default.htm). A vital role of the community health nurse is to follow up with the woman’s sex partner(s) who require(s) evaluation and treatment. Partner notification and expedited treatment, along with avoidance of sexual activity until treatment/cure, are key to stopping the spread of STDs. In addition to medications, women and their partners need individualized counseling on reducing risky sexual behaviors.
Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome Today, the HIV/AIDS epidemic represents a growing and persistent health threat to women in the
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United States, especially young women and women of color. In 2015, 19% of the 39,513 new HIV diagnoses in 2015 were women (CDC, 2017b). Among women diagnosed with HIV/AIDS, 61% are black, yet black women make up only 12% of the general U.S. population. The majority of infants born with HIV are black. For all ethnicities, primary transmission in men occurs through sexual contact with other men, whereas in women, the route is high-risk heterosexual contact. As of 2015, HIV/AIDS is no longer a top 10 cause of death globally, thanks to more available treatment and increased use of safe sex practices (WHO, 2017).
According to the CDC (2009), risk factors for and barriers to prevention of HIV/AIDS for women include the following:
• Young age at sexual initiation • Lack of awareness regarding disease and condom use • Sexual inequality in relationships • Biological vulnerability to sexually transmitted infections • Substance abuse • Poverty; dropping out of school • Stigma surrounding testing and treatment • Working in the sex trade • Participants in unprotected sex
In November 2008, the USDHHS released the updated Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents (USDHHS, 2013). Treatment guidelines continually evolve with new research and experience. The use of antiretroviral drugs has reduced the rate of death for HIV disease in women, which peaked in 1993–1994 at 6 per 100,000, down to 2.5 per 100,000 (CDC, 2009). It is imperative that the community health nurse working with this population stays abreast of the current trends for both counseling and treatment options. Community health nurses also must target at-risk populations and campaign for the use of safer sex practices and routine HIV testing for those at risk.
Other Issues in Women’s Health Unintentional Injury or Accidents and Intimate Partner Violence Although unintentional injury affects women less commonly than men, several areas of concern still exist for women. For example, older women are at increased risk for accidents such as falls. Falls account for the majority of serious unintentional injuries and lead to 40% of all deaths from injury in people older than 75 years (Stevens, 2005). Factors that may be responsible for this major cause of injury among older adults are an unsteady gait, reduced vision, and a hazardous environment. Older women experience an increasing number of falls; therefore the nurse must identify the preventable factors. Whether working with older adults in the home or in institutional settings, nurses must be knowledgeable about hazards that may be corrected to decrease the incidence of falls.
Intimate partner violence (IPV), sometimes called domestic abuse, is the single largest cause of injury to women between the ages of 15 and 44 in the United States—more common than muggings, car accidents, and rapes combined. IPV is committed by a current or former boyfriend/girlfriend/spouse. In 2008, 552,000 females age 12 and over were victims of nonfatal, violent abuse.
Abuse in women is often explained as accidental injury. Approximately 6% of visits made by women to emergency departments are for injuries that result from physical battering by their husbands, former husbands, boyfriends, or lovers. Intimate partner violence includes physical, sexual, emotional, economic, and psychological abuse. A subset of intimate partner violence is dating violence, which occurs in a romantic relationship. Reports of teen dating abuse indicate that one in five teens reports some sort of abuse and one in four girls report being sexually coerced (CDC, 2013b).
Nurses employed in community health settings need to know how to make assessments, provide support, and make referrals to agencies dealing with intimate partner violence (see Boxes 17.3 through 17.5). Understanding the state laws related to reporting known or suspected intimate partner violence is important. The American Medical Association and American Nurses Association
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advocate that all women be assessed for IPV. Questions should be posed privately in nonjudgmental but specific terms (i.e., “Do you feel safe?” “Have you ever been hit, punched, slapped, or kicked?”) with follow-up questions if the woman responds “yes” (Kovach, 2004). Many nurses are past or current victims of abuse; assessing abuse with clients can evoke painful emotions that the nurse may not be ready to confront. Chapter 27 contains additional information about intimate partner violence.
Disability More women than men have disabilities resulting from acute conditions, but women experience fewer disabilities resulting from chronic conditions because they report their symptoms earlier and receive necessary treatment. Women report proportionately more days of restricted activity than men.
BOX 17.3 Intimate Partner Violence Strategies for Nurses It is important not to revictimize the woman who admits to intimate partner violence. Avoid asking the woman “why” or talking negatively about the abuser. Sit down with her, give her time to talk, listen actively. Provide her with privacy and confidentiality as much as you can. Useful statements include:
“I believe what you are telling me.” “I am here for you.” “This will only get worse.” “You deserve better.” “I am afraid for your safety.” “You deserve to be treated with respect.” “It is a crime.”
This approach will empower the victim. Episodes of imminent danger must be reported to the police. An emergency plan should be formulated with the woman. Resources including phone numbers for hotlines and the local women’s shelter should be provided in a format that is easy to conceal (such as on a business card). Adapted from Perry SE, Hockenberry MJ, Lowermilk DL, Wilson D: Maternal child nursing care, Maryland Heights, MO, 2010, Mosby, p 62.
BOX 17.4 Signs of Intimate Partner Violence
• Overuse of health services • Nonspecific, vague complaints • Missed appointments • Injuries without legitimate explanation • Injuries not matching reported cause • Untreated serious injuries • Intimate partner describing the cause of injuries • Intimate partner refusing to leave the woman’s room
Adapted from Krieger CL: Intimate partner violence: a review for nurses, Nurs Womens Health 12(3):224–334, 2008.
BOX 17.5 Resources For Victims of Intimate Partner Violence
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National Domestic Violence Hotline: 1-800-799-SAFE (7233) and http://www.thehotline.org Dating Violence on Women’s Health.gov: http://womenshealth.gov/violence-against-women/ National Coalition Against Domestic Violence: http://www.ncadv.org Office on Violence Against Women: http://www.ovw.usdoj.gov
Disabling conditions limit the physical functional abilities of many women, but the health care delivery system has often overlooked the unique needs of this aggregate. In planning care for disabled women, community health nurses should focus attention on enabling women to strengthe
