question #3

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Community and Public Health Nursing

Promoting the Public’s Health

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Community and Public Health Nursing

Promoting the Public’s Health TENTH EDITION

Cherie Rector, PhD, RN, PHN Professor Emeritus

Department of Nursing California State University, Bakersfield

Bakersfield, California

Mary Jo Stanley, PhD, RN, CNS, CNE Professor

Director, School of Nursing California State University, Stanislaus

Turlock, California

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Tenth edition

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With love, to my husband, my children, and my grandchildren. —Cherie Rector

To my husband and three sons—you make my heart smile. You are the steady seas in which I sail; thank you for your

unwavering support. —Mary Jo Stanley

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ABOUT THE AUTHORS

Dr. Cherie Rector, PhD, RN, PHN, is a native Californian and an Emeritus Professor in the Department of Nursing at California State University, Bakersfield. While there, she served as lead faculty in community health nursing, Director of the School Nurse Credential Program and the RN to BSN Program, helping to develop and revise curriculum in those areas. She also developed an online curriculum for the RN to BSN program, and taught in-person, distance learning, and online courses in graduate and undergraduate programs. Prior to that, she served in an administrative position as Director of Allied Health and the Disabled Students Program at College of the Sequoias. She has also been the Coordinator of the School Nurse Credential Program and the RN to BSN Program at California State University, Fresno, overseeing curriculum development in those areas, for both online and in-person classes. Undergraduate teaching areas have included community health nursing, foundations/health assessment, health teaching, leadership, and capstone classes; in addition, she has taught graduate courses in community health nursing, research, vulnerable populations, family theories, interprofessional development, and school nursing. She has served as a consultant to school districts and hospitals in the areas of child health, research, and evidence-based practice; has served on various state, local, and national boards and task forces; and has had leadership roles in professional nursing organizations. Over the course of her career, Dr. Rector has practiced in community health and school nursing settings and in acute care neonatal nursing. Her grants, research, publications, and presentations have focused largely on child and adolescent health, school nursing, public health nursing, nursing education, and program development for underrepresented students. She earned an associate degree in nursing from College of the Sequoias and a BSN from the Consortium of the California State Universities, Long Beach. She completed a master’s degree in nursing (Clinical Nurse Specialist, Community Health) and a school nurse credential from California State University, Fresno. Her PhD in educational psychology is from the University of Southern California. She is an active member of the American Public Health Association (PHN

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Section), the Western Institute of Nursing, Sigma Theta Tau, and the Association of Community Health Nursing Educators. Dr. Mary Jo Stanley, PhD, RN, CNS, CNE, is a Professor and Director of the School of Nursing at California State University, Stanislaus. Prior to this role, she served as the RN-BSN Program Director, helping create online curriculum and instruction for the program. Previous positions in academia include coordinator for the second degree prelicensure program at the University of Colorado, Colorado Springs; in addition to this role, she also coordinated community health placements for RN-BSN students overseeing curriculum in those areas. At the University of Northern Colorado, Dr. Stanley coordinated summer community health clinical placements revising and updating curriculum. Undergraduate teaching areas have included community health, leadership and management, health assessment, foundations, health promotion, health education, capstone practicum, and professional roles; in addition, she has taught graduate classes in nursing education, contemporary practices, and nursing research and has served as graduate project Chair for Masters of Science in Nursing students. Dr. Stanley has consulted for online instruction and is a certified online course reviewer. Over the course of Dr. Stanley’s career, she has practiced in community and school health settings, and in acute care in the ICU and PACU. Her research, publications, presentations, and grants have focused on educational development, strategies for teaching, and community health. She earned a Bachelor of Science in Nursing, Master of Science in Nursing, Clinical Nurse Specialist, and School Nurse Credential from San Jose State University. She completed her PhD in nursing with an emphasis on education from the University of Northern Colorado and is a Certified Nurse Educator (CNE). She is an active member of the Association of Community Health Nursing Educators and Sigma Theta Tau International.

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CONTRIBUTORS

Contributors to the 10th Edition

Sheila Adams-Leander, RN, PhD, CCC Associate Professor School of Nursing Milwaukee School of Engineering Milwaukee, Wisconsin Online Faculty for Doctorate of Nursing Practice Program College of Nursing and Health Professions Grand Canyon University Phoenix, Arizona Chapter 5, Transcultural Nursing

Peggy H. Anderson, DNP, MS, RN Associate Teaching Professor Undergraduate Program Coordinator Brigham Young University College of NursingProvo, Utah Chapter 20, School-Age Children and Adolescents

Anne Watson Bongiorno, RN, PHD, APRN-BC, CNE Professor Department of Nursing SUNY Plattsburgh Plattsburgh, New York Chapter 4, Evidence-Based Practice and Ethics

Yezenia Cadena-Malek, RN, BSN, MSHS Health Promotion Educator Army Public Health Nursing/Health Promotion Department of Preventive Medicine JBSA Fort Sam Houston San Antonio, Texas Chapter 8, Communicable Disease

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Denise Cummins, DNP, RN, WHNP-BC Assistant Teaching Professor College of Nursing Brigham Young University Provo, Utah Chapter 12, Planning, Implementing, and Evaluating Community/Public Health Programs

Heide R. Cygan, DNP, RN, PHNA-BC Assistant Professor Department of Community, Systems and Mental Health Nursing College of Nursing Rush University Chicago, Illinois Chapter 13, Policy Making and Advocacy

Beverly A. Dandridge, MSN, FNP, MSAJS, CAPT, USPHS Department of Homeland Security USPHS Commissioned Corps Liaison Washington, District of Columbia Chapter 17, Disasters and Their Impact Chapter 28, Public Settings

Mary Ann Drake, PhD, RN, CNE Professor Department of Nursing Webster University Saint Louis, Missouri Chapter 14, Family as Client

Rachell A. Ekroos, PhD, APRN, FNP-BC, AFN-BC, FAAN Chief Executive Officer Center for Forensic Nursing Excellence International Las Vegas, Nevada Chapter 18, Violence and Abuse

Naomi E. Ervin, PhD, RN, PHCNS-BC, FNAP, FAAN

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Retired Professor Shelby, Michigan Chapter 15, Community as Client

Deborah S. Finnell, RN, DNS, CARN-AP, FAAN Professor Emerita Johns Hopkins School of Nursing Baltimore, Maryland Chapter 25, Behavioral Health in the Community

Lakisha Nicole Flagg, DrPH, MS, MPH, RN, APHN-BC, CPH Strategy, Policy, and Communications Program Manager Louisiana Department of Health’s Bureau of Family Health Adjunct Faculty Graduate Program Texas Tech University Science Center Lubbock, Texas Chapter 15, Community as Client

Carmen George, DNP, MSN, BSN, WHNP-BC Assistant Professor of Nursing School of Nursing University of Nevada Las Vegas Chapter 19, Maternal–Child Health

Patricia (Trish) Hanes, PhD, MSN, MAED, MS-DPEM, RN, CNE, NEMAA, CSSGB Professor Emeritus School of Nursing Azusa Pacific UniversityAzusa, California Chapter 3, History and Evolution of Public Health Nursing

Lenore Hernandez, PhD, MSN, RN, CNS, APRN- BCADM, CDE Clinical Nurse Specialist in Diabetes Department of Medicine Northern California Veterans Healthcare Administration Martinez, California Chapter 23, Working With Vulnerable People

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Judith L. Hold, EdD, RN Assistant Professor of Nursing Wellstar School of Nursing Kennesaw State University Kennesaw, Georgia Chapter 21, Adult Health

Ezra C. Holston, PhD, MSN, RN Assistant Director Utah State University Department of Nursing and Health Professions Logan, Utah Chapter 14, Family as Client

Vanessa Amore Jones, DNP, APRN, FNP-C Director of Graduate Nursing Studies Assistant Professor, DNP Program Coordinator University of North Georgia Dahlonega, Georgia Chapter 21, Adult Health

Betty C. Jung, MPH, RN, MCHES Director for Public Health Expertise Network of Mentors Adjunct Lecturer Department of Public Health Southern Connecticut State University New Haven, ConnecticutChapter 7, Epidemiology in the Community

Mary Lashley, PhD, RN, PHNCS, BC, CNE Professor Department of Nursing Towson University Towson, MarylandAllentown, Pennsylvania Chapter 26, Working With the Homeless

Angelique Lawyer, MSN, MPH, PHNA-BC Public Health Consultant Gaia Public Health Solutions

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Chapel Hill, North Carolina Chapter 29, Private Settings

Jeanne M. Leffers, PhD, RN, FAAN Professor Emeritus University of Massachusetts,Dartmouth North Dartmouth, Massachusetts Chapter 9, Environmental Health and Safety

Colleen Marzilli, PhD, DNP, MBA, RN-BC, CCM, PHNA- BC, CNE, NEA-BC, FNAP Coordinator Concurrent ADN/BSN Program Coordinator CONHS International Programs Associate Professor School of Nursing The University of Texas at Tyler Tyler, Texas Chapter 10, Communication, Collaboration, and Technology

Ruth McDermott-Levy, PhD, MPH, RN, FAAN Associate Professor and Director Center for Global & Public Health M. Louise Fitzpatrick College of Nursing Villanova University Villanova, Pennsylvania Chapter 9, Environmental Health and Safety

Charlene Niemi, PhD, RN, PHN, CNE Assistant Professor Nursing Program California State University, Channel Islands Camarillo, California Chapter 24, Clients With Disabilities

Carol Pochron, MSN, RN Adjunct Instructor Department of Nursing DeSales University Center Valley, Pennsylvania

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Adjunct Instructor Department of Nursing Moravian College Bethlehem, Pennsylvania Board Member of Parish Nurse Coalition of the Greater Lehigh Valley

Per Diem Nurse Department of Hospice Lehigh Valley Health Network Allentown, Pennsylvania Chapter 29, Private Settings

Cherie Rector, PhD, RN, PHN Professor Emeritus Department of Nursing California State University, Bakersfield Bakersfield, California Chapter 1, Introduction: The Journey Begins Chapter 4, Evidence-Based Practice and Ethics Chapter 6, Structure and Economics of Community/Public Health Services Chapter 10, Communication, Collaboration, and Technology

Judith M. Scott, PhD, RN Assistant Professor Helen and Arthur E. Johnson Beth-El College of Nursing and Health Sciences University of Colorado Colorado Springs Colorado Springs, Colorado Chapter 22, Older Adults

Jody Spiess, PhD, RN, GCPH Assistant Professor Nursing Department Webster University Saint Louis, MO Chapter 14, Family as Client

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Mary Jo Stanley, PhD, RN, CNS, CNE Professor Director, School of Nursing California State University, Stanislaus Turlock, California Chapter 28, Public Settings Chapter 29, Private Settings Chapter 30, Home Health and Hospice Care

Rebecca E. Sutter, DNP, APRN, BC-FNP Mason and Partners Clinic Co-Director Associate Professor of Nursing School of Nursing College of Health and Human Services George Mason University Fairfax, Virginia Chapter 23, Working With Vulnerable People

Susan M. Swider, PhD, PHNA-BC, FAAN Director, DNP Tracks in Advanced Public Health Nursing Transformative Leadership: Population Health Department of Community Systems and Mental Health Nursing College of NursingRush University Chicago, Illinois Chapter 13, Policy Making and Advocacy

Dana Todd, PhD, APRN Professor School of Nursing and Health Professions Murray State University Murray, Kentucky Chapter 2, Public Health Nursing in the Community Chapter 11, Health Promotion Through Education Chapter 19, Maternal–Child Health

Lauren Traveller, DNP, APRN, FNP-C Assistant Professor of Nursing Southern Utah University

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Cedar City, Utah Chapter 18, Violence and Abuse

Katharine West, DNP, MPH, RN, PHN, CNS Associate Faculty College of Nursing, Southern California Campus University of Phoenix Ontario, California Chapter 16, Global Health Nursing

Robin M. White, PhD, MSN, RN Director of BSN Nursing Program Associate Professor University of Tampa Nursing Program Tampa, Florida Chapter 27, Rural, Migrant, and Urban Health

Elizabeth Wright, MSN, APRN, CNE Assistant Professor Nursing Post Licensure Division Indiana Wesleyan University Marion, Indiana Chapter 30, Home Health and Hospice Care

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Contributors to the 9th Edition

Sheila Adams-Leander, RN, PhD Associate Professor Milwaukee School of Engineering University Milwaukee, Wisconsin Chapter 5

Peggy H. Anderson, DNP, MS, RN Associate Teaching Professor Brigham Young UniversityCollege of Nursing Provo, Utah Chapter 22

Barbara Blake, RN, PhD, ACRN, FAAN Professor Kennesaw State University Kennesaw, Georgia Chapter 23

Anne Bongiorno, PhD, APHN-BC Associate Professor State University of New York, Plattsburgh Plattsburgh, New York Chapter 4

Bonnie Callen, PhD, RN, PHCNS-BC Associate Professor (Retired) University of Tennessee, Knoxville Knoxville, Tennessee Chapter 24

Beverly A. Dandridge, MSN, FNP, MSAJS, CCHP CAPT, USPHS Commissioned Corps Department of Homeland Security USPHS Commissioned Corps Liaison

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Washington, District of Columbia Chapters 17 and 30

Janna L. Dieckmann, PhD, RN Associate Professor University of North Carolina at Chapel Hill Chapel Hill, North Carolina Chapter 26

Rebecca Doughty, MN, RN, PhD(c) Director of Health Services Spoken Public Schools Spokane, Washington Chapter 30

Mary Ann Drake, PhD, RN, CNE Professor Webster University St. Louis, Missouri Chapter 18

Naomi Ervin, PhD, RN, PHCNS-BC, FNAP, FAAN Adjunct Professor Madonna University Livonia, Michigan Chapter 25

Deborah S. Finnell, DNS, PHMHP-BC, CARN-AP, FAAN Associate Professor Johns Hopkins School of Nursing Baltimore, Maryland Chapter 27

MAJ Lakisha N. Flagg, DrPH, MS, CPH, APHN-BC Chief, Army Public Health Nursing Brooke Army Medical Center Joint Base San Antonio Fort Sam Houston, Texas San Antonio, Texas Chapter 15

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Ezra C. Holston, PhD, RN Assistant Professor University of Tennessee, Knoxville Knoxville, Tennessee Chapter 19

Barbara Joyce, PhD, RN, CNS, ANEF Associate Professor Helen and Arthur E. Johnson Beth-El College of Nursing & Health Sciences University of Colorado Colorado Springs Colorado Springs, Colorado Chapter 20

Betty C. Jung, MPH, RN, MCHES Program Director Public Health Expertise Network of Mentors Adjunct Lecturer Southern Connecticut State University New Haven, Connecticut Chapter 7

Katherine Laux Kaiser, PhD, RN, PHCNS-BC Professor University of Nebraska Medical CenterCollege of Nursing Omaha, Nebraska Chapter 21

Mary Lashley, PhD, RN, PHNCS-BC Professor Towson University Towson, Maryland Chapter 28

Angelique Lawyer, MSN, MPH, APHN-BC, RN Nurse Consultant, Chief Surgeon’s Office National Guard Bureau Arlington, Virginia Chapter 31

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Jeanne M. Leffers, PhD, RN, FAAN Professor Emeritus University of Massachusetts, Dartmouth North Dartmouth, MassachusettsChapter 9

Karin L. Lightfoot, PhD, MSN, RN-BC, PHN Assistant Professor California State University, Chico Chico, California Chapters 8 and 14

Colleen Marzilli, PhD, DNP, MBA, RN-BC, CCM, APHN- BC, CNE Assistant Professor The University of Texas at Tyler Tyler, Texas Chapter 10

Debra J. Millar, MSN, RN, APHN-BC Assistant Professor California State University, Stanislaus Turlock, California Chapters 12 and 16

Mary Ellen Miller, PhD, RN, APHN-BC Associate Professor Director, Bridging the Gaps Lehigh Valley Affiliate DeSales University Center Valley, Pennsylvania Chapter 31(Lead)

Margaret Oot-Hayes, PhD, RN Professor Regis College Weston, Massachusetts Chapter 30

Judith M. Paré, PhD, RN

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Dean, School of Nursing and Behavioral Sciences Becker College Worcester, Massachusetts Chapter 29

Carol Pochron, MSN, RN Adjunct Professor DeSales University Center Valley, Pennsylvania Chapter 31

Cherie Rector, PhD, RN, PHN Professor Emeritus Department of Nursing California State University, Bakersfield Bakersfield, California Chapters 1, 2, and 29

Annmarie Donahue Samar, PhD, PHCNS-BC, NEA-BC, RN Professor Framingham State University Framingham, Massachusetts Chapter 10

Lisabeth M. Searing, PhD, RN Assistant Professor Illinois Wesleyan University Bloomington, Illinois Chapter 6

Bryan W. Sisk, RN, BSN, MPH Associate Director Patient Care Services Nurse Executive Central Texas Veterans Health Care System Temple, Texas Veteran’s Content Expert Contributor

Susan M. Swider, PhD, APHN-BC, FAAN

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Professor, Department of Community, Systems and Mental Health Nursing Program Director, DNP in Advanced Public Health Nursing and Leadership to Enhance Population Health Outcomes Rush UniversityCollege of Nursing Chicago, Illinois Chapter 13

Gloria Ann Jones Taylor, PhD, RN Professor Kennesaw State University Kennesaw, Georgia Chapter 23

Dana Todd, PhD, APRN Associate Professor Murray State University Murray, Kentucky Chapters 3, 11, and 21

Kristine D. Warner, PhD, MPH, RN Assistant Dean and Managing Director MEPN Program University of California, San Francisco San Francisco, California Chapter 2

Robin M. White, PhD, MSN, RN Assistant Professor University of Tampa Tampa, Florida Chapter 29

Marjory D. Williams, PhD, RN Associate Chief Nursing Service, Education and Research Central Texas Veterans Health Care System Temple, Texas Veteran’s Content Expert Contributor

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Elizabeth Wright, MSN, RN Assistant Professor of Nursing Indiana Wesleyan University Marion, Indiana Chapter 32

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REVIEWERS

Barbara Blackford, MSN, RN-CNE Assistant Professor Marian University Indianapolis, Indiana

Anne Bongiorno, PhD, APHN-BC, CNE Professor SUNY Plattsburgh Plattsburgh, New York

Kelly Brittain, PhD, RN Associate Professor Michigan State University College of Nursing East Lansing, Michigan

Esther Brown, EdD, RN, FCN-BC, ThB Associate Professor Widener University Chester, Pennsylvania

Angeline Bushy, PhD, RN, FAAN Professor, Bert Fish Eminent Chair University of Central FloridaCollege of Nursing Daytona Beach, Florida

Adelita G. Cantu, PhD, RN Associate Professor University of Texas at San Antonio School of Nursing San Antonio, Texas

Holly Cassells, PhD, RNC Chair, Graduate Nursing Program University of the Incarnate Word San Antonio, Texas

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Stephanie Chung, PhD, RN Assistant Professor Georgian Court University Lakewood, New Jersey

Jennifer Cooper, DNP, MSN Assistant Professor Hood College Frederick, Maryland

Joan Creed, DNP, RN, CCM Clinical Assistant Professor University of South Carolina Columbia, South Carolina

Margaret C. Delaney, EdD, APRN, PNP-BC Instructor Benedictine University Lisle, Illinois

Kathie DeMuth, MSN, RN Assistant Professor Bellin College Green Bay, Wisconsin

Christina DesOrmeaux, PhD, RN Assistant Clinical Professor The Cizik School of Nursing The University of Texas Health Science Center at Houston Houston, Texas

Kathleen Dever, EdD, MS, RN Associate Professor Wegmans School of Nursing St. John Fisher College Rochester, New York

Lisa J. Fardy, DNP, MSN, MPH, RN, PHCNS-BC Associate Professor of Nursing and Public Health Regis College

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Weston, Massachusetts

Cindy Farris, PhD, MSN, MPH, CNE Assistant Professor Florida Gulf Coast University Fort Myers, Florida

Jackie Gillespie, MN, RN, Retired CNE Nursing Educator (Retired) Clemson University School of Nursing Clemson, South Carolina

Patty Nolan Goldsmith, MS, RN, PHNA-BC Senior Lecturer University of Arizona College of Nursing Tucson, Arizona

Dawn M. Goodolf, PhD, RN Associate Professor Moravian College Bethlehem, Pennsylvania

Donna S. Guerra, EdD, MSN, RN Clinical Assistant Professor University of Alabama in Huntsville Huntsville, Alabama

Susan Harrington, PhD, RN Associate Professor Grand Valley State University Grand Rapids, Michigan

Tammy Kiser, DNP, RN Assistant Professor of Nursing James Madison University Harrisonburg, Virginia

Alexis Koenig, EdD, MSN, RN, CNE, CCHP

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Associate Professor East Stroudsburg University East Stroudsburg, Pennsylvania

Julie A. Kruse, PhD, RN Associate Professor Oakland UniversitySchool of Nursing Rochester, Michigan

Kimberly Lacey, DNSc, MSN, RN, CNE Professor Southern Connecticut State University New Haven, Connecticut

Barbara Whitman Lancaster, DNP, APN, WHNP-BC Assistant Professor Middle Tennessee State University Murfreesboro, Tennessee

Erica Lemberger, DNP, FNP-BC, AFN-BC, RN, SANE A/P Associate Professor Spalding University Louisville, Kentucky

Amanda Jean Madrid, RN, MSN, PHN-BC Assistant Professor California Baptist University Riverside, California

Aimee McDonald, PhD, RN Assistant Professor William Jewell College Liberty, Missouri

Cindy McZeal, MSN, PHN, RN Program Coordinator California State University Los Angeles Los Angeles, California

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Sandra E. Monk, PhD, RN, CHPN Assistant Professor Shorter University Rome, Georgia

Geraldine Moore, EdD, RN, BC, AE-C Professor Molloy CollegeBarbara H. Hagan School of Nursing and Health Sciences Rockville Centre, New York

Linda Morgan, PhD, MSN, RN, PHN Associate Professor Reinhardt University Waleska, Georgia

Susan A. Natale, PhD, RN, NEA-BC Associate Professor Curry College Milton, Massachusetts

Sabita Persaud, PhD, RN, PHNA-BC Associate Professor Notre Dame of Maryland Baltimore, Maryland

Tami J. Pobocik, PhD, RN Associate Professor Saginaw Valley State University University Center, Michigan

Pamela Rafferty-Semon, MSN-Ed, RN Associate Lecturer Kent State University Kent, Ohio

Mary Jean Ricci, MSN, RN-BC Director of Clinical Education, Assistant Professor of Nursing, Chair of Population Health

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Drexel University Philadelphia, Pennsylvania

Diane Riff, DNP, APRN, NP-C Associate Professor University of Louisville Louisville, Kentucky

Kathleen Rindahl, DNP, RN, FNP-C Associate Professor Fresno State UniversitySchool of Nursing Fresno, California

Ronna Schrum, DNP, RN, CRNP Assistant Professor Frostburg State University Frostburg, Maryland

Kathleen F. Tate, EdD, MSN, MBA, RN, CNE Associate Professor of Nursing Northwestern State University Shreveport, Louisiana

Antionella Upshaw, PhD, RN, BS Assistant Professor Southern University and A&M College Baton Rouge, Louisiana

Maria Warnick, MSN, CRNP Assistant Director Gwynedd Mercy University Gwynedd Valley, Pennsylvania

Rita West, DNSc, RN, NEA-BC Assistant Professor Baptist College of Health Sciences Memphis, Tennessee

Lori A. Wheeler, PhD, RN

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Assistant Professor Thomas Jefferson University Philadelphia, Pennsylvania

Kathlene H. Williams, MS, RN, CNE Assistant Professor of Nursing McNeese State University Lake Charles, Louisiana

Debra Windle, PHN, MSN, CNS Nursing Faculty California State University Long Beach Long Beach, California

Pamela J. Worrell-Carlisle, PhD, RN Assistant Professor School of NursingGeorgia Southern University Statesboro, Georgia

Amy Yakos, MSN, RN-BC, CEN Clinical Lecturer Ball State University Muncie, Indiana

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PREFACE

The 10th edition of Community and Public Health Nursing: Promoting the Public’s Health provides undergraduate nursing students an introduction to community/public health and population- focused nursing in the community. Community settings may include public health departments, community-based organizations, schools, correctional facilities, industries, and businesses. The textbook introduces students to key populations with whom they may work in community settings and to commonly occurring situations in which they may find themselves as new nurses in the community and in other settings.

Community/public health nursing skills provide new nurses with a broader focus of patient care (e.g., families, aggregates, communities, populations), not just individual patients. Even if new graduates plan on employment in acute care settings (which is often the most familiar setting for them), a public health and population focus is useful there. A recent example of how this is helpful is the COVID-19 pandemic, which has burdened many hospitals as they sought to provide care for patients and to find adequate PPE, staff, and bed space. This pandemic brought to the forefront the importance of public health in ensuring our nation’s health and prosperity. It is important for acute care nurses to have an understanding of their patients’ unique circumstances and how to best join with patients and their families in working to prevent disease and further complications, and to promote better health. To help students gain a holistic view of the patient, throughout this book students are provided with examples and information that will broaden their knowledge of patients and enable them to provide more effective nursing care—wherever they may be employed.

The purpose of this book is to give undergraduate students a solid, basic grounding in public health principles and community/public health nursing practice. It is our hope to generate an interest in this important nursing specialty and that some graduates will join us in working to prevent disease, promote health, and protect at-risk populations.

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Chapters reflect contributors’ and reviewers’ broad spectrum of views and expertise, coalescing into a carefully edited and cohesive textbook with a shared community/public health vision.

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New to This Edition

This edition reflects a continuing effort to communicate in a user- friendly style with nursing students who are entering the world of community/public health nursing for the first time. We focus on showing the connection between community/public health population-focused nursing and the practice of acute care nursing, providing students with examples and information that will broaden their knowledge of their patients and enable them to provide more effective nursing care wherever they may choose to practice. We also point out to students that population-focused care is not only unique to public health but also important in acute care settings (e.g., infection control, programs to reduce length of stays or readmission rates), and many hospital systems recognize the need for more community-based options. Health care reform has changed the landscape for patients and providers, and health care is becoming even more community-based. Population-focused tools and interventions are not only important in community/public health nursing—they are needed in acute care, as infection rates continue to rise, and nurse-sensitive outcome indicators are closely monitored.

Expanded and new content in this 10th edition includes the following:

Healthy People 2030: Content from the updated framework informs readers about this decade’s health goals and objectives for various population groups. Ten essential public health services: Content is added throughout the text and an exercise in each of the end-of-chapter Active Learning Exercises sections asks students to consider and apply these essentials. LGBTQ, veteran, and refugee populations: Coverage has been expanded as follows:

We have included specific sections on these vulnerable groups in Chapter 23, Working With Vulnerable People. LGBTQ content is incorporated throughout the textbook and in some features in an effort to help nursing students to better comprehend and address the needs of this population.

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Veteran’s health content is the focus of some features (e.g., some of the Stories From the Field and Perspectives boxes) and critical thinking activities to better explore this population and the role of the community/public health nurse (C/PHN) in serving them.

Streamlining of content: To better represent population and aggregate health:

Reading-intensive text has been converted into more concise, bulleted lists. More graphics and infographics have been included to help students understand basic concepts. The Summary at the end of each chapter is a bulleted list that clearly reinforces key points and concepts. Some supplemental material has been moved to thepoint.lww.com/Rector10e.

Special Boxes in This Book: This section of this book’s front matter, found immediately following the Table of Contents, makes it easier to find the features and stories that bring the theoretical content in the text to life.

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Organization of This Book

For the 10th edition, the content has been streamlined into 7 units and 30 chapters.

Unit 1, “Foundations of Community/Public Health Nursing,” covers fundamental principles and background about community/public health nursing.

Chapter 1, “The Journey Begins: Introduction,” discusses basic public health concepts of health, illness, wellness, community, aggregate, population, and levels of prevention. The chapter introduces leading health indicators, along with Healthy People 2030 goals and objectives. Chapter 2, “Public Health Nursing in the Community,” explains roles and settings for community/public health nursing, the three primary functions of public health, and the 10 essential public health services. Standards of practice are also discussed. Chapter 3, “History and Evolution of Public Health Nursing,” examines the stages of public health nursing’s rich and meaningful history, its nursing leaders, the evolution of nursing education, and the social influences that have shaped our current practice. Features highlighting historical landmarks and C/PHN experiences during different time periods, along with historical photos and resources, bring this history to life. Chapter 4, “Evidence-Based Practice and Ethics,” considers values, ethical principles, and ethical decision-making in community/public health nursing and acute care settings. The chapter also introduces quality and safety, evidence-based practice, research principles, and the use of systematic reviews to improve practice. Chapter 5, “Transcultural Nursing,” defines cultural principles, highlighting the importance of cultural diversity and the need for cultural sensitivity. Information presented includes cultural assessment and folk remedies, as well as complementary and alternative medicine.

Unit 2, “Community/Public Health Essentials,” covers the structure of community/public health within the overall health system

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infrastructure and introduces the basic public health tools of epidemiology, communicable disease control, and environmental health.

Chapter 6, “Structure and Economics of Community/Public Health Services,” examines the economics of health care and compares U.S. outcomes with those of other countries, while also discussing the private and government health insurance options. It also examines the functions of official health agencies and their organizational structures, as well as landmark legislation and policies related to public health. Chapter 7, “Epidemiology in the Community,” highlights basic concepts of epidemiology and different methods of epidemiologic investigation and research, along with the C/PHN’s role in epidemiology. Chapter 8, “Communicable Disease,” presents a population focus on communicable disease control and immunization programs, highlighting vaccine hesitancy and effective approaches with clients. The chapter also discusses communicable disease investigations and common communicable diseases often seen in C/PHN practice. Chapter 9, “Environmental Health and Safety,” reviews environmental health concepts and assessments, the precautionary principle, having an ecologic perspective, and the use of an upstream approach to reduce environmental risks.

Unit 3, “Community/Public Health Nursing Toolbox,” includes common tools used by the community/public health nurse to ensure effective practice.

Chapter 10, “Communication, Collaboration, and Technology,” discusses communication, collaboration, working with groups, contracting with clients, and the C/PHN’s use of motivational interviewing and OARS, as well as informatics and health technology. Technologies examined include Big Data, EHRs, mHealth, and GIS, among others, and examples of technology applications are provided. Chapter 11, “Health Promotion Through Education,” presents health education, the three types of learning, health promotion

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and change, along with learning theories and models, as well as a description of teaching in the community. Chapter 12, “Planning, Implementing, and Evaluating Community/Public Health Programs,” focuses on identifying problems and planning and developing community health programs. The chapter examines designing interventions and evaluating outcomes, along with social marketing approaches and grant funding. Chapter 13, “Policy Making and Advocacy,” concludes this unit with an explanation of the C/PHN’s role in political advocacy, policy analysis, and policy making, highlighting examples of C/PHN and community involvement in addressing policy issues.

Unit 4, “The Health of Our Population,” further expands the focus of the community/public health nurse.

Chapter 14, “Family as Client,” examines the family as the C/PHN’s client and discusses methods of family assessment. Conceptual frameworks and application of the nursing process to family health help promote healthy families. Home visiting protocols are discussed, along with contracting and referrals. Chapter 15, “Community as Client,” applies the nursing process to communities as clients (contrasted to individual patient focus in acute care). The chapter presents models and frameworks for community assessment and discusses different types of assessments, along with sources of data, community diagnoses, and community development. Chapter 16, “Global Health Nursing,” presents global health principles and data methods of international organizations. Topics covered include international agencies, nongovernmental organizations, and various foundations, along with global health problems/practices as well as global service-based learning and the ethical considerations involved. Chapter 17, “Disasters and Their Impact,” examines preparedness with a closer look at disasters, terrorism, mass casualty events, and war. Phases of a disaster and disaster management are covered, along with disaster plans and treatment for survivors. Also discussed is the C/PHN’s role in emergency preparedness, disaster management, preventive measures against terrorism, and Healthy People 2030 objectives.

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Chapter 18, “Violence and Abuse,” encompasses violence across the life span, including child abuse, elder abuse, community violence, and intimate partner violence. Crisis intervention is also included.

Unit 5, “Aggregate Populations,” introduces the family as an aggregate, along with other aggregates with whom the C/PHN routinely works.

Chapter 19, “Maternal–Child Health,” covers common issues, concerns, and interventions for maternal–child health clients and their infants (e.g., complications of pregnancy and childbirth, teen pregnancy, STIs, substance abuse), including health services for mothers and infants through preschool. Chapter 20, “School-Age Children and Adolescents,” examines physical and emotional health problems affecting children and adolescents (e.g., diabetes, asthma, injuries, communicable disease, substance abuse, preventive programs), along with learning problems and disabilities. Chapter 21, “Adult Health,” discusses the leading causes of death, genomic risks, environmental factors, and health care needs of the adult population. The chapter also presents the effects of chronic illness and the C/PHN’s role in working with adults to provide early detection, education, and rehabilitation. Chapter 22, “Older Adults,” covers the unique issues facing the older client (e.g., common myths, preventive measures, health services, end-of-life care) and the C/PHN’s role in working with this population.

Unit 6, “Vulnerable Populations,” provides information about client groups that are often aggregated by public health departments.

Chapter 23, “Working With Vulnerable People,” describes vulnerable populations, contributing factors, and helpful models or frameworks related to vulnerability. The chapter also discusses social determinants of health and the socioeconomic gradient leading to health disparities, along with the C/PHN’s role. Chapter 24, “Clients With Disabilities,” covers issues related to disabilities, the role of Healthy People and legislation (e.g.,

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ADA, IDEA) in meeting the needs of the disabled population. It reinforces the importance of the C/PHN's role with this population. Chapter 25, “Behavioral Health in the Community,” addresses behavioral health issues (e.g., mental health, substance use) and the C/PHN’s role in focusing on these problems using frameworks and screening tools. Chapter 26, “Working With the Homeless,” covers the homeless population and problems associated with homelessness (e.g., poverty, lack of affordable health care and housing, mental illness, addictions, financial troubles, health problems). The chapter also examines the C/PHN role as an advocate and case manager. Chapter 27, “Rural, Migrant, and Urban Communities,” encompasses the challenges and common problems facing these populations. It also explores issues of social justice, medically underserved populations, and frontier nursing.

Unit 7, “Settings for Community/Public Health Nursing,” examines public and private settings in more depth, as well as home health and hospice nursing.

Chapter 28, “Public Settings,” describes practice options in government-sponsored agencies, such as state and local public health departments, public schools, correctional facilities, and the U.S. Public Health Service. Chapter 29, “Private Settings,” includes a focus on C/PHN opportunities in private agencies (e.g., nurse-led health centers, faith-based nursing, occupational health, entrepreneurship). Chapter 30, “Home Health and Hospice Care,” discusses the important roles of home health and hospice/palliative care nursing, especially given our aging population.

The appendix presents the Quad Council Tier 1 Community/Public Health Nursing Competencies.

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Features of the Text

The 10th edition of Community and Public Health Nursing: Promoting the Public’s Health includes key features from previous editions as well as new features, including the following:

Evidence-Based Practice boxes supplement current research cited throughout the text, incorporating specific research examples pertinent to chapter content and explaining how they can be applied to achieve optimal client, aggregate, and population outcomes. Thought-provoking questions challenge students’ understanding of evidence-based concepts and the application of EBP/research in community/public health nursing practice. Stories From the Field (titled From the Case Files in the ninth edition) boxes present a scenario/case study, followed by student-centered, application-based questions that focus on the nursing process. Students are challenged to reflect on assessment and intervention in typical, yet challenging, examples of public health nursing as it is used in practice. Questions ask students to apply chapter content to examples that highlight client situations. Levels of Prevention Pyramid boxes, unique to this text in their complexity and comprehensiveness, enhance understanding of the levels of prevention concepts that are basic to public/community health nursing. Each box addresses a chapter topic, describing nursing actions at each of the three levels of prevention. We place primary prevention (rather than tertiary prevention) at the pyramid’s base to reflect its importance as a foundation for health. Healthy People 2030 boxes highlight pertinent goals and objectives to promote health related to specific populations or problems. Perspectives (titled Voices From the Community/Student Voices in the ninth edition) boxes provide stories (viewpoints) from a variety of sources. Perspectives may be from nursing students, novices or experienced public health nurses, faculty members, policy makers, or clients. These short features are designed to

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promote critical thinking, help students reflect on commonly held misconceptions about public/community health nursing, and recognize the link between skills learned in this specialty practice and other practice settings, especially acute care hospitals. What Do You Think? boxes provoke thought or stir discussion on subject matter that is often unique to public health, similar to how instructors might stop and ask a thought-provoking question during lecture. These features encourage the reader to pause and more deeply consider an issue. QSEN: Focus on Quality boxes highlight quality and safety concepts. These include QSEN (Quality and Safety Education for Nurses) concepts related to environmental health and disasters, patient-centered care (family/community; empowerment), teamwork/collaboration (communication; system barriers), EBP/QI/ethics, and data (e.g., tracking the homeless). Population Focus boxes help refocus student attention to chapter concepts from a population-focused viewpoint. Although chapter content generally contains population-based information, in selected chapters an additional focus on population is needed. Current case studies or examples of effective population-based interventions help make the concept of population-based health more evident and understandable to students. C/PHN Use of the Nursing Process boxes allow students to see how assessment, diagnosis, planning, intervention, and evaluation are used within the context of community/public health situations as presented in selected chapters. Learning Objectives and Key Terms sharpen the reader’s focus and provide a quick guide for mastering the chapter content. The Introduction section presents the chapter topic, and the bulleted Summary section provides an overview of material covered, serving as a concise and focused review. A References list at the end of each chapter provides current research as well as classic sources that offer a broad base of authoritative information for furthering knowledge on each chapter’s subject matter. Active Learning Exercises (titled Activities to Promote Critical Thinking in the ninth edition) challenge students, foster critical

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thinking, and promote application of chapter content. They often include active involvement in solving community health problems in the form of Internet activities, small group work, and interviews with clients, key community informants, or experts. One of the exercises in each chapter is a thought question related to the 10 essential public health services to promote evaluation and application in community/public health nursing. Additional assessment tools are provided throughout the chapters (and on thePoint) to enhance student assessment skills with individuals, families, or aggregates/populations.

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A Comprehensive Package for Teaching and Learning

To further facilitate teaching and learning, a carefully designed ancillary package has been developed to assist faculty and students.

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Resources for Instructors Tools to assist with teaching this text are available upon its adoption on at http://thePoint.lww.com/Rector10e.

An e-Book gives you access to the book’s full text and images online. The Test Generator lets you put together exclusive new tests to help assess students’ understanding of the material. Test questions are mapped to chapter learning objectives and page numbers. An extensive collection of materials is provided for each book chapter:

Pre-Lecture Quizzes (and answers) are quick, knowledge- based assessments that allow you to check students’ reading comprehension. PowerPoint Presentations provide an easy way for you to integrate the textbook with your students’ classroom experience, either via slide shows or handouts. Multiple- choice and true/false questions are integrated into the presentations to promote class participation and allow you to use i-clicker technology. Assignments (and suggested answers) include group, written, clinical, and Web assignments. Case Studies with related questions (and suggested answers) give students an opportunity to apply their knowledge to a client case similar to one they might encounter in practice.

An Image Bank lets you use the photographs and illustrations from this textbook in your PowerPoint slides or as you see fit in your course. Sample Syllabi provide guidance for structuring your community and public health nursing course. A QSEN Competency Map identifies content and special features in the book related to competencies identified by the QSEN Institute. A BSN Essentials Competency Map identifies book content related to the BSN Essentials.

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Contact your sales representative or check out LWW.com/Nursing for more details and ordering information.

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Resources for Students An exciting set of resources is available to help students review material and become even more familiar with vital concepts. Students can access all these resources on at http://thePoint.lww.com/Rector10e, using the codes printed on the inside front cover of their textbooks.

NCLEX-Style Review Questions for each chapter help students review important concepts and practice for NCLEX. Podcasts educate students about community health topics. Journal Articles offer access to current articles relevant to each chapter and available in Wolters Kluwer journals to familiarize students with nursing literature. Supplemental Materials offer additional information to accompany the textbook content. Links to Videos enable examination of thought-provoking issues related to vulnerable populations. Learning Objectives help readers identify important chapter content and focus their reading.

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A Comprehensive, Digital, Integrated Course Solution: Lippincott® CoursePoint+

The same trusted solution, innovation, and unmatched support that you have come to expect from Lippincott CoursePoint+ is now enhanced with more engaging learning tools and deeper analytics to help prepare students for practice. This powerfully integrated digital learning solution combines learning tools, case studies, virtual simulation, real-time data, and the most trusted nursing education content on the market to make curriculum-wide learning more efficient and to meet students where they’re at in their learning. And now, it’s easier than ever for instructors and students to use, giving them everything they need for course and curriculum success!

Lippincott CoursePoint+ for Rector & Stanley: Community and Public Health Nursing, 10th edition, includes the following:

Engaging course content provides a variety of learning tools to engage students of all learning styles. A more personalized learning approach gives students the content and tools they need at the moment they need it, giving them data for more focused remediation and helping to boost their confidence. Powerful tools students need to learn the critical thinking and clinical judgment skills that will help them become practice- ready nurses, including:

Video Cases help students anticipate what to expect as a nurse, with detailed scenarios that capture their attention and integrate clinical knowledge with community and public health concepts that are critical to real-world nursing practice. By watching the videos and completing related activities, students will flex their problem-solving, prioritizing, analyzing, and application skills to aid both in NCLEX preparation and preparation for practice. Interactive Modules help students quickly identify what they do and do not understand, so they can study smartly. With exceptional instructional design that prompts students to discover, reflect, synthesize, and apply, students actively

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learn. SmartSense remediation links to the eBook are integrated throughout. Lippincott Clinical Experiences: Community, Public, and Population Health Nursing (also available for separate purchase), codeveloped with nursing educators Jone Tiffany, DNP, RN, CNE, CHSE, ANEF, and Barbara Hoglund, EdD, MSN, FNP-BC, CNE, offers clinical experiences that consistently expose students to diverse settings, situations, and populations. As students immerse themselves in a safe and engaging virtual environment, they are exposed to the real-life application of key community, public, and population health concepts. Students make observations, hold virtual conversations, triage at a disaster scene, do research online, conduct interviews, and more. The students’ virtual experience is enhanced by surrounding curricula, including suggested readings, active learning assignments, and assessments, which are designed to assist with their knowledge acquisition and enhance their critical thinking skills. Additional real-world clinical assignments can also supplement or replace current clinical activities or Practicum. These clinicals get students thinking about their communities through a community health lens and looking at larger public health and population health issues. Reporting tools track students’ learning and progress.

Unparalleled reporting provides in-depth dashboards with several data points to track student progress and help identify strengths and weaknesses. Unmatched support includes training coaches, product trainers, and nursing education consultants to help educators and students implement CoursePoint+ with ease.

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ACKNOWLEDGMENTS

This book continues as an evolving work in progress. Our goal is to continually update and improve it, incorporating input from nursing students, faculty, and public health nurses. We welcome and encourage feedback. We thank the reviewers for their thoughtful critiques and suggestions, and the contributors (past and present) who have shared their time and expertise.

We especially want to thank Meredith Brittain, senior development editor, who gave careful attention to detail, as well as the big picture, in producing our final product. Her efforts are greatly appreciated, and the textbook is a testament to her focus on precision and detail. We would also like to recognize freelance development editor David Payne for his careful editing and helpful observations. We recognize the diligent work of our acquisitions editors, Christina Burns and Michael Kerns, who guided us through this process from start to finish. We also thank others at Wolters Kluwer for their support, including Ashley Pfeiffer and Alicia Jackson.

Appreciation is also given to Charlene Niemi, PhD, RN, PHN, CNE, for her work assisting us in finalizing and editing several chapters and pitching in on short notice to revise and update chapter sections when needed. Family, friends, and colleagues were also instrumental in providing moral support and encouragement. It is our hope that nursing students and faculty will find our efforts meaningful.

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CONTENTS

UNIT 1 Foundations of Community/Public Health Nursing CHAPTER 1 The Journey Begins: Introduction

Cherie Rector Community Health The Concept of Community The Concept of Health Components of Community/Public Health Practice Characteristics of Community/Public Health Nursing

CHAPTER 2 Public Health Nursing in the Community Dana Todd

Core Public Health Functions Standards of Practice Roles of C/PHNs Settings for Community and Public Health Nursing Practice

CHAPTER 3 History and Evolution of Public Health Nursing Patricia (Trish) Hanes

Historical Development of Community/Public Health Nursing CHAPTER 4 Evidence-Based Practice and Ethics

Cherie Rector and Anne Watson Bongiorno Research That Makes a Difference: The Nurse-Family Partnership (NFP) Research and Evidence-Based Practice Impact of Research on Community/Public Health and Nursing Practice Values and Ethics in Community/Public Health Nursing Values Ethics

CHAPTER 5 Transcultural Nursing Sheila Adams-Leander

The Concept of Culture Characteristics of Culture Ethnocultural Health Care Practices Role and Preparation of the Community/Public Health Nurse Transcultural Community/Public Health Nursing Principles

UNIT 2 Community/Public Health Essentials CHAPTER 6 Structure and Economics of Community/Public Health Services

Cherie Rector Historical Influences on Health Care Health Care Organizations in the United States International Health Organizations

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Development of Today’s Health Care System The Economics of Health Care Sources of Health Care Financing: Public and Private Trends and Issues Influencing Health Care Economics Effects of Health Economics on Community/Public Health Practice Implications for Community/Public Health Nursing

CHAPTER 7 Epidemiology in the Community Betty C. Jung

How Epidemiology Supports the Ten Essentials of Public Health Services Historical Roots of Epidemiology Concepts Basic to Epidemiology Sources of Information for Epidemiologic Study Methods in the Epidemiologic Investigative Process Conducting Epidemiologic Research

CHAPTER 8 Communicable Disease Yezenia Cadena-Malek

Basic Concepts Regarding Communicable Diseases Major Communicable Diseases in the United States Primary Prevention Secondary Prevention Tertiary Prevention Legal and Ethical Issues in Communicable Disease Control

CHAPTER 9 Environmental Health and Safety Ruth McDermott-Levy and Jeanne M. Leffers

Environmental Health and Nursing Concepts and Frameworks for Environmental Health Core Functions of Public Health Global Environmental Health

UNIT 3 Community/Public Health Nursing Toolbox CHAPTER 10 Communication, Collaboration, and Technology

Cherie Rector and Colleen Marzilli Communication in Community/Public Health Nursing Communicating with Groups Contracting in Community/Public Health Nursing Collaboration and Partnerships in Community/Public Health Nursing Health Technology

CHAPTER 11 Health Promotion Through Education Dana Todd

Healthy People 2030 and Key Concepts Related to Health Promotion Health Promotion Through Change Change Through Health Education

CHAPTER 12 Planning, Implementing, and Evaluating Community/Public Health Programs

Denise Cummins Planning Community Health Programs: The Basics

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Identifying Group or Community Health Problems Evaluating Outcomes Marketing and Community Health Programs Securing Grants to Fund Community Health Programs

CHAPTER 13 Policy Making and Advocacy Heide R. Cygan and Susan M. Swider

Health in These United States: How Healthy Are We? Health Policy Analysis Policy Analysis for the PHN Political Action and Advocacy for C/PHNs Current US Health Policy Options Power and Empowerment

UNIT 4 The Health of Our Population CHAPTER 14 Family as Client

Mary Ann Drake, Jody Spiess and Ezra C. Holston Family Health and Family Health Nursing Family Characteristics and Dynamics Family Health Nursing: Preparing for the Home Visit Applying the Nursing Process to Family Health

CHAPTER 15 Community as Client Naomi E. Ervin and Lakisha Nicole Flagg

When the Client Is a Community: Characteristics of Community/Public Health Nursing Practice Theories and Models for Community/Public Health Nursing Practice Principles of Community/Public Health Nursing What Is a Healthy Community? Dimensions of the Community as Client The Nursing Process Applied to the Community as Client Types of Community Needs Assessment Methods for Collecting Community Data Sources of Community Data Data Analysis and Diagnosis Planning to Meet the Health Needs of the Community Implementing Health Promotion Plans for the Community Evaluation of Implemented Community Health Improvement Plans

CHAPTER 16 Global Health Nursing Katharine West

A Framework for Global Health Nursing Assessment Global Health Concepts Global Health Trends Global Health Ethics

CHAPTER 17 Disasters and Their Impact Beverly A. Dandridge

Disasters Terrorism and Wars

CHAPTER 18 Violence and Abuse Rachell A. Ekroos and Lauren Traveller

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Dynamics and Characteristics of a Crisis Overview of Violence Across the Life Cycle History of Violence Against Women and Children Violence Against Children Intimate Partner Violence Elder Abuse and Maltreatment of Older Adults Other Forms of Violence Healthy People 2030 and Violence Prevention Levels of Prevention: Crisis Intervention and Family and Intimate Partner (IP) Violence Violence From Outside the Home The Nursing Process

UNIT 5 Aggregate Populations CHAPTER 19 Maternal–Child Health

Dana Todd and Carmen George Health Status and Needs of Pregnant Women and Infants Infants, Toddlers, and Preschoolers Health Services for Infants, Toddlers, and Preschoolers Role of the C/PHN

CHAPTER 20 School-Age Children and Adolescents Peggy H. Anderson

School: Child’s Work Poverty: A Major Social Determinant of Health in School-Age Children and Adolescents Health Problems of School-Age Children Adolescent Health Health Services for School-Age Children and Adolescents

CHAPTER 21 Adult Health Vanessa Amore Jones and Judith L. Hold

Demographics of Adult Women and Men Life Expectancy Health Disparities Health Literacy Major Health Problems of Adults Women’s Health Men’s Health Role of the Community Health Nurse

CHAPTER 22 Older Adults Judith M. Scott

Geriatrics and Gerontology Health Status of Older Adults Dispelling Ageism Meeting the Health Needs of Older Adults Levels of Prevention Health Costs for Older Adults: Medicare and Medicaid Elder Abuse Approaches to Older Adult Care Health Services for Older Adult Populations End of Life: Advance Directives, Hospice, and Palliative Care

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Care for the Caregiver The Community Health Nurse in an Aging America

UNIT 6 Vulnerable Populations CHAPTER 23 Working With Vulnerable People

Rebecca E. Sutter and Lenore Hernandez The Concept of Vulnerable Populations Vulnerability and Inequality in Health Care Working With Vulnerable Populations Social Justice and Public Health Nursing

CHAPTER 24 Clients With Disabilities Charlene Niemi

Perspectives on Disability and Health Health Promotion and Prevention Needs of Persons With Disabilities Civil Rights Legislation Families of Persons With Disabilities Universal Design The Role of the Community/Public Health Nurse

CHAPTER 25 Behavioral Health in the Community Deborah S. Finnell

Contemporary Issues Prevention of Substance Use and Mental Disorders Mental Health Substance Use Tobacco Use Community-and Population-Based Interventions

CHAPTER 26 Working with the Homeless Mary Lashley

Scope of the Problem HEALTH CARE AND THE HOMELESS Resources To Combat Homelessness Role Of The C/Phn

CHAPTER 27 Rural, Migrant, and Urban Communities Robin M. White

Definitions and Demographics Rural Health Migrant Health Agricultural Labor and Immigration Policies Changing Urban Health

UNIT 7 Settings for Community/Public Health Nursing CHAPTER 28 Public Settings

Mary Jo Stanley and Beverly A. Dandridge Public Health Nursing Public Health Funding and Governmental Structures

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Nursing Roles in Local, State, and Federal Public Health Positions Correctional Nursing Correctional Nursing Careers

CHAPTER 29 Private Settings Carol Pochron, Angelique Lawyer and Mary Jo Stanley

Nurse-Led Health Centers Faith Community Nursing Occupational and Environmental Health Nursing Nurse Entrepreneur in Community/Public Health Nursing

CHAPTER 30 Home Health and Hospice Care Elizabeth Wright and Mary Jo Stanley

Home Health Care Hospice Care

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SPECIAL BOXES IN THIS BOOK

C/PHN Use of the Nursing Process Box 8-7, Administering an Immunization Campaign in a

Community Setting Box 14-13, Family Health Box 20-6, Addressing Childhood Obesity Box 22-4, Nursing Care Plan For Community Older Adults:

Example of Risk for Falls: Ms. Belmont Box 22-10, Resources for Managing Alzheimer’s Disease Box 24-8, Supporting a Family With a Child With Autism Box 25-7, Detection and Management of At-Risk Alcohol

Use Box 26-12, An On-Site Nursing Clinic for Homeless Women

and Children Box 27-12, Working With Migrant Families

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Evidence-Based Practice Box 4-3, A Change of Position Box 5-2, Can Culture Affect Your Neurobiology? Box 5-6, Cultural Identity and Outcomes Box 8-6, Pertussis: New Preventive Strategies for an Old

Disease Box 10-2, Community/Public Health Nurse–Client

Communication Box 10-11, Using Mobile Phone Data to Assess Drivers of

Seasonal Outbreaks of Rubella in Kenya Box 18-9, Generational Transmission of Intimate Partner

Violence Box 19-1, Reducing Child Mortality in Bangladesh Box 19-4, Home Visiting Box 19-7, Getting Families to Use Child Booster Seats Box 20-2, Emotional Impact on Children and Youth of

Having Diabetes Box 21-1, Landmark Research on Cardiovascular Disease Box 21-3, Genomics and Pharmacogenomics Box 21-7, Church-Based Blood Pressure Interventions for

Young Black Males Box 22-1, Health Risks Faced by Older Adults Box 23-9, Caring and Compassion Box 26-8, Impact of Cell Phone Use on Coping and Social

Connectedness Among Homeless Youth Box 28-10, School Nursing Box 30-9, Nurses and Compassion Fatigue

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Healthy People 2030 Box 1-4, Issues in Community/Public Health Nursing Box 1-5, Proposed Leading Health Indicators Box 2-3, Selected Public Health Infrastructure Objectives Box 5-7, 2030 Objectives With Statistically Significant

Racial/Ethnic Disparities in Leading Health Indicators at Healthy People 2020 Midcourse Review

Box 7-5, Objectives Box 8-3, Immunization and Infectious Diseases: Select 2030

Objectives Box 9-2, Objectives for Environmental Health Box 10-6, Selected Objectives Related to Health Literacy or

Health Communication Box 11-1, Objectives for Educational and Community-Based

Programs Box 11-2, Key Factors for Social Determinants of Health

(Selected Objectives) Box 12-1, Recommended Leading Health Indicators and

Objectives Box 14-12, Selected Goals and Objectives Related to Family

Health Box 17-11, Objectives Related to Disaster Preparedness Box 18-11, Selected Violence-Related Objectives Box 19-3, Objectives for Maternal, Infant, and Child Health Box 20-1, Objectives to Improve the Health and Well-Being

of Children Box 20-7, Objectives to Improve the Health and Well-Being

of Adolescents Box 21-2, Select Objectives Related to Obesity Box 21-4, The Objectives for Women Box 21-6, The Objectives for Men Box 23-5, Social Determinants of Public Health Box 24-1, Disability and Health—Objectives Box 25-5, Selected Mental Health and Mental Disorders

Objectives Box 25-6, Selected Substance Use Objectives Box 26-1, Objectives Related to Homelessness Box 27-4, Health Issues in Rural America

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Box 28-2, Content Areas for Children and Adolescents Box 28-4, Public Health Priorities Box 29-1, Objectives Related to Private Settings and

Occupational Safety and Health Box 29-2, Key Health Indicators Applicable to Nurses

Working in Private Settings

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Levels of Prevention Pyramid Box 1-8, Link Between Poor Diet, Inactivity, and Obesity Box 3-4, Promoting Community/Public Health Nursing Box 4-10, Distributive Justice for Battered Women and

Children Box 7-4, Levels of Prevention Pyramid Box 9-4, Pesticides Exposures Box 10-10, Children’s Health and the Environment Box 11-5, Application to Client Teaching Box 14-1, A Home Visit to an Infant With Gastroesophageal

Reflux Box 15-6, The Problem of Child Abuse Box 16-5, Acute Respiratory Infection in Children Box 17-3, Responding to a Tornado Box 18-12, Promoting Crisis Resolution Box 19-10, Prenatal and Newborn Care Box 20-3, Prevention of Type 2 Diabetes Mellitus in School-

Age Children Box 21-8, Breast Cancer Box 22-2, Transitioning to Older Age Box 25-4, The C/PHN Works With High-Risk Populations for

Mental Disorders and Substance Abuse Box 26-15, Preventing Illness Among Homeless Male

Addicts Box 27-10, Domestic Violence in the Migrant Population Box 28-5, Cervical Cancer in the Community Setting Box 28-11, Obesity in a School Setting

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Perspectives Box 5-8, Learning About Other Cultures Box 7-10, Adult Lead Poisoning From the Use of an Asian

Remedy for Menstrual Cramps—Example of an Epidemiologic Investigation

Box 8-5, PHN: Personal Belief Exemption and Immunization Box 9-6, A Student Viewpoint on Environmental Health in

Health Systems Box 9-9, A C/PHN Viewpoint on Climate Change Box 9-13, A Nurse’s Viewpoint on a California Wildfire Box 10-4, Mr. Sanchez Needs an Interpreter Box 13-9, A Volunteer’s Viewpoint on Campaigning for an

RN Box 14-10, A C/PHN Nursing Instructor’s Viewpoint on

Home Visits—How Your Knock Helps Families Open the Door

Box 15-2, A Public Health Nurse’s Viewpoint on Addressing Adolescent Pregnancy

Box 15-5, A Public Health Nursing Student Viewpoint on Addressing Adolescent Pregnancy

Box 16-2, Volunteering as a Nurse–Midwife in Africa Box 16-3, A Nurse Volunteer’s Viewpoint on Personal

Challenges While Serving Overseas Box 16-6, A World Health Organization Regional Advisor’s

Viewpoint on the Effect of War on International Cooperation

Box 16-8, A Student Nurse’s Viewpoint on Studying Abroad in Ecuador

Box 17-1, Viewpoint of a Victim of the Thomas Fire Box 17-2, Viewpoint of a Survivor of the Route 91 Mass

Shooting Box 18-5, A School Nurse’s Viewpoint on Child Sexual

Abuse—Emily’s Secret Box 18-7, Viewpoint of a Victim of Intimate Partner Violence Box 19-5, A Nursing Student’s Viewpoint on the Dangers of

Childbirth Box 23-8, A C/PHN’s Viewpoint on Community/Public

Health Nursing

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Box 23-15, An Emergency Room Nurse’s Viewpoint on Community/Public Health Nursing

Box 24-2, Focus on Persons With Disabilities Box 24-3, A Community Member Viewpoint on Active

Shooter Response by Persons With Disabilities Box 24-5, A Nurse’s Viewpoint on Community Health

Nursing Box 24-7, A Community Member Viewpoint on Hearing Loss Box 26-3, A Homeless Couple’s Viewpoint on Living in Their

Car Box 26-5, A C/PHN’s Viewpoint on Caring for the Homeless Box 26-7, A Homeless Female Veteran’s Viewpoint Box 26-11, A Nurse’s Viewpoint on Working With the

Homeless Box 26-13, A C/PHN’s Holistic Approach to Homelessness Box 27-3, A Nursing Student Viewpoint on Rural

Transportation Box 27-11, Nurse and Nursing Instructor Viewpoints on

Migrant Health Box 27-13, C/PHN Instructors’ Viewpoints on Urban Health

Nursing Box 28-6, A C/PHN Instructor Viewpoint on Community

Health Nursing Box 28-12, A School Nurse Viewpoint on Community Health

Nursing Box 28-14, A Correctional Nursing Viewpoint on Community

Health Nursing Box 28-17, A Supervisor and a Director of Correctional

Nursing Viewpoint on Hiring New Nurses Box 29-8, Viewpoint of an Executive Director of a Nurse-Led

Community Clinic Box 29-10, A Nurse Entrepreneur’s Viewpoint Box 30-2, A Nursing Instructor’s Viewpoint on Medicare

Guidelines Box 30-5, A Home Care Nurse’s Viewpoint on Home Care

Technology Box 30-8, A Hospice Nurse’s Viewpoint on Hospice/Palliative

Care Nursing

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Population Focus Box 7-6, Epidemiology and Social Media Box 20-8, Using Evidence-Based Practice to Design

Substance Abuse Prevention Strategies for Adolescents Box 21-10, Public Health and the Veteran Population Box 23-12, Improving Health Care Professionals’ Caring for

LGBTQ Persons Box 23-13, Veterans Health Box 23-16, Challenges for Community/Public Health Nursing

Related to Refugee Resettlement Box 26-2, Tent Cities and Solutions for the Homeless Box 30-10, Hospice Care for Children

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QSEN: Focus on Quality Box 4-2, Patient-Centered Care for EBP and Ethics Box 13-7, Safety Box 22-6, Safety for Older Adults Box 23-6, Patient-Centered Care for Working With

Vulnerable Populations Box 25-8, Patient-Centered Care for Behavioral Health:

Adolescent Access to and Use of Marijuana Box 26-9, Quality Improvement for Homeless Populations Box 28-8, Patient-Centered Care for Correctional Nurses

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Stories from the Field Box 3-2, New York City Public Health Nurses and the 1918

Influenza Pandemic Box 4-7, Independence Versus Safety Box 4-9, A Family Living in Poverty Box 4-11, An Older Client Gives Up Box 5-5, Being Sensitive to Cultural Beliefs and Practices Box 5-11, The Importance of Cultural Sensitivity Box 5-12, Emily’s New Clients Box 7-7, How Public Health Nurses Make the Case Box 9-5, Chemical Exposure Risks in the Clinical Setting Box 9-11, Flint, Michigan Box 9-12, Fracking Box 12-3, Application of the Omaha System in Reducing

Community Transmission During an Influenza Outbreak Box 12-4, Nursing Students and a Social Marketing

Campaign Box 13-2, Opioids in America Box 14-8, Factoring in the Ravina Family’s Stage of

Development Box 14-9, A Home Visit to James Cutler and Brian Hoag Box 14-14, Assessing the Beck Family’s Nutritional Status Box 14-15, A Family Assessment for Lorenzo Box 15-4, Working With the Community on a Safety

Assessment Box 15-7, Community Assessment of a Rural County in a

West Coast State Box 16-4, Addressing Malaria in the Community Box 17-8, Missed Opportunities for an Older Veteran Box 18-6, Neonaticide Box 18-10, Helping Youth Build the Strength to Prevent

Suicide Box 18-13, Community/Public Health Nursing and a Potential

Family in Crisis Box 19-6, Mop Bucket Drowning Box 19-9, A Case of Kernicterus Box 20-4, Why Parents and Caregivers Are Inconsistent in

Their Use of Car Restraints for Children

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Box 22-3, Minnie Blackstone Box 22-14, Case Management: Role of the C/PHN Box 23-4, Teen Pregnancy Box 23-10, A View of Disasters Box 26-6, Crisis Shelter Intake of Roberto, a Homeless Youth Box 26-14, Faith-Based Outreach Box 27-5, Frontier Nursing: Then and Now Box 27-8, A Case of Active Tuberculosis in a Rural

Community Box 28-3, Tuberculosis Exposure (Compare Your Local

Response With That Outlined Here) Box 29-3, Three Nurse-Led Clinics Box 29-5, Wellness Screening Box 29-6, Family-Centered Care Box 29-11, Creating a Safety Culture Box 30-4, Beyond the Front Door

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What do you Think? Box 1-3, The Link Between Personal Health and the

Environment Box 3-1, Communicable Diseases: Now vs. Then Box 4-12, Predatory Drug Pricing Box 5-1, Transition to a Majority–Minority Nation Box 6-1, Service Over Salaries Box 6-4, Nonpayment for Preventable Medical Errors Box 6-5, Rationing of Health Care Services Box 9-7, Climate Refugees Box 9-8, Pandemics and Pollution Box 13-1, Access to Health Care Box 14-3, Questions for Self-Evaluation Box 16-7, Effects of Conflict on International Cooperation Box 21-5, Fad Diets Box 22-11, Mrs. Stetson’s Story Box 22-12, Services in Your Community Box 26-4, Street or Shelter? Which Would You Choose? Box 26-10, Reflecting on Personal Beliefs and Values About

Homelessness Box 27-6, Undocumented Migrant Workers Box 28-15, Potential Botulism Outbreak in Prison Inmates

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UNIT 1 Foundations of

Community/Public Health Nursing

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CHAPTER 1

The Journey Begins: Introduction “For a community to be whole and healthy, it must be based on people's love and concern for each other.”

—Millard Fuller (1935–2009), Founder, Habitat for Humanity

KEY TERMS Aggregate Community Community health Community health nursing Geographic community Health Health continuum Health promotion Illness Population Population focused Primary prevention Public health Public health nursing Secondary prevention Tertiary prevention Wellness

LEARNING OBJECTIVES Upon mastery of this chapter, you should be able to:

1. Explain the concepts of community, population, aggregate, and public health.

2. Give specific examples of nursing interventions that differentiate the three levels of prevention.

3. Describe three benefits that community/public health nursing experience can provide to those working in acute care nursing.

4. Identify examples of how the eight characteristics of community/public health nursing can be applied.

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INTRODUCTION

Opportunities and challenges in nursing are boundless and rapidly changing. You have spent a lot of time and effort learning how to care for individual patients in medical–surgical and other acute care–oriented nursing specialties. You have provided nursing care in familiar acute care settings for the very ill, both young and old, but always with other professionals at your side. Now you are entering a unique and exciting area of nursing— community/public health.

As one of the oldest specialty nursing practices, public health nursing offers unique challenges and opportunities. Public health nursing is community based and population focused. A nurse entering this field will encounter the complex challenge of working with populations rather than just individual clients and the opportunity to carry on the heritage of early public health nursing efforts with the benefit of modern advances. In doing so, there are the challenges of:

Expanding nursing's focus from the individual and family to communities and populations Determining the needs of populations at risk and designing interventions to specifically address them Learning the complexities of a constantly changing health care system

Operating within an environment of rapid change and increasingly complex challenges, this nursing specialty holds the potential to shape the quality of community health services and improve the nation's health.

Now you are being asked to leave that familiar acute care setting and go out into the community—into homes, schools, recreational facilities, work settings, parishes, and even street corners that are commonplace to your clients and unfamiliar to you. Here, in the community, you will:

Find few or no monitoring devices or charts full of laboratory data Have no professional and allied health workers next to you to assist you Use the nontangible skills of listening, assessing, planning, teaching, coordinating, evaluating, and referring Draw on the skills you have learned throughout your acute care setting experiences (e.g., behavioral health and women's, children's, and adult health nursing) and begin to “think on your feet” in new and exciting situations

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Often, your practice will be solo, and you will need to combine creativity, ingenuity, intuition, and resourcefulness along with these skills. Talk about boundless opportunities and challenges! (see Box 1-1).

BOX 1-1 PERSPECTIVES

A Nursing Student Viewpoint on Community/Public Health Nursing I was really terrified when I got to my community/public health rotation and found that I had to go knock on people's doors! I was close to graduating and felt comfortable in the hospital (the routines and machines). Now, I had to actually find apartments in an area of the city where I never go! And, was unclear about my tasks. I had minimal equipment —a baby scale, a blood pressure cuff, a stethoscope, a thermometer, and a paper tape measure. I was assigned a 16-year-old mother with a 4-month-old baby. I don't even have children! What can I tell her? She is a teenager who “knows it all.” My clinical instructor told me to “build a relationship with her” and to “gain trust and rapport,” difficult to do when you are scared to death. But I needed this class to finish nursing school, so I drove over there and knocked on her door. The apartment building was disheveled. When she answered the door, she seemed uninterested—or maybe a little defensive. I told her who I was and why I was there, and she motioned me inside pointing toward the baby,

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propped up on the tattered couch. I spent the next 15 weeks visiting Anna and her baby every Thursday—weighing and measuring the baby, doing Ages & Stages Questionnaires and sharing the results with Anna about developmental milestones, getting her appointments for immunizations, listening to her story of abuse and abandonment, and I began to realize that what I was doing was actually exciting and rewarding. By the end of my rotation, I was going to miss Anna and little José! I had provided education on baby-proofing her apartment, finding resources for food and clothing, and getting birth control. We even talked about how she could finish high school. After graduation, I took a job in the ED and thought of Anna and José when young mothers would bring in their sick babies. I used C/PHN skills in “connecting” with a teen mom to ensure follow through with antibiotics and antipyretics we were prescribing for her baby's high fever and serious infection. One day, I glanced up from my paperwork to see Anna and José. She looked so relieved to see me! She was frantic with worry about the serious burn José had on his right hand. The other nurses were mumbling about “child abuse” and how “irresponsible teen mothers always were.” Anna had left José with a neighbor while she went to an appointment about GED. The older woman was not used to dealing with a busy toddler, and Jose was able to reach the handle of a pan of refried beans. The team treated José's burn, and I gave Anna instructions for follow-up care. The bond we had developed was still there. She trusted me, and I knew that she would follow through with the instructions. The other nurses who were making comments about Anna did not know her circumstances. I feel that I am a more effective ED nurse because of the things I learned during my C/PHN rotation. Someday, when I get tired of the hospital, I may work as a public health nurse. You never know!

Madison, age 24

You may feel that this new setting is too demanding and be anxious about how you will perform in it. But perhaps, just perhaps, you will find that it is rewarding, that it constantly challenges you, interests you, and allows you to work holistically with clients of all ages, at all stages of illness and wellness, and that it absolutely demands the use of your critical thinking skills. And some of you may decide, when you finish your community/public health nursing course, that you have found your career choice. Even if you are not drawn away from acute care nursing, your community/public health nursing experience will give you:

Deeper understanding of the people for whom you provide care—where and how they live, the family and cultural dynamics at play, and the

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problems they will face when discharged from your care A realization that clients are not only individuals or families, but also aggregates, communities, and populations, giving you an expanded view of nursing Knowledge of myriad community agencies and resources to better assist you in providing a continuum of care for your clients

Finding out begins with understanding the concepts of community and health. This chapter provides an overview of these basic concepts, the components of public health practice, and the salient characteristics of contemporary community/public health nursing practice, so that you can enter this specialty area of nursing in concert with its intentions. The opportunities and challenges of community/public health nursing will become even more apparent as the chapter progresses. We begin by discussing community health and how it provides the context for community/public health nursing practice.

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COMMUNITY HEALTH

Human beings are social creatures. We generally live out our lives in the company of other people. An Eskimo is part of a small, tightly knit community of close relatives; a rural Mexican may live in a small village with hardly more than 200 members. In contrast, someone from New York City might be a member of many overlapping communities, such as professional societies, a political party, a religious group, a cultural society, a neighborhood, and the city itself. Even those who try to escape community membership always begin their lives in some type of group, and they usually continue to depend on groups for material and emotional support.

We can draw two important conclusions from this fact:

Communities are an essential and permanent feature of the human experience. As systems theory reminds us, just as a whole is greater than the sum of its parts, so the health of a community is more than the sum of the health of its individual citizens.

Systems theory proposes that systems are open and that there is interaction between systems and their environment (Bertalanffy, 1968). A community that achieves a high level of wellness is composed of healthy citizens, functioning in an environment that protects and promotes health. The communities in which people reside and work have a profound influence on our collective health and wellbeing (Scott et al., 2018). For instance, do you suppose that green space in a city can influence health? In a population- based study of 1,680 urban adults living in a deprived area of the United Kingdom, the overall prevalence of psychological distress was 22.7%. However, for those living near adequate green spaces, there was a 54% reduction in risk of psychological distress (Pope et al., 2018). Healthier communities can be created.

Before going further, it would be helpful to distinguish between the concepts of community health and public health. Although both are organized community efforts aimed at the promotion, protection, and preservation of the public's health, community health has been defined as “the health status of a defined group of people”….and the “private and public (governmental)” actions taken to “promote, protect, and preserve their health” (McKenzie, Pinger, & Seabert, 2018, p. 6). Community health is the identification of needs, along with the protection and improvement of collective health, within a geographically defined area.

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A more comprehensive definition is a “multi-sector and multi- disciplinary collaborative enterprise that uses public health science, evidence-based strategies, and other approaches to engage and work with communities in a culturally appropriate manner, to optimize the health and quality of life of all persons who live, work, or are otherwise active in a defined community or communities” (Goodman, Bunnell, & Posner, 2014, p. 5).

To understand the nature and significance of community health, it is necessary to more closely examine the concepts of community and of health, which are covered in the following sections. The remainder of this section focuses on public health.

Public health is a broader concept and often goes beyond community boundaries, dealing with populations around the world. Public health, as a specialty of nursing practice, seeks to provide organizational structure, a broad set of resources, and the collaborative activities needed to accomplish the goal of an optimally healthy community. When you work in hospitals or other acute care settings, your primary focus is the individual patient. Patients' families are often viewed as ancillary, and little thought is given to the world outside the hospital. Public health, however:

Broadens the focus of care to families, aggregates, communities, and populations Views the community as the recipient of service and health as the product Is concerned with the interchange between population groups and their total environment and with the impact of that interchange on collective health

The terms community health nurse and public health nurse are combined throughout this text (C/PHN).

Although many believe that health and illness are issues concerning only individuals, evidence indicates that they are also community issues and that the world is a community. Many types of professionals are involved in public health, forming a complex team, such as:

A city planner designing an urban renewal project A social worker providing counseling about child abuse or working with adolescent substance abusers A physician treating clients affected by a sudden outbreak of hepatitis and assisting public health epidemiologists and public health nurses (PHNs) to find the source Those working in prenatal clinics, programs providing meals for older adults, genetic counseling centers, and educational programs for early

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detection of cancer

The professional nurse is an integral member of this team, a linchpin and a liaison between physicians, social workers, government officials, and law enforcement officers. Community/public health nurses (C/PHNs) work in every conceivable kind of community agency, from a state public health department to a community-based advocacy group. Their duties range from examining infants in a well-baby clinic to teaching older adult stroke victims in their homes to planning community and population-focused interventions (e.g., marketing campaigns to reduce tobacco use). They also carry out epidemiologic research and engage in health policy analysis and decision- making. Despite its breadth, however, public health nursing is a specialized practice, generally requiring a bachelor's degree, and certification is needed in some states. There is currently no national nursing certification for public health nursing (only renewals), but one is available specifically for public health professionals (including PHNs) through the National Board of Public Health Examiners (American Association of Colleges of Nursing, 2019). Together, we will examine the unique contribution made by this nursing specialty to our health care system.

Historically, as a practice specialty, public health has been associated primarily with the efforts of official or government entities—for example, federal, state, or local tax-supported health agencies that target a wide range of health issues. In contrast, private health efforts or nongovernmental organizations (NGOs), such as those of the American Lung Association or the American Cancer Society, work toward solving selected health problems. The latter augments the former. Currently, community health practice encompasses both approaches and works collaboratively with all health agencies and efforts, public or private, which are concerned with the public's health. In this text, community health practice refers to a focus on specific, designated communities. It is a part of the larger public health effort and recognizes the fundamental concepts and principles of public health as its birthright and foundation for practice. In the IOM's landmark publication, The Future of the Public's Health (1998), the mission of public health is defined simply as “fulfilling society's interest in assuring conditions in which people can be healthy” (p. 7). See Box 1-2.

BOX 1-2 PERSPECTIVES

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A Public Health Nursing Instructor Viewpoint When I first introduce the topic of public health, many students don't understand why they have to take this “different” class; they are accustomed to acute care settings, and public health nursing seems so foreign to them. So, I ask students “Why do people end up being hospitalized?” Typical answers include “They needed surgery,” “They had an accident,” and the like. Then, I tell them the story of 4-year-old Jackson: “Why is Jackson in the hospital? (Because he has asthma and pneumonia.) What caused the asthma and pneumonia? (He got a cold and it got worse, resulting in pneumonia, exacerbated by his asthma.) Why did it get worse? (Because he lives in a poor neighborhood.) How does that cause more problems? (Because he is exposed to more asthma triggers, [such as air pollution, mold, dust mites/cockroach allergens, and cigarette smoke] which exacerbate his asthma when he gets an upper respiratory infection—often leading to pneumonia.) Why is he living there? (Because his family is poor and can only afford an apartment in a crowded building located in an area of town near factories and highways. The building is poorly maintained.) Why can't his parents work harder so they can move to a better place? (Because he lives with his mother and 3 siblings, and she works two jobs. That income only covers rent, food, and a few bills.) Why can't his mom get a better job? (Because she doesn't have the skills and education needed to get a higher paying job.) But why…?” And then they become more aware of why this class is important and begin to comprehend how complicated social and economic issues affect health.

Adapted from Federal, Provincial and Territorial Advisory Committee on Population Health (ACPH) (1999).

Winslow's classic 1920 definition of public health still holds true and forms the basis for our understanding of community health in this text: Public health is “the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals” (CDC, 2017c, para 1).

A more recent and concise definition of public health is:

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“Public health promotes and protects the health of people and the communities where they live, learn work and play” (American Public Health Association, 2018, para. 1).

A Web site sponsored by the Association of Schools of Public Health with support from Pfizer Public Health, What Is Public Health? (ASPH, 2018), provides some interesting videos and information about this topic and also proffers this definition:

“Public health protects and improves the health of individuals, families, communities, and populations, locally and globally” (para. 1). Examples of global public health issues include “improving access to health care, controlling infectious disease, and reducing environmental hazards, violence, substance abuse, and injury” (para. 3). “Public health professionals focus on preventing disease and injury by promoting healthy lifestyles” (para. 2).

One of the challenges public health practice faces is to remain responsive to the community's health needs. As a result, its structure is complex; numerous health services and programs are currently available or will be developed. Examples include health education, family planning, accident prevention, environmental protection, immunization, nutrition, early periodic screening and developmental testing, school programs, mental health services, occupational health programs, and the care of vulnerable populations. The Department of Homeland Security, for example, is a community health and safety agency established in the aftermath of the terrorist attacks on New York City and Washington, DC, on September 11, 2001. See Chapter 6.

The core public health functions have been delineated as assessment, policy development, and assurance. These are discussed in more detail in Chapter 2.

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THE CONCEPT OF COMMUNITY

The concepts of community and health together provide the foundation for understanding community health. Broadly defined, a community is a collection of people who share some important feature of their lives (Fig. 1- 1). In this text, the term community refers to 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.

FIGURE 1-1 There are many different types of communities.

A community can be a society of people holding common rights and privileges (e.g., citizens of a town), sharing common interests (e.g., a community of farmers), or living under the same laws and regulations (e.g., a prison community). The function of any community includes its members' collective sense of belonging and their shared identity, values, norms, communication, and common interests and concerns (Anderson & McFarlane, 2019).

Some communities—for example, a tiny village in Appalachia—are composed of people who share almost everything. They live in the same location, work at a limited type and number of jobs, attend the same churches, and make use of the sole health clinic with its visiting physician and nurse. Other communities, such as members of Mothers Against Drunk Driving (MADD), are large, scattered, and composed of individuals who share only a common interest and involvement in a certain goal. Although most communities of people share many aspects of their experience, it is

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useful to identify three types of communities that have relevance to community health practice: geographic, common interest, and health problem or solution. Unit 4 contains more in-depth information about the community as client.

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Geographic Community A community that is defined by its geographic boundaries is called a geographic community. A city, town, or neighborhood is a geographic community.

Consider the community of Hayward, Wisconsin. Located in northwestern Wisconsin, it is set in a wooded environment, far removed from any urban center and in a climatic zone characterized by extremely harsh winters. With a population of approximately 2,300, it is considered a rural community. The population fluctuates with the seasons: summers bring hundreds of tourists and seasonal residents. Hayward is a social system as well as a geographic location. The families, schools, hospital, churches, stores, and government institutions are linked in a complex network. This community, like others, has an informal power structure. It has a communication system that includes gossip, the newspaper, the “co-op” store bulletin board, radio, television, and social media. In one sense, then, a community consists of a collection of people located in a specific place and is made up of institutions organized into a social system.

A few miles south are other communities, including Northwoods Beach and Round Lake; these, along with Hayward and other towns and isolated farms, form a larger community called Sawyer County. If a nurse worked for a health agency serving only Hayward, that community would be of primary concern; however, if the nurse worked for the Sawyer County Health Department, this larger community would be the focus. A PHN employed by the State Health Department in Madison, Wisconsin, would have an interest in Sawyer County and Hayward, but only as part of the larger community of Wisconsin.

Frequently, a single part of a city can be treated as a community. Cities are often broken down into census tracts, or neighborhoods. In New York City, the neighborhood called Harlem is a community, as is the Haight- Ashbury district of San Francisco.

In community health, identifying a geographic area as a community is useful because it:

Provides a clear target for the analysis of health needs Makes available data, such as morbidity and mortality figures, that can augment assessment studies to form the basis for planning health programs Facilitates mobilizing community members for action and forming groups to carry out intervention and prevention efforts that address needs specific to that community, such as shelters for battered women,

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work site safety programs in local hazardous industries, or improved sexual health education in the schools Helps in gaining the support of politically powerful individuals and resources present in a geographic community

On a larger scale, the world can be considered as a global community. Indeed, it is very important to view the world this way. Borders of countries change with political upheaval.

Communicable diseases are not aware of arbitrary political boundaries. A person can travel around the world in <24 hours, and so can diseases, such as Zika virus, Ebola, or COVID-19. Global pandemics require cooperation and information sharing among affected nations. Political uprisings in the Middle East have an impact on people in Western countries. Floods or tsunamis in Southeast Asia or volcanic eruptions in Iceland have meaning for other national economies. The world is one large community that needs to work together to ensure a healthy today and a healthier and safer tomorrow. Globalization raises an expectation of health for all, for if good health is possible in one part of the world, the forces of globalization should allow it elsewhere and everyone then enjoys the benefits (World Health Organization, 2020b). We learn more about global health in Chapter 16.

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Common-Interest Community A community also can be defined by a common interest or goal. A collection of people, even if they are widely scattered geographically, can have an interest or goal that binds the members together. This is known as a common- interest community.

The members of a church in a large metropolitan area and families who have lost members to suicide are both common-interest communities. Sometimes, within a certain geographic area, a group of people may develop a sense of community by promoting their common interest. Individuals with disabilities who are scattered throughout a large city may emerge as a community through a common interest in promoting adherence to federal guidelines for wheelchair access, parking spaces, elevators, or other services for those with disabilities. The residents of an industrial community may develop a common interest in air or water pollution issues, whereas others who work but do not live in the area may not share that interest. Communities form to protect the rights of children, stop violence against women, promote sensible gun laws, clean up the environment, develop a smoke-free environment, or provide support for social and structural change (e.g., Black Lives Matter). The kinds of shared interests that lead to the formation of communities vary widely.

Common-interest communities whose focus is a health-related issue can join with community health agencies to promote their agendas. The single- minded commitment that characterizes such communities can be a mobilizing force for action. Many successful prevention and health promotion efforts, including improved services and increased community awareness of specific problems, have resulted from the work of common- interest communities.

Moms Demand Action is a current example. It began in response to the Sandy Hook school shooting in 2012, when Shannon Watts, a mother of five children, looked for an organization like Mothers Against Drunk Drivers that addressed the gun violence problem in America and the lack of regulations around gun sales in many places (see more on violence and abuse in Chapter 18). She couldn't find one, so she started a Facebook page that got instant and overwhelming responses from other mothers across the country. She had previously worked for 15 years as a communications executive, and even though she was now a stay-at-home mom, she felt passionately about the need for mothers to bring a new narrative to the public debate on guns. She has now organized a grassroots network of mothers to promote gun violence prevention and work together with Mayors Against Illegal Guns to enact common sense gun legislation at the local, state, and national levels (Everytown for Gun Safety Action Fund, 2020; Karlis, 2018).

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While supporting the second amendment, Moms Demand Action seeks to counter the powerful influence of the gun lobby and fight the public health crisis of gun violence. Stating that “seven American children or teens are shot and killed every day,” this organization seeks “sensible gun laws and policies” to protect families and children (Karlis, 2018, para. 5). After the Parkland, Florida high school shooting, a related organization, Students Demand Action, was organized and now has over 50,000 volunteers who are working to register new voters and raise awareness. Moms Demand Action has over 6 million members and volunteers who attend city and county government meetings and state legislative hearings and question lawmakers on their views about gun legislation.

Watts feels that they are successful because “a gun extremist's love will never match a mother's love for her child” (Karlis, 2018, para. 30). It is important for women to be involved, as Watts notes that “if you compare women in America to our peers in high-income countries, we're 16 times more likely to be shot” (Karlis, 2018, para. 30). But it's not just mothers who are active in Moms Demand Action. Men also take time to march, attend meetings, canvas their neighborhoods for support, assist candidates who favor sensible gun legislation, help fundraise, as well as attend advocacy days at their state capitols. In conjunction with Everytown for Gun Safety, they are also encouraging more women to run for office and hope to ensure legislation to prevent child accidental gun deaths, strengthen background checks, prevent domestic abusers from owning firearms, and strengthen gun trafficking laws (Moms Demand Action, 2018). You can learn more about their successful lobbying and legislation at https://momsdemandaction.org/about/victories/

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Community of Solution A type of community encountered frequently in community/public health practice is a group of people who come together to solve a problem that affects all of them. This type of community is known as a community of solution. The shape of this type of community varies with the nature of the problem, the size of the geographic area affected, and the number of resources needed to address the problem.

For example, a water pollution problem may involve several counties whose agencies and personnel must work together to control upstream water supply, industrial waste disposal, and city water treatment. This group of counties forms a community of solution focusing on a health problem. Figure 1-2 depicts some communities of solution related to a single city.

FIGURE 1-2 A city's communities of solution. State, county, and city boundaries (solid lines) may have little or no bearing on health solution boundaries (dashed lines).

In recent years, communities of solution have formed in many cities to address the spread of diseases and have worked with community members to assess public safety and security and create plans to make the community a safer place in which to live. Recently, Flint, Michigan was faced with a

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growing water crisis involving high levels of lead and an outbreak of Legionnaire's disease, eventually leading to criminal charges being brought against state and city officials for “misconduct in office, conspiracy, and willful neglect of duty” (Kennedy, 2016, para. 71). Public health agencies, social service groups, schools, citizens, and media personnel banded together to create public awareness of the dangers and to promote preventive behaviors. See Chapter 9.

Governments can create communication barriers, so better coordination between community partners and governmental authorities and sharing of technology and knowledge are critical components in communities of solution. Stout, Howard, Lewis, McPherson, and Schall (2017), working with the Institute for Healthcare Improvement, reported on several successful projects initiated and completed by communities of solution in the United States, Africa, and South America. These included multi-year initiatives with the following goals:

To reduce mortality by 66% in those younger than age 5 To assist 186 communities in supplying permanent housing to over 106,000 homeless people To help establish local health assemblies that promote public health initiatives in a poor, remote country in which a 5th grade education is the highest level of education available to residents of 36 small, isolated villages (initiatives included providing community health workers, immunizations, malaria detection and treatment, midwives providing family planning, establishing nursery schools, building secondary schools with science curricula to increase the numbers of health care providers, establishing eco-tourism to help with road building and improve economic growth)

As you can see, a community of solution is an important conduit for change in community/public health.

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Populations and Aggregates Population health is a foundation of community/public health practice (National Quality Forum, 2018). The three types of communities just discussed underscore the meaning of the concept of community: in each instance, a collection of people chose to interact with one another because of common interests, characteristics, or goals. The concept of population has a different meaning.

In this text, the term population refers to all of the people occupying an area or to all of those who share one or more characteristics (Anderson & McFarlane, 2019).

In contrast to a community, a population is made up of people who do not necessarily interact with one another and do not necessarily share a sense of belonging to that group. A population may be defined geographically, such as the population of the United States or a city's population. This designation of a population is useful in community/public health for epidemiologic study and for collecting demographic data for purposes such as health planning. A population also may be defined by common qualities or characteristics, such as the older adult population, the homeless population, or a particular racial or ethnic group. In community/public health, this meaning becomes useful when a specific group of people (e.g., homeless individuals) is targeted for intervention; the population's common characteristics (e.g., the health- related problems of homelessness) become a major focus of the intervention.

In this text, the term aggregate refers to a mass or grouping of distinct individuals who are considered as a whole and who are loosely associated with one another. It is a broader term that encompasses many different-sized groups. Both communities and populations are types of aggregates. Unit 5 discusses community/public health nursing with aggregates, and Unit 6 discusses vulnerable populations. In Unit 7, we will examine the different settings for community/public health nursing.

The aggregate focus, or a concern for groupings of people in contrast to individual health care, is a distinguishing feature of community/public health practice. C/PHNs may work with aggregates such as pregnant and parenting teens, older adults with diabetes, or gay men with HIV/AIDS.

Because of community/public health nursing's focus on communities, aggregates, and families, new nursing and health care delivery systems may

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develop that are more profitable and effective in preventing health problems that require expensive hospitalizations. Community/public health workers, including C/PHNs, must clearly define the community targeted for study and intervention and understand its complexity before assessing its needs and designing interventions to address them. To help define the community, the C/PHN should answer the following questions:

Who makes up the community? Where are they located, and what are their characteristics? What are the characteristics of the people in terms of age, gender, race, socioeconomic level, and health status? How does the community interact with other communities? What is its history? What are its resources? Is the community undergoing rapid change, and, if so, what are the changes?

These questions, as well as the tools needed to assess a community for health purposes, are discussed in detail in Chapter 15.

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THE CONCEPT OF HEALTH

Health, in the abstract, refers to a person's physical, mental, and spiritual state; it can be positive (as being in good health) or negative (as being in poor health).

The World Health Organization (WHO) offers a positive explanation of health as “a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity” (WHO, 2020a, para. 1). Building on this classic definition, our definition of health in this text is as follows: a holistic state of wellbeing, which includes soundness of mind, body, and spirit.

Health is determined by more than just medical care. It is influenced by various factors—location of home, education, income, diet, exercise, accessibility of health care, and health behaviors (County Health Rankings, 2018). See Figure 1-3 for the County Health Rankings Model. Likewise, the WHO (2020a) has outlined the prerequisites for health as “peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and equity” (para. 5).

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FIGURE 1-3 County Health Rankings Model demonstrates how many factors lead to health outcomes. (Courtesy of University of Wisconsin Population Health Institute. County Health Rankings & Roadmaps 2019. https://www.countyhealthrankings.org/countyhealth-rankings- model. County Health Rankings Model © 2014 UWPHI. Used with permission.)

Community health practitioners place a strong emphasis on wellness, which includes this definition of health but also incorporates the capacity to develop a person's potential to lead a fulfilling and productive life—one that can be measured in terms of quality of life. Today, our health is greatly affected by our lifestyles, preventive measures we take, and risk behaviors in which we engage (Saint Onge & Krueger, 2017). We are increasingly aware of the strong relationship of health to environment (Box 1-3), although this concept is not new (Thompson & Schwartz Barcott, 2017).

BOX 1-3 What Do You Think?

The Link Between Personal Health and the Environment Life expectancy increased from

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47.3 years in 1900 to 76.8 years in 2000, and it is estimated that about 25 years of this growth can be attributed to public health advances (e.g., infectious disease control/prevention). The remainder of the gain is the result of improvements in prevention and therapeutic interventions (e.g., lifestyle behaviors, medical advances).

1. Do you think there is a direct link between your health and your environment?

2. If your answer is Yes, then how? If it is No, then what else might explain the findings?

Source: CDC (2011).

Over 150 years ago, Florence Nightingale explored the relationship between health/illness and the environment. She believed that a person's health was greatly influenced by ventilation, noise, light, cleanliness, diet, and a restful bed (Nightingale, 1859/1992). As is well documented, the built environment, or manmade structures and surroundings in a community (e.g., highways and bike paths, parks and open spaces, public buildings, and housing developments), significantly affects the health of individuals, aggregates, and populations (CDC, 2017a; Hankey & Marshall, 2017; Mueller et al., 2017). Nightingale's model, along with others, is explained in Chapter 15, and the environment's relationship to health is discussed in more detail in Chapter 9.

Culture also shapes our view of health. Some cultures see health as the freedom from and absence of evil and illness as punishment for being bad or doing evil or a result of witchcraft (Iheanacho et al., 2016). Many individuals come from families in which beliefs regarding health and illness are heavily influenced by religion, superstition, folk beliefs, or “old wives' tales.” C/PHNs commonly encounter such beliefs when working with various groups in the community. Chapter 5 explores these beliefs more thoroughly for a better understanding of how health beliefs influence every aspect of a person's life, as well as principles of transcultural nursing in the community.

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The Health Continuum: Wellness–Illness Western societies often exhibit a polarized or “either/or” way of thinking about health: either people are healthy and well or they are ill. Yet, wellness is a relative concept, not an absolute, and illness is a state of being relatively unhealthy. The study of factors affecting health and illness is known as epidemiology and is discussed in Chapter 7. There are many levels and degrees of wellness and illness, from a robust 75-year-old woman who is fully active and functioning at an optimal level of wellness to a 75-year-old man with end-stage renal disease whose health is characterized as frail. Someone recovering from pneumonia may be mildly ill, whereas a teenage boy with functional limitations because of episodic depression may be described as mildly well. The continuum, however, can change.

Because healthiness involves a range of degrees from optimal health at one end to total disability or death at the other (Fig. 1-4), it often is described as a health continuum. This health continuum applies not only to individuals but also to families and communities. A nurse might speak of a “family in crisis,” meaning one that is experiencing a relative degree of illness or altered functioning, or of a healthy family, meaning one that exhibits many wellness characteristics, such as effective communication and conflict resolution, as well as the ability to effectively work together and use resources appropriately. More information on working with families and communities is included in Chapters 14 and 15.

FIGURE 1-4 The health continuum. A person's relative health is usually in a state of flux, either improving or deteriorating. This diagram of the wellness–illness continuum shows several examples of people in changing states of health.

Likewise, a community, as a collection of people, may be described in terms of degrees of wellness or illness. The health of an individual, family, group, or community moves back and forth along this continuum throughout

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the lifespan. Healthy people make healthy communities and a healthy society.

The Declaration of Alma Ata, which took place in 1978, noted that health is a “fundamental human right” and that the level of health must be raised for all countries in order for any society to improve their health (WHO, 2020d, para. 2).

By thinking of health relatively, as a matter of degree, the scope of nursing practice can be broadened to focus on preventing illness or disability as well as promoting wellness. Traditionally, most health care has focused on treatment of acute and chronic conditions at the illness end of the continuum. Gradually, the emphasis is shifting to focus on the wellness end of the continuum, as outlined in the government document, Healthy People 2030 (U.S. Department of Health and Human Services [USDHHS], Office of Disease Prevention and Health Promotion [ODPHP], 2020). The vision for Healthy People 2030 is for everyone to reach their “full potential” and enjoy “wellbeing” throughout their lives (para.10). This effort aims to improve the health of American citizens by establishing objectives and benchmarks that can be monitored over time. There have been Healthy People objectives for 2000, 2010, 2020, and now for 2030. A main foundational principle is that a population's health and wellbeing are a prerequisite to securing a flourishing and equitable society. The mission, foundational principles, and five overarching goals of Healthy People 2030 were used to guide further planning (USDHHS, 2020).

The goals overarch topics and objectives (Box 1-4). The objectives are stated in measurable terms that specify targeted incidence and prevalence changes and address age, gender, and culturally vulnerable groups along with improvement in public health systems. Healthy People 2030 boxes can be found in selected chapters. There are three types of objectives:

Core objectives rely on health statistics data from established sources (e.g., U.S. Census, surveys, datasets) for accurate assessment of progress meeting targets. Developmental objectives are selected from “high priority areas without reliable baseline data, but with established evidence-based interventions” (Association for State and Territorial Health Officers, 2019, para. 4). Research objectives are areas for potential studies without consistent evidence-based interventions.

BOX 1-4 HEALTHY PEOPLE 2030 Issues in Community/Public Health Nursing

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Mission To promote, strengthen, and evaluate the Nation's efforts to improve the health and wellbeing of all people. Foundational Principles Foundational principles explain the thinking that guides decisions about Healthy People 2030.

Health and wellbeing of all people and communities are essential to a thriving, equitable society. Promoting health and wellbeing and preventing disease are linked efforts that encompass physical, mental, and social health dimensions. Investing to achieve the full potential for health and wellbeing for all provides valuable benefits to society. Achieving health and wellbeing requires eliminating health disparities, achieving health equity, and attaining health literacy. Healthy physical, social, and economic environments strengthen the potential to achieve health and wellbeing. Promoting and achieving the Nation's health and wellbeing is a shared responsibility that is distributed across the national, state, tribal, and community levels, including the public, private, and not-for-profit sectors. Working to attain the full potential for health and wellbeing of the population is a component of decision-making and policy formulation across all sectors.

Healthy People 2030 Overarching Goals

Attain healthy, thriving lives and wellbeing, free of preventable disease, disability, injury, and premature death. Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and wellbeing of all.

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Create social, physical, and economic environments that promote attaining full potential for health and wellbeing for all. Promote healthy development, healthy behaviors, and wellbeing across all life stages. Engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and wellbeing of all.

Reprinted from U.S. Department of Health and Human Services (USDHHS). Office of Disease Prevention & Health Promotion. (2019). Healthy People 2030: Framework. Retrieved from https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People- 2030/Framework

Progress toward the Healthy People 2020 objectives was mixed at the midcourse review, with only 21.1% of the 1,054 measurable objectives meeting or exceeding targeted goals. Some improvement was noted in 19.1%, but 11.1% actually reported worse outcomes on proposed goals (USDHHS, 2017). Healthy People 2020 and Healthy People 2030 emphasize that the health of an individual is linked to the health of the larger community and that this larger community's health is related to the health of the corresponding state and ultimately our nation (Artiga & Hinton, 2018; CDC, 2018a; USDHHS, 2019). See Figure 1-5. The recommended leading health indicators for Healthy People 2030 are an outcomes metric for measuring progress toward national public health goals. The main topic areas under which the leading health indicators are organized are compared in Box 1-5.

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FIGURE 1-5 The health of the individual is related to community, state, and national health. (From California Department of Public Health (CDPH). (August 2015). Portrait of promise: The California statewide plan to promote health and mental health equity. Report to the legislature and the people of California by the Office of Health Equity, CDPH. (p. 18). Retrieved from https://www.cdph.ca.gov/Programs/OHE/CDPH%20Document%2 0Library/ADA%20Approved%20POP%20Report.pdf#search=soci al%20determinants%20of%20health%20graphic)

BOX 1-5 HEALTHY PEOPLE 2030 Proposed Leading Health Indicators The leading health indicators (LHIs) are used to measure the health of the nation. For Healthy People 2020, there were 26 objectives/indicators arranged under 12 general topic areas. As a group, the leading health indicators reflect the major health concerns in the United States.

Healthy People 2030 has proposed 18 topic areas and 34 measures of health/objectives. A comparison of the Healthy People 2020 and the recommended Healthy People 2030 topic areas is shown below.

The Healthy People 2020 midcourse review assessed progress toward the goals derived from the 2020 LHIs. Only 8 of the 26 objectives/indicators (i.e., in the 6 topic areas accompanied by an asterisk in the below table) met or exceeded targeted goals, as follows:

Both Environmental Quality targets were exceeded. One of the two Injury and Violence targets was exceeded (decreased homicide rate). Both Maternal, Infant, and Child Health targets were met. One of the four Nutrition, Physical Activity, and Obesity targets was exceeded (aerobic and strengthening age 18 and over). One of the two Substance Abuse targets was exceeded (adolescents' use of alcohol or illicit drugs in past 30 days). One of the two Tobacco targets was exceeded (9th to 12th graders smoking in past 20 days).

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Some improvement was shown in 8 additional objectives/indicators, but 3 objectives demonstrated worse outcomes.Note: The final version of Leading Health Indicators for Healthy People 2030 had not been completed by the August 2020 rollout of Healthy People 2030 objectives and are due at a later date.

*One or two objectives met or exceeded target. Source: NASEM (2020); ODPHP (2016).

Probably the most commonly recognized metric for the health of a nation is the life expectancy of its citizens. Life expectancy in the United States dropped from 78.7 years for a child born in 2015 to 78.6 for 2016 (Kochanek, Murphy, Jiaquan, & Arias, 2017).We now have a lower life expectancy than other developed nations. For instance, we are below the average life expectancy of 80.3 years for the nations of Canada, France, Germany, Japan, Mexico, and the United Kingdom (Donnelly, 2018).

Community characteristics of health have been described by the Centers for Disease Control and Prevention (CDC) as health-related quality of life indicators. Two sources of community-level health indicators include the County Health Rankings and Roadmaps and the Prevention Status Reports (CDC, 2017b). Compare your county's ratings with those of others in your state. Many indicators of community health have been used over the years, such as income distribution, unemployment rates, number of health professionals, and lifestyle choices. Health Resources in Action (2013) sought to define and describe the elements of healthy communities by getting feedback from government and nongovernmental organizations that work

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with communities to improve the health of populations (see Box 1-6). How many of these are found in your city or community? (Are you surprised that only two of these elements contain the word “health”?)

BOX 1-6 Qualities of a Healthy Community

Equity and justice (few disparities) Low poverty levels indicating that jobs are available (a generally good economy) Education Health care and services to prevent illness Environment that is sustainable and wide-ranging community participation that is fair and inclusive Employ environmental strategies Participation across multiple sectors Capability to examine and address their own health problems Collaborative strategies Housing/shelter Civic engagement Public policy that focus on health Availability of healthy food Safety Ability to have active lives Transportation Empowered residents Healthy child development Data are employed to guide and evaluate programs

Adapted from Health Resources in Action (2013).

Healthy communities and healthy cities impact the health of their populations and vice versa. In the 1980s, the WHO initiated the Healthy Cities movement to improve the health status of urban populations. This movement fosters “health and wellbeing through governance, empowerment and participation, creating urban places for equity and community prosperity, and investing in people for a peaceful planet” (WHO, Regional Office for Europe, 2018, p. 3).

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Health as a State of Being Health refers to a state of being, including many different qualities and characteristics.

An individual might be described as energetic, outgoing, enthusiastic, beautiful, caring, loving, and intense. Together, these qualities become the essence of a person's existence; they describe a state of being. A geographic community, such as a neighborhood, might be characterized as congested, deteriorating, unattractive, dirty, and disorganized, all of which suggest diminishing degrees of vitality. A population, such as workers involved in a massive layoff, might be characterized as banding together to provide support and share resources to effectively seek new employment. Such a community shows signs of healthy adaptation and positive coping.

Health involves the total person or community. All of the dimensions of life affecting everyday functioning determine an individual's or a community's health, including physical, psychological, spiritual, economic, and sociocultural experiences. All of these factors must be considered when dealing with the health of an individual or community. The approach should be holistic, including not only physical and emotional status but also the status of home, family, and work.

When considering an aggregate or group of people in terms of health, it becomes useful for intervention purposes to speak of the “health of a community” (Fig. 1-6). With aggregates as well as individuals, health as a state of being does not merely involve that group's physical state but also includes psychological, spiritual, and socioeconomic factors.

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FIGURE 1-6 Healthy communities promote the health of their inhabitants.

As an example, the health of the population on the island of Puerto Rico, an American territory, was dramatically changed on September 20, 2017 when Hurricane Maria directly hit the island with winds of 155 miles per hour (nearly category 5) and stayed over the island for more than 30 hours (Fig. 1-7; Abbasi, 2018; Meyer, 2017). Two weeks earlier, Hurricane Irma had hit the island, and while much milder than Maria, it had already caused serious problems with the power system (Zorrilla, 2017). Flooding occurred in coastal areas, and an estimated 472,000 homes were seriously damaged (over 87,000 completely destroyed). It is estimated that 440,000 of the 3.4 million inhabitants were without power to their homes for 6 months. Most of Puerto Rico's 69 hospitals were without fuel for generators. Three to four days after landfall, only three of the major hospitals were managing to function.

FIGURE 1-7 San Juan, Puerto Rico after Hurricane Maria.

Many patients with surgical emergencies had to be sent to the U.S. mainland for treatment. One in seven people on the island have diabetes, and people threw out insulin after the storm due to lack of refrigeration. Pharmacies couldn't function for several weeks, dialysis centers had no access to electricity or water for several days, and physicians were unable to reopen their offices in rural areas for a few months due to lack of access to electronic medical records (Abbasi, 2018; Alcorn, 2017). There are still serious concerns about the effects on the mental health of survivors of having lived through such a destructive event (Lybarger, 2018). Many found the

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response of the federal government to be slow and deficient (Alcorn, 2017; Zorrilla, 2017).

The official death toll was estimated at 64, but one Harvard study put the number of deaths between 800 and 8,500. The Puerto Rican government updated the death toll estimate in 2018 to 1,427 (Kishore et al., 2018; Robles, 2018). A study done later that year by George Washington University and the University of Puerto Rico (Milken Institute, 2018) estimated deaths of between 2,658 and 3,290. Survivors must deal with serious environmental threats and the loss of their homes and businesses. Environmental hazards include sewage-contaminated drinking water or well water from Superfund sites (recognized by the federal government as extremely contaminated), along with mud contaminated by diesel and fuel oil used in power plants. Mold exposure is also problematic, and people lived in temporary tents or shelters for many months after the event. There were literally tons of downed trees and manmade debris, leading to trash and pollution problems for months and years to come. All of these things continue to affect the health of Puerto Ricans (Newkirk II, 2017). Many dimensions of health were significantly affected by this crisis. We examine disaster and bioterrorism in Chapter 17.

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Subjective and Objective Dimensions of Health Health involves both subjective and objective dimensions; that is, it involves both how people feel (subjective) and how well they can function in their environment (objective).

Subjectively, a healthy person is one who feels well and who experiences the sensation of a vital, positive state. Healthy people are full of life and vigor, capable of physical and mental productivity. They feel minimal discomfort and displeasure with the world around them. People experience varying degrees of vitality and wellbeing, and the state of feeling well fluctuates. Some mornings we wake up feeling more energetic and enthusiastic than we do on other mornings. How people feel varies day by day, even hour by hour; nonetheless, how they feel overall is a strong indicator of their overall state of health.

Health also involves the objective dimension of ability to function. A healthy individual or community carries out necessary activities and achieves enriching goals. Unhealthy people not only feel unwell, but they are limited, to some degree, in their ability to carry out daily activities.

Indeed, levels of illness or wellness are measured largely in terms of ability to function (van Puffelen et al., 2015). A person confined to bed is often labeled sicker than an ill person managing self-care. A family that meets its members' needs is healthier than one that has poor communication patterns and is unable to provide adequate physical and emotional resources. A community actively engaged in crime prevention or in policing of industrial wastes shows signs of healthy functioning. The degree of functioning is directly related to the state of health (Box 1-7).

BOX 1-7 PERSPECTIVES

Voices from the Community I never thought much about being healthy or not, now that you ask. I keep busy, I cook like I'm expecting company, I have a good appetite. I really think all these so- called healthy things people suggest are fads, just

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so someone can get rich—like tofu and low fat this and that. Don't give me margarine, only butter, … and skim milk, it's like drinking water! I work in my garden, I read, and I eat fresh foods. And don't talk to me about my smoking, it's the one pleasure I have left.

Bettie, age 81

The ability to function can be observed. A man dresses and feeds himself and goes to work. Despite financial limitations, a family supports its members through an emotional crisis. A community provides adequate resources and services for its members. These performances, to some degree, can be regarded as indicators of health status.

The actions of an individual, family, or community are motivated by their values. Some activities, such as walking and taking care of personal needs, are functions valued by most people. In assessing the health of individuals and communities, the C/PHN can observe people's ability to function but also must know their values, which may contrast sharply with those of the nurse. The influence of values on health is examined more closely in Chapter 4.

The subjective dimension (feeling well or ill) and the objective dimension (functioning) together provide a clearer picture of people's health. When they feel well and demonstrate functional ability, they are close to the wellness end of the health continuum. Even those with a disease, such as arthritis or diabetes, may feel well and perform well within their capacity. These people can be considered healthy or closer to the wellness end of the continuum. Figure 1-8 depicts the relationships between the subjective and objective views of health.

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FIGURE 1-8 Subjective and objective views of the wellness– illness continuum.

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Continuous and Episodic Health Care Needs Community/public health practice encompasses care for populations in all age groups with birth-to-death developmental health care needs. These continuous needs may include, for example, assistance with providing a toddler-proof home, help in effectively dealing with the progressive emancipation of preteens and teenagers, anticipatory guidance for reducing and managing the stress associated with retirement, or help coping with the death of an aged parent. These are developmental events experienced by most people, and they represent typical life occurrences. The C/PHN has the skills to work at the individual, family, and group level to meet these needs.

In addition, populations may have a one-time, specific, negative health event, such as an illness or injury that is not an expected part of life. These episodic needs might derive from a head injury incurred from an automobile crash or a diagnosis of tuberculosis or another communicable disease. In reaction to such an event in 2016, the CDC raised its Emergency Operations Center's response level for Zika virus outbreaks in the Americas to its highest alert status (Level 1). Although most cases were then found in South American and the Caribbean, there was concern about spread due to travel to the U.S. mainland. In 2018, the level was reduced to 2, with 452 symptomatic Zika cases having been reported in the United States in 2017 (only seven of which were deemed to be acquired by local mosquito-borne transmission in Texas and Florida). In 2018, preliminary data revealed just 74 Zika cases acquired by local mosquito-borne transmission (CDC, 2018b, 2018c). By early October 2019, ten cases were reported; none were acquired locally (CDC, 2019). In a response to a novel coronavirus (COVID-19) pandemic, on March 13, 2020, a nationwide emergency was declared by President Trump (Federal Emergency Management Agency, n.d.). Chapter 7 discusses epidemiology in regard to COVID-19. Find more information on communicable diseases in Chapter 8 and on the public health system in Chapter 6.

In a given day, the C/PHN may interact with clients having either continuous or episodic health care needs or both. For example, how do middle-aged adults, planning their retirement and preparing for the death of an aged parent, deal with their adult child's AIDS diagnosis? Or, how do parents of a teenager confront their child's drug dependence? Complex situations such as these may be positively influenced by the interaction with and services of the C/PHN.

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COMPONENTS OF COMMUNITY/PUBLIC HEALTH PRACTICE

Community/public health practice can best be understood by examining two basic components—promotion of health and prevention of health problems. The levels of prevention are a key to community/public health practice.

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Promotion of Health Promotion of health is recognized as one of the most important components of public health and community health practice. Health promotion includes all efforts that seek to move people closer to optimal wellbeing or higher levels of wellness.

Nursing, in particular, has a social mandate for engaging in wellness and health promotion (Salmond & Echevarria, 2017). Health promotion programs and activities include many forms of health education—for example, teaching the dangers of drug use, demonstrating healthful practices such as regular exercise, and providing more healthpromoting options such as heart- healthy menu selections.

Community health promotion, then, encompasses the development and management of wellness promotion and preventive health care services that are responsive to community health needs. Wellness programs in schools and industry are examples. Demonstration of such healthful practices as eating nutritious foods and exercising more regularly often is performed and promoted by individual health workers. In addition, groups and health agencies that support a smoke-free environment, encourage physical fitness programs for all ages, or demand that food products be properly labeled underscore the importance of these practices and create public awareness.

The goal of health promotion is to raise levels of wellness for individuals, families, populations, and communities (WHO, 2020c, 2020e). Public health efforts promote health, ensuring healthy lives and promoting wellbeing for all age groups. In this country, during the 1980s, the U.S. Public Health Service published the Surgeon General's Report, Healthy People, and continued with goals and objectives each decade since then to address the health of the nation.

This report:

Provided vision and an agenda for significantly reducing preventable death and disability nationwide, enhancing quality of life, and greatly reducing disparities in the health status of populations Emphasized the need for individuals to assume personal responsibility for controlling and improving their own health destiny Challenged society to find ways to make good health available to vulnerable populations whose disadvantaged state placed them at greater risk for health problems Called for an intensified shift in focus from treating preventable illness and functional impairment to concentrating resources and targeting efforts that promote health and prevent disease and disability

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The Institute of Medicine's 2002 hallmark report, The Future of the Public's Health in the 21st Century, notes that the majority of health care spending, “as much as 95%,” focuses on “medical care and biomedical research,” whereas evidence suggests that “behavior and environment are responsible for over 70% of avoidable mortality” and that health care is only one of many “determinants of health” (p. 2).

The implications of this national agenda for health have far-reaching consequences for persons engaged in health care. For centuries, health care has focused on the illness end of the health continuum, but health professionals can no longer justify concentrating most of their efforts exclusively on treating the sick and injured. We now live in an age when it is not only possible to promote health and prevent disease and disability, but it is our mandate and responsibility to do so. For more on health promotion, see Chapter 11.

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Prevention of Health Problems Prevention of health problems constitutes a major part of community/public health practice. Prevention means anticipating and averting problems or discovering them as early as possible to minimize potential disability and impairment. It is practiced on three levels in community/public health: primary, secondary, and tertiary prevention (Lenartowicz, 2018). These concepts recur throughout the chapters of this text, in narrative format and in the Levels of Prevention Pyramids, because they are basic to community/public health nursing (Box 1-8).

BOX 1-8 Levels of Prevention Pyramid Link Between Poor Diet, Inactivity, and Obesity SITUATION: Poor nutritional habits and inactivity are leading to obesity and a greater incidence of type 2 diabetes among children and adults. GOAL: Using the three levels of prevention, avoid or promptly diagnose and treat, negative health conditions, and improve population health.

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Primary prevention precludes the occurrence of a health problem; it includes measures taken to keep illness or injuries from occurring. It is applied to a generally healthy population and precedes disease or dysfunction. Primary prevention involves anticipatory planning and action on the part of community/public health professionals, who must project themselves into the future, envision potential needs and problems, and then design programs to counteract them so that they never occur. The concepts of primary prevention and planning for the future are foreign to many social groups, who may resist on the basis of conflicting values.

Examples of primary prevention activities by a C/PHN include:

Providing childhood vaccinations and yearly flu shots Encouraging older people to install and use safety devices (e.g., grab bars by bathtubs, handrails on steps) to prevent injuries from falls Teaching young adults healthy lifestyle behaviors, so that they can make them habitual behaviors for themselves and their children Working through a local health department in consultation with a school district to help control and prevent communicable diseases such as measles, pertussis, or varicella by providing regular immunization programs and vaccine oversight Instructing a group of overweight individuals on how to follow a well- balanced diet while losing weight to prevent nutritional deficiency (Box 1-8) Teaching safe sex practices or the dangers of smoking/vaping and substance abuse Serving on a fact-finding committee exploring the effects of a proposed toxic waste dump on the outskirts of town

Because it is our view that this is where most of the emphasis should be placed in the health care system, we use it as the base of our pyramid, instead of the usual placement of tertiary prevention as the base (Leavell & Clark, 1953).

Secondary prevention involves efforts to detect and treat existing health problems at the earliest possible stage, when intervention is most likely to be effective in controlling or eradicating it. This is the goal behind testing of

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water and soil samples for contaminants and hazardous chemicals in the field of community environmental health.

Examples of secondary prevention activities by a C/PHN include:

Conducting community hypertension and cholesterol screening programs to help identify high-risk individuals and encourage early treatment to prevent heart attacks or stroke Encouraging breast and testicular self-examination, regular mammograms, and Pap smears for early detection of possible cancers and providing skin testing for tuberculosis Assessing for early signs of child abuse in a family, emotional disturbances among widows, or alcohol and drug abuse among adolescents

Tertiary prevention attempts to reduce the extent and severity of a health problem to its lowest possible level, so as to minimize disability and restore or preserve function. The individuals involved have an existing illness or disability whose impact on their lives is lessened through tertiary prevention. See more on clients living with disabilities in Chapter 24.

Examples include:

Treatment and rehabilitation of persons after a stroke to reduce impairment Postmastectomy exercise programs to restore functioning Early treatment and management of diabetes to reduce problems or slow their progression

In community/public health, the need to reduce disability and restore function applies equally to families, groups, communities, and individuals. Many groups form for rehabilitation and offer support and guidance for those recuperating from some physical or mental disability. Examples include:

Alcoholics Anonymous Halfway houses for psychiatric patients discharged from acute care settings Ostomy clubs Drug rehabilitation programs

In broader community health practice, tertiary prevention is used to minimize the effects of an existing unhealthy community condition. Examples of such prevention are:

Insisting that businesses provide wheelchair access Warning urban residents about the dangers of a chemical spill

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Recalling a contaminated food or drug product Preventing injuries among survivors and volunteers during rescue in an earthquake, fire, hurricane, mass casualty incident due to gun violence, or even a terrorist attack

Health assessment of individuals, families, and communities is an important part of all three levels of preventive practice. Health status must be determined to anticipate problems and select appropriate preventive measures. C/PHNs working with young parents who themselves have been victims of child abuse can institute early treatment for the parents to prevent abuse and foster adequate parenting of their children. If the assessment of a community reveals inadequate facilities and activities to meet the future needs of its growing senior population, agencies and groups can collaborate to develop the needed resources.

Health problems are most effectively prevented by maintenance of healthy lifestyles and healthy environments. To these ends, community/public health practice directs many of its efforts to providing safe and satisfying living and working conditions, nutritious food, and clean air and water (Ali & Katz, 2018).

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CHARACTERISTICS OF COMMUNITY/PUBLIC HEALTH NURSING

As a specialty field of nursing, community/public health nursing adds public health knowledge and skills that address the needs and problems of communities and aggregates and focuses care on communities and vulnerable populations. Community/public health nursing is grounded in both public health science and nursing science, which makes its philosophical orientation and the nature of its practice unique. It has been recognized as a subspecialty of both fields. Recognition of this specialty field continues with a greater awareness of the important contributions made by community/public health nursing to improve the health of the public.

Knowledge of the following elements of public health is essential to community/public health nursing (ANA, 2013; Quad Council Coalition Competency Review Task Force, 2018):

Priority of preventive, protective, and healthpromoting strategies over curative strategies (see Chapters 11 and 12) Means for measurement and analysis of community health problems, including epidemiologic concepts and biostatistics (see Chapter 7) Influence of environmental factors on aggregate health (see Chapter 9) Principles underlying management and organization for community health, because the goal of public health is accomplished through organized community efforts (see Chapters 6, 12, and 15) Public policy analysis and development, along with health advocacy and an understanding of the political process (see Chapters 6 and 13)

Confusion over the meaning of “community health nursing” arises when it is defined only in terms of where it is practiced. Because health care services have shifted from the hospital to the community, many nurses in other specialties now practice in the community. Examples of these practices include home health care, community mental health, geriatric nursing, long- term care, and occupational health. Although C/PHNs today practice in the same or similar settings, the difference often lies in applying the public health principles to large groups and communities of people—or having a population focus within the community one serves (Fig. 1-9).

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FIGURE 1-9 Difference in client focus between basic nursing and community/public health nursing.

For nurses moving into this field of nursing, it requires a shift in focus— from individuals to a broader focus on aggregates and populations. Nursing and other theories undergird its practice, and the nursing process is one of its basic tools. See Chapters 14 and 15 for more details.

Community/public health nursing, then, as a specialty of nursing, combines nursing science with public health science to formulate a community-based and population-focused practice (Anderson & McFarlane, 2019). “Public health nursing practice focuses on population health through continuous surveillance and assessment of the multiple determinants of health with the intent to promote health and wellness; prevent disease, disability, and premature death; and improve neighborhood quality of life” (Box 1-9; ANA, 2013, p. 2). Examples of community/public health nursing include:

BOX 1-9 The Definition and Practice of Public Health Nurses Public health nursing is the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences (para. 2).

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Key characteristics of practice include (1) a focus on the health needs of an entire population, including inequities and the unique needs of subpopulations; (2) assessment of population health using a comprehensive, systematic approach; (3) attention to multiple determinants of health; (4) an emphasis on primary prevention; and (5) application of interventions at all levels—individuals, families, communities, and the systems that impact their health (para. 4).

The baccalaureate degree in nursing (BSN) is recommended for entry- level public health nurses (para. 12). Reprinted from American Public Health Association (APHA) Public Health Nursing Section. (2013). The definition and practice of public health nursing. Washington, DC: APHA. Used with permission.

Developing a program for providing food and shelter for homeless individuals sleeping in a park based on one's concern for this population Collaborating to institute an educational program on vaping in the local school system Assessing the needs of older people in retirement homes to ensure necessary services and provide health instruction and support

C/PHNs use primary, secondary, and tertiary interventions (levels of prevention) that are evidence-based and develop programs and services that help achieve health for all.

During the first 70 years of the 20th century, community health nursing was known as public health nursing. The PHN section of the American Public Health Association's (2013) definition of a PHN is someone who promotes and protects the health of populations and who is prepared at the baccalaureate level. The PHN also makes systematic and comprehensive assessments of population health and examines the many social determinants of health affecting “the application of interventions at all levels—individuals, families, communities, and the systems that impact their health” (para. 4). The later title of community health nursing was adopted to better describe where the nurse practices. For the purposes of this text, the term used for community health nurse and public health nurse is C/PHN.

The characteristics of public health nursing in Box 1-10 are particularly salient to the practice of this specialty (Quad Council, 1997). ANA (2013) adapted these eight principles in their Scope and Standards of Practice for Public Health Nursing.

BOX 1-10 Key Characteristics of Public Health Nursing

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1. The main focus is “systematic and comprehensive” population health care (para. 2).

2. Population health must remain a focus when providing care to individuals, families, and aggregates.

3. Primary prevention takes precedence, prioritizing health promotion and disease prevention.

4. Clients are collaborative partners in planning, policymaking, and developing strategies and programs.

5. Interventions are instituted to “create healthy environments” and affect the social and economic conditions of populations, permitting them to flourish (para. 2).

6. There is an ongoing obligation to “actively identify and reach out to all who might benefit from a…service” (para. 2).

7. Allocated resources must support growth in “maximum population health benefit,” utilizing evidence-based practice and quality improvement (para. 2) 8. Population health is most efficiently achieved “through collaboration with members of other professions,” stakeholders, and organizations (para. 2).

Source: Quad Council (1997).

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Population Focused The central mission of public health practice is to improve the health of population groups. Community/public health nursing shares this essential feature with public health practice: it is population focused, meaning that it is concerned for the health status of population groups and their environment and prevention of disease (Association of Public Health Nurses, 2018).

A population may consist of older adults living throughout the community or of Syrian refugees clustered in one section of a city. It may be a scattered group with common characteristics, such as people at high risk of developing diabetes or battered women living throughout a county. It may include all people living in a neighborhood, district, census tract, city, state, or province.

Working with individuals and families as aggregates has been common for community health nursing; however, such work must expand to incorporate a population-oriented focus, a feature that distinguishes community/public health nursing specialties. Basic nursing focuses on individuals, and community/public health nursing focuses on aggregates, but the many variations in community needs and nursing roles inevitably cause some overlap.

A population-oriented focus requires the assessment of relationships. When working with groups and communities, the nurse does not consider individuals separately but rather in context—that is, in relationship to the rest of the community.

When an outbreak of hepatitis occurs, for example, the C/PHN does more than just work with others to treat it. The nurse tries to stop the spread of the infection, locate possible sources, and prevent its recurrence in the community. As a result of their population-oriented focus, C/PHNs seek to discover possible groups with a common health need, such as expectant mothers, or groups at high risk for development of a common health problem (e.g., obese children at risk for type 2 diabetes, victims of child abuse). C/PHNs continually look for problems in the environment that influence community health and seek ways to increase environmental quality. They work to prevent health problems and promote healthier lifestyles, such as promoting school-based education about nutrition and physical activity or exercise programs for groups of seniors (Fig. 1-10).

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FIGURE 1-10 Healthy eating habits can begin in childhood.

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The Greatest Good for the Greatest Number of People A population-oriented focus involves a new outlook and set of attitudes. Individualized care is important, but prevention of aggregate problems in community/public health nursing practice reflects more accurately its philosophy and benefits more people. The community or population at risk is the client. Furthermore, because C/PHNs are concerned about several aggregates at the same time, service will, of necessity, be provided to multiple and overlapping groups. The ethical theory of utilitarianism promotes the greatest good for the greatest number. Further discussion of ethical principles in community/public health nursing can be found in Chapter 4.

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Clients as Equal Partners The goal of public health, increasing both the years and quality of healthy life and eliminating health disparities for populations, requires a partnership effort. Just as learning cannot take place in schools without student participation, the goals of public health cannot be realized without consumer participation. Community/public health nursing's efforts toward health improvement only go so far.

Clients' health status and health behavior will not change unless people accept and apply the proposals (developed in collaboration with clients) presented by the C/PHN. C/PHNs can encourage individuals' participation by promoting their autonomy rather than permitting dependency. For example, older persons attending a series of nutrition or fitness classes can be encouraged to take the initiative and develop health or social programs on their own. Independence and feelings of self-worth are closely related. By treating people as independent adults, with trust and respect, C/PHNs promote self-reliance and the ability to function independently. Autonomy is an important objective of public health, as is equality (Knight, 2016), and these are discussed in more detail in Chapter 4.

Frequently, consumers are intimidated by health professionals and are uninformed about health and health care. They do not know what information to seek and are hesitant to act assertively. For example, a migrant worker brought her 2-year-old son, who had symptoms resembling those of scurvy, to a clinic. Recognizing a vitamin C deficiency, the physician told her to feed the boy large quantities of orange juice but gave no further explanation. Several weeks later, she returned to the clinic, but the child was much worse. After questioning her, the nurse discovered that the mother had been feeding the child large amounts of an orange soft drink, not understanding the difference between that beverage and orange juice. Obviously, the quality of care is affected when the consumer does not understand and cannot participate in the health care process.

Health literacy, or “the degree to which an individual has the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions,” is an important concept that is discussed more fully in Chapter 10 (CDC, 2019, para. 1).

When people believe that their health, and that of the community, is their own responsibility, not just that of health professionals, they will take a more active interest in promoting it. The process of taking responsibility for developing one's own health potential is called self-care. As people maintain their own lives, health, and wellbeing, they are engaging in self-care. Some examples of self-care activities at the aggregate level include building safe

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playgrounds, developing teen employment opportunities, and providing senior exercise programs.

When people's ability to continue self-care activities falls below their need, they experience a self-care deficit. At this point, nursing may appropriately intervene. However, nursing's goal is to assist clients to return to or reach a level of functioning at which they can attain optimal health and assume responsibility for maintaining it (Alligood, 2018; Schulman-Green, Jaser, Park, & Whittemore, 2016; Zandiyeh, Hedayati, & Zare, 2015). To this end, C/PHNs foster their clients' sense of responsibility by treating them as adults capable of managing their own affairs. Nurses can encourage people to negotiate health care goals and practices, develop their own programs, contact their own resources (e.g., support groups, transportation services), identify and implement lifestyle changes that promote wellness, and learn how to monitor their own health.

When planning for the health of communities, for example, partnerships must be established, and the values and priorities of the community incorporated into program planning, data collection and interpretation, and policymaking. More information on program planning is given in Chapter 12.

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Prioritizing Primary Prevention In community/public health nursing, the promotion of health and prevention of illness are a first-order priority. Less emphasis is placed on curative care.

Some corrective actions always are needed, such as cleanup of a toxic waste dump site, or stricter enforcement of day care standards, but community health best serves its constituents through preventive and healthpromoting actions (Ali & Katz, 2018; Anderson & McFarlane, 2019). These include services to mothers and infants, prevention of environmental pollution, school health programs, senior citizens' fitness classes, and “workers' right-to-know” legislation that warns against hazards in the workplace.

Another distinguishing characteristic of community/public health nursing is its emphasis on positive health, or wellness (Anderson & McFarlane, 2019). Medicine and acute care nursing have dealt primarily with the illness end of the health continuum. In contrast, community health nursing always has had a primary charge to prevent health problems from occurring and to promote a higher level of health.

C/PHNs concentrate on the wellness end of the health continuum in a variety of ways. They teach proper nutrition or family planning, promote immunizations among preschool children, encourage regular physical and dental checkups, assist with starting exercise classes or physical fitness programs, and promote healthy interpersonal relationships. Their goal is to help the community reach its optimal level of wellness.

This emphasis on wellness changes the role of community/public health nursing from a reactive to a proactive stance. It places a greater responsibility on C/PHNs to find opportunities for intervention. In clinical nursing and medicine, individual patients seek out professional assistance because they have health problems. They present their problems to the health care practitioner for diagnosis and treatment. C/PHNs, in contrast, seek out potential health problems in the community. They identify high-risk groups and institute preventive programs. C/PHNs visit clients in their homes and other settings (Fig. 1-11).

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FIGURE 1-11 A C/PHN visits a client's home.

For example, they watch for early signs of child neglect or abuse and intervene when any occur, often long before a request for help is made. They look for possible environmental hazards in the community, such as smoking in public places or lead-based paint in older housing units, and work with appropriate authorities to correct them. A wellness emphasis requires taking initiative and making sound judgments, which are characteristics of effective community/public health nursing.

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Selecting Interventions That Create Healthy Conditions in Which Populations May Thrive With our population focus, it is prudent for C/PHNs to design interventions for the whole community, not limiting it only to those individuals seeking service or the poor and vulnerable, but promoting the health of entire populations and working to prevent “disease, injury and premature death” (ANA, 2013, p. 3).

Advocacy for our clients (individuals, families, aggregates, communities, or populations) is an essential function of community/public health nursing. We want to create healthy environments for our clients so that they can thrive and not simply survive, and we do this by having a proactive stance toward trends in health care and society, ever changing public concerns, and work with policy and legislative activities (ANA, 2013). More information about health advocacy and policymaking is provided in Chapter 13.

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Actively Reaching Out We know that some clients are more prone to develop disability or disease because of their vulnerable status (e.g., poverty, no access to health care, homelessness). Outreach efforts are needed to promote the health of these clients and to prevent disease.

In acute care and primary health care settings, like emergency rooms or physician offices, clients come to you for service. However, in community/public health, nurses must focus on the whole population—not just those who come to us for services—and seek out clients wherever they may be (ANA, 2013). Like Lillian Wald and her Henry Street Settlement, C/PHNs must learn about the populations they serve and be willing to search out those most at risk. You can learn more about the rich history of community/public health nursing in Chapter 3. Unit 6 covers vulnerable populations.

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Optimal Use of Available Resources It is our duty to wisely use the resources we are given. For most state and local public health agencies, budgets are critically stressed. The use of documented evidence as a basis for community/public health nursing practice promotes more efficient and cost-effective strategies in health promotion (ANA, 2013; Quad Council, 2018). Tertiary health care has gotten the largest percentage of our health care dollar, leaving decreased funds for primary and secondary services. The lack of regular sources of health care sends many people to expensive emergency departments for treatment (IOM, 2002; Siekman & Hilger, 2018).

It is vital that C/PHNs ground their practice in research and evidence (see Chapter 4) and use that information to educate policy makers about best practices (see Chapter 13). Using personnel and resources effectively and prudently will pay off in the long run.

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Interprofessional Collaboration C/PHNs must work in cooperation with other team members, coordinating services and addressing the needs of population groups. This interprofessional collaboration among health care workers, other professionals and organizations, and clients is essential for establishing effective services and programs.

Individualized efforts and specialized programs, when planned in isolation, can lead to fragmentation and gaps in health services. Interprofessional collaboration is an even greater necessity when working with population groups, especially those from vulnerable or at-risk segments. Collaboration improves client outcomes, staff communication, and the quality of care (Lage, Rusinak, Carr, Grabowski, & Ackerly, 2015).

Collaboration involves working with members of other professions on community advisory boards and health planning committees to develop needs assessment surveys and to contribute toward policy development efforts. In addition to partnering with the population, other groups the C/PHN collaborates with include:

Academic institutions, and others conducting research Businesses and pertinent industries Community organizations, coalitions, and advocacy groups Community service agencies such as schools, law enforcement, urban planning, and emergency response Faith-based organizations Health care providers and facilities Legislative, regulatory, and policymaking bodies Local, state, and federal public health organizations Members of the public health team, such as epidemiologists, social workers, health promotion specialists, nutritionists, environmental health workers, and health educators (ANA, 2013, p. 15)

Interprofessional collaboration requires clarification of each team member's role, a primary reason for C/PHNs to fully understand the nature of their practice. When planning a city-wide immunization program with a community group, for example, nurses need to explain the ways in which they might contribute to the program's objectives. They can share their knowledge of the public's preference about times and locations for the program, meet with various local agencies and organizations (e.g., health insurance companies, local hospitals) to gain financial support, help to organize and give immunizations, and influence planning for follow-up programs. Collaboration is discussed further in Chapter 10.

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Another component includes development of policies to promote and protect the health of clients. Meeting with local legislators and providing testimony to local, state, and national bodies are common methods of ensuring enactment of effective health policies.

Client participation is promoted when people serve as partners on the health care team. An aim of community/public health nursing is to collaborate with people rather than do things for them.

As consumers of health services are treated with respect and trust, confidence and skill in self-care are gained. Thus, promoting their own health and that of their community as their contribution to health programs becomes increasingly valuable. C/PHNs encourage the involvement of health care consumers by soliciting their ideas and opinions, by inviting them to participate on health boards and committees, and by finding ways to promote their participation in decisions affecting their collective health. By assessing the needs of community, based partly upon the population's perceptions, the C/PHN can discover the most pressing health needs and work toward more effective interventions. Community assessment and intervention are explored in depth in Chapters 12 and 15.

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SUMMARY

Community health is defined as the identification of needs and the protection and improvement of collective health within a geographically defined area. A community is a collection of people who share some common interest or goal. Three types of communities were discussed: geographic, common-interest, and health problem-solving communities. Health is an abstract concept that includes all of the many characteristics of a person, family, or community, whether physical, psychological, social, or spiritual. People have levels of illness or wellness known as the health continuum. Health has both subjective and objective dimensions: the subjective involves how well people feel; the objective refers to how well they are able to function. Health care needs may be continuing, as with developmental concerns that occur over a person's lifetime, or episodic, occurring unexpectedly throughout a lifetime. Eight important characteristics of public health nursing practice are the client is the population; the primary obligation is to achieve the greatest good for the greatest number of people; working with clients as equal partners; primary prevention is the priority; focus on strategies that create healthy environmental, social, and economic conditions; actively identify and reach out to all who might benefit; make optimal use of available resources and create new evidence-based strategies; and collaborate with a variety of professions, populations, organizations, and other stakeholders to promote and protect the health of populations (ANA, 2013).

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ACTIVE LEARNING EXERCISES

1. Debate similarities and differences between community/public health nursing and acute care nursing. Give examples of how public health principles are relevant for nurses working in hospitals (e.g., population health, epidemiology).

2. Identify specific examples of each of the three types of communities in your area (geographic, interest, solution). Discuss any local needs that are not being met (e.g., substance abuse, transportation) and how they might be addressed. Who should be involved as community members in addressing interventions?

3. Discuss the levels of prevention (primary, secondary, tertiary). Review your County Health Ranking and list three health issues found in your community. Decide on one primary, one secondary, and one tertiary intervention to address one of these health issues.

4. Using the eight characteristics of public health nursing outlined in this chapter, give specific examples of how a community/public health nurse might demonstrate four characteristics in addressing common health issues in your area.

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CHAPTER 2

Public Health Nursing in the Community “One good community nurse will save a dozen policemen.”

—Herbert Hoover

KEY TERMS Advocate Assessment Assurance Case management Clinician Collaborator Educator Leader Manager Policy development

LEARNING OBJECTIVES Upon mastery of this chapter, you should be able to:

1. Identify the three core public health functions basic to community/public health nursing.

2. Differentiate among seven different roles of the community/public health nurse.

3. Discuss the seven roles within the framework of public health nursing functions.

4. Explain the importance of each role for influencing people's health. 5. Describe seven settings in which a community/public health nurse

might practice. 6. Identify principles of effective nursing practice in the community.

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INTRODUCTION

Historically, community and public health nurses (C/PHNs) have engaged in many professional roles. Nurses in this professional specialty have provided care to the sick, taught positive health habits and self-care, advocated on behalf of needy populations, developed and managed health programs, provided leadership, and collaborated with other professionals and consumers to implement changes in health services. Although the practice settings may have differed, the essential goal of the C/PHN has always been a healthier community. The home certainly has been one site for practice, but so too have public health clinics, schools, factories, and other community-based locations. Today, the roles and settings of community/public health nursing practice have expanded even further, offering a wide range of professional opportunities.

This chapter examines how the conceptual foundations and core functions of community/public health practice are integrated into the various roles and settings of community/public health nursing. It provides an opportunity to gain greater understanding about how and where this nursing specialty is practiced. Moreover, it will expand awareness of the many existing and future possibilities for C/PHNs to improve the public's health. As you read through this chapter, think about client populations that you may have encountered in the acute care setting and consider your role with these same populations in a community setting. You may just discover a community/public health nursing specialty area that you have never considered.

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CORE PUBLIC HEALTH FUNCTIONS

The various roles and settings for practice hinge on three primary core functions of public health—assessment, policy development, and assurance—and are applied at three levels of service—individual, family, and community (Institute of Medicine, 1988, 2002; CDC, 2018). Essential services that are linked to these core functions are also covered below.

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Assessment An essential first function in public health, assessment, means that the C/PHN must first gather and analyze information that will affect the health of the people to be served. Assessment is the systematic collection, assembly, analysis, and dissemination of information about the health of a community. Health needs, risks, environmental conditions, political agendas, and financial and other resources need to be assessed (Schneider, 2017). Data may be gathered in many ways (e.g., interviewing people in the community, conducting surveys, gathering information from public records, applying research).

The C/PHN is typically both trusted and valued by clients, agencies, and private providers. Trust placed in the nurse can often be attributed to demonstrating consistency, honesty, and dependability, and to an ongoing presence in the community. Although securing and maintaining the trust of others are pivotal to all nursing practice, they are even more critical when working in the community. Trust can afford a nurse access to client populations that may be difficult to engage. In the capacity of a trusted professional, C/PHNs gather relevant client data that enable them to identify strengths, weaknesses, and needs. It is important to recognize that as difficult as it may be for the nurse to gain the trust and respect of the community, if ever lost, these may not be easily reinstated.

At the community level, nurses perform assessment both formally and informally as they identify and interact with key community leaders. With families, the nurse can evaluate family strengths and areas of concern in the immediate living environment and in the neighborhood. At the individual level, the nurse identifies people within the family in need of services and evaluates their functional capacity using specific assessment measures and a variety of tools. Assessment of communities and families as the initial step in the nursing process is discussed more fully in Chapters 14 and 15.

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Policy Development Policy development is enhanced by the synthesis and analysis of information obtained during assessment to create comprehensive public health policy (Schneider, 2017). At the community level, the nurse provides leadership in convening and facilitating community groups to evaluate health concerns and develop a plan to address those concerns. Often, the nurse recommends specific training and programs to meet identified health needs of target populations (see Chapter 12) and raises the awareness of key policy makers about factors such as health regulations and budget decisions that negatively affect the health of the community (see Chapter 13).

With families, the nurse recommends new programs or increased services based on identified needs. Additional data may be needed to detect trends in groups or clusters of families, so that effective intervention strategies can be employed with these families.

At the individual level, the nurse assists in the development of standards for individual client care, recommends or adopts risk classification systems to assist with prioritizing individual client care, and participates in establishing criteria for opening, closing, or referring individual cases.

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Assurance Assurance is the pledge to our constituents that services necessary to achieve agreed-upon goals are provided by encouraging the actions of others (public or private) or requiring action through regulation or provision of direct services (Schneider, 2017). These activities often consume most of the C/PHN's time. Nurses perform the assurance function at the community level when they provide services to target populations, improve quality assurance activities (e.g., Quality and Safety Education for Nurses/QSEN), maintain safe levels of communicable disease surveillance and outbreak control, and collaborate with community leaders in the preparation of a community emergency preparedness plan. In addition, they participate in outcomes research, provide expert consultation, promote evidence-based practice, ensure competence and currency, and provide services within the community based on standards of care. QSEN features are found in later chapters.

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Essential Services To more clearly articulate the services that are linked to the core functions of assessment, policy development, and assurance, the Public Health Functions Steering Committee developed a list of 10 essential public health services in 1994 (Centers for Disease Control & Prevention [CDC], 2018). This initial effort to define the service components of the core functions provided an organized service delivery plan for public health providers across the country. A model depicting the relationships between the core functions and the essential services was eventually developed (Box 2-1). In March 2020, proposed revisions to the 10 essential public health services were distributed for comment; the final version was launched in September 2020 (CDC, 2020). Some of the changes included more emphasis on communication, equity, diversity, quality improvement, updating terminology, and use of more active language (Public Health National Center for Innovations, 2020).

BOX 2-1 Public Health Nursing Within the Core Public Health Functions Model

This model includes assessment, policy development, and assurance surrounding the 10 essential services. Monitor Health; Diagnose and Investigate; Inform, Educate, and Empower; Mobilize Community Partnerships; Develop Policies; Enforce Laws; Link to Services; Assure Competent Workforce; Evaluate; Research and System Management are at the center of the model, as they are related to each essential service.

Assessment is the systematic collection, assembly, analysis, and dissemination of information about the health of a community. Policy development uses the scientific information gathered during assessment to create comprehensive public health policies. Assurance is the pledge to constituents that services necessary to achieve agreed-upon goals are provided by encouraging actions of others (private or public), requiring action through regulation, or providing service directly

The community/public health nurse or C/PHN health nurse carries out these core functions and essential services at the

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individual, family, and community levels.

Source: Centers for Disease Control and Prevention (2018); Institute of Medicine (1988, 2002).

As illustrated in Box 2-1, this model shows the types of services necessary to achieve the core functions of assessment, policy development, and assurance. It also emphasizes the circular or ongoing nature of the process. The placement of equity in the center of the model represents the need to address health inequities, barriers, and discrimination in all public health services (Public Health National Center for Innovations, 2020).

As you review this model, think about what types of services might be provided in each category, depending on whether you are focusing on an individual, a family, or a community. It is not necessary for the C/PHN to personally provide all of the listed services. Working in collaboration with an interdisciplinary team, the nurse can support the efforts of others to achieve improved health in the community. What is important is that the team members all recognize their respective roles and work toward the same goal. A description of the original 10 essential services is found in Box 2-2. An example applying the 10 essential services to environmental health can be found at https://www.cdc.gov/nceh/ehs/10-essential- services/index.html.

BOX 2-2 Ten Essential Public Health Services

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1. Assess and monitor population health status, factors that influence health, and community needs and assets.

2. Investigate, diagnose, and address health problems and hazards affecting the population.

3. Communicate effectively to inform and educate people about health, factors that influence it, and how to improve it.

4. Strengthen, support, and mobilize communities and partnerships to improve health.

5. Create, champion, and implement policies, plans, and laws that impact health.

6. Utilize legal and regulatory actions designed to improve and protect the public's health.

7. Assure an effective system that enables equitable access to the individual services and care needed to be healthy.

8. Build and support a diverse and skilled public health workforce. 9. Improve and innovate public health functions through ongoing

evaluation, research, and continuous quality improvement. 10. Build and maintain a strong organizational infrastructure for public

health.

Reprinted from CDC. (2020). 10 essential public health services (revised, 2020). Retrieved from https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html

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STANDARDS OF PRACTICE

In 2008, the American Association of Colleges of Nursing (AACN) published the revised The Essentials of Baccalaureate Education for Professional Nursing Practice, a major step in providing clear guidelines as to what constitutes professional nursing education. This document provides nine essentials that are expected outcomes for baccalaureate nursing education (2019). This document is currently under revision. AACN developed a supplemental resource, Public Health: Recommended Baccalaureate Competencies and Curricular Guidelines for Public Health Nursing, to enhance population-focused activities associated with each of the nine essentials (2013), and it is also undergoing revision (2019). These documents clearly articulate the growing need to prepare nurses to assume roles in the community setting.

Community/public health nursing practice is further defined by specific standards developed under the auspices of the American Nurses Association (ANA) in collaboration with the Quad Council of Public Health Nursing Organizations (ANA, 2013), which is now the Council of Public Health Nursing Organizations (CPHNO). The CPHNO is composed of representatives from the Alliance of Nurses for Healthy Environments; the American Public Health Association, Public Health Nursing Section (APHA-PHN); the Association of Community Health Nursing Educators (ACHNE); and the Association of Public Health Nurses. These four organizations represent academics and professional practitioners, providing a broad spectrum of views regarding professional practice in the field of community/public health nursing.

Public Health Nursing: Scope and Standards of Practice (ANA, 2013), which is now the Council of Public Health Nursing Organizations (CPHNO). The CPHNO provides guidance as to what constitutes public health nursing and how it can be differentiated from other nursing specialties. The standards of care it outlines are consistent with the nursing process and include assessment, population diagnosis and priorities, outcomes identification, planning, implementation, and evaluation. This document is an important reference for all those practicing in the community. It provides the basis for evaluating an individual's performance in this field and is used by many employers to assess job performance. The C/PHN also provides nursing services based on other standards developed by the ANA, such as:

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Code of Ethics for Nurses with Interpretive Statements (2015a) Nursing's Social Policy Statement (2010) Nursing: Scope and Standards of Practice (2015b)

Each of these documents provides essential information regarding sound general nursing practice. When combined with Public Health Nursing: Scope and Standards of Practice (ANA, 2013), they provide the C/PHN with a clear understanding of accepted practice in this nursing specialty.

ACHNE, in addition to their collaboration with ANA, published the updated Essentials of Baccalaureate Nursing Education for Entry-Level Community/Public Health Nursing in 2010 (Education Committee of ACHNE). This document builds on previous versions and is consistent with both the Essentials document (AACN, 2008) and the scope and standards of public health nursing practice (ANA, 2013). It describes core professional values as well as knowledge and basic competencies. Core values of professional behavior emphasize community/population as client, prevention, partnership, healthy environment, and diversity (ACHNE, Education Committee, 2010). An emphasis of Healthy People 2030 (USDHHS, 2020) is to create and support a competent public and personal health care workforce, and it includes professional competencies required for sound practice (see Box 2-3).

BOX 2-3 HEALTHY PEOPLE 2030 Selected Public Health Infrastructure Objectives

PHI, public health infrastructure.

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Reprinted from U. S. Department of Health & Human Services. (2020). Public health infrastructure. Retrieved from https://health.gov/healthypeople/objectives-and-data/browse- objectives/publichealth-infrastructure

The Quad Council of Public Health Nursing Organizations (which is now the CPHNO) updated its own document, Community/Public Health Nursing (C/PHN) Competencies, in 2018. The competencies include eight domains (pp. 36–40):

1. Assessment and analytic skills 2. Policy development/program planning skills 3. Communication skills

4. Cultural competency skills 5. Community dimensions of practice skills 6. Public health sciences

skills 7. Financial planning, evaluation, and management skills 8. Leadership and systems thinking skills

The competencies consist of three tiers of practice, beginning with the C/PHN generalist in tier one, followed by the C/PHN manager overseeing programs in tier two, and ending with C/PHN administrator practice skills requiring higher-level education and authority in tier three (Quad Council Coalition, 2018). The tier one public health nursing competencies are listed in this book in the appendix and also on the inside back cover.

With specific standards of practice and clear competencies to achieve, the C/PHN can integrate the core functions of assessment, policy development, and assurance, as well as the 10 essential services, throughout all of the various roles and community settings of practice.

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ROLES OF C/PHNS

Just as the health care system is continually evolving, community/public health nursing practice evolves to remain effective with the clients it serves. Over time, the role of the C/PHN has broadened. This breadth is reflected in the description of public health nursing from the APHA-PHN (2013): Public health nursing … focuses on improving the population health by emphasizing prevention and attending to multiple determinants of health. Often used interchangeably with community health nursing, [it] includes advocacy, policy development, and planning…. Public health nursing action occurs through community applications of theory, evidence, and a commitment to health equity (para. 3).

C/PHNs wear many hats while conducting day-to-day practice. This chapter examines seven major roles of the C/PHN: clinician, educator, advocate, manager, collaborator, leader, and researcher. It also describes the factors that influence the selection and performance of those roles.

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Clinician Role The most familiar role of the C/PHN is that of clinician or care provider. Different from such a role in the acute care setting, the clinician role in community/public health means that the nurse ensures health services are provided not just to individuals and families but also to groups and populations. Nursing service is still designed for the special needs of clients; however, when those clients compose a group or population, clinical practice takes different forms. It requires different skills to assess collective needs and tailor service accordingly. For instance, one C/PHN might visit older residents in a seniors' high-rise apartment building. Another might serve as the clinic nurse in a rural prenatal clinic that serves migrant farm workers. These are opportunities to assess the needs of aggregates and design appropriate services. For C/PHNs, the clinician role involves certain emphases that are different from those of basic nursing. Three clinician emphases, in particular, are useful to consider here: holism, health promotion, and skill expansion.

Holistic Practice Most clinical nursing seeks to be broad and holistic. In community health, however, a holistic approach means considering the broad range of interacting needs—physical, emotional, social, spiritual, and economic—that affect the collective health of the “client” as a large system rather than as an individual (Dossey & Keegan, 2016). In community/public health, the client is a composite of people whose relationships and interactions with each other must be considered in totality. Holistic practice must emerge from this systems perspective (Fig. 2-1).

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FIGURE 2-1 C/PHN student visiting an elderly client in her home.

For example, when working with a group of pregnant teenagers living in a juvenile detention center, the nurse would consider the girls' relationships with one another, their parents, the fathers of their unborn children, and the detention center staff. The nurse would evaluate their ages, developmental needs, and peer influences, as well as their knowledge of pregnancy, delivery, and issues related to the choice of keeping or giving up their babies. The girls' reentry into the community and their future plans for school or employment would also be considered. Holistic service would go far beyond the physical condition of pregnancy and childbirth. It would incorporate consideration of pregnant adolescents in this community as a population at risk. What factors contributed to these girls' situations, and what preventive efforts could be instituted to protect these or other teens from future pregnancies? The clinician role of the C/PHN involves holistic practice from an aggregate perspective.

Focus on Wellness The clinician role in community/public health also is characterized by its focus on promoting wellness. As discussed in Chapter 1, the C/PHN provides service along the entire range of the health continuum, but especially emphasizes promotion of health and prevention of illness. The C/PHN may provide education to healthy aggregate populations (e.g., schoolchildren, pregnant mothers). Effective services also include seeking out clients who are at risk for poor health and

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offering preventive and health-promoting services, rather than waiting for them to come for help after problems arise.

Nurses identify groups and populations who are vulnerable to certain health threats, and they design preventive and health-promoting programs to address these threats in collaboration with the community (Murdaugh, Parsons, & Pender, 2019). Examples include immunization of preschoolers, family planning programs, blood pressure screening, and prevention of behavioral problems in adolescents. Protecting and promoting the health of vulnerable populations is an important component of the clinician role and is addressed extensively in the chapters in Unit 6, which cover vulnerable aggregates.

Expanded Skills Nursing requires multiple skills, including observation, listening, communication and counseling, and integrates psychological and sociocultural factors into practice.

Additionally, environmental and community-wide considerations— such as problems caused by pollution, violence and crime, drug abuse, unemployment, poverty, homelessness, and limited funding for health programs—have created a need for stronger skills in assessing the needs of groups and populations and intervening at the community level (CDC, 2019). The clinician role in population-based nursing also requires skills in collaboration with consumers and other professionals, community organization and development, research, program evaluation, administration, leadership, and skill in epidemiology and biostatistics, as well as an ability to effect change (ANA, 2013). These skills are addressed in greater detail in later chapters.

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Educator Role A second important role of the C/PHN is that of educator or health teacher. Health teaching, a widely recognized part of nursing practice, is legislated through nurse practice acts and is one of the major functions of the C/PHN (ANA, 2013).

The educator role is especially useful in promoting the public's health for at least two reasons:

1. Community clients are usually not acutely ill and can absorb and act on health information. For example, a class of expectant parents, unhampered by significant health problems, can grasp the relationship of diet to fetal development. They understand the value of specific exercises to the childbirth process, are motivated to learn, and are more likely to perform those exercises. Thus, the educator role has the potential for finding greater receptivity and providing higher-yield results.

2. A wider audience can be reached. With an emphasis on populations and aggregates, the educational efforts of community/public health nursing are appropriately targeted to reach many people. Instead of limiting teaching to one-on-one or small groups, the nurse has the opportunity and mandate to develop educational programs based on community needs that seek a community-wide impact.

Whereas nurses in acute care often teach patients one-on-one, focusing on issues related to their illness and hospitalization, C/PHNs go beyond these topics to educate people in a variety of areas. Community-living clients need and want to know about issues such as family planning, weight control, smoking cessation, and stress reduction. Aggregate-level concerns also include such topics as environmental safety, sexual discrimination and harassment at school or work, violence, and drugs. C/PHN teaching addresses questions such as: What foods and additives are safe to eat? How can people organize the community to work for reduction of gun violence? What are health consumers' rights? Topics C/PHNs teach extend from personal and family health to environmental health and community organization. The emphasis throughout the health teaching process continues to be on illness prevention and health promotion (Rhodes, Visker, Cox, Forsyth, & Woolman, 2017). Telehealth (which is discussed in Chapter 10) is useful when needing to reach distant clients or groups. Health teaching as a tool for community/public health nursing practice is discussed in detail in Chapter 11.

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Advocate Role The issue of clients' rights is important in health care. Every patient or client has the right to receive just, equal, and humane treatment.

The role of the nurse includes client advocacy, which is highlighted in the ANA Code of Ethics for Nurses with Interpretive Statements (2015a), Nursing's Social Policy Statement (2010), and Nursing's Social Policy Statement: Understanding the Profession from Social Contract to Social Covenant (Fowler, 2016). Our current health care system is often characterized by fragmented and depersonalized services, and many clients—especially the poor, the disadvantaged, those without health insurance, and people with language barriers—frequently are denied their rights. They become frustrated, confused, discouraged, and unable to cope with the system on their own. The C/PHN often acts as an advocate for clients, pleading their cause or acting on their behalf. Clients may need someone to explain which services to expect and which services they ought to receive, to make referrals as needed, or to guide them through the complexities of the system and ensure the satisfaction of their needs. This is particularly true for minorities and disadvantaged groups (Fig. 2-2; Kalaitzidis & Jewell, 2015; Lassi & Bhutta, 2015; Nsiah, Siakwa, & Ninnoni, 2019).

FIGURE 2-2 Like nurses working in every type of setting, C/PHNs are advocates for their clients.

Advocacy Goals Client advocacy has two underlying goals:

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1. Help clients gain greater independence or self-determination. Until clients can research the needed information and access health and social services for themselves, the C/PHN acts as an advocate for them by showing them what services are available, those to which they are entitled, and how to obtain them.

2. Make the system more responsive and relevant to the needs of clients (Byers, 2015; Nsiah et al., 2019). By calling attention to inadequate, inaccessible, or unjust care, C/PHNs can facilitate change (see Chapter 13).

Consider the experience of the Merrill family. Sarah Merrill has three small children. Early one Tuesday morning, the baby, Samuel, suddenly started to cry. Nothing would comfort him. Sarah went to a neighbor's apartment, called the local clinic, and was told to come in the next day. When she arrived, she was told that the clinic did not take appointments and was too busy to see any more patients that day. Sarah's neighbor reassured her that “sometimes babies just cry.” For the rest of the day and night, Samuel cried incessantly. On Wednesday, Sarah and her children made the 45-minute bus ride to the clinic and waited 3 hours in the crowded reception room; the wait was punctuated by interrogations from clinic workers. Sarah's other children were restless, and the baby was crying. Finally, they saw the physician. Samuel had an inguinal hernia that could have strangulated and become gangrenous. The doctor admonished Sarah for waiting so long to bring the baby in. Immediate surgery was necessary. Someone at the clinic told Sarah that Medicaid would pay for it. Someone else told her that she was ineligible. At this point, all of her children were crying. Sarah had been up most of the night. She was frantic and confused and felt that no one cared. This family needed an advocate.

Advocacy Actions The advocate role incorporates four characteristic actions: being assertive, taking risks, communicating and negotiating well, and identifying resources and obtaining results. Let's consider how a C/PHN might have taken each of these actions in the case of the Merrill family.

1. Advocates must be assertive. Fortunately, in the Merrill's dilemma, the clinic had a working relationship with the City Health Department and contacted Tracy Lee, a C/PHN liaison with the clinic, when Sarah broke down and cried. Tracy took the initiative to identify the Merrill's needs and find appropriate solutions. She contacted the Department of Social Services and helped the Merrill family to establish eligibility for coverage of surgery and

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hospitalization costs. She helped Sarah arrange for the baby's hospitalization and care for the other children.

2. Advocates must take risks—go “out on a limb” if need be—for the client. Tracy was outraged by the kind of treatment received by the Merrill family: the delays in service, the impersonal care, and the surgery that could have been planned as elective rather than as an emergency. She wrote a letter describing the details of the Merrill's experience to the clinic director, the chairman of the clinic board, and the nursing director. This action resulted in better care for the Merrill family and a series of meetings aimed at changing clinic procedures and providing better telephone screening.

3. Advocates must communicate and negotiate well by bargaining thoroughly and convincingly. Tracy stated the problem clearly and politely, yet firmly argued for its solution.

4. Advocates must identify and obtain resources for the client's benefit. By contacting the most influential people in the clinic and appealing to their desire for quality service, Tracy was able to facilitate change and hopefully improve service for other patients.

Advocacy at the population level incorporates the same goals and actions. Whether the population is homeless people, battered women, or migrant children, the C/PHN in the advocate role speaks and acts on their behalf. The goals remain the same: to promote clients' self-determination and to shape a more responsive system (Dickson & Lobo, 2018; Dworkin & Sood, 2016). Advocacy for large aggregates, such as those with inadequate health care coverage or access to care, means changing national policies and laws (see Chapter 13).

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Manager Role C/PHNs, like all nurses, engage in the role of managing health services (Kagan, Schachaf, Rapaport, Livine, & Madjar, 2017). The management process, like the nursing process, incorporates a series of problem-solving activities or functions: planning, organizing, leading, and controlling and evaluating.

As a manager, the nurse helps achieve clients' goals by assessing their needs, planning and organizing to meet those needs, directing and leading to achieve results, and controlling and evaluating the progress to ensure that goals are met. The nurse serves as a manager when overseeing client care as a case manager, supervising ancillary staff, managing caseloads, running clinics, or conducting community health needs assessment projects.

Nurse as Planner The first function in the management process is planning. A planner sets the goals and direction for the organization or project and determines the means to achieve them.

Planning includes defining goals and objectives, determining the strategy for reaching them, and designing a coordinated set of activities for implementing and evaluating them, which tends to include broader, more long-range goals (Gordon, 2018). Planning may be strategic. An example of strategic planning is setting 2-year agency goals to reduce opioid abuse in the county by 10%. Planning may be operational, focusing more on short-term planning needs. An example of operational planning is setting 6-month objectives to implement a new computer system for client record keeping.

The concepts of planning with individuals, families, and communities are discussed further in Chapters 12, 14, and 15.

Nurse as Organizer The second function of the manager role is that of organizer. This involves designing a structure within which people and tasks function to reach the desired objectives. A manager must arrange matters so that the job can be

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done. People, activities, and relationships have to be assembled to put the plan into effect. In the process of organizing, the nurse manager provides a framework for the various aspects of service, so that each runs smoothly and accomplishes its purpose (Feetham & Doering, 2015; Weatherford, Bower, & Vitello-Cicciu, 2018).

Nurse as Leader In the manager role, the C/PHN also must act as a leader. As a leader, the nurse directs, influences, or persuades others to effect change that will positively impact people's health and move them toward a goal (Rosa, 2016; Weatherford et al., 2018).

The leading function includes persuading and motivating people, directing activities, ensuring effective two-way communication, resolving conflicts, and coordinating the plan. Coordination means bringing people and activities together, so that they function in harmony while pursuing desired objectives.

Transformational and authentic leadership is characterized by the ability of leaders to inspire change and demonstrate empathy and leads to increased job satisfaction and performance (Lee, Chiang, & Kuo, 2019). Change management strategies are necessary to achieve the Triple Aim of improving population health, reducing health care costs, and providing improved patient outcomes (Shirey & White-Williams, 2015).

Nurse as Controller and Evaluator The fourth management function is to control and evaluate projects or programs. A controller monitors the plan and ensures that it stays on course. In this function, the C/PHN must realize that plans may not proceed as intended and may need adjustments or corrections to reach the desired results or goals and must judge outcomes against original goals and objectives (Swider, Levin, & Reising, 2017).

An example of the controlling and evaluating function is evident in a program started in several preschool day care centers. The goal of the project is to reduce the incidence of illness among the children through intensive health education on prevention that addresses both the physical health and emotional health of the children with staff, parents, and children. At first, staff closely monitored the application of the prevention principles in day-to-day care, and the two C/PHNs managing the project were pleased with the progress of the classes. After several weeks, however, staff became busy and did not follow some plans carefully.

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Preventive activities, such as coughing into the shirtsleeve and washing the hands after using the bathroom and before eating, were not being closely monitored. Several children who were clearly sick had not been kept at home. Staff often overlooked quiet or reserved children and did not include them in activities. To address these problems and get the project back on course, the nurses worked with staff and parents to motivate them. They held monthly meetings with the staff, observed the classes periodically, and offered one-on-one instruction to staff, parents, and children. One activity was to establish competition between the centers for the best health record, with the promise of a photograph of the winning center's children and an article in the local newspaper. Their efforts were successful.

Management Behaviors As managers, C/PHNs engage in many different types of behaviors. First described in a classic book by Mintzberg (1973), the management roles were grouped into three sets of behaviors: decision-making, transferring of information, and engaging in interpersonal relationships (Management at Work, 2019).

Decision-Making Behaviors Mintzberg identified four types of decisional roles or behaviors: entrepreneur, disturbance handler, resource allocator, and negotiator.

A manager serves in the entrepreneur role when initiating new projects. Starting a nurse-managed center to serve a homeless population is an example. C/PHNs play the disturbance handler role when they manage disturbances and crises—particularly interpersonal conflicts among staff, between staff and clients, or among clients (especially when being served in an agency). The resource allocator role is demonstrated by determining the distribution and use of human, physical, and financial resources. Nurses play the negotiator role when bargaining, perhaps with higher levels of administration or a funding agency, for new health policy or budget increases to support expanded services for clients (Management at Work, 2019).

Transfer of Information Behaviors Three informational roles or behaviors include monitor, information disseminator, and spokesperson.

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The monitor role requires collecting and processing information, such as gathering ongoing evaluation data to determine whether a program is meeting its goals. In the disseminator role, nurses transmit the collected information to people involved in the project or organization. In the spokesperson role, nurses share information on behalf of the project or agency with outsiders (Management at Work, 2019). See Chapter 10 for more on communication.

Interpersonal Behaviors While engaging in various interpersonal roles, the C/PHN may function as a figurehead, a leader, and a liaison.

In the figurehead role, the nurse acts in a ceremonial or symbolic capacity, such as participating in a ribbon-cutting ceremony to mark the opening of a new clinic or representing the project or agency for news media coverage. In the leader role, the nurse motivates and directs people involved in the project. In the liaison role, a network is maintained with people outside the organization or project for information exchange and project enhancement (MindTools, n.d.).

Management Skills Three basic management skills are needed for successful achievement of goals: human, conceptual, and technical.

Human skills refer to the ability to understand, communicate, motivate, delegate, and work well with people (Cherry & Jacob, 2020). An example is a nursing supervisor's or team leader's ability to gain the trust and respect of staff and promote a productive and satisfying work environment. A manager can accomplish goals only with the cooperation of others. Therefore, human skills are essential to successful performance of the manager role. Conceptual skills refer to the mental ability to analyze and interpret abstract ideas for the purpose of understanding and diagnosing situations and formulating solutions (Lalleman, Smid, Lagerwey, Oldenhof, & Schuurmans, 2015). Examples are analyzing demographic data for program planning and developing a conceptual model to describe and improve organizational function.

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Technical skills refer to the ability to apply special management- related knowledge and expertise to a particular situation or problem. Such skills performed by a C/PHN might include implementing a staff development program or developing a computerized management information system (Lalleman et al., 2015). See Chapter 10 on technology in community/public health nursing.

Case Management Case management has become the standard method of managing health care in the delivery systems in the United States, and managed care organizations have become an integral part of community-oriented care.

Case management is a systematic process by which a nurse assesses clients' needs, plans for and coordinates services, refers to other appropriate providers, and monitors and evaluates progress to ensure that clients' multiple service needs are met in a cost-effective manner. With health care reform, the importance of case management, or care coordination among an interdisciplinary team, is emphasized as a means to control costs and improve client outcomes (National Committee for Quality Assurance, 2018; Phillips & Fitzsimons, 2015).

As clients leave hospitals earlier, as families struggle with multiple and complex health problems with meager resources, as more older persons need alternatives to nursing home care, as competition and scarce resources contribute to fragmentation of services, and as the cost of health care continues to increase, there is a growing need for someone to oversee and coordinate all facets of needed service (Chait & Glied, 2018; Cook, Hall, Garvan, & Kneipp, 2015). Through case management, the nurse addresses this need in the community (Fig. 2-3).

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FIGURE 2-3 C/PHNs may serve as case managers for battered women and other aggregates.

The activity of case management often follows discharge planning as a part of continuity of care. When applied to individual clients, it means overseeing their transition from the hospital back into the community and monitoring them to ensure that all of their service needs are met. Case management also applies to aggregates (Young et al., 2018). In this context, it involves overseeing and ensuring that group or population health-related needs are met, particularly for those who are at high risk of illness or injury.

For example, the C/PHN may work with battered women who come to a shelter. First, the nurse must ensure that their immediate needs for safety, security, food, finances, and childcare are met. Then, the nurse must work with other professionals to provide more permanent housing, employment, ongoing counseling, and financial and legal resources for this group of women. Whether applied to families or aggregates, case management, like other applications of the manager role, uses the three sets of management behaviors and engages the C PHN as planner, organizer, leader, controller, and evaluator. See Unit 6.

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Collaborator Role C/PHNs seldom practice in isolation. They work with many people, including clients, other nurses, physicians, teachers, health educators, social workers, physical therapists, nutritionists, occupational therapists, psychologists, epidemiologists, biostatisticians, attorneys, secretaries, environmentalists, city planners, and legislators.

As members of the health team, C/PHNs assume the role of collaborator, which means working jointly with others in a common endeavor, cooperating as partners. Successful community/public health practice depends on this multidisciplinary collegiality and leadership (Brown, 2017).

The following examples show a C/PHN employed by the local Area Agency on Aging functioning as collaborator. Three families needed to find good nursing homes for their grandparents. The nurse met with the families, including the older adult members; made a list of desired features, such as a shower and access to walking trails; and then worked with a social worker to locate and visit several homes. The grandparents' respective physicians were contacted for medical consultation, and, in each case, the older adult member made the final selection. In another situation, the C/PHN collaborated with the city council, police department, neighborhood residents, and manager of a senior citizens' high-rise apartment building to help a group of older people organize and lobby for safer streets.

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Leadership Role C/PHNs are becoming increasingly active in the leadership role, separate from leading within the manager role mentioned earlier. The leadership role focuses on effecting change; thus, the nurse becomes an agent of change.

As leaders, C/PHNs seek to initiate changes that positively affect people's health. They also seek to influence people to think and behave differently about their health and the factors contributing to it. The role of social determinants of health, such as the availability of health services and how the physical environment affects population health, is discussed in Chapter 11 in relation to health promotion of individuals and communities.

At the community level, the leadership role includes health planning and may involve working with a team of professionals to direct and coordinate projects, such as a campaign to restrict marketing of e- cigarettes to adolescents or to lobby legislators for improved child day care facilities. When nurses guide community/public health decision-making, stimulate an industry's interest in health promotion, initiate group therapy, direct a preventive program, or influence health policy, they assume the leadership role.

A broader attribute of the leadership role is that of visionary. A leader with vision sees what can be and leads people on a path toward that goal (Katz, 2018; Nolan et al., 2015). A leader's vision may include long-and short-term goals.

In one instance, it began as articulating the need for stronger community/public health nursing services to an underserved population in an inner-city neighborhood served by a C/PHN. In this densely populated, tenant-occupied neighborhood, drugs, crime, and violence were commonplace. One summer, an 8-year-old boy was shot and killed. The enraged immigrant families in the neighborhood felt helpless and hopeless. The nurse visited several families, and they shared their concerns with him. The nurse felt strongly about this community and offered to work with them to effect change. He gathered volunteers from neighborhood churches, and, together, they began to discuss the community's concerns. They prioritized their needs and began planning to make their community healthier. The nurse organized his workweek such that he could provide health screening and education to families in the basement of a church on

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one morning each week. Initially, only a few families accessed this new service. In a matter of months, however, it became recognized as a valuable community service and was expanded to a full day; the increasing volunteer group soon outgrew the space. The C/PHN worked closely with influential community members and the families being served. They determined that many more services were needed in this neighborhood, and they began to broaden their outreach and think of ways to provide the needed services.

Within a year, the group had written several grants to the city and to a private corporation in an effort to expand the voluntary services. The funding that they obtained allowed them to rent vacant storefront space, hire a part-time nurse practitioner, contract with the health department for additional community/public health nursing services, and negotiate with the local university to have medical, nursing, and social work students placed there on a regular basis. The group, under the visionary leadership of the C/PHN, planned to add a one-on-one reading program for children, a class in English as a second language for immigrant families, a mentoring program for teenagers, and dental services. Even the police department had opened a substation in the neighborhood, making their presence more visible. This C/PHN's vision filled an immediate, critical need in the short term that developed into a comprehensive community center in the long term. Violence and crime diminished, and the neighborhood became a safer place where children could play.

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Researcher Role In the researcher role, C/PHNs engage in the systematic investigation, collection, and analysis of data for solving problems and enhancing community/public health practice. Research is an investigative process in which all C/PHNs can become involved by asking questions and looking for evidence-based solutions (Wilson, Rosemberg, Visovatti, Munro-Kramer, & Feetham, 2017). The ongoing need for evidence-based practice is supported by Healthy People 2030, as public health researchers incorporate “stakeholder engagement throughout all phases,” which helps them to more accurately determine successful programs and interventions (Livingood, Bilello, Choe, & Lukens-Bull, 2018, p. 155).

C/PHNs practice the researcher role at several levels. In addition to everyday inquiries, nurses often participate in agency and organizational studies to determine such matters as practice activities, priorities, and education of C/PHNs (Livingood et al., 2018). The researcher role (at all levels) helps to determine needs, evaluate effectiveness of care, and develop a theoretic basis for community/public health nursing practice. Chapter 4 will explain this research in greater detail.

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SETTINGS FOR COMMUNITY AND PUBLIC HEALTH NURSING PRACTICE

The previous section examined major C/PHN roles, which can now be placed in context by viewing the settings in which they are practiced. The sites are increasingly varied and include a growing number of nontraditional settings and partnerships with nonhealth groups. Employers of C/PHNs range from state and local health departments and home health agencies to managed care organizations, businesses and industries, and nonprofit organizations. For this discussion, these settings are grouped into seven categories: homes, ambulatory service settings, schools, occupational health settings, residential institutions, faith communities, and the community at large (domestic and international). This section provides a brief overview of the various settings. Chapters 28 and 29 will provide much more detail on specific roles and settings, including both public and private practice settings.

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Homes Since Lillian Wald and the nurses at the Henry Street Settlement first started their practice in 1893 (see Chapter 3), the most frequently used setting for community/public health nursing practice has been the home. In the home, all of the public health nursing roles are performed to varying degrees. Clients who are discharged from acute care institutions, such as hospitals or behavioral health facilities, may be referred to C/PHNs for continued care and follow-up. Here, the nurse can see clients in a family and environmental context and tailor service to the clients' unique needs (Fig. 2-4; Keeling, 2015).

FIGURE 2-4 C/PHNs make home visits to assess and follow up with clients.

For example, Mr. White, 67 years of age, was discharged from the hospital with a colostomy. Jessica Levitz, the C/PHN from the county visiting nursing agency, immediately started home visits. She met with Mr. White and his wife to discuss their needs as a family and to plan for Mr. White's care and adjustment to living with a colostomy. Practicing the clinician and educator roles, she reinforced and expanded on the teaching started in the hospital for colostomy care, including bowel training, diet, exercise, and proper use of equipment. As part of a total family care plan, Jessica provided some forms of physical care for Mr. White as well as counseling, teaching, and emotional support for both Mr. White and his wife. In addition to consulting with the physician and social service worker, she arranged and supervised visits from the home health aide, who

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gave personal care and homemaker services. She thus performed the manager, leader, and collaborator roles.

The home is also a setting for health promotion. Many C/PHN visits focus on assisting families to understand and practice healthier living behaviors. Nurses may, for example, instruct clients on parenting, infant care, child growth and development, diet, exercise, coping with stress, or managing grief and loss.

The character of the home setting is as varied as the clients served by the C/PHN. In one day, the nurse may visit a well-to-do widow in her spacious home, a middle-income family in their modest bungalow, an older transient man in his one-room fifth-story walk-up apartment, and a teen mother and her infant living in a group foster home. In each situation, the nurse can view the clients in perspective and, therefore, better understand their constraints, capitalize on their resources, and tailor health services to meet their needs.

In the home, unlike in most other health care settings, clients are on their own “turf.” They feel comfortable and secure in familiar surroundings and often are better able to understand and apply health information. Client self-respect can be promoted, because the client is host and the nurse is a guest.

Sometimes, the thought of visiting in clients' homes can cause anxiety. This may be your first experience outside the acute care, long-term care, or clinic setting. Visiting clients in their own environment may make you feel uncomfortable. You may be asked to visit families in unfamiliar neighborhoods and have to walk through those neighborhoods to locate the clients' homes. Frequently, fear of the unknown is the real fear—a fear that often has been enhanced by stories from previous nursing students. This may be the same feeling as that experienced when caring for your first client, first entering the operating room, or first having a client in the intensive care unit. However, in the community, more variables exist, and the nurse should follow the specific instructions given during the clinical experience and everyday commonsense safety precautions. General guidelines for safety and making home visits are covered in detail in Chapter 14.

Changes in the health care delivery system, along with shifting health economics and service delivery (discussed in Chapter 6), are moving the primary setting for C/PHN practice away from the home. Many local public health departments are finding it increasingly difficult to provide widespread home visiting by their public health nurses.

Instead, many agencies are targeting populations that are most in need of direct intervention. Examples include families with low-birth-weight

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babies, clients requiring directly observed administration of tuberculosis medications, and families requiring ongoing monitoring because of identified child abuse or neglect. With limited staff and financial resources, the highest-priority clients or groups are targeted.

With skills in population-based practice, C/PHNs serve the public's health best by focusing on sites where they can have the greatest impact. At the same time, they can collaborate with various types of home care providers, including hospitals, other nurses, physicians, rehabilitation therapists, community aides, and durable medical equipment companies, to ensure continuous and holistic service. The nurse continues to supervise home care services and engage in case management. The increased demand for highly technical acute care in the home requires specialized skills that are best delivered by nurses with this expertise. Chapter 30 further examines the nurse's role in the home health and hospice settings.

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Ambulatory Service Settings Ambulatory service settings include a variety of venues for C/PHN practice in which clients require day or evening services that do not include overnight stays. Examples include the following:

A local public health department A clinic offering comprehensive services in an outpatient department of a hospital or medical center A comprehensive community or neighborhood health center A specialized clinic, such as a family planning clinic or a well-child clinic, in a community location convenient for clients, such as in a church basement or a pharmacy A day care center, such as for those with physical disabilities or behavioral health issues A nurse-managed health center, often provided as a community service component of a school of nursing, with the mission of enhancing student clinical experiences while meeting identified community needs in the areas of primary health care and health promotion (see Chapter 29) A medical practice office, such as associated with a health maintenance organization and involving screening, referrals, case management services, counseling, health education, and group work An independent nursing practice in a community nursing center that also may include home visits A setting associated with a selected client group, such as a migrant camp, tribal land, correctional facility, children's day care center, faith community, coal-mining community, or remote frontier area

In each ambulatory setting, all of the community/public health nursing roles are used to varying degrees (Box 2-4).

BOX 2-4 PERSPECTIVES

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A Graduating Student's Viewpoint on Postgraduation Employment Before entering nursing school, I spent 5 years on active duty as a corpsman in the Navy. I remembered seeing some nurses who visited our hospital wearing what looked like Navy uniforms but was told that they worked for the federal government and weren't in the Navy. I didn't think much of it until I was looking up information on the U.S. Public Health Service and the Surgeon General. Only then did it dawn on me that those nurses were part of the Commissioned Corps of the Public Health Service. I didn't even know they existed, much less what they did, so I looked around the section of the Web site dealing with nursing. It turns out that they do quite a bit— respond to disasters, provide health services to Native Americans, and even work with the federal prisons. It surprised me to find out that they hire new graduates for many of their positions. I still haven't decided what I want to do after I graduate, but I may seriously consider this option. They even have an extern program available while I'm still in school—who knows, I may be in uniform again. See Chapter 28 for more about the U.S. Public Health Service.

Matt, age 29

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Schools Schools of all levels make up a major group of settings for community/public health nursing practice. Nurses from community/public health nursing agencies frequently serve private schools at elementary and intermediate levels. Public schools are served by the same agencies or by C/PHNs who are hired directly by the school system. The C/PHN may work with groups of students in preschool settings, such as Montessori schools or Head Start centers, as well as in vocational or technical schools, junior colleges, and college and university settings. Specialized schools, such as those for students with developmental disabilities, are another setting for community/public health nursing practice (Fig. 2-5).

FIGURE 2-5 School nursing is another community/public health nursing role.

C/PHNs' roles in school settings are changing. School nurses, whose primary role initially was that of clinician (for individual, family, and population health), are widening their practice to include more health education, interprofessional collaboration, and client advocacy. For example, one school had been accustomed to using the nurse as a first-aid provider and record keeper. Her duties were handling minor problems, such as headaches and cuts, and keeping track of such events as

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immunizations and medication administration at a local high school. This nurse sought to expand her practice and, after consultation and preparation, collaborated with a health educator and some of the teachers to offer a series of classes on personal hygiene, diet, and sexuality. She started a drop-in center for health counseling at the school and established a network of professional contacts for consultation and referral.

Nurses in school settings also assume managerial and leadership roles and recognize that the researcher role should be an integral part of their practice. The nurse's role with school-age and adolescent populations is discussed in detail in Chapters 20 and 28.

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Occupational Health Settings Business and industry provide another group of settings for community/public health nursing practice. Employee health has long been recognized as making a vital contribution to individual lives, the productivity of business, and the well-being of the entire nation. Organizations are expected to provide a safe and healthy work environment, in addition to offering insurance for health care.

More companies, recognizing the value of healthy employees, are going beyond offering traditional health benefits to supporting health promotional efforts. Some businesses, for example, offer healthy snacks, such as fruit at breaks, and promote walking or jogging during the noon hour. A few larger corporations have built exercise facilities for their employees, provide health education and wellness programs, and offer financial incentives for losing weight or staying well.

Occupational health settings range from industries and factories, such as an automobile assembly plant, to business corporations and even large retail sales systems. The field of occupational health offers a challenging opportunity, particularly in smaller businesses, where nursing coverage usually is not provided. Chapter 29 more fully describes the role of the nurse serving the working adult population.

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Residential Institutions Any facility where clients reside can be a setting in which community/public health nursing is practiced. Residential institutions include halfway houses, in which clients live temporarily while recovering from drug addiction, and inpatient hospice programs, in which terminally ill clients live.

Some residential settings, such as hospitals, exist solely to provide health care; others provide a variety of services and support. C/PHNs based in a community agency maintain continuity of care for their clients by collaborating with hospital personnel, visiting clients in the hospital, and planning care during and after hospitalization. Some C/PHNs serve one or more hospitals on a regular basis as a liaison with the community and by providing consultation for discharge planning and periodic in- service programs to keep hospital staff updated on community services for their clients. Other C/PHNs with similar functions are based in the hospital and serve the hospital community.

A continuing care center is another example of a residential site providing health care that may use community/public health nursing services. In this setting, residents are usually older adults; some live quite independently, whereas others become increasingly dependent and have many chronic health problems.

The nurse functions as advocate and collaborator to improve services. The nurse may, for example, coordinate available resources to meet the needs of residents and their families and help safeguard the maintenance of quality operating standards. Chapter 22 discusses the C/PHN's role with older adults. Chapter 30 discusses nursing services needed by clients after hospitalization through home care services or by families and clients in hospice programs. Sheltered workshops and group homes for children or adults with mental illness or developmental disability are other examples of residential institutions that serve clients who share specific needs.

C/PHNs also practice in settings where residents are gathered for purposes other than receiving care, where health care is offered as an adjunct to the primary goals of the institution. For example, many nurses work with camping programs for healthy children and adults offered by religious organizations and other community agencies, such as the Boy Scouts, Girl Scouts, and YMCA.

Other camp nurses work with children and adults who have chronic or terminal illnesses, through disease-related community agencies such as the American Lung Association, American Diabetes Association, and

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American Cancer Society. Camp nurses practice all available roles, often under interesting and challenging conditions and around the clock.

Another often-overlooked practice setting is the correctional institution. Inmates, whether incarcerated for the short or long term, have the same health care needs as the general public. The challenge to the nurse in this setting is to provide health care in an unbiased and nonjudgmental manner within the realities of the setting.

Because of the unique nature of this population, there are typically additional health and social service needs, often stemming from the reason for the incarceration in the first place (e.g., drug abuse) and that place them at increased risk for select health problems (e.g., AIDS, tuberculosis, poor nutrition). Chapter 28 discusses the role of the nurse in the correctional setting.

Residential institutions provide unique settings for the C/PHN to practice health promotion. Clients are more accessible, their needs can be readily assessed, and their interests can be stimulated. These settings offer the opportunity to generate an environment of caring and optimal quality health care provided by community/public health nursing services.

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Faith Communities Faith community nursing finds its beginnings in an ancient tradition. The beginnings of community/public health nursing can be traced to religious orders (see Chapter 3), and for centuries, religious and spiritual communities were important sources of health care.

In faith community nursing today, the practice focal point remains the faith community and the religious belief system provided by the philosophical framework. This nursing specialty may take different names, such as church-based health promotion, parish nursing, or faith community nursing practice. Whatever the service is called, it involves a large-scale effort by the church community to improve the health of its members through education, screening, referral, treatment, and group support.

The ANA, in collaboration with the Health Ministries Association, has published standards of care for faith community nursing practice in collaboration with the Health Ministries Association, Inc. (ANA, 2017). The standards act as guidelines for faith communities that plan to offer or are offering faith community nursing services. This specialty area of practice is guided by a variety of standards set up by several groups. Together, these standards provide guidance and direction for caregiving within the faith community.

When C/PHNs work as faith community nurses, they enhance accessibility to available health services in the community while meeting the unique needs of the members of that religious community, practicing within the framework of the tenets of that religion. In most situations, the nurse is a practitioner of the same religious belief system. Chapter 29 provides more detailed information about this specialty area of practice.

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Community at Large Unlike the six settings already discussed, the seventh setting for community/public health nursing practice is not confined to a specific philosophy, location, or building. When working with groups, populations, or the total community, the nurse may practice in many different places (Box 2-5). For example, a C/PHN, as clinician and health educator, may work with a parenting group in a church or town hall. Another nurse, as client advocate, leader, and researcher, may study the health needs of a neighborhood's older adult population by collecting data throughout the area and meeting with university researchers or resource professionals in many places. Also, a nurse may work with community-based organizations such as an LGBTQ advocacy organization or a support group for parents experiencing the violent death of a child. Again, the community at large becomes the setting for practice for a nurse who serves on health care planning committees, lobbies for health legislation at the state capital, runs for a school board position, or assists with flood relief in another state or another country (Fig. 2-6). See Box 2-5.

FIGURE 2-6 The C/PHN works with many different groups, including older adults.

BOX 2-5 Innovative Community/Public Health Nursing Practice In some community/public health nursing courses, students do not

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have access to an established agency such as a health department or community center from which to establish a client base. Student nurses and practicing C/PHNs can provide outreach services and do case finding in innovative settings such as these:

Leader's role—initiate, plan, strategize, collaborate, and cooperate with community groups to present programs that are focused on specific populations' needs.

Educator's role—teach nutrition, stress management, safety, exercise, prevention of sexually transmitted diseases, and other men and women's health issues, child home/school/play and stranger safety, and child growth and development, and provide anticipatory guidance. Have pamphlets available to support verbal information on health and safety topics, specific diseases, social security, Medicare, and Medicaid.

Clinician's role—perform blood pressure screening, height, weight, blood testing for diabetes and cholesterol, occult blood test, hearing and vision tests, scoliosis measurements, and administration of immunizations.

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Advocate's role—provide information regarding community resources as needed, cut “red tape” for those who need it, answer questions, and guide people to additional resources, such as Web sites and “800” phone numbers.

Collaborator's role—join with other social service and health professionals as team members to address the needs of clients (families, aggregates, communities).

Researcher's role—investigate an issue or problem, talk with community members, collect data, analyze results, and share outcomes (disseminate).

Although the term “setting” implies a place, remember that community/public health nursing practice is not limited to a specific site, but is a specialty of nursing that is defined by the nature of its practice, not its location, and it can be practiced anywhere. As you read through this chapter, perhaps an area of practice or a particular population captured your attention. If you are interested in tribal health, you might consider working as a U.S. Public Health Service nurse, or if you find that you are more interested in providing comprehensive health promotion programs to rural individuals, a nurse-managed health center may be of interest. Opportunities for community/public health nursing run the gamut from the American Red Cross, state and local health departments, the Peace Corps, to various international aid groups. Both private and public health agencies are actively seeking nurses with an interest in improving the health of their communities.

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SUMMARY

The various roles and settings for practice hinge on three primary functions of public health—assessment, policy development, and assurance—and are applied at three levels of service—individual, family, and community. Assessment is the systematic collection, assembly, analysis, and dissemination of information about the health of a community. Policy development involves convening and facilitating community groups to evaluate health concerns and develop a plan to address those concerns, recommending new programs or increased services based on identified needs to address the needs of families, and developing standards for individual client care. Assurance is the pledge to provide services to clients that are necessary to achieve agreed-upon goals by encouraging the actions of others (public or private) or requiring action through regulation or provision of direct services. The 10 essential public health services fall within the three core functions and represent the scope of work done by C/PHN and other public health professionals. Community/public health nursing practice is defined by specific standards of practice developed by organizations such as AACN, ANA, and the CPHNO (formerly the Quad Council of Public Health Nursing Organizations) in publications related to ethics, scope of practice, and core competencies. C/PHNs play many roles, including that of clinician, educator, advocate, manager, collaborator, leader, and researcher. There are many types of settings in which the C/PHN may practice. These settings can be grouped into seven major categories: homes, ambulatory service settings, occupational health settings, residential institutions, faith communities, and the community at large. Community/public health nursing practice is not limited to a specific site but is a specialty of nursing that is defined by the nature of its practice (i.e., population health), not solely its location.

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ACTIVE LEARNING EXERCISES

1. Discuss ways in which a C/PHN can make service holistic and focused on wellness with: a. Preschool-age children in a day care setting b. A group of chemically dependent adolescents c. A group of older adults living in a senior high-rise building 2. Explain how at least 3 of the 10 essential public health services could be employed by a C/PHN in addressing a health risk in your community (e.g., opioid epidemic, low immunization rates, adolescent vaping, environmental hazards).

3. Think of a recent problem in your community and describe 3 of the 7 roles outlined in this chapter that you, as a C/PHN, would use to help intervene in dealing with the problem.

4. Choose one of the C/PHN roles or practice areas described in this chapter that may be of interest to you. Discuss the similarities and differences between the C/PHN roles or practice areas you chose with those chosen by other classmates.

5. Compare one of the examples used in this chapter to describe C/PHN roles (e.g., advocate for the Merrill family) to one of your client's issues. How can you apply exemplars of that role to your clinical experience?

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CHAPTER 3

History and Evolution of Public Health Nursing “Our basic idea was that the nurse's peculiar introduction to the patient and her organic relationship with the neighborhood should constitute the starting point for a universal service to the region. We considered ourselves best described by the term ‘public health nurses.’”

—Lillian Wald (1867–1940), Pioneer of Public Health Nursing

KEY TERMS American Nurses Association (ANA) District nursing Frontier Nursing Service Henry Street Settlement Industrial nursing National League for Nursing (NLN) National Organization for Public Health Nursing (NOPHN) Population health Rural nursing Visiting nurse associations (VNAs)

LEARNING OBJECTIVES Upon mastery of this chapter, you should be able to:

1. Describe the four stages of community/public health nursing's development.

2. Identify the contributions of selected nursing leaders throughout history to the advancement of community/public health nursing.

3. Discuss the academic and advanced professional preparation of community/public health nurses.

4. Compare and contrast community health nursing with public health nursing.

5. Analyze the relationship between our historical roots and current nursing practice.

6. Discuss governmental landmarks in the evolution of community/public health nursing.

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INTRODUCTION

You just left the home of a client who is concerned about a new family that just moved into the building where she lives. This family of six lives in an apartment with barely enough room for two. After years in this neighborhood, you are well aware of the high rents charged for apartments with peeling paint, rodents, and garbage all around the buildings. Your client is concerned that the young mother looks “worn out” and coughs all the time. She said she tried to help, but the family doesn't speak much English. She describes four young children all under the age of about 5. She's never seen the husband, but you know that most of the men in this neighborhood leave early in the morning to try to get some day work, so you are not surprised. You thank her for the information and assure your client that you will do what you can to help her new neighbors. You start thinking about how you will prepare for the visit to the family who doesn't even expect you. At the top of your planning list is trying to find someone who speaks their language; you only know a few words. You suspect without even seeing the mother what the cough means, although you hope you are wrong. Then you think about the four young children living so close together and creating so much work for a woman who isn't well. The husband may want to help his wife more, but if he doesn't work, they don't have money to pay rent and buy food. You wonder if he has the cough too.

As you read this scenario, what picture comes to mind? What language does this family speak? What disease does this young mother most likely have? Now, think about when this event might have occurred. If you thought this was a current scenario, it certainly could be, but this scenario was actually set in the early 1900s. This family emigrated from Greece and had not yet mastered the English language. The mother exhibits signs of consumption (the common name for tuberculosis at that time). Because birth control information was not available to most women, the mother was unable to effectively space out her pregnancies. The filthy and overcrowded housing, termed tenements, was typical of the time. The husband found work as a laborer where he could. Few social services were available—if there was no work, then there was no food for the family, and no money to pay the rent. The family came to America with the hope of a new start, but what they found was in many ways worse without their support system of family and friends.

Community/public health nurses (C/PHNs) in the early 20th century had to deal with many of the same issues we face today.

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We thought that tuberculosis (TB) was a disease of the past; now clients with TB, including multidrug-resistant strains, are becoming alarmingly more common (Centers for Disease Control and Prevention (CDC), 2019). Poverty, communicable diseases, poor housing, lack of social services, and limited access to family planning information remain as challenges to improving the health of our population (see Fig. 3-1).

FIGURE 3-1 Public health nursing: Where inspection begins. (From the American Red Cross and U.S. Medical Department of Sanitary Service (1917–1918). Retrieved from https://commons.wikimedia.org/wiki/File:Medical_Department_- _Sanitary_Service_-_Sanitation_- _Public_health_nursing._Where_inspection_begins_-_NARA_- _45499047.jpg)

As a C/PHN, you will be facing similar challenges to those faced by nurses of the past. History is exciting because we get to hear the “voices” of nurses who have gone before us and to see what they endured and the extent of their dedication and service while establishing the profession. It is also essential, for without it, we often fail to see patterns and learn from past mistakes.

This chapter traces community/public health nursing's rich historical development, highlighting the contributions of several nursing leaders and examining the global societal influences that shaped early and evolving community/public health nursing practice. The final section of the chapter describes the academic and advanced professional preparation required of C/PHNs today. Nursing's past influences its present, and both guide its future in the 21st century.

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HISTORICAL DEVELOPMENT OF COMMUNITY/PUBLIC HEALTH NURSING

The history of community/public health nursing, since its recognized inception in Europe and more recently in America, encompasses continuing change and adaptation (Donahue, 2011; Keeling, Hehman, & Kirchgessner, 2018). The historical record reveals a professional nursing specialty that has been on the cutting edge of innovations in public health practice and has provided leadership to public health efforts. (See Table 3-1 for information about the four general stages that mark the development of public/community health nursing.)

TABLE 3-1 Development of Community Health Nursing

See Chapter 1 for a more complete discussion of the terms public health nurse and community health nurse and Chapter 2 for descriptions and discussion of the development of public health and community health.

In the historical evolution of this specialty, a shift in thinking about the focus of practice resulted in the broader use of the term community health nurse to refer to the generalist practice in this specialty. The title public health nurse now refers not just to those working in public health agencies but also those working in many diverse community settings where population-focused nursing occurs (Edmonds, Campbell, & Gilder, 2016; Kulbok, Thatcher, Park, & Meszaros, 2012). It is important to recognize that the work of the nurse is, as it always has been, to improve the health of the whole community, however that community is defined. The term community/public health nurse (C/PHN) will generally be used throughout this text.

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Early Home Care Nursing (Before Mid-1800s)

The Origins of Early Nursing The early roots of home care nursing began with religious and charitable groups (Table 3-2; Pugh, 2001; Theofanidis & Sapountzi-Krepia, 2015):

TABLE 3-2 Landmarks in Nursing History: Pre-1800s

Source: Donahue (2011); Nutting and Dock (1907).

Deaconesses: Women in ancient Rome who cared for needy patients Knights Hospitaller: Warrior monks in Western Europe who protected and cared for pilgrims on their way to Jerusalem, founded in the early 11th century The Misericordia: A group of monks in Florence, Italy, who provided first aid care for accident victims on a 24-hour basis around the year 1244

Medieval times saw the development of various institutions devoted to the sick, including hospitals and nursing orders.

During the 17th century, nursing care for the poor expanded in Europe:

In England, the Elizabethan Poor Law, written in 1601, provided medical and nursing care to the poor and disabled. In France, St. Frances de Sales organized the Friendly Visitor Volunteers in the early 1600s (Dolan, 1978). In 1617, St. Vincent de Paul started the Sisters of Charity in Paris, France, an organization composed of nuns and laywomen dedicated to serving the poor and needy. They emphasized preparing nurses and supervising nursing care, as well as determining causes and solutions

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for clients' problems, thereby laying a foundation for modern community/public health nursing (Bullough & Bullough, 1978).

The Industrial Revolution (about 1760–1840) led to increased migration to cities. Hospitals were built in larger cities, and dispensaries were developed to provide greater access to physicians; however, medical education had no standardized curriculum until 1904 (Schwartz, Ajjarapu, Stamy, & Schwinn, 2018). Hospitals were mostly used by the indigent; for most others, nursing care was still given in the home. Public health challenges included the following:

In both Europe and America, overcrowding and poverty led to epidemics, high infant mortality, occupational diseases and injuries, and increasing mental illness. Disease was rampant; mortality rates were high; and institutional conditions, especially in prisons, hospitals, and “asylums” for the insane, were deplorable. The sick and afflicted were kept in filthy rooms without adequate food, water, cover, or care for their physical and emotional needs (Bullough & Bullough, 1978).

Dorothea Dix (1802–1887) brought attention to the plight of the mentally ill, abused, and neglected in US jails and almshouses. Her accomplishments included the following:

In one of the first social research efforts in the United States, she presented her firsthand accounts of the terrible situations she found to the legislatures of Massachusetts, New York, New Jersey, and Pennsylvania (Reddi, 2005). Through her efforts, there was an almost 10-fold increase in the number of mental institutions, and the overall care of the mentally ill improved. Although not trained as a nurse, Dix would, in later years, oversee the Union Army female nurses prior to resuming her efforts with the mentally ill (Desrochers, 2012).

Although few in number, both Catholic and Anglican religious nursing orders continued the work of caring for the sick poor in their homes. It was in the midst of these deplorable conditions and in response to them that Florence Nightingale began her work.

The Early Nightingale Years

“Health is not only to be well but to use well the powers we have.”—Florence Nightingale (1820– 1910).

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Born in 1820 into a wealthy English family, Florence Nightingale helped bring about major reforms in health care and improved the status of nursing through her extensive travel, excellent education—including training at the first school for nurses in Kaiserswerth, Germany, and determination to serve the needy (Fig. 3-2 and Table 3-3).

FIGURE 3-2 Florence Nightingale's concern for populations at risk, as well as her vision and successful efforts at health reform, provided a model for community health nursing today.

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TABLE 3-3 Contributions of Florence Nightingale

Source: Donahue (2011); Florence Nightingale Museum Trust (1997); Lee et al. (2013); Nightingale (1859/1969); Richardson (2010); Rooney (2016); Woodham-Smith (1951).

During the Crimean War (1854–1856) in Scutari, Nightingale observed the deplorable conditions in the military hospitals, including thousands of sick and wounded men lying in filth, without beds, clean coverings, food, water, or laundry facilities (Florence Nightingale Museum Trust, 1997; Lee, Clark, & Thompson, 2013; Woodham-Smith, 1951). In response, she organized competent nursing care and established kitchens and laundries, resulting in hundreds of lives saved. Her work further demonstrated that capable, holistic nursing intervention could prevent illness and improve the health of a population at risk—precursors to modern community/public health nursing practice (Hogan, 2015).

Nightingale's subsequent work reforming health in the military was supported by implementation of another public health strategy: the use of biostatistics. Through meticulously gathered data and statistical comparisons, Nightingale demonstrated that military mortality rates, even in peacetime, were double those of the civilian population because of the terrible living conditions in the barracks—what we describe today as evidence-based practice (Rooney, 2016).

She promoted five essential components to optimal health and healing— pure air, pure water, efficient drainage, cleanliness, and adequate lighting. Specifically, her concern was with the environment of patients, the need for keen observation, the focus on the whole patient rather than the disease, and

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the importance of assisting nature to bring about a cure (Nightingale, 1876, 1969; Palmer, 2001). This work led to important military reforms and prioritization of hygiene (Lee et al., 2013). See Chapter 15 for more on the Nightingale model.

Miss Nightingale's concern for populations at risk included the sick at home. Her book, Notes on Nursing: What It Is, and What It Is Not, published in England in 1859, was written to improve nursing care in the home. It was also during this period that Nightingale clarified nursing as a woman's occupation (Evans, 2004). This gender distinction in nursing was due more to the culture of the times than as a direct exclusion of men from the practice; it was consistent with social norms of that period.

Florence Nightingale also became a skillful lobbyist for health care reform. Her exemplary influence on English politics and policy improved the quality of existing health care and set standards for future practice. Furthermore, she demonstrated how population-focused nursing works (Lee et al., 2013).

Nightingale's work, particularly her five essential components to optimal health and healing, are relevant to today's community/public health nursing:

Pure air is important in reducing the transmission of airborne pathogens, such as tuberculosis (TB), which continues to be a worldwide public health threat. Drug-resistant TB strains continue to proliferate, particularly among poorer nations. In 2017, 10.4 million people were infected with TB; while 1.7 million people died. The World Health Organization (WHO, 2018) estimates that one-quarter of the world's population has latent TB! Three agencies—WHO, UNICEF, and the United States Agency for International Development (USAID)—jointly developed a document that directly reflects Nightingale's components of pure water, efficient drainage, and cleanliness as evidence-based practice. Improving Nutrition Outcomes with Better Water, Sanitation, and Hygiene gives guidelines for achieving Global Nutrition Goals for 2025 and other health goals (WHO, 2015). Efficient drainage is an issue even in first world countries as disease- bearing mosquitoes breed in stagnant water. Cleanliness, specifically hand hygiene, continues to be a topic of teaching for disease prevention; the Centers for Disease Control and Prevention (CDC, 2016) launched a “Clean Hands Count” educational campaign for health care providers and the public. Adequate lighting is relevant to nurses in the community as they assess home safety, particularly in older adults, who may have limited vision and balance, and community safety, such as poor exterior lighting,

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which can cause accidents and have other safety implications (Lee et al., 2013).

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District Nursing (Mid-1800s–1900)

Nightingale's Continued Influence The next stage in the development of community/public health nursing was the formal organization of visiting nursing or district nursing—for example, nurses working outside hospitals in community settings, such as homes, focusing on care and health promotion (Runciman, 2014).

In 1859, William Rathbone, an English philanthropist, became convinced of the value of home nursing as a result of private care given to his wife. In 1861, with Florence Nightingale's help and advice, Rathbone opened a training school for nurses connected with the Royal Liverpool Infirmary and established a visiting nurse service for the sick poor in Liverpool.

As the service grew, visiting nurses were assigned to districts in the city —hence the name, district nursing. The names of these nurses were entered into a central register, and they were known as “Queen's Nurses,” as Queen Victoria recognized the benefits of this program for her people and was a supporter (Hughes, 1902, 344) (see Fig. 3-3).

FIGURE 3-3 A Queen's District Nurse making a call in Scotland, 1927. (Retrieved from https://www.nlm.nih.gov/exhibition/picturesofnursing/exhibition2. html)

Florence Nightingale documented the need for community/public health nursing in her writings and recorded conversations:

“Hospitals are but an intermediate stage of civilization. At present, hospitals are the only place where the sick poor can be nursed, or,

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indeed often the sick rich. But the ultimate object is to nurse all sick at home” (Nightingale, 1876, para. 8). “The aim of the district nurse is to give first-rate nursing to the sick poor at home” (Nightingale, 1876 [also cited in Mowbray (1997, p. 24)]). “The health visitor must create a new profession for women” (conversation with Frederick Verney, 1891 [cited in Mowbray (1997, p. 25)]).

Founding of the American Red Cross and Evolution of Disaster Nursing In May 1881, Clara Barton and others founded the American Red Cross, modeling it after the International Red Cross, which was founded in 1863 and is responsible for more global outreach and response in its humanitarian efforts (Table 3-4). Below are some milestones in the history of the American Red Cross:

TABLE 3-4 Landmarks in Nursing History: 1800–1900

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Source: Bowery Boys (2017); D'Antonio (2017); Donahue (2011); Keeling et al. (2018); Lewinson et al. (2017).

August 1881: A chapter was founded in Dansville, New York. September 1881: A devastating forest fire in Michigan claimed 800 victims; this was the newly formed organization's first disaster response, setting the stage for future fire response (Hanes, 2016). 1898: Clara Barton went to Havana, Cuba, during the Spanish– American War with supplies for victims, the first record of Red Cross military collaboration. 1905: The American Red Cross was chartered by the Congress to provide relief during disasters and emergencies, support the military, help communities become more resilient, and conduct other well-known activities, such as blood collection.

Today the Red Cross continues working toward the health and betterment of our local communities and our nation by giving assistance to those in need during both small and catastrophic crises (American Red Cross, 2020).

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Home Visiting Takes Root Although district nurses primarily cared for sick individuals, they also taught cleanliness and wholesome living to their patients, even during that early period (Kalisch & Kalisch, 2004). The problems of early home care patients in the United States were numerous and complex. Thousands of European and eastern European immigrants as well as poor African Americans filled tenement housing in the poorest and most crowded slums of the large coastal cities during the late 1800s. Inadequate sanitation, unsafe and unhealthy working conditions, prejudices, and language and cultural barriers added to poverty and disease (Table 3-5; Box 3-1).

TABLE 3-5 Some Public Health Issues of the 18th to the 20th Centuries

Source: Rosenberg (2008).

BOX 3-1 What Do You Think?

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Communicable Diseases: Now vs. Then What diseases can we treat today? Which have been eradicated worldwide? Discuss some recent outbreaks of historic diseases, including where, when, and why they occurred. Describe some new diseases that were not identified or did not occur in this time period. What are the roles of the C/PHN in health promotion and disease prevention?

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Public Health Nursing (1900–1970) By the beginning of the 20th century, district nursing had broadened its focus to include the health and welfare of the general public, not just the poor. This new emphasis was part of a broader consciousness about public health. As demand rose, the number of private health agencies increased. These agencies supplemented the often-limited work of government health departments.

As Bullough and Bullough point out, specialized programs (e.g., infant welfare, tuberculosis clinics, venereal disease control) were developed and “although the hospital nursing school movement emphasized the care of the sick, a small but growing number of nurses were finding employment in preventive health care” (1978, p. 143). In 1900, there were an estimated 200 public health nurses (PHNs); by 1912, that number had grown to 3,000 (Gardner, 1936). This was an important development: “it brought health care and health teaching to the public, gave nurses an opportunity for more independent work, and helped to improve nursing education” (Bullough & Bullough, 1978, p. 143). Around 1900, Jessie Sleet was hired by the Charity Organization Society's (COS) tuberculosis committee as a temporary district nurse in New York City (Mosley, 2007). Credited as the first Black public health nurse, Jessie Sleet was a pioneer in early public health nursing practice and forged the way for many others (Table 3-6). By 1910, new federal laws made states and communities accountable for the health of their citizens. Catholic sisters and Lutheran deaconesses, as trained nurses operating out of motherhouses in various cities in the United States, provided care for local communities, sometimes working with other agencies such as the Red Cross (Keeling et al., 2018).

TABLE 3-6 Landmarks in Nursing History: 1900–1970

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Source: Donahue (2011); Keeling et al. (2008); The College of Physicians of Philadelphia (2020).

Nurses Making a Difference The role of the district nurse expanded during this stage. Lillian D. Wald (1867–1940), a leading figure in this expansion, first used the term public health nursing to describe this specialty (Ruel, 2014; Table 3-7). District nurses, while caring for the sick, had pioneered in health teaching, disease prevention, and promotion of good health practices. Nurses working outside of the hospital increased their knowledge and skills in specialized areas such as tuberculosis, maternal and child health, school health, and mental disorders.

TABLE 3-7 Lillian Wald, Public Health Nurse and Social Activist

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Source: Bullough and Bullough (1978); Christy (1970); Donahue (2010); Fee and Bu (2010); Feld (2008); Hawkins and Watson (2003); Kalisch and Kalisch (2004); Ruel (2014); Wald (1915, 1934); Vessey and McGowen (2006).

Lillian Wald's contributions to public health nursing were enormous:

Appalled by the conditions of an immigrant neighborhood in New York's Lower East Side, she and a nurse friend, Mary Brewster, started the Henry Street Settlement in 1893 to provide nursing and welfare services. The Lower East Side was home to many poor Irish, Italian, Jewish, and Chinese immigrants, and the Henry Street Visiting Nurse Service visited many sick children and families in their homes (Bowery Boys, 2017) (Fig. 3-4). During one of the worst periods of depression, nurses from this organization supplied individuals and families with ice for keeping food fresh, meals, medicine, and sterilized milk; made referrals to hospitals and clinics, as needed; and “emphasized the human dignity of even the poorest” tenement families (Fee & Bu, 2010, p. 1206).

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FIGURE 3-4 Iconic image of nurse crossing rooftops in New York City, 1908. (Used with permission of Visiting Nurse Service of New York.)

Wald's books, The House on Henry Street (1915) and Windows on Henry Street (1934), depict her work and convey her love of public health nursing (Fig. 3-5). The following Web site provides moving videos and photos of the neighborhood, Wald's Baptism of Fire, and TheHouse on Henry Street: https://www.henrystreet.org/about/our-history/exhibit-the-house-on- henrystreet/

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FIGURE 3-5 Lillian Wald as a student at New York Hospital Training School for Nurses, 1891. (Used with permission of the Visiting Nurse Service of New York.)

Wald's Growing Influence Wald used her success at the Henry Street Settlement in reducing illness- caused employee absenteeism as evidence to address the issue of childhood illness and school absenteeism (Bullough & Bullough, 1978; Hawkins & Watson, 2003). In the early 1900s, medical inspectors sent home about 15 to 20 children per day from each school in New York City for health-related reasons, but no one followed up with them to make sure that they were properly treated and returned to school. Wald suggested that placing nurses in the schools would allow for follow-up on recurring cases and home visits during the periods of exclusion. She argued that the nurses could supplement the work done by local physicians, who occasionally examined the children. Offering the services of one nurse for 1 month, Wald hoped to demonstrate how effective a school nurse could be. Lina Rogers Struthers was the first

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school nurse appointed in this endeavor (Kalisch & Kalisch, 2004). One year after this initial experiment, the number of children sent home from the New York City schools had dropped dramatically, another example of evidence- based practice. By September 1903, only 1,000 children needed to be excluded (compared with 10,000 one year earlier); this was about a 10-fold reduction. By 1905, 44 nurses covered 181 public schools (Hawkins & Watson, 2003; Vessey & McGowen, 2006).

In 1909, Wald embarked on another visionary path. She convinced the Metropolitan Life Insurance Company that nurse intervention could reduce death rates (Hamilton, 2007; Hawkins & Watson, 2003). In collaboration with the Henry Street Settlement, the company organized the Visiting Nurse Department and provided services to policyholders in a section of Manhattan, beginning a program of industrial nursing. The success of this program resulted in expansion to other parts of the city and to 12 other eastern cities within a year. By 1912, the company had 589 Metropolitan nursing centers (Kalisch & Kalisch, 2004; Ruel, 2014). Industrial nurses proliferated after Wald's work with the Metropolitan Life Insurance Company in 1909 (Toering, 1919).

Another Nurse—Another Problem As Lillian Wald worked to alleviate suffering caused by disease and poverty, Margaret Sanger began another battle. Born in 1879, she saw her own mother die at age 49, after 18 pregnancies and a long battle with tuberculosis. She attended nursing school and began working as a visiting nurse (Ruffing- Rahal, 1986).

The Comstock Act of 1873 prevented her from providing her female clients any information on contraception, despite the fact that affluent and educated Americans had reliable contraception. Even discussing contraception was prohibited (Baker, 2011). In 1912, she watched helplessly as a 28-year-old mother of three died from abortion-induced septicemia; a woman who had earlier begged her for information on preventing future pregnancies (Ruffing-Rahal, 1986). Margaret Sanger opened her first birth control clinic in Brooklyn, but 10 days later it was closed, and she was arrested (Fig. 3-6). She persisted and other clinics succeeded, resulting in the eventual formation of the International Planned Parenthood Federation (Baker, 2011).

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FIGURE 3-6 Margaret Sanger, thought to be standing in front of her birth control clinic.

Public Health Nursing Advances PHNs gradually gained more autonomy in such areas as home care and instruction of good health practices to families and community groups (Figs. 3-7 and 3-8). They worked with children and families affected by polio and administered the polio vaccine, once developed, at mass immunization clinics. One account relates a single PHN's experience providing care to those living in an isolated outpost on Kodiak Island, Alaska, during an outbreak of tuberculosis-related pneumonia (Carter, 2001; Curtis, 2008; Keeling et al., 2018). Industrial nursing also expanded, with 66 US firms employing nurses by 1910 (Bullough & Bullough, 1978). Out of necessity, PHNs began keeping better records of their services and continued home visiting for those in need. They also responded to population health needs, as more individual care was now available at hospitals and health centers (see Box 3-2).

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FIGURE 3-7 Well baby clinic in Framingham, Massachusetts (1920).

FIGURE 3-8 “Nurse Immunizing Man in Overalls in Front of a Large Group,” Mississippi, ca. 1920s. (Retrieved from https://commons.wikimedia.org/wiki/File:Nurse_immunizing_man _in_overalls,_in_center_of_large_group_(16429738357).jpg)

BOX 3-2 STORIES FROM THE FIELD

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New York City Public Health Nurses and the 1918 Influenza Pandemic The 1918 influenza pandemic caused over 40 million deaths worldwide and 675,000 US deaths. The country was at war (World War I), and the American Red Cross, the U.S. Public Health Service, and health care workers were stretched thin. The epidemic began in New York City with three cases during mid-September of 1918. It spread quickly and crossed social class and income boundaries; within a few days, there were 31 new cases reported (Keeling, 2009; Keeling & Wall, 2015).

Cities across the Eastern seaboard requested assistance, and a coordinated plan for a decentralized response was set in place. Lillian Wald, who directed the Henry Street visiting nurses, had weathered epidemics on the Lower East Side of New York City before and quickly responded to this new, even more virulent threat. When making home visits, nurses found “whole families were ill … without anyone to give them the simplest nursing care” (Keeling, 2009, p. 2735). One person described “People, desperate in their need watched from windows and doorways for the nurse. They surrounded her on the street, imploring her to go in six directions at once” (Geister, 1957, pp. 583–584).

Wald noted about 500 calls for nursing services to patients with influenza and pneumonia in the “first four days of October” and that nurses were instructed to wear masks but “31 out of … 170 had succumbed to influenza” (Keeling, 2009, p. 2736). The Nurses' Emergency Council was organized for a citywide response, led by Lillian Wald, who requested that all who employed nurses allow them to work in caring for those afflicted by the epidemic. With this central structure, duplication of services was avoided, and services could be provided more quickly.

Wald requested automobiles for the visiting nurses to help them travel more quickly and carry “linens, pneumonia jackets, and quarts of soup”; the nurses started work early every morning and went out again at 4 PM to check on cases reported later each day (Keeling, 2009, p. 2737). They finished rounds around midnight, only to start again early

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the next morning. In Harlem, a nurse reported on a family of seven —“the mother has influenza, the father has lobar pneumonia, two children have measles and bronchopneumonia, and one child is only four weeks old,” noting that they had no care until their case was reported to the visiting nurse association. This was a common situation across the city.

As the epidemic began to subside, the Nurses' Emergency Council discontinued central services on the 6th of November, and the Henry Street nurses opened postinfluenza clinics to address the follow-up needs of families. There were about 11,000 deaths from influenza and about 10,000 deaths from pneumonia reported in New York City over the 2-month period of the epidemic. All that the nurses could provide was comfort care—clean linens, bed baths, fluids, and monitoring. There was little help from the federal level of government; private, philanthropic, and religious organizations worked together with local government and nursing agencies to combat the deadly epidemic.

1. How has your city or country responded to the novel coronavirus (COVID-19) pandemic? In what ways is this similar to the 1918 flu pandemic?

2. What disease threats are most likely to affect your community? 3. What resources are available? 4. How would public health nurses be involved?

Source: Geister (1957); Keeling (2009); Keeling and Wall (2015).

During the 20th century, the institutional base for much of public health nursing shifted to the government.

By 1955, 72% of the counties in the continental United States had local health departments, staffed primarily by PHNs, who emphasized health promotion and provided care for the ill at home (Erwin & Brownson, 2017). Some of the district nursing services, known as visiting nurse associations (VNAs), remained privately funded and administered, offering their own home nursing care. In some places, city or county health departments joined administratively and financially with VNAs to provide a combination of services, such as home care of the sick and health promotion to families (Fig. 3-9). The Red Cross offered public health nursing services from 1912 to 1951: first via the Rural Nursing Services headed by Fannie Clement; second via the Town and Country Nursing Service, which served both rural areas and cities; and third via the Red Cross Public Health Nursing Service. The Red Cross also provided public health nursing services to

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families of soldiers during both World Wars (Ramsay, 2012; Sarnecky, 2018).

FIGURE 3-9 A public health nurse walks past a rural wooden house.

An innovative example of rural nursing was the Frontier Nursing Service, which was started by Mary Breckinridge (1881–1965) in 1925, to serve mountain families in Kentucky. From six outposts, nurses on horseback (see Fig. 3-10) visited remote families to deliver babies and provide food and nursing services. The work was hard, but rewarding; it combined general public health nursing and midwifery (January, 2009). From the beginning, Breckinridge insisted on accurate record keeping; this was used to assess patient risks and treatments.

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FIGURE 3-10 Mary Breckinridge on horseback. Photo Courtesy of Frontier Nursing University Archives. Used with permission.

Over the years, the service has expanded to provide medical, dental, and nursing care. The Frontier Nursing Service continues today, with its remarkable accomplishments of reducing mortality rates and promoting health among this disadvantaged population, as the parent holding company for the Frontier Nursing University. It is the largest nurse–midwifery program in the United States. In addition, Mary Breckinridge Healthcare, Inc. consists of multiple rural health care agencies (Carter, 2018; Dawley, 2003) (see Box 3-3).

BOX 3-3 PERSPECTIVES

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Roaming Through the Hills With the Public Health Nurse (1920) As a state nursing supervisor, I visit PHNs during a typical week providing services in rural Virginia. The first PHN's territory consisted of a mountainous area, with winding, often muddy roads. Our first visit was made on horseback: “The road straight up the mountain was winding and lovely and way below in a gorge ran a stream” on our way to Star- Chapel School. After traveling by horseback all day, we crossed a final stream to reach a house that backed up to the mountain; “the stream dashing over the rocks at the front door” where we were invited to spend the night (Webb, 2011, pp. 291–292). The family was eager to help the nurse who had cared for others during the 1918 flu epidemic.

At the school, we checked the children, and the PHN talked to them about how to prevent disease and the importance of personal hygiene. We visited two more schools on the way back home. In the southwest corner of the state, I visited another PHN, and we traveled 30 miles by logging train, which seemed to be “balanced on the peak of a mountain top” to visit a small, isolated town that desperately wants a nurse to visit schoolchildren and families (Webb, 2011, p. 292).

In another county, the PHN visits with a girl who is recovering from meningitis, and her mother brags that she wants a clean glass and washes her hands now before she eats every meal. We then travel to a log cabin where mothers and children meet every week, and the PHN weighs babies and provides health pamphlets and talks about “babies, screening houses, homemade ice boxes,” and other topics of interest (Webb, 2011, p. 293). At an old stone fireplace, the women cook gingerbread and make hot cocoa. We later visited a rundown camp and found women there each having between three and eight children, along with a 14-year-old who had stopped dipping snuff, as the nurse advised. The nurse had promised her a prize, and she proudly claimed it. The PHN talked with a 12-year-old girl who refused to go to school and found that the reason was that she couldn't see, and her

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eyes were hurting. The mother agreed that she needed to see a specialist, but the girl would not agree to this unless her father made her go.

The PHN was disappointed to see a 4-year-old, who had agreed to stop chewing tobacco, come by to visit her with a cigarette in his mouth! Our state needs many more PHNs, and we are budgeting the money for services, but we don't have enough nurses who are willing to do this type of rural pioneer nursing. It can be very rewarding (Webb, 2011).

A silent film showing these nurses making visits on horseback during difficult conditions (begin at about the 10-minute mark) can be found at: https://collections.nlm.nih.gov/catalog/nlm:nlmuid-8600028A-vid

1. Where are rural nurses practicing today? 2. How has it changed from the 1920s? 3. What problems continue in this population? How can current

resources (e.g., technologic, pharmacologic, social, political) be effectively used by PHNs?

Adapted from a 1920 article found in Webb (2011).

This public health nursing stage was characterized by service to the public, with the family targeted as a primary unit of care (Fig. 3-11). Official health agencies, which placed greater emphasis on disease prevention and health promotion, provided the chief institutional base.

FIGURE 3-11 This Works Progress Administration (WPA) photograph shows a New Orleans public health nurse making a house call during the Great Depression, 1936. (Retrieved from https://commons.wikimedia.org/wiki/File:NurseHousecall1936.jpg )

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For instance, from 1928 to 1941, the East Harlem Nursing and Health Service offered “integrated family service(s)” by interdisciplinary independent PHNs to those living within an 87-city block area populated by mostly Italian immigrant and Italian American factory workers and laborers and their families (D'Antonio, 2013, p. 992). In New York City, 87% of babies were delivered at home, often by PHNs, and their services were in demand during the Great Depression as they worked to sustain families and address the social determinants of health that devastated them (D'Antonio, 2013).

Nurses in Military Service Since Florence Nightingale's service to the British soldiers during the Crimean War, nurses have continued to provide service during wartime.

Women served in many capacities (nurses, cooks, seamstresses) during the Revolutionary War. Clara Barton, a founder of the American Red Cross, volunteered her services during the Civil War, as did about 20,000 women of different races and classes (D'Antonio, 2010, 2013). In 1901, the Army Nurse Corps was established, and in 1908, the Navy Nurse Corps was added (Lineberry, 2013). During World War I, many new graduates responded to the pleas of the Red Cross for nurses to care for the sick and wounded and entered the Army Nurse Corps. At the start of World War II, the Red Cross called for 50,000 nurses to join the armed services (Lineberry, 2013). The Cadet Nurse Corps was created in 1942 to feed the demand for nurses during World War II, but military nurses didn't receive permanent commissioned officer status until 1947 (Robinson, 2009). In 1945, President Franklin D. Roosevelt “desegregated nursing in the U.S. Armed Forces” (D'Antonio, 2010, p. 132). About 74,000 nurses served during the Second World War; some ended up behind enemy lines, in combat, and as Japanese prisoners of war (Lineberry, 2013) (see Fig. 3-12). Over 28,500 nurses are actively employed in the service branches under the Defense Health Agency and the U.S. Public Health Service (Military Health System Communications Office, 2018).

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FIGURE 3-12 WW II, 1944. Surgical ward treatment at the 268th Station Hospital, Base A, Milne Bay, New Guinea. (Retrieved from https://commons.wikimedia.org/wiki/File:Surgical_ward_treatment _at_the_268th_Station_Hospital…_(5546316741).jpg)

The Profession Evolves By the 1920s, public health nursing was acquiring a more professional stature, in contrast to its earlier association with charity. Nursing as a whole was gaining professional status as a science, as well as an art. The formation of national nursing organizations began during this stage and contributed to nursing's professional growth.

The American Society of Superintendents of Training Schools for Nurses in the United States and Canada:

Founded in 1893 by Isabel Hampton Robb Purpose: to establish educational standards for nursing Became the National League of Nursing Education in 1912, the forerunner of the current National League for Nursing (NLN), established in 1952 (Ellis & Hartley, 2012; Stegen & Sowerby, 2019)

The American Nurses Association (ANA): Developed from a meeting of nursing leaders who initiated an alumnae organization of 10 schools of nursing to form the National Associated Alumnae of the United States and Canada in 1896 Purpose: to promote nursing education and practice standards In 1899, renamed the Nurses' Associated Alumnae of the United States and Canada Canada excluded from the title in 1901, because New York, where the organization was incorporated, did not allow representation

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from two countries Became the ANA in 1911; Canadian nurses formed a separate nursing organization (Ellis & Hartley, 2012).

The National Organization for Public Health Nursing (NOPHN): Founded by Lillian Wald and Mary Gardner in 1912 Purpose: setting standards for PHNs (Christy, 1970; Feld, 2008; NOPHN, 1939) In 1931, developed “general and specialized objectives” regarding work with individuals, families, and communities In 1940, added 12 functions of PHNs (Abrams, 2004, p. 507); began using community health nurse as a more inclusive gesture In 1952, merged with NLN (Abrams, 2004)

These three organizations, in particular, strengthened ties between nursing groups and improved nursing education and practice. The accomplishments of Wald and other nurse leaders reflect their concern for populations at risk and demonstrate how leadership, involvement in policy formation, and use of epidemiology led to improved health for the public (see Table 3-8 for information on famous PHNs).

TABLE 3-8 A Partial List of Famous Nurses in the Development of US Public Health Nursing 1800–1950

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Source: AAHN (2018); Carter (2018); Dickens (1907); Keeling et al. (2018); National Geographic (2013); Nursingtheory.org (2016); Red Cross (2018); Sarnecky (2018); Spring (2017).

The multiple problems faced by many families impelled a trend toward nursing care generalized enough to meet diverse needs and provide holistic services, but there was also a call for specialization in some densely populated areas, where tuberculosis, infant care, and school children were a primary concern (Brainard, 2012; King, 2011; Ruel, 2014) (see Figs. 3-13 and 3-14).

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FIGURE 3-13 A public health nurse carrying the classic PHN bag in Oakridge, Tennessee, 1947. Note dark uniform, hat, and sensible shoes. (Retrieved from https://commons.wikimedia.org/wiki/File:Public_Health_Nursing_ Oak_Ridge_1947_(12000263256).jpg)

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FIGURE 3-14 In Alaska in 1954, a public health nurse makes a home visit to clients, aided by an Eskimo man and his dog team. (Retrieved from https://commons.wikimedia.org/wiki/File:1956_Alaska_- _Eskimo_and_dog_team.jpg)

As nursing education became increasingly rigorous, collegiate programs included public health as essential content in basic nursing curricula.

Adelaide Nutting developed the first such course in 1912, at Teachers College in New York, in affiliation with the Henry Street Settlement. A group of agencies met in 1946 to establish guidelines for public health nursing, and by 1963, public health content was required for NLN accreditation in all baccalaureate degree–level nursing programs (Kulbok & Glick, 2014; Spring, 2017). The nurse practitioner (NP) movement, starting in 1965 at the University of Colorado, was initially a part of public health nursing and emphasized primary health care to rural and underserved populations. The number of educational programs to prepare NPs increased, with some NPs continuing in public health and others moving into different clinical areas (Hawkins & Watson, 2010).

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Community Health Nursing (1970 to the present) The emergence of the term community health nursing heralded a new era (Table 3-9). By the late 1960s and early 1970s, while PHNs continued their work, many other nurses who were not necessarily practicing public health were based in the community. Their practice settings included community- based clinics, doctors' offices, worksites, and schools (Fig. 3-15). To provide a label that encompassed all nurses in the community, the ANA and others called them community health nurses. This term was not universally accepted, however, and many people—including nurses and the general public—had difficulty distinguishing community health nursing from public health nursing and determining whether community health nursing was a generalized or a specialized practice.

TABLE 3-9 Landmarks in Nursing History: 1970 and Beyond

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Source: Donahue (2011), Keeling et al. (2018), USDHHS (n.d.); American Nurses Association (2014).

FIGURE 3-15 Germany, 2008. A nurse vaccinates a US marine at Stuttgart Army Health Clinic. (Retrieved from https://commons.wikimedia.org/wiki/File:USMC-080918-M- 0884D-002.jpg)

To help resolve this confusion, the following actions were taken:

The ANA's Division of Community Health Nursing: Developed A Conceptual Model of Community Health Nursing in 1980 to distinguish generalized preparation at the baccalaureate level from specialized preparation at the masters or postgraduate level Defined the generalist as one who provides nursing service to individuals and groups of clients while keeping “the community

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perspective in mind” (American Nurses Association, Community Health Nursing Division, 1980, p. 9)

In 1984, the U.S. Department of Health and Human Services, Bureau of Health Professions, Division of Nursing:

Convened a Consensus Conference on the Essentials of Public Health Nursing Practice and Education in Washington, DC (U.S. Department of Health and Human Services [USDHHS], Division of Nursing, 1984) Identified community health nursing as the broader term, referring to all nurses practicing in the community, regardless of their educational preparation Identified public health nursing as a part of community health nursing involving a generalist practice for nurses prepared with basic public health content at the baccalaureate level and a specialized practice for nurses prepared in public health at the master's level or beyond (Table 3-10)

In 2009, the Association of Community Health Nursing Educators (ACHNE) released an updated revision of their original document, Essentials of Baccalaureate Education for Entry-Level Community/Public Health Nursing, noting that both terms encompass population-based practice.

TABLE 3-10 Community/Public Health Nursing

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In this text, the terms public health nursing and community health nursing are combined (C/PHN), but whichever term is used to describe this nursing specialty, the fundamental issues and defining criteria remain the same:

Are populations or communities the target of practice? Are the nurses prepared in public health and engaging in public health practice?

Finally, confusion also arose regarding the changing roles and functions of C/PHNs. Accelerated changes in health care organization and financing, technology, and social issues made increasing demands on C/PHNs to adapt to new patterns of practice. Many new kinds of community/public health services appeared. Hospital-based programs reached into the community. Private agencies proliferated, offering home care and other community-based services.

The debate over these areas of confusion continued through the 1990s, and some issues remain unresolved. Still, the direction in which public health and community health nursing must move remains clear: to care for, not simply in, the community. Public health nursing continues to mean the synthesis of nursing and the public health sciences applied to promoting and protecting the health of populations. Community health nursing, for some, refers more broadly to nursing in the community. Community health nurses are carving out new roles for themselves in primary health care. Collaboration and interdisciplinary teamwork are recognized as crucial to effective community nursing. This field of nursing is assuming responsibility as a full professional partner in community health.

Community/public health nurses:

Work through many kinds of agencies and institutions, such as senior citizen centers, ambulatory services, mental health clinics, and family planning programs Conduct community needs assessment, document nursing outcomes, engage in program evaluation and quality improvement, assist in formulating public policy, and conduct community nursing research Seek to promote health, not just prevent illness, by applying current research evidence; promoting healthier lifestyle practices such as eating healthy diets, exercising, and maintaining social support systems; promoting healthy conditions in schools and work sites; and designing meaningful activities for children, adolescents, adults, and older adults (Kulbok et al., 2012; Milbrath & DeGuzman, 2015) Seek to provide holistic care by collaborating with others to offer more coordinated, comprehensive, and personalized services—a case- management approach

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The 2020 Gallup Poll is an example of the current attention given to the opinions of consumers. In this poll, nursing is the most highly rated profession with respect to honesty and ethics; it has held that position for 18 consecutive years. The honesty and ethical standards of nurses were rated either “high” or “very high” by 85% of respondents, ahead of physicians (65%), pharmacists (64%), police officers (54%), and members of clergy at 40% (Reinhart, 2020). And, as history has demonstrated, nursing's most effective contributions to the overall health of our nation are based in the community.

Nurses comprise the largest group of professionals in the public health workforce—about 16% or 47,000 employees in local, state, and federal agencies (Beck, Boulton, & Coronado, 2014). A study conducted 2 years later estimated a total number of full-time equivalent nurses working at state and local health departments at 40,791 (Beck & Boulton, 2016). As funding is limited in community and public health, it is important for C/PHNs to continue to demonstrate their worth. According to the U.S. Bureau of Labor Statistics (2020), job growth for registered nurses continues to be robust (with employment of registered nurses projected to grow 12% from 2018 to 2028); a significant driver of growth is the continuing recognition of the importance of preventive health care (Box 3-4).

BOX 3-4 Levels of Prevention Pyramid Promoting Community/Public Health Nursing SITUATION: The general population is aware of nurses working in acute care settings or clinics, but fewer people interact regularly with population-focused, community-based nurses. As budgets are tightened, C/PHNs need to market their unique skill set and influence on health promotion and disease prevention in order to nurture this important nursing specialty. GOAL: To clarify and enhance the community/public health nurse's role to promote greater impact of services.

Tertiary Prevention

Promote increasing influence of the nurse through an expanded role in service delivery

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Minimize the impact of community misunderstandings of the nurse's role through education

Secondary Prevention

Promote aggregate-level interventions Foster nurse involvement on community boards and other political groups

Primary Prevention

Participate in policy formation Be politically active Assist in acquiring funding for community health programs Conduct research on health and nursing outcomes to enhance evidence-based practice Collaborate with the news media to publicize current public health issues

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SUMMARY

Community/public health nursing developed historically through four stages.

1. The early home care stage (before the mid-1800s) emphasized care to the sick poor in their homes by various lay and religious orders.

2. The district nursing stage (mid-1800s) included voluntary home nursing care for the poor by specialists or “health nurses” who treated the sick and taught wholesome living to patients.

3. The public health nursing stage (1900–1970) was characterized by an increased concern for the health of the general public.

4. The community health nursing stage (1970 to the present) includes increased recognition of community health nursing as a specialty field, with focus on communities and populations.

Nursing leaders contributed to development of community/public health nursing, most notably:

Florence Nightingale, who outlined public health nursing Clara Barton, a Civil War nurse who founded the American Red Cross and shaped disaster nursing Lillian Wald, who developed public health nursing, influenced legislation and policy, and instituted school and industrial nursing as new areas of public health

Community/public health nursing encompasses many areas dealing with individuals, families, communities, and populations. Some examples include public health, disaster nursing, environmental health, health education, home health, hospice, midwifery, military nursing, missionary nursing, occupational/industrial health, ombudsman/community advocate, policy formation/social justice/political activism, population health, research, rural nursing, school nursing, visiting nurses, and volunteerism. Academic preparation for community/public health nursing begins at the baccalaureate level. The need for advanced preparation was recognized in the early 20th century, as college-level coursework was provided for this specialty. C/PHNs work in interdisciplinary teams in a variety of agencies with various populations to promote health.

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TABLE 3-11 History of Public Health Nursing and the 10 Essential Public Health Services

Source: CDC. (2020).

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ACTIVE LEARNING EXERCISES

1. Select one societal influence on the development of community/public health nursing and explore its continuing impact. What other events are occurring today that shape community/public health nursing practice? Using current, credible resources, support your arguments with documentation.

2. Research the life and works of a historical public health nursing leader. Using this information, determine how this practitioner might deal with a current population-based issue, such as the opioid epidemic, sexually transmitted diseases, obesity, vaping, gun violence, or child neglect and abuse.

3. Read an historical article about early public health nursing experiences. Compare these experiences with your public health clinical experiences today. What are the most striking similarities and differences?

4. Choose two areas of community/public health nursing where you might like to practice (Table 3-10). Compare and contrast those two areas describing geographic locations (e.g., international, rural), type of employment (e.g., public, private, grant funded), and job description, duties, activities areas of focus, and nursing orientation (e.g., individual, families, communities, populations). Compare your information with a classmate's selections.

5. After reviewing Box 3-11, review the 10 essential public health services (see Box 2-2 ) and give 4 additional examples of how they were implemented in historical community/public health settings (historical actions). Include who implemented them, what they did, where it occurred, and when. Give an example related to today's community/public health nursing practice.

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CHAPTER 4

EvidenceBased Practice and Ethics “Research is formalized curiosity. It is poking and prying with a purpose.”

—Zora Neale Hurston (1891–1960), Novelist We must not see any person as an abstraction. Instead, we must see in every person a universe with its own secrets, with its own treasures, with its own sources of anguish, and with some measure of triumph.”

—Elie Wiesel from The Nazi Doctors and the Nuremberg Code

KEY TERMS

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RESEARCH/EVIDENCEBASED PRACTICE Community-based participatory research (CBPR) Evidencebased practice Integrative review Meta-analysis Randomized control trial (RCT) Research Scoping review Systematic review Validity

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ETHICS Autonomy Beneficence Bioethics Distributive justice Egalitarian justice Ethical decision-making Ethical dilemma Ethics Fidelity Instrumental values Justice Moral Moral evaluations Nonmaleficence Respect Restorative justice Social justice Terminal values Value Value systems Values clarification Veracity

LEARNING OBJECTIVES Upon mastery of this chapter, you should be able to:

1. Discuss the concept of evidencebased practice (EBP) in community/public health.

2. List the necessary steps in the process of EBP. 3. Analyze the potential impact of research on community/public health

nursing practice. 4. Identify the community/public health nurse's role in conducting

research and using research findings to improve his or her practice. 5. Describe the nature of values and value systems and their influence on

community/public health nursing. 6. Articulate the impact of key values on professional decision-making. 7. Discuss the application of ethical principles to community/public

health nursing decision-making.

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8. Use a decision-making process with and for community/public health clients that incorporates values and ethical principles.

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INTRODUCTION

As a new student in community/public health nursing, you may ask, “Can I really do something to make a difference in the lives of my clients?” You may feel shocked and discouraged by the crushing poverty and overwhelming sense of helplessness experienced by many of your clients and by the continual recurrence of problems such as substance abuse, domestic violence, unemployment, and criminal activity. For the first time in your life, you may truly confront the inequalities and injustices of our health care system. You will face many ethical dilemmas in community/public health nursing. You may ask, “Why should I bother to make home visits to pregnant teens? Why should I offer smoking cessation classes at the local homeless shelter? Will it really matter?”

Recent public health nursing research validates that nursing care does matter and that you really can make a difference in the lives of your clients. For example, NurseFamily Partnership (NFP) programs, based on research conducted by David Olds and his colleagues, are reaping results in many communities across the United States and around the world (Coalition for EvidenceBased Policy, 2015; Karoly, 2017; Mejdoubi et al., 2015; NurseFamily Partnership, 2017, 2018). See Figure 4-1.

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FIGURE 4-1 Research that makes a difference: the NurseFamily Partnership. (Source: NurseFamily Partnership. Retrieved from https://www.nursefamilypartnership.org/wp- content/uploads/2019/11/Miller-State-Specific-Fact- Sheet_US_2019.pdf; Karoly, L. A. (2017). Investing in the early years: The costs and benefits of investing in early childhood in New Hampshire. RAND. Retrieved from https://www.rand.org/pubs/research_reports/RR1890.html; NurseFamily Partnership. (2019). About us. Retrieved from https://www.nursefamilypartnership.org/about/)

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RESEARCH THAT MAKES A DIFFERENCE: THE NURSEFAMILY PARTNERSHIP (NFP)

In an early longitudinal study by Olds and his research team (1997) conducted with a primarily white sample in a semirural setting over a 15-year period, regular visits by public health nurses (PHNs) to poor, unmarried women and their first-born children resulted in dramatic differences when compared with similar mothers and children in a control group. Many of the women were younger than age 19. PHNs made an average of nine prenatal visits and 23 child-related visits (until the child turned 2 years old). The effects of the intervention continued for up to 15 years after the birth of the first child.

Statistically significant differences were noted in the following outcomes:

Fewer subsequent pregnancies and an increased percentage of live births Longer intervals of time between first and second births Fewer incidences of reported child abuse and neglect Fewer months on public assistance and food stamps Fewer reported arrests and convictions of mothers Less impairment from alcohol or other drug use reported by mothers

A 2014 study examining data from 1,138 women compiled over two decades (1990–2011) looked at outcome measures of maternal mortality and preventable-cause child mortality rates (Olds et al., 2014b). Four treatment interventions were examined:

Transportation for prenatal care (control group) Developmental screening for infants and toddlers, as well as transportation (control group) Prenatal and postpartum home visiting with transportation (intervention group) Transportation, screening, prepregnancy/postpregnancy home visiting and infant/toddler home visiting (intervention group—NFP components)

Findings revealed the following:

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Maternal mortality rates for both control groups were higher than for those in both of the intervention groups. Results comparing the two control groups versus the two intervention groups were statistically significant (p = 0.008), indicating that the interventions were worthwhile. Child data, only available in groups 2 (2nd control group) and 4 (2nd intervention group), revealed statistical significance for preventable- cause child mortality rate (p = 0.04) for those in the group with all components of the NFP.

These and other studies are powerful evidence noting the effectiveness of a program of regular C/PHN visits to this vulnerable group. A classic study by the Olds research team examining pregnancy outcomes, childhood injuries, and repeated childbearing (Kitzman et al., 1997) was recognized by the National Institute of Nursing Research (National Institutes of Health, n.d.b) as one of 10 landmark nursing research studies.

The NFP model is based on theory and research. Olds and his colleagues have conducted repeated randomized controlled trials (RCTs) with different populations living in a variety of settings and contexts, over varying lengths of time (Eckenrode et al., 2010; Karoly, 2017; Kitzman et al., 2010a, 2010b; Olds et al., 2014a, 2014b; Sierau et al., 2016), and have consistently found that the NFP program results in the benefits mentioned in Figure 4-1 (NFP, 2018).

In a time of tight budgets, number crunchers may ask: do PHNs really make a difference, or can less expensive health care workers also get results? An early study by Olds et al. (2004) examined differences between PHN and paraprofessional (e.g., home aides) visitation in a large, randomized study of mostly Mexican American low-income first-time mothers.

At the beginning of the study, no statistical differences were noted between participants in both groups. Two years after the end of the program, participants visited by paraprofessionals had fewer low birth weight babies and better results than did control subjects on measures of mastery and mental health, and their home environments were conducive to early learning. However, mothers visited by nurses showed immediate as well as long- term benefits.

They had longer intervals between first and second births, there were fewer incidences of domestic violence, and their home environments were found to be conducive to early learning. Children of those mothers had better behavioral adaptation during testing, more advanced language scores, and better executive functioning. Others have reported similar findings (Olds et al., 2014a).

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Later research found “no significant paraprofessional effects on emotional/behavioral problems” among children of mothers with fewer psychological means in a study comparing paraprofessionals to control group counterparts (p. 114). Those children visited by nurses were found to have

Fewer emotional and behavioral problems overall at age 6 years (p = 0.08) Fewer internalizing problems at age 9 years (p =0.08) Less dysfunctional attention at age 9 years (p = 0.07) When compared with control-group counterparts, nurse-visited children exhibited better receptive language at the ages of 2, 4, and 6 years (p = 0.01) and better sustained attention at ages 4, 6, and 9 years (p = 0.006).

Olds and his fellow researchers are convinced that PHNs are the key to success.

In tough budget times, state and local agencies may be hesitant to expand programs. But the costs of PHN visits are more than offset by the large savings in both dollars and human suffering (NFP, 2017). Over the years, several think tank and policy groups have done cost–benefit analyses of the NFP, all concluding that this program reaps large returns on investment.

The cost effectiveness of NFP was verified by Wu, Dean, Rosen, and Muennig (2017). Compiling data from RCTs and other available data, they concluded that the program was most effective with high-risk mothers—improving population health and “saving both money and lives” (p. 1586). Quality-adjusted life years were 0.19 higher and with additional earnings along with other reported benefits, the net gain would be $9,617 per child visited by a PHN. They estimated 100% certainty that the program would gain even higher economic benefits over costs.

When H.R. 3590 (The Patient Protection and Affordable Care Act —“Obamacare”) was passed in 2010, early childhood home visitation programs were singled out as effective practices, and new grant funding to states was made available to promote these programs. The number of newly enrolled clients increased 25-fold between 2010 and 2013 (NFP National Service Office, 2015). In February 2018, additional funds were allocated to support these programs through 2020 (Maternal Child Health Bureau, n.d.).

Dr. Olds and his colleagues have encouraged replication, using the established framework undergirding their proven results. The value of this program that provides PHN visits to at-risk mothers and children in their homes has been validated. So, PHNs really do make a difference! See Box 4- 1.

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BOX 4-1 PERSPECTIVES

An NFP Nurse Viewpoint on Public Health Nursing I walked into the high school not sure what to expect, after all, I was used to visiting my clients in their homes. A very young looking girl walked in, noticeably pregnant and extremely shy. I tried to meet her eyes, but she kept looking down as we walked to a room. We met there every week for 6 weeks. Several months later when my client called to tell me that her mom had physically abused her and that her brother had threatened her with a gun, I felt helpless. I listened to her and hooked her up with resources for a safe place to go. If she couldn't count on her own mom, how would she ever succeed, I wondered?

She called me a lot after that day, many times just to talk. She wanted desperately to go to school, but since leaving her mom's home, she lived too far away to walk. I gave her as many bus passes as I could to get her to school and back. I thought that would be enough, until I could speak to school officials and find her some permanent transportation. Little did I know, but I was the ONLY one who cared if this child got to school or not. I tried tirelessly to get through to case workers, school officials, and social workers. I never thought that I would have this problem; a pregnant girl who wanted to go to school and adults who didn't care. How could this girl win?

My client gave birth to her baby and continued to faithfully keep our scheduled visits. We would laugh and have fun, while covering the program curriculum. She was doing a great job of parenting her baby and growth and development was on target. The baby was thriving. She was living somewhere new and again insisted that she wanted to go to school. We found out what district she was in and they needed her to get a physical exam and records from her old school. I encouraged her but was not too sure if she could get it all done. Those types of errands are easy for most

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people, but for someone who has no means of transportation and little support, it is a huge ordeal.

A week later I got a phone call, it was my client. I had to ask who it was because this young lady sounded so sure of herself and assertive. I couldn't believe that it was her! When had she started to speak up and articulate like this? She was calling to tell me that she had gotten her physical and her school records, and she was just waiting to hear from the school. I told her how proud I was of her for being so responsible.

The next time I saw my client, she rushed to the door and pulled me inside. She wanted to show me something and led me to her room. There, laid out on the bed was her ROTC uniform, complete with shiny black shoes. Her grandmother was willing to help with the baby so that she could participate. She looked me right in the eyes and said in a powerful voice… “What do you think?” I told her that I had no doubt in my mind that she would do great things in life, and that I was so proud of her. She said “Ms. Jody, I don't know why you are so proud; you are the one who taught me to be this way.” Amazing! I have had so many success stories and seen so many healthy moms and babies. I love working with this program. What I do can make a big difference.

Jody, RN, PHN, NFP Nurse

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RESEARCH AND EVIDENCEBASED PRACTICE

This evidence about the effectiveness of public health nursing visits could be gleaned only by conducting formal nursing research. Research in nursing is not a new phenomenon; Florence Nightingale is considered the earliest nurse researcher. She collected and analyzed data on the soldiers she cared for during the Crimean War (1859). She also employed principles of evidencebased practice (EBP) because she sought to enhance their care by using evidence to improve her nursing practice and patient outcomes.

This section defines the terms research and EBP, explains the need for EBP, lists and describes the steps of the EBP process, differentiates EBP implementation from research and quality improvement, discusses the need for ethical oversight of research, and presents the basic components of research that are needed to promote EBP.

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Defining Research and EBP Research is the systematic collection and analysis of data related to a particular problem or phenomenon. Research that is properly conducted and analyzed has the potential to yield valuable information that can affect the health of large groups of people. Indeed, it should guide our practice of community/public health nursing, and it often serves as the basis for changes in health care policies and programs.

According to Melnyk and Fineout-Overholt (2019), EBP in nursing means just that—systematically searching for and critically appraising and synthesizing evidence (or research findings), along with consideration of expert clinical nursing judgment and patients' wishes, in making decisions about how to care for patients or clients.

Rebar and Gersch (2015, p. 11) describe EBP as

Reviewing the best available evidence, most often the results of research Using the nurse's clinical expertise Determining the values and cultural needs of the individual Determining the preferences of the individual, family, and community

Alvidrez et al. (2019) discuss evidencebased interventions in public health and recognize that some of the best available evidence includes not only that from clinical research but also from health data (e.g., immunization rates, mortality rates, health status surveys) and practice (e.g., program evaluations, reports from expert panels).

Clinical reasoning is an important component in EBP. Practice knowledge of expert clinical nurses is vital to the process and efficacy of results (Belita et al., 2018; Glynn, McVey, Wendt, & Russell, 2017). Training programs are necessary for nurses to successfully apply EBP to their practices, in the community as well as in acute care (Black, Balneaves, Garossino, Puyat, & Qian, 2015).

The Quad Council Coalition, the preeminent public health nursing alliance that has now been renamed the Council of Public Health Nursing Organizations, delineated specific proficiencies required of public health nurses. The Quad Council Coalition PHN Competencies include analytic assessment skills, basic public health science skills, and policy development/program planning skills that include research and EBP (2018). In the current national atmosphere of managed care, value-based care, and obstinately rising health care costs, the importance of conducting valid research on how health care dollars can be spent to benefit the greatest number of people is vitally important. (The Quad Council Tier 1

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Community/Public Health Nursing Competencies are listed in the appendix; the Tier 2 and Tier 3 competencies are found at http://www.quadcouncilphn.org/documents-3/2018-qcc-competencies/.)

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The Need for EBP Across many different settings, from acute to community-based care, implementation of EBP guidelines or practices has been shown to improve nursing practice and client outcomes, as well as reduce costs and standardize care (Kutney-Lee et al., 2015; Lasater, Germack, Small, & McHugh, 2016; Melnyk, Fineout-Overholt, Giggleman, & Choy, 2017; Zhu, Dy, Wenzel, & Wu, 2018).

How did this more recent paradigm shift toward EBP occur? Dr. Archie Cochrane, a British epidemiologist, is widely regarded as the force behind evidencebased clinical practice in medicine (Brucker, 2016). Even though we often cling to “the way we've always done it,” we certainly have ample evidence of the need for a shift to EBP in health care: the Institute of Medicine (IOM; now the National Academy of Medicine) has been studying the issues of health care quality and effectiveness since 2000 and has called for widespread and systematic changes through its seminal reports:

To Err Is Human: Building a Safer Health System (IOM, 2000) Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) Priority Areas for National Action: Transforming Health Care Quality (IOM, 2003) The Future of the Public's Health in the 21st Century (IOM, 2003) For the Public's Health: The Role of Measurement in Action and Accountability (IOM, 2011) For the Public's Health: Investing in a Healthier Future (IOM, 2012).

These landmark reports draw attention to the fact that we spend billions of dollars each year researching new treatments and more than a trillion dollars annually on health care, but “we repeatedly fail to translate that knowledge and capacity into clinical practice” (IOM, 2003, p. 2). As discussed in Chapter 6, the United States has a large, complex, and expensive health care system, with lower-than-expected quality and safety outcomes affecting population health.

The Future of Nursing highlights the need for nurses to work with other health professionals in “redesigning health care” by “conducting research” and improving practices through evidencebased means (IOM, 2011, pp. 7, 11).

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Steps of the EBP Process The effective practitioner uses his or her clinical judgment and expertise to reflect on the practice of community/public health nursing and determine whether safe, effective, quality, and cost-efficient care is being delivered. Problems or situations that need clarification can then be identified, and current research can be reviewed to guide needed changes in practice. Although acknowledged barriers exist, they can be overcome using available resources (Cline, Burger, Amankwah, Goldenberg, & Ghazarian, 2017). Melnyk and Fineout-Overholt (2019, p. 17) outline the steps of the EBP process:

Step “0”: Cultivate a spirit of inquiry within an EBP culture/environment. Step 1: Ask the burning clinical question in PICOT format (see below). Step 2: Search for and collect the most relevant best evidence. Step 3: Critically appraise the evidence for its validity, reliability, and applicability, and then synthesize that evidence. Step 4: Integrate the best evidence with one's clinical expertise, patient preferences, and values in making a practice decision or change. Step 5: Evaluate outcomes of the practice decision or change based on evidence. Step 6: Disseminate the outcomes of the EBP decision or change.

These steps will be explored in more detail, as well as available resources and implications for community/public health nursing practice.

Cultivating a Spirit of Inquiry For effective change to occur, nurses must continually examine, question, and challenge current practices (Melnyk & Fineout-Overholt, 2019).

We need to be continually curious about how we can best conduct our practice and the evidence needed to guide our clinical decision-making; we also need to be immersed in a supportive culture that sustains this curiosity. Asking questions such as, “Why are we doing this?” and “Is there evidence to support this practice?” demonstrates this spirit of inquiry.

Asking the Question What if you or your colleagues doubt the effectiveness of some method in your current nursing practice and want to find out whether there is new

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research or evidence that may convince you to make a change? How do you begin your journey to EBP?

Melnyk and others suggest that the first step to solving the problem is “asking the burning clinical question” (2019, p. 17). This question may be about client care or effective interventions, such as

What methods are most effective in ensuring client medication compliance with tuberculosis protocols? What is the best information I can give new mothers about preventing sudden infant death syndrome?

It could also be about systems approaches to population health:

What is the most effective method of improving human papillomavirus (HPV) vaccination rates for adolescents? How can C/PHNs better collaborate with families, physicians, and hospitals in preventing quick readmission of heart failure patients due to poor understanding and control of symptoms?

The PICOT question is one way to develop an answerable, searchable EBP question. First, the population or problem must be specified (P) and an intervention (I) determined, then a comparison intervention or issue (C) is identified and an outcome (O) is measured over a specific period of time (T). Example:

Ashley, a school nurse working at a Midwestern high school, noticed an increase in levels of obesity and depression among her students (Population/Problem) and searched for examples of EBP-based interventions that might be helpful. She found studies linking obesity with depression among adolescents (Goldschmidt, Wall, Loth, & Neumark-Sztainer, 2015; Hoare et al., 2014), along with a systematic review of longitudinal studies indicating a bidirectional association (Mannan, Mamun, Doi, & Clavarino, 2016). Two pretest/posttest studies with relatively small sample sizes found positive results for depression and healthy lifestyle scores using an intervention called COPE—Creating Opportunities for Personal Empowerment (Intervention; Hoying & Melnyk, 2016; Hoying, Melnyk, & Arcoleo, 2016). Further searching led to a large-scale RCT (n = 779) that included once- a-week sessions in a 15-week health class, integrating COPE (cognitive–behavioral skills-building intervention) and 20 minutes of physical activity (Melnyk et al., 2013). A control group participated in a Healthy Teens program consisting of general health skills that did not employ cognitive–behavioral therapy (Comparison).

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Testing for obesity (pedometer steps, body mass index [BMI]) and mental health outcomes (social skills, anxiety and depression scores; Outcome) were completed pre-and immediately postintervention, and again at 6 months postintervention (Time). Results indicated that COPE was more effective than the comparison, with significant differences related to obesity and social skills tests, but decreases occurred in both groups for anxiety and depression at first posttest and again at 6 months (no statistical differences).

A second study of the RCT evaluated results again at 12 months postintervention (Melnyk et al., 2015) and found those in the COPE group had significantly lower BMIs, lower rates of overweight/obesity, and more average pedometer steps compared with the Healthy Teen group. For those with high depression scores, significant improvements were noted in the COPE group versus the control group. Grades were also better.

Armed with a plan and prior approval from her school nursing supervisor, Alison presented the information at a monthly school nurses meeting. A couple of other nurses wanted to join Alison in a pilot study at each of their high schools. Along with Megan, their supervisor, they developed an implementation plan and methods of evaluating outcomes. They began their COPE program in health classes the next fall and found similar outcomes to the RCTs.

They worked together to write an abstract for a state school nursing conference, and it was accepted for a poster presentation. They were busy discussing their study with many other school nurses at the poster session of their school nurses' conference and decided to try writing a manuscript for a school nursing journal. Alison and her colleagues had seen a problem, researched it, and operationalized an intervention that bore significant outcomes. They had also disseminated their research, and it all began with a question (Melnyk, 2017).

Finding the Evidence Melnyk and Fineout-Overholt (2019) stress the importance of systematically searching for all relevant research on a clinical question of interest and critically analyzing the evidence, while keeping in mind the unique needs of the clients served, as well as current practice standards, guidelines, and ethical considerations. It is also important to gather input from expert clinicians, review big data sources such as existing federal, state, and county databases, and examine social or other media sources on your topic (Wong, Chiang, Choi, & Loke, 2016). See Chapter 10 and Levels of Evidence on thePoint.

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Excellent places to begin are integrative or systematic reviews that compile all recent studies and summarize what is known about the problem or situation. The Cochrane Collaboration (www.cochrane.org) lists systematic reviews on various topics of interest to both physicians and nurses. Scoping reviews are conducted to discover new evidence on a subject, types of evidence available in a specific area of inquiry, or to determine missing areas in a body of literature (Munn et al., 2018). Meta-analysis is a statistical method used to combine results of multiple smaller research studies (similar in content, purpose, subjects) to increase the statistical power of the overall findings (Hoffman, 2019). It may be used alone or together with systematic reviews.

By combining the results of many similar studies, meta-analysis affords greater statistical power and can give the researcher a more complete general perspective, especially when research on a certain issue may seem inconclusive (Melnyk & Fineout-Overholt, 2019). For instance, a community/public health nurse (C/PHN) working with a group of adults who have diabetes might be interested in the systematic review and meta-analysis on the importance of resistance exercise (using weights) for clients with type 2 diabetes. Findings included increased insulin sensitivity, increased muscle density, abdominal fat loss, and reduction in hemoglobin A1c levels. The best results were noted in participants using high- intensity resistance exercise (Liu et al., 2019). Although a C/PHN may certainly have a “hunch” that exercise is good for clients, this newer systematic review and meta-analysis of current studies provides solid evidence on which to base specific recommendations.

Other systematic reviews and meta-analysis on promoting adherence to antiretroviral therapy (ART) for human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) clients might be helpful to a C/PHN supervisor in designing an AIDS case management program employing C/PHNs.

A systematic review of 124 studies including a large majority of RCTs done in North America, Africa, and Europe found a “large and overall strong evidence base” for five interventions: (1) cognitive–behavioral therapy; (2) education; (3) directly observed therapy; (4) treatment supporters; and (5) active reminder devices for ART, such as text messaging (Chaiyachati, Ogbuoji, Price, Suthar, & Barnighausen, 2014, p. s199).

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A later meta-analysis of studies focusing on ART adherence among pregnant women in Africa found that there were differences in the results for those getting education, social support, and structural support. Results were higher than those with only text reminders and others with only social and structural support (Omonaiye, Nicholson, Kusljic, & Manias, 2018). From this evidence, a C/PHN case manager may conclude, provided the client population is similar to those studied, that medication compliance may be most effectively ensured through development of a nurse–client relationship, group support, and focused patient education on medication management skills.

Critical Appraisal of the Evidence Collection and critical analysis of the best evidence in the literature, like that done by the school nurses above, constitute the second and third steps in the EBP process. Systematic reviews should be carefully examined to determine validity (Park, 2018). You can do this by asking these types of questions:

What was the review question (specific population, intervention, etc.) and search strategy? Were the studies in the review properly designed and executed (were findings valid)? Were there similar results found in all studies? How reliable are the results (only minimal bias)?

Were sample sizes large enough and results statistically significant? Were there confounding factors (e.g., outside influences that make you doubt the results; differences between groups in intervention or outcome assessment, high rates of attrition)?

It is also helpful to compare the results with those of previous research and clinical practice, and keep in mind that at least one large-scale study has found that over one third of systematic reviews neglected to fully discuss adverse events or outcomes (Melnyk & Fineout-Overholt, 2019; Parsons, Golder, & Watt, 2019). Grids outlining levels and quality of evidence in public health nursing are available in research or EBP textbooks and online.

What if no systematic reviews are available in your area of interest? Where can you find the necessary evidence needed to make good practice decisions? You can look for RCTs, meta-analysis research, program evaluation studies, systematic literature reviews, or practice guidelines, keeping in mind that several studies (or one or two large-scale, tightly controlled studies) are preferred.

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Integrating the Evidence It is important to make a decision based on your clinical expertise and knowledge of your clients' values and preferences when incorporating this information into your practice (Melnyk & Fineout-Overholt, 2019). You can do this by asking:

How can I apply these results to my community/public health nursing practice? Are my clients similar to the population studied? Will it benefit my clients? Does this go against my client's values or preferences? Do I have the necessary resources?

Evidence has shown that C/PHNs have been effective with different client populations in ameliorating postpartum depression, promoting awareness, and facilitating improved family functioning in families with neglected and abused children, and the benefits of the NFP for children, mothers, and families have been consistently demonstrated (Coalition for EvidenceBased Policy, 2015; Karoly, 2017; Mejdoubi et al., 2015; NurseFamily Partnership, 2017, 2018; Sierau et al., 2016).

The Cochrane Public Health and Health Systems Web site may yield useful systematic reviews (https://publichealth.cochrane.org). Newer research outside of public health nursing may also be applied in the community, depending on one's clinical expertise and knowledge of clients. The Cochrane Nursing Care Web site may be helpful (https://nursingcare.cochrane.org/resources). The Joanna Briggs Institute (n.d.) provides evidencebased tools for health professionals through their broad global collaboration with hospitals and universities.

For instance, a recent systematic review about the effectiveness of nicotine replacement therapy (NRT) in gaining long-term smoking cessation found 133 studies with almost 65,000 participants. When compared with no intervention or a placebo, NRTs such as transdermal patches (Fig. 4-2), gum, nasal sprays, and lozenges were found to be more helpful in increasing rates of successfully quitting smoking by 50% to 60%.

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FIGURE 4-2 Recent research concludes that nicotine replacement therapy is effective in smoking cessation.

The research was termed “high quality” and researchers felt that further research was not likely to alter these conclusions (Hartmann-Boyce, Chepkin, Ye, Bullen, & Lancaster, 2018, para. 7). This research might spark an interest in C/PHNs to consider promoting these products to aid in smoking cessation when providing counseling for adult clients who wish to stop smoking.

When examining population-based strategies, The Community Guide (n.d.) provides task force recommendations based on systematic reviews, along with additional resources on various topics of interest (https://www.thecommunityguide.org).

Evaluating Outcomes A critical step of the EBP process is to evaluate any practice change. For instance, if you decide to implement findings from the systematic review on NRT smoking cessation cited above, a standardized protocol of home visits and further patient education/follow-up by C/PHNs would need to be established. Baseline and postintervention data would need to be collected to deduce any potential positive change noted. Results can vary based on specific environment, population, implementation, and other factors.

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Evidence can lead you to choose a course, but evaluation of your outcomes is necessary to ensure that you have achieved the best results (Melnyk & Fineout-Overholt, 2019).

The design of an evidencebased research project represents the overall plan for carrying out the study or intervention. A major consideration in selecting a particular design is to try to control as much as possible those factors that are not included but can influence the results. An example of control is easily demonstrated in a classic study by Douglas, Mallonee, and Istre (1999):

Researchers wanted to discover the percentage of homes with functioning smoke alarms. They initially conducted a telephone survey, a commonly used method of survey research in community health and found that 71% of households reported functioning smoke alarms. Concerned that this might be an inflated number, they conducted an on- site survey to confirm the results. After face-to-face interviews, they found that only 66% of householders reported having functioning alarms. However, when researchers were actually able to go into homes and tested the smoke alarms in person, only 49% were fully functioning. By having researchers test the smoke alarms, this design controlled for inflated results of the more commonly conducted, convenient, and economical telephone survey.

Is self-report always unreliable? Results may vary, but a study of 589 12- year-olds reporting toothbrushing frequency compared with oral hygiene indices found that self-report could be used in place of levels of plaque, for instance, when studying dental caries in adolescents (Gil et al., 2015). The C/PHN must determine the most efficient, cost-effective, and reliable method of obtaining necessary data.

Once an intervention is developed, further studies can evaluate its appropriateness and, ultimately, its effectiveness. Beyond EBP implementation, other lines of clinically based research can also be designed.

Disseminating Outcomes We need to share our results to improve the body of knowledge in community/public health nursing and provide studies that can be used in future systematic reviews. Often, C/PHNs are required to report results to stakeholders (e.g., grant-funding agencies, local or county governing bodies).

Formal reports are often required, or scorecards may be used that compare local results with state and national data.

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We can also share outcomes information with our colleagues locally, through staff meetings, informal networking, blogs, or pertinent listserv, etc. When EBP outcomes are shared at state and national professional meetings or through publication in peer-reviewed journals, a wider audience can be reached, and our knowledge base is exponentially increased.

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Differences Between EBP Implementation, Quality Improvement, and Research If you have worked as a student in an acute care hospital, you have been introduced to quality or performance improvement (QI/PI) initiatives. QI/PI became even more important to health care after the IOM reports cited earlier. These approaches involve a systematic analysis of data and processes with the aim of improving the delivery of health care.

Over the last decade, the National Quality Forum (2019) has endorsed over 300 quality measures, and hospitals are now required to publicly report certain quality data indicators. The Centers for Medicare and Medicaid Services began to financially penalize hospitals by not paying for services when certain quality indicators (e.g., pressure ulcers, hospital acquired infections, readmission rates) were not met (Lasater et al., 2016). See Chapter 6.

Accrediting bodies for acute care hospitals first mandated quality care initiatives, but these are now spreading to ambulatory areas and other settings (Dunlap et al., 2016). With the push for accreditation in public health agencies, this issue is becoming even more pertinent to C/PHNs and to public health systems with a focus on population health (Gerding, DeLellis, Neri, & Dignam, 2018; Kronstadt, Beitsch, & Kaye, 2015; Thomas, Corso, & Monroe, 2015).

Along with EBP, quality improvement (QI) is another core competency needed by all health professionals, as noted in many of the seminal national reports mentioned earlier. For those working in hospitals where QI is at the forefront, it can be difficult to discern differences between EBP, research, and QI. Thinking critically about practice problems is an important component of all three approaches. Reflecting on why we do things a particular way and critically thinking through a problem in a purposeful, systematic way are vital steps in the process. QI involves gathering and using data and methods of improving processes and procedures to determine effective nursing interventions that can improve patient outcomes and systems approaches, such as rapid-cycle testing and compliance monitoring (Balakas & Smith, 2016). Quality and Safety Education for Nurses (QSEN) provides guidance on using skills needed to provide improved care and outcomes (Altmiller, 2019). QSEN features are found in selected chapters of this book.

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The differences between QI/PI, EBP implementation, and clinical research are sometimes unclear (Ginex, 2017). Melnyk and Fineout-Overholt (2019) note that EBP project implementation does not often involve being able to generalize findings because representative samples are not used. Rather, convenience samples of inpatients or clients are used to test initiatives for practice improvement. However, that distinction alone does not release nurses from gaining ethical approval (e.g., Institutional Review Board [IRB], Human Subjects Committee [HSC]). This is certainly required when disseminating results through publication or national presentations.

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Obtain Institutional Review Board or Human Subjects Committee Approval Whenever research is to be conducted that involves human subjects, prior approval must be gained from either an IRB or a HSC. This can be true for research studies or when measuring client outcomes elicited from EBP- implemented changes in nursing interventions (unless, perhaps, this is a QI effort that affects all clients equally and involves only one setting).

The reason for this approval is to safeguard the rights of prospective study participants (Melnyk & Fineout-Overholt, 2019). Each health department should have a committee or a gatekeeper, such as the health officer, who understands the federal guidelines for protecting subjects involved in research studies.

Sadly, one of the most egregious examples of exploitation of human subjects was a study carried out by the U.S. Public Health Service. The Tuskegee study, begun in 1932 and ended in 1972, sought to learn more about syphilis and to justify treatment services for blacks in Alabama (Centers for Disease Control and Prevention [CDC], 2015).

The 399 men with syphilis who participated in the study had agreed to be examined and treated. However, they were misled about the exact purpose of the study and were not given all of the facts; therefore, they were unable to truly give informed consent. Even after penicillin became the drug of choice for treatment of syphilis in 1947, the researchers failed to offer this treatment to the infected participants (CDC, 2015).

Later, a nurse historian found evidence that research on syphilis, also funded by the Public Health Service, was conducted in Guatemala beginning in 1946. However, these participants were purposely infected with syphilis, causing even greater outrage and a formal apology from President Barack Obama to Guatemalan President Alvaro Colom (Reverby, 2011; Rodriguez, 2013).

Questions remain regarding biospecimens from both the Guatemala and Tuskegee studies still being used in ongoing research, raising ethical concerns and issues regarding compensation to victims and their families (Rodriguez, 2013; Spector-Bagdady & Lombardo, 2018).

Because of earlier Nazi atrocities, the Nuremberg Code and the Declaration of Helsinki were adopted by the world scientific community and then revised in 1975 as a means of ensuring ethical research practices; the President's Council on Bioethics was established in 2001 after President Clinton apologized on behalf of the nation to the Tuskegee participants and their families in 1997 (Blais & Hayes, 2016; CDC, 2020).

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The following ethical principles are widely viewed as basic protections for research participants (U.S. Department of Health and Human Services [USDHHS], 2016b). Freedom from harm or exploitation encompasses several aspects:

First, no research can be done that may inflict permanent or serious harm. Second, the research study must be stopped if it becomes evident that harm may come to participants. Debriefing, or allowing participants to ask questions of the researcher at the conclusion of the study, as a means of protecting them from any unseen psychological harm, is also a component. There should be some identified benefits from participation in the research study, and any costs or risks should be clearly outlined, so that participants can more easily determine the cost–benefit ratio (referred to as full disclosure). Subjects should also be told that they are able to withdraw from the study at any time without prejudice or penalty (known as self- determination). Consent forms should include full disclosure of the nature of the study, the time and commitment required of subjects, the researcher's contact information, and a pledge of confidentiality (or assurance of privacy).

Vulnerable subjects, as determined by federal guidelines, include children; people with mental, emotional, or physical disabilities; institutionalized people (e.g., prisoners); pregnant women; and the terminally ill. Special care must be taken to ensure protection of vulnerable subjects. Data collection can only begin after approval has been obtained from the proper entities (USDHHS, 2016a).

Informed consent is an area where clear distinctions between research, EBP, and QI are problematic. If you change your practice to benefit your clients, based on the best evidence and your clinical judgment/knowledge of your clients, it would be cumbersome to ask for written consent from every patient before implementing changes. This might be part of a QI initiative or a trial EBP implementation. It is not feasible, and it is expected that professional practice changes will be made over time without consulting clients. However, clinical management oversight is expected to ensure that client rights are not violated. See Box 4-2.

BOX 4-2 QSEN: Focus on Quality Patient-Centered Care for EBP and Ethics

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Patient-Centered Care: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient preferences, values, and needs (Cronenwett et al., 2007, p. 123).

(See https://qsen.org/competencies/pre-licensure-ksas/#quality_improvement for the knowledge, skills, and attitudes associated with this QSEN competency.) You have all dealt with individual patients in acute care settings. Some of you have also worked closely with patient families. Now, you will be widening your lens to focus on larger groups of patients (e.g., aggregates) and communities (e.g., populations). How do these QSEN competencies apply to aggregates such as mothers addicted to drugs or to population groups such as the elderly in your community?

As health care continues to evolve, nurses are being asked to shift to systems thinking, rather than just focus on an individual patient. Leslie et al. (2018) noted that systems thinking was needed to improve the quality of health care, and that a quality health system was critical to the success of universal health care coverage around the world. We must solve the problems with quality and safety in health care. A systematic review of transitional care interventions that aimed to reduce hospital readmissions found that, to be successful, interventions needed to be flexible in response to patient needs, extend beyond the hospital stay, and include intensive discharge planning (Kansagara et al., 2016). High quality systems are patient centered and promote positive experiences for our clients. It is important that clients are treated with respect and courtesy, have their questions about care and medications answered and their needs met about requests for information or education, as well as health topics explained in a way that are easily understood (Cook et al., 2015).

For example, we will not effectively address the high rates of early readmission for heart failure patients by simply checking prescriptions before discharge for an individual patient or even giving them reminder magnets to put on their refrigerators in the hope that this will help them remember to take their medications. Studies of the effectiveness of home-based interventions reveal that they can reduce readmissions and ED visits for clinically complex patients (Coppa, Winchester, & Roberts, 2018), as well as reduce risk factors for those with recurring strokes or transient ischemic attacks (Towfight et al., 2017). Nurse home visits and disease management clinics can lower rates of all-cause mortality and hospital readmissions after heart failure hospitalizations (Van Spall et al., 2017).

We need to work with interdisciplinary teams to identify high-risk patients, prepare patients and their families for discharge, and then work with specialized programs that follow patients while they are at home to make sure they are continuing to adhere to medication and other intervention

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regimens (Rashid et al., 2017). Transitional care management has been shown to be effective for patients with multiple chronic conditions. Home visits by nurses reduced 30-day readmission rates, and after 6-month follow- up, the total cost of care for “highest risk patients” was significantly less (Jackson, Kasper, Williams, & DuBard, 2016, p. 163). Keeping care patient centered and demonstrating respect for our clients (individuals, families, aggregates, or populations) is a key to success.

What other problems do you see that could benefit from a broader focus on quality and safety?

Source: Cook et al. (2015); Coppa et al. (2018); Cronenwett et al. (2007); Jackson et al. (2016); Kansagara et al. (2016); Leslie et al. (2018); Rashid et al. (2017); Towfight et al. (2017); Van Spall et al. (2017).

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Understanding Research Basics to Promote EBP To fully integrate the principles of EBP, it is important to have a basic understanding of the research process. More in-depth information on this subject is available in nursing research texts (e.g., Polit & Beck, 2018), but a brief synopsis (Steps in the Research Process) is provided on . EBP methods are encouraged over basic research, especially for practicing C/PHNs. Doctorally prepared nurses and public health professionals, sometimes in conjunction with practicing C/PHNs or health department staff, more often conduct traditional research studies (Balakas & Smith, 2016). Problems recently identified and studied within community/public health nursing include the following:

Systematic review of nurse-led interventions with homeless populations (Weber, 2019) Systematic review of the impact of weight stigma on psychological and physiological health outcomes for overweight and obese adults (Wu & Berry, 2018) Qualitative meta-synthesis of PHNs' role in identifying and managing perinatal mental health problems (Noonan, Galvin, Doody, & Jomeen, 2017) Key informant recommendations for how to engage African American women in community-based health promotion (Holt, Johnson, & Zabler, 2018) Early through late adolescents' evaluation of a Facebook page that provides sexual health education (Jones, Williams, Sipsma, & Patil, 2018) Noise concerns of residents living near fracking sites in Southwest Pennsylvania (Richburg & Slagley, 2017) Identifying community priorities for neighborhood livability: Engaging neighborhood residents to facilitate community assessment (Reyes & Meyer, 2020). Use of health care after piloting a homeless medical respite program (Biederman, Gamble, Wilson, Douglas, & Feigal, 2019) Association of elevated blood pressure in rural, low-income preschoolers with mother's hypertension during pregnancy (Johnson, Montgomery, & Ewell, 2018) Perceptions of PHNs and school nurses regarding HPV vaccination in Missouri (Rhodes, Visker, Cox, Forsyth, & Woolman, 2017) Using a mixed-methods approach to improve health through public housing resident and staff collaboration (Noonan, Hartman, Briggs, & Biederman, 2017)

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Individual health outcomes secondary to a nurse-led coalition-based health promotion program for underserved diverse populations (Simpson & Hass, 2019) Patient rationale for seeking HIV postexposure prophylaxis: qualitative study of a nurse-led program (O'Byrne, Orser, MacPherson, & Valela, 2018) Impact of expanded health insurance coverage for unauthorized pregnant women on prenatal care use (Atkins, Held, & Lindley, 2018)

A research question is a starting point for both traditional research and EBP methods. Although somewhat similar in purpose (to answer a question), there are fewer steps in the EBP process. Formulation of a PICOT question in EBP is a similar process to the research question outlined in the steps of the research process, especially in its specificity.

Each of the research study titles above provides clues to the population of interest and the problem or intervention. Outcomes and time period can be discerned by reading the abstract and journal article (e.g., PICOT). Clear research questions, thorough review of the literature, human subjects protection, and a sound research design are factors to consider when evaluating the results of studies for incorporation into your practice.

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IMPACT OF RESEARCH ON COMMUNITY/PUBLIC HEALTH AND NURSING PRACTICE

Research has the potential to have a significant impact on community/public health nursing in several ways, by affecting public policy and the community's health, the effectiveness of community/public health nursing practice in providing positive outcomes for our clients, and the status and influence of nursing as a profession.

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Community/Public Health Practice and Patient Outcomes Research, with policy or practice implications for addressing the health needs of aggregates, has been conducted on numerous topics (Ellen, Lavis, Horowitz, & Berglas, 2018). Many studies done by nurses and others have examined issues related to prevention, lifestyle change, quality of life, and health needs of specific at-risk populations (Box 4-3).

BOX 4-3 EvidenceBased Practice A Change of Position

For generations, mothers were told that babies would be at risk of aspiration if they were put to sleep on their backs. Why did this change? In the late 1980s, research indicated that prone positioning of infants was related to greater incidences of sudden infant death syndrome (SIDS), according to a group at the National Institute of Child Health and Human Development (NIH) who conducted an epidemiologic study examining SIDS risk factors (Hoffman, Damus, Hillman, & Krongrad, 1988). In the early 1990s, an expert panel from the same institute and the American Academy of Pediatrics concluded that infant sleeping positioning was an important factor in prevention of SIDS, and a recommendation was made for parents to place their infants on their backs when sleeping. The Back to Sleep campaign began in 1994 (National Institutes of Health, n.d.a). C/PHNs have been instrumental in education about SIDS and are often sources of support for families who have lost infants to SIDS (Stastny, Keens, & Alkon, 2016).

Since then, the incidence of SIDS has continued to drop in the United States—from 130.3 deaths in 1990 to 38.0 deaths per 100,000 live births in

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2016. The most dramatic drop occurred shortly after the Back to Sleep campaign was instituted (Lambert, Parks, & Shapiroi-Mendoza, 2018). Despite this decrease, SIDS is the fourth leading cause of infant death (Newberry, 2019). And there remains an ethnic difference in incidence with American Indians having a rate of 205.8 deaths and non-Hispanic Black infants 181.0, compared to lower rates for non-Hispanic Whites and for Hispanics (see charts, CDC, 2019).

The term sudden unexpected infant death (SUID) encompasses SIDS, accidental suffocation and strangulation in bed, or infant death due to unknown causes (CDC, 2019). Research continues with studies showing:

Association of bed sharing and/or smoking with increased SUID (MacFarlane et al., 2018). Increased risk factors for SIDS with maternal smoking and being a twin (Friedmann, Dahdouh, Kugler, Mimran & Balayla, 2017). Pathology-based study of medullary astrogliosis demonstrated differences in the intensity of “glial fibrillary acidic protein staining” in specific medullar regions between infants sleeping alone or bed-sharing indicating differing mechanisms for death, such as asphyxiation with infant bed sharing (Spinelli, Byard, Van Den Heuvel, & Collins-Praino, 2018, para. 27). CDC monitoring from 2009 to 2015 found that between 12.2% and 33.8% of respondents reported nonsupine sleep positions, 61.4% bed sharing with infants, and 38.5% using soft bedding such as bumper pads and thick blankets. Results showed cultural and racial differences as factors (Bombard et al., 2018). The importance of collaborative translation of knowledge with our clients (Middlemiss, Cowan, Kildare, & Seddio, 2017). Evidence from U.S. Indian Health Services and New Zealand SIDS prevention programs show that better responses occur when we align our messages of risk, safety, and practices with cultural groups' long-held value and norms.

Especially with groups where bed sharing is a norm, the message focuses on keeping infant sleep spaces safe and avoiding asphyxiation, while acknowledging that some families don't adhere to the avoidance of bed sharing. Families and friends are included in the conversation about safe practices to promote their ownership of the message and how it impacts infant health.

Current recommendations from the American Academy of Pediatrics (AAP, 2016) to reduce the risk of SIDS and other sleep-related infant deaths advise parents to always

Place sleeping infants in a supine position (not on side or stomach) until age 1.

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Use a firm sleeping surface (no pillows or quilts under the baby) and no sitting devices for prolonged sleep especially in infants under 4 months. Keep soft objects (stuffed toys, pillows, bumper pads, blankets) away from infant's sleep area. Place infant in own bed, in parent's room near parent's bed for first 6 to 12 months (no bed sharing). Breast-feeding is recommended.

Avoid maternal smoking during and after pregnancy and infant's exposure to secondhand smoke. Avoid alcohol and illicit drug use. Offer a pacifier at sleep time throughout the first year of life (it has been shown to reduce the risk of SIDS).

Avoid overheating (do not overbundle babies, watch for sweating) or cover their heads. Encourage “tummy time” to aid in development and reduce incidence of positional plagiocephaly (uneven, flat head). Get regular prenatal care. Immunize infants according to CDC and AAP guidelines. Avoid the use of commercial devices that are inconsistent with safe sleep guidelines (e.g., wedge pillows, carbon dioxide dispersion mattresses). These may be marketed as effective in reducing SIDS cases, but there is not sufficient proof of efficacy.

1. Do your community/public health clients put their babies to sleep on their backs? If not, ask them about their concerns, including any cultural norms for sleeping arrangements.

2. How can you best approach them about the beneficial effects of following AAP's safe infant sleeping recommendations?

Source: AAP (2016); Bombard et al. (2018); CDC (2019); Friedmann et al. (2017); Hoffman et al. (1988); Lambert et al. (2018); Middlemiss et al. (2017); National Institutes of Health (n.d.a); Newberry (2019); Spinelli et al. (2018); Stastny et al. (2016).

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Public Policy and Community/Public Health Research results can influence public policy, the quality of services, and, in turn, the public's health (Ellen et al., 2018). Examining the U.S. history of the paradigm change from positive feelings toward cigarette smoking to approval of tobacco control policies provides a powerful example of the use of research in changing health policies and promoting population health. This change began in a few states and has spread, to varying degrees, across all 50 states.

The Tobacco Control Scorecard was first developed in 2004. It statistically estimates the effectiveness of various policies on rates of smoking. A 2018 study updated these estimations of “policy effect size” and found that taxing cigarettes, smoke-free air laws, wide-ranging media bans, mass media campaigns, smoking cessation treatment programs, and “graphic health warnings” each play important roles in reducing rates of cigarette smoking, with large tax increases being the most powerful (Levy, Tam, Kuo, Fong, & Chaloupka, 2018, p. 454). They also noted that further research on regulation of the contents of tobacco products was necessary.

Projections about the outcomes and benefits of those policies is another research area helpful to policymakers: computer simulation models have been employed to determine which policy changes yield the most benefit in net total savings and lives saved. Michigan had enacted some tobacco control policies, yet had higher adult smoking prevalence than states with similar policies. Michigan had among the lowest in expenditures related to tobacco control.

A study, using SimSmoke tobacco policy simulation model, examined the effect of tobacco control policies and found a relative reduction rate of 22% from 1993 to 2013 and a projected reduction rate of 30% by 2054. Of the 22% reduction, policies that raised taxes represented 44% of that reduction, smoke-free air policies 28%, and cessation treatment policies 26%. An additional 2% was associated with youth access policies. By 2054, about 234,000 smoking-related deaths are projected to have been prevented. If additional policies were to be enacted, it is estimated that 80,000 more lives could be saved (Levy, Huang, Havukai, & Meza, 2016).

In the United States, it is estimated that the total economic costs of smoking reach as high as $300 billion per year, split between direct medical care for adults ($170 billion) and lost productivity from premature death and secondhand smoke exposure ($156 billion). About $25.8 billion per year in taxes and legal settlements are received by states (Hall & Doran, 2016).

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Nursing's Professional Status and Influence Another way in which research has a significant impact on community/public health nursing is in its potential to enhance nursing's status and influence. As community/public health nursing research sheds light on the critical health needs of at-risk populations, exposes deficiencies in the health care system, demonstrates more efficient and cost-effective methods for delivering services, and documents the effectiveness of nursing interventions, the profession will gain a stronger voice and have a greater impact on health policy and programs. After all, C/PHNs have always been advocates for their clients and promoted policies that improved health.

Some examples of research that influences public health nursing's professional status include

A scoping review of environmental health nursing research (Polivka & Chaudry, 2018) Evidence of public health nursing effectiveness: A realist review (Swider, Levin, & Reising, 2017) An academic practice partnership: Building capacity to meet sexual health education policy requirements of a public-school system (Cygan, McNaughton, Reising, & Reid, 2018) Fluoride varnish application, a QI project implemented in a rural pediatric practice (Gnaedinger, 2018) Sexually transmitted disease services and third-party payer reimbursement: Attitudes, knowledge, and current practices among 60 health departments/districts. Why does this matter to PHNs? (Kovar & Bynum, 2019) Development of a comprehensive infection control program for a short- term shelter serving trafficked women (Jones et al., 2019) A community-based participatory research (CBPR) approach to finding community strengths and challenges to prevent youth suicide and substance abuse (Holliday, Wynne Katz, Ford, & Barbosa-Leiker, 2018) Chicago public school nurses examine barriers to school asthma care coordination (Pappalardo et al., 2019)

These examples reflect the diversity of research studies and EBP implementation across community/public health nursing areas. From the QI project of applying fluoride varnish for a 4-month period using a protocol developed by the California Dental Association for infants and toddlers (Gnaedinger, 2018) to the large-scale survey of staff members in 60 rural and urban health departments regarding knowledge, attitudes, and billing practices for sexually transmitted disease services that has both policy and

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funding implications, C/PHNs are actively involved in promoting research and EBP and highlighting the importance of nursing knowledge.

The CBPR study that involves searching for the needs of a tribal community in determining programs and services that address problems on the reservation reflects the partnership and engagement of nurse researchers, community members, and other stakeholders in decision-making and developing research knowledge and interventions (Holliday et al., 2018). This exemplifies the definition of community-based participatory research (CBPR) as described by Jull, Giles, and Graham (2017).

Strong documentation supports the effectiveness of community/public health nursing interventions. Nurses in the community setting must provide empirical proof of their worth as professionals while serving the needs of their clients. This kind of information must be made visible if it is to influence legislators, planners, administrators, and other decision-makers in health care. As visibility increases, nursing's status and influence will grow.

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The Community/Public Health Nurse's Role in Research Community/public health nursing has a focus on health promotion and disease prevention and providing services across the lifespan where people live, work, and learn. C/PHNs also focus on the development of community capacity building for health and work with partnerships, coalitions, and policy makers to promote a healthier environment.

C/PHNs have two important responsibilities with respect to research in community/public health: to apply research findings to practice (EBP) and to conduct or participate in nursing research. Because research results provide essential information for improving health policy and the delivery of health services, C/PHNs must be knowledgeable consumers of research. That is, they need to be able to critically examine research reports and apply study findings to improve the public's health.

C/PHNs have many opportunities to apply the results of other investigators' research and systematic reviews, but a necessary prerequisite is to be informed about research findings. As an essential part of their role, C/PHNs must read the journals focusing on community/public health nursing. Nursing agencies and employment sites in community/public health can encourage nurses to become more knowledgeable about research findings by subscribing to journals and circulating them among staff, by holding seminars to discuss recent research results, and by promoting nurses' application of research findings in their practice.

Although the amount of community/public health nursing research is expanding and its quality is improving, many more C/PHNs need to conduct research and participate in EBP. An increasing number of nurses have developed skill in research through advanced preparation, and they are conducting investigations related to aggregate health needs. Other C/PHNs work collaboratively with trained investigators on a variety of research projects affecting community/public health.

Whether initiated by the nurse or involving the nurse as a team member, these projects are an opportunity to influence the types of research questions that are addressed and the ways in which the research is carried out, factors that ultimately affect the community's health (Melnyk & Fineout-Overholt, 2019).

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VALUES AND ETHICS IN COMMUNITY/PUBLIC HEALTH NURSING

EBP includes not only the research process but also the knowledge and long- standing values nurses bring to their practice. According to the classic treatise by Carper (1978), this is the art of nursing. Our personal history and experiences contribute to our understanding of what it means to be a good nurse.

Values and beliefs support

Your decisions about the right course of action to take How to be just and fair in dealing with others What outcomes you deem to be right

Nursing, like many other professions, has ethical codes that guide decision-making and provide a framework for thinking about the moral dimensions of practice issues. Nursing has had an ethical code for practice since 1910, when Gettner published “The Nightingale Pledge.” This evolved into the current “Code of Ethics for Nurses,” as the American Nurses Association (ANA) has updated the code to reflect current issues and ideologies. The latest document was approved in 2015 (Box 4-4). In this chapter, we consider the role of nurses in ethics and discuss recent issues that you may encounter in your community/public health practice.

BOX 4-4 Code of Ethics for Nurses— Provisions, Approved as of January 6, 2015 The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of their health problems.

1. The nurse respects the unique attributes of every person, practices with compassion and respect for each person's self- worth and dignity.

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2. “The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population” (p. v).

3. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.

4. The nurse is responsible and accountable for individual nursing practice and determines actions consistent with the nurse's obligation to provide optimum patient care, with a focus on health promotion.

5. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to “maintain competence, and to continue personal and professional growth” (p. v).

6. The nurse is a key member of the team in maintaining and improving ethical environments for both patient care and the work of nursing in the provision of safe and quality care.

7. The nurse plays a leadership role in advancement of the profession through contributions to practice, education, administration, and knowledge development and most importantly the development of health policy and nursing policy.

8. The nurse works together with “other health professionals and the public” to protect and promote human rights and diminish health disparity and improve health diplomacy in the community and globally (p. v).

9. The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the reliability and integrity of the nursing profession and its practice, and for shaping social policy.

Adapted from American Nurses Association (ANA) (2015).

The Code of Ethics for Nurses:

Is based on the values of respect and dignity for all individual as well as society at large Includes a mandate to respect the values and beliefs of each individual nurse Provides an essential first step in ethical decision-making by helping us to explore the ethical values that shape our practice, a process called values clarification (see for resources on values and values clarification).

Just as EBP is the result of the rigorous application of scientific method, our philosophy of nursing is based on clarity about our ethical code of

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practice, informing a logical system for moral reasoning, which grounds practice with integrity within the context of social justice (ANA, 2015).

Nurses in public health focus their practice on providing care for populations within our community of concern. When the needs of the individual must be evaluated in light of the needs of the larger group, this can lead to ethical concerns. Using an objective ethical reasoning process assists with separating the myriad of social, political, and economic issues from the actual ethical concerns (ANA, 2010, 2015; Fowler, 2015). Consider the following situations:

You are providing health care to a population of migrant farm workers whose housing lacks adequate sanitation and refrigeration. You recognize that this is a valid health and safety issue. However, when you report the situation to your supervisor, you are told that since these farm workers are here illegally, challenging these conditions may bring about negative consequences for the workers. What would you do? What if you were working in a homeless shelter and were told to evict someone who would not agree to take a tuberculin skin test? You agree that residents should comply with this demand, but would you hesitate to implement the eviction if the resident were a frail older adult or the teenage mother of a newborn?

Within the United States, many marginalized people are failed by the health care system or may go without any health care at all. At the same time, affluent individuals enjoy a plethora of health care options, including preventive screenings and health promotion classes. C/PHNs often are confronted by this disparity when making ethical decisions about client care. Social justice, human rights, and equality are hallmarks of public health nursing ethics (see more in Chapters 13, 23, and 27).

Progress in the United States often is linked to the exploitation of people in less-developed countries, and this contributes to widening disparities in health, wealth, and human rights. Distributive justice, or the fair allocation of goods and services, comes into play (discussed later in this chapter and in Chapter 23). Failure to respond to such global challenges only leads to greater poverty and deprivation, continuing conflict, escalating migration, and the spread of infectious disease, all further adding to our ethical dilemmas.

Advances in technology also contribute to ethical dilemmas. For example, electronic health records make client information readily accessible, thus raising issues of confidentiality, clients' rights, issues of empowerment, and informed consent (Vezyridis & Timmons, 2015). Sensitive information is now frequently stored electronically and may be accessed through unethical means (Davis, 2018). Technology also forces

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nurses to confront the issues of genetic testing and stem cell research (Box 4- 5), as well as assisted suicide and euthanasia (Katz, 2015). Further ethical questions arise regarding limb transplants, such as hand transplants and the decisions about who is to receive them, as well as what happens to tissues removed during biopsy or surgery (Cooney et al., 2018). Ethical issues in nursing practice are changing at a rapid pace, especially in oncology nursing, where the benefits of genetically sound evidencebased care need to be contemplated with ethical considerations (Beamer, 2017).

BOX 4-5 Immortal Cells, Ethical Dilemma

Stained HeLa cervical cancer cells under the microscope.

How would you feel if tissues or cells taken from you during surgery or a routine biopsy were subsequently used in health research without your knowledge or permission (or remuneration)? That happened to Henrietta Lacks, a black woman from Baltimore, whose cells (known as HeLa cells) were the first immortal human cells and used in the development of the field of virology. HeLa cells were tested in the first space missions to determine zero gravity's effects and were vital to the development of polio and hepatitis B vaccines, as well as chemotherapy, in vitro fertilization, cloning, and gene mapping (Skloot, 2011). These cells, taken from a biopsy of her cervix a few months before she died of cervical cancer in 1951, were useful in the development of medications for leukemia, herpes, hemophilia, and influenza. They have been used in innumerable studies around the world to test the effects of massive radiation (e.g., nuclear blasts), hormones, vitamins, steroids, tuberculosis, salmonella, and hemorrhagic fever. HeLa cells were also instrumental in many historic scientific discoveries (e.g., cigarettes caused lung cancer, how cancer cells grew differently from normal cells, how HIV infected cells) and continue to be used today in scientific research.

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Although this happened in the 1950s, today, it is still often considered legal for a researcher to use tissues removed from your body for scientific research without your consent. It has been considered by law to be “abandoned waste” and may be used for gain without the knowledge, consent, or reimbursement to the donor. A recent revision to the “Common Rule,” a federal regulation that governs researchers and human subjects, failed to substantially change the rules on human specimen collection and use (Jaschik, 2017). Source: Jaschik (2017); Skloot (2011); “The Immortal Life of Henrietta Lacks,” produced by Oprah Winfrey et al. and released in 2017 (IMDb, 2019, retrieved from https://www.imdb.com/title/tt5686132/).

Underlying every issue and influencing every ethical and professional decision are values. Ethics and values are inextricably intertwined in professional decision-making, because values are the criteria by which decisions are made. Ethical decision-making is central to nursing practice (Milliken, 2018). The topics of values and ethics are each covered below.

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VALUES

What are values in nursing? According to Baillie (2017), these are

Respect and dignity Commitment to quality of care Compassion Improving lives Working together for patients

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Standards for Behavior In general, moral values (Kinneging, 2016)

Function as standards that guide actions and behavior in daily situations Act as a code of conduct for living one's life Become internalized to inform a personal code of conduct Undergird behavioral norms Act as a voice of conscience

Values often remain relatively stable over time, persisting to provide continuity to personal and social existence. Some values endure over time, but others may change as societal norms evolve (Bongiorno, 2018). Social life in the community requires standards within the individual as well as an agreement about standards among groups of individuals (Pereira, 2015). A group's culture provides a set of enduring values. We organize values into a hierarchical system in which certain values have more weight or importance than others. As an individual confronts social situations throughout life, isolated values learned in early childhood come into competition with other values, requiring a weighing of one value against another. Concern for others' welfare, for instance, competes with self-interest. Through experience and maturation, the individual integrates values learned within different contexts into systems in which each value is ordered relative to other values (Adams et al., 2018). More recent research has examined moral regulation within the framework of avoidance versus approach motivation (Lee, Padilla-Walker, & Nelson, 2015). For example, if you used duty as a basis for action, these would be proscriptive moral emotions. Duty is a consequential emotion, where you would think about concrete negative consequences to an action. For example, what would happen if you did not study well for an exam in nursing school? Prescriptive moral emotions might focus more abstractly and in a positive manner on what ought to be done; these might inspire you to study so that you can be a better nurse at the bedside. Think about which beliefs or values inspire you to do well in nursing school (Cornwall & Higgins, 2015).

Reference Values have a reference quality. That is, they may refer to end states of existence called terminal values, such as spiritual salvation, peace of mind, or world peace, or they may refer to modes of conduct called instrumental values, such as confidentiality, keeping promises, and honesty. Sometimes values may conflict (Husted, Husted, Scotto, &

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Wolf, 2015). (Go to for a figure depicting factors that influence terminal values.) A nurse may experience a conflict between two moral values, such as whether to act honestly (tell a client about a fatal diagnosis) or to act respectfully (honor the family's request not to tell the client).

Preference A value may show preference for one mode of behavior over another, such as exercise over inactivity, or it may show a preference for one end state over another, such as physical fitness and leanness over sedentary lifestyle and obesity. The preferred end state, or mode of behavior, is located higher in the personal value hierarchy.

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Value Systems Value systems generally are considered organizations of beliefs that are of relative importance in guiding individual behavior (Hultman, 2017). Instead of being guided by single or isolated values, behavior at any point in time (or over a period of time) is influenced by multiple or changing clusters of values. It is important to understand how values are integrated into a person's total belief system, how values assume a place in a hierarchy of values, and how this hierarchical system changes over time.

Hierarchical System of Values Learned values are integrated into an organized system of values, and each value has an ordered priority with respect to other values (Hultman, 2017). For example, a person may place a higher value on physical comfort than on exercising. This system of ordered priority is stable enough to reflect the continuity of someone's personality and behavior within culture and society, yet it is sufficiently flexible to allow a reordering of value priorities in response to changes in the environment or social setting (e.g., society's emphasis on physical fitness and youth) or changes based on personal experiences (e.g., diagnosis of type 2 diabetes). Behavioral change would be regarded as the visible response to a reordering of values within an individual's hierarchical value system.

Conflict Between Values in a System Nurses often enter patient and community situations that activate several values in their system of beliefs. Because not all of the activated values are compatible with one another, conflict between values occurs.

This conflict between values is a part of the decision-making process and resolving these value conflicts is crucial to making good decisions. C/PHNs face such conflicts of values when caring for patients whose determinants of health create a situation in which they must decide how to use scarce resources for care (Blacksher, 2015). This can be a struggle when patients want the freedom to choose how to live their life but don't want to suffer, either. One example is how the smoker with chronic obstructive pulmonary disease wants home health visits but refuses to quit smoking. Even within a single community agency, nurses may find that they prioritize client service or programming values differently.

Some values seem to consistently triumph over others, persisting as stronger directives for individual behavior. Providing quality health care for

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all without sacrificing the basic rights of a few is an ongoing ethical struggle for most people (Martin 2017; Strair, 2017). It is the hierarchical system and changes to that system of values that determine, in part, how conflicts are resolved and how decisions are made. One way to understand the influence of values on your own behavior, as well as on that of community/public health clients, and to properly prioritize them is to use various values clarification techniques in decision-making.

Values clarification is a process that helps to identify the personal and professional values that guide your actions, by prompting you to examine what you believe about the worth, truth, or beauty of any object, thought, or behavior and where this belief ranks compared with your other values (see thePoint for activities to help you identify your values). Values clarification may be helpful for patients making decisions for treatment and screening processes, such as whether to choose a certain drug or treatment that is in keeping with the patients' lifestyle (Palacio, Kirolos, & Tamariz, 2015).

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ETHICS

How is ethics defined and what is meant by the term ethical? The Merriam

Webster Online Dictionary (2019) defines ethics as “the principles of conduct governing a group” (para. 4). Long-standing values are central to any consideration of ethics or ethical decision-making. Most nurses easily recognize the moral crisis in extreme decisions such as futile care and abortion dilemmas. Less obvious moral dilemmas often found in the routine practice of community/public health nursing are not always easy to identify or analyze from an ethical perspective. What constitutes an ethical problem is not always obvious.

Ethics may be viewed as behaviors governed by a set of principles based on long-standing values. Ethics are often idealized as “what ought to be.” Ethical decision-making means making a choice that is consistent with a moral code and can be justified from an ethical perspective. Of necessity, the decision-maker must exercise moral judgment. The term “moral” refers to conforming to a standard that is right and good. C/PHNs become “moral agents” by making decisions that have direct and indirect consequences for the welfare of their patient population. Bioethics refers to using ethical principles and methods of decision- making in questions involving health care issues, while keeping the centrality of the patient as the focus of practice (Vaughn, 2017). In public health, the population is the patient.

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Public Health Ethics Protection and promotion of health are at the core of community/public health nursing. Public health ethics is “a systematic process to clarify, prioritize, and justify possible courses of public health action based on ethical principles, values and beliefs of stakeholders, and scientific and other information” (CDC, 2017, para. 1).

Specific ethical principles apply to public health in that we advocate for populations such as healthy communities and the equitable distribution of limited resource. Ethical decisions seek to balance individual rights and the collective good in the use of resources. Community/public health nursing often bases its practice on values related to preventing disease or harm and developing community input into solving problems while respecting individual rights. A major moral value is the empowerment of the disenfranchised and equal access to resources. Promoting health, protecting confidentiality (except in cases in which disclosure is justified), and collaborating or partnering with other community agencies are viewed as universal practices. Other principles include respecting diverse values or beliefs and working effectively with different cultural groups to enhance the social and physical environment while employing competent public health professionals. Public health is most often concerned with distribution of resources and shaping behavior and thoughts, which may include resources, such as clean water, and constraints, such as quarantine. We need to keep in mind the responsibility to global justice when implementing public health programs and policy (Jennings, 2015). Without care for global justice, there may be an uneasy balance between individual and public interests and rights. See Chapter 16.

A framework is applied in public health ethics inquiry. Three core functions of this inquiry include

1. Identifying and clarifying the ethical dilemma 2. Analyzing it in terms of alternative courses of action and their

consequences 3. Resolving the dilemma by deciding which course of action best incorporates and balances the guiding principles and values (CDC, 2017, para. 5)

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Identifying Ethical Situations Ethics involves making evaluative judgments. To be ethically responsible in the practice of community/public health nursing, it is important to develop the ability to recognize evaluative judgments as they are made and implemented in nursing practice. Nurses must be able to distinguish between evaluative and nonevaluative judgments.

Evaluative statements involve judgments of value, rights, duties, and responsibilities. Examples are “Parents should never strike their children” and “It is the duty of every citizen to vote.” Among the words to watch for are verbs such as want, desire, refer, should, or ought and nouns such as benefit, harm, duty, responsibility, right, or obligation.

Sometimes, the evaluations are expressed in terms that are not direct expressions of evaluations but clearly are functioning as value judgments. Winland-Brown et al. (2015) provide useful clinical applications of the ANA code of ethics and refer to the obligations or duties of nurses to both patient and self (see Box 4-4). Another important step is to distinguish between moral and nonmoral evaluations.

Moral evaluations refer to judgments that conform to standards of what is right and good. Moral evaluations assess human actions, institutions, or character traits rather than inanimate objects, such as parks or architectural structures. They are prescriptive–proscriptive beliefs having certain characteristics separating them from other evaluations such as aesthetic judgments, personal preferences, or matters of taste. Moral evaluations also have distinctive characteristics (Elemers, 2017):

Morality and sociability impact social judgment. We want to be able to anticipate others' actions that could lead to benefit or harm or their skill and ability. Values possess universality or reflect a standpoint that applies to everyone. They are evaluations that everyone in principle ought to be able to make and understand, even if some individuals, in fact, do not. Moral evaluations avoid giving a special place to a person's own welfare. They have a focus that keeps others in view or at least considers one's own welfare on a par with that of others.

Moral evaluations, such as “parents should take care of their children,” meet these criteria. A nonmoral evaluation, such as “Mrs. X has five children,” does not evoke a moral judgment of Mrs. X but instead is an assessment of her family composition.

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Resolving Moral Conflicts and Ethical Dilemmas When judgments involve moral values, conflicts are inevitable. In clinical practice, the nurse may be faced with moral conflicts, such as the choice between preserving the welfare of one set of clients over that of others. Examples include the following:

The nurse may have to choose whether to keep a promise of confidentiality to persons who are infected by HIV when they continue to have unprotected sex with unknowing partners. The nurse may have to choose between protecting the interests of colleagues or the interests of the employing institution by reporting a nurse who has made a medication error but has failed to report that error.

Each of these decisions involves an ethical dilemma, which occurs when moral values conflict with one another, causing the nurse to face a choice with equally attractive or undesirable alternatives (Robichaux, 2017). Ethical dilemmas create difficult decision-making, even in ordinary nursing situations.

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Decision-Making Frameworks To resolve ethical dilemmas or the conflict between moral values in community/public health nursing practice and to provide morally accountable nursing service, several frameworks for ethical decision-making have been proposed. Among these frameworks, three key steps are considered as fundamental to choosing between alternative courses of action that reflect moral reasoning (Martin, 2017). These steps separate questions of fact from questions of value, identify both clients' and nurse's value systems, and consider ethical principles and concepts (Box 4-6).

BOX 4-6 A Framework for Ethical Decision-Making Step 1. Clarify the ethical dilemma.

Whose problem is it? Who should make the decision? Who is affected by the decision? What ethical principles are related to the problem?

Step 2. Gather additional data.

Have as much information about the situation as possible. Be up to date on any legal cases related to the ethical question.

Step 3. Identify options.

Brainstorm with others to identify as many alternatives as possible. The more options identified, the more likely it is that an acceptable solution will be found.

Step 4. Make a decision (choose from the options identified).

Determine the most acceptable option—that is, the one more feasible than others.

Step 5. Act (carry out the decision).

It may be necessary to collaborate with others to implement the decision and identify options.

Step 6. Evaluate (after acting on a decision, evaluate its impact).

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Was the best course of action chosen? Would an alternative have been better? Why? What went right and what went wrong? Why?

Note: Although legal requirements or social expectations may sway a decision one way or another, they are extrinsic to the ethical analysis and should not be confused with right and wrong. What is legal and what is expected are not necessarily right and wrong.

The identification of clients' values and those of other persons involved in conflict situations is an important part of ethical decision-making (Box 4- 7).

BOX 4-7 STORIES FROM THE FIELD Independence Versus Safety C/PHNs encounter value differences every day, and value differences, in turn, create ethical problems. Consider, for example, the dilemma faced by one nurse in Seattle on her first home visit to an older adult male, Mr. Bell, referred by concerned neighbors. This 82-year-old gentleman was homebound and living alone with severe arthritis under steadily deteriorating conditions. Overgrown shrubs and vines covered the yard and house, making access impossible except through the back door. A wood burning stove in the kitchen was the sole source of heat. The kitchen, along with a corner of the dining room, constituted Mr. Bell's living quarters. The remainder of the once-lovely three-bedroom home, including the bathroom, was layered with dust, unused. His bed was a cot in the dining room; his toilet, a 2- lb coffee can under the cot. Unbathed, unshaven, and existing on food and firewood

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brought by neighbors, Mr. Bell seemed to be living in deplorable conditions. Yet he prized his independence so highly that he adamantly refused to leave. Mr. Bell had one son living in a neighboring state but had little contact with him.

The conflict of values between Mr. Bell's choice to live independently and the nurse's value of having him in a safer living situation raises several ethical questions. When do health practitioners or family members have the right or duty to override an individual's preferences? When do neighbors' rights (Mr. Bell's home was an eyesore and his care was a source of anxiety for his neighbors) supersede one homeowner's rights? Should the nurse be responsible when family members can help but won't take action?

In this case, the nurse entering Mr. Bell's home applied her values of respect for the individual and his right to autonomy even at the risk of public safety. Not until he fell and broke a hip would he reluctantly agree to be moved into a nursing home.

1. What are Mr. Bell's values? What are the values of neighbors who are concerned about him but feel that they can no longer care for him?

2. What are the nurse's values? What are the values of the nurse's employer?

3. What are society's values? What ethical principle does this story most exemplify?

An ethical decision-making framework that was first described by Guo in 2008 and that is referred to as the DECIDE model is initially useful in determining the problem and reviewing options. What is missing from this model is the patients' preference, a vital component (Nelson, 2015). For public health, patients' preference may be replaced with the harm-versus- benefit argument. The DECIDE model includes the following steps:

1. D—Define the problem (or problems). What are the key facts of the situation? Who is involved? What are their rights and duties and your rights and duties?

2. E—Ethical review. What ethical principles have a bearing on the situation, and which principle or principles should be given priority in making a decision?

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3. C—Consider the options. What options do you have in the situation? What alternative courses of action exist? What help, means, and methods do you need to use?

4. I—Investigate outcomes. Given each available option, what consequences are likely to follow from each course of action open to you? Which is the most ethical thing to do?

5. D—Decide on action. Having chosen the best available option, determine a specific action plan, set clear objectives, and then act decisively and effectively.

6. E—Evaluate results. Having initiated a course of action, assess how things progress, and when concluded, evaluate carefully whether you achieved your goals.

Other frameworks can be used. The framework for ethical decision- making shown in Box 4-6 helps to organize thoughts and acts as a guide through the decision-making process. The steps help to determine a course of action, with heavy responsibility at the evaluation level: here the outcomes need to be judged and decisions repeated or rejected in future situations. Box 4-6 also summarizes several views in the field on ethical decision-making. This framework advocates keeping multiple values in tension before resolution of conflict and action on the part of the nurse. It suggests that it is not capable of resolution until all possible alternative actions have been explored. Three tests may be helpful to your decision-making process (Husted et al., 2015):

Impartiality test—Did you use an objective method that examined whether the ethical principles were upheld? Universalizability test—Is this decision one that you can generalize to most people from a rational point of view? Context test—Did you examine the multiple perspectives of this issue, engage the team in your decision-making process, and consider patient preference where possible?

Final resolution of the ethical conflict occurs through a conscious choice of action, even though some values would be overridden by other stronger, presumably more moral values. Conflict resolution techniques can be helpful to the process, including developing empathy, reframing, reflective listening, and assertive messaging (Martin, 2017). Communication and conflict are discussed in Chapter 10.

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Basic Values that Guide Decision-Making When applying a decision-making framework, certain values influence community/public health nursing decisions. Three basic human values are considered key to guiding decision-making in the provider–client relationship: self-determination, wellbeing, and equity. The resolution may not be absolute, as there are many lenses with which to view an ethical dilemma, but using a consistent, objective method of analysis is vital (Box 4- 8).

BOX 4-8 Confronting Challenges for Ethical Decision-Making in Nursing Nurses in every specialty area regularly face ethical situations and dilemmas such as end-of-life decisions, patient privacy, or organizational policies (Rainer, Schneider, & Lorenz, 2018). It is the nature of our profession. Ethical sensitivity and awareness are important characteristics for effective nursing, and empathy is needed in order to build trust and rapport with our clients (Adams, 2018; Milliken & Grace, 2017b). As we strive to work through ethical dilemmas, we should consider some common challenges:

Routine Actions—Nursing often values routines or “the way we have always done it,” This mindset can prevent us from seeking important information and correctly considering ethical principles. Social Structures—Organizational constraints (e.g., procedures, policies) may limit actions and individual beliefs.

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Rule of Thumb Decision-Making—Nurses often have set ways of handling common challenges, and this may obscure the full picture in novel or complex ethical situations (e.g., cultural differences, new technologies/advances). Moral Disengagement—Because we are individuals, moral reasoning and self-awareness are varied. But when we or a colleague use minimizing behaviors (e.g., ignoring consequences, displacing responsibility, demeaning or labeling clients or coworkers), we need to pause and reflect on our levels of empathy and engagement and refocus our efforts. Situational Factors—Health care workers can have a great deal of power over clients, and the use of scientific jargon, professional detachment, and undue persuasion (piling on) can lead to unethical outcomes. Whistleblowers should be protected as they often provide a needed check to our system of health care (Niemi, 2016).

Source: Adams (2018); Milliken & Grace (2017b); Niemi (2016); Rainer et al. (2018).

Self-Determination The value of self-determination or individual autonomy is a person's exercise of the capacity to shape and pursue personal plans for life.

Respect for self-determination:

Is instrumentally valued because self-judgment about a person's goals and choices is conducive to an individual's sense of wellbeing Is the basis for informed consent Is based on the belief that better outcomes will result when autonomy is held in high regard Can maximize the outcomes of enhanced self-concept, enhanced health- promoting behaviors, and enhanced quality of care Is emphasized in the United States but does not receive the same emphasis in all societies or ethnic groups In health care contexts, is of such high ethical importance in U.S. society that it overrides practitioner determinations in many situations (Ryan & Deci, 2017)

Client empowerment is an approach that differs from the paternalistic approach to health care, in which decisions are made for, rather than with, the client; instead, it enables patients and professionals to work in partnership (Akpotor & Johnson, 2018). Many physicians and other health providers, including C/PHNs, fail to recognize the high value attributed to self- determination by many consumers or the differences in views of self- determination among ethnic groups. The freedom of our patients must be

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respected and integrated into the matrix of health care decisions in any encounter or program (Carter, Entwistle, & Little, 2015; Resnik, 2018).

The conflict between provider and consumer may be broader. When self- determination deteriorates into self-interest, it poses a major roadblock to equitable health care. Self-interest is the fulfillment of one's own desires, without regard for the greater good. Consumers mostly have to fend for themselves when they encounter the world of for-profit health care, just as they do in other commercial markets. This “buyers beware” pattern contributes to that deterioration.

When providing health care, the nurse should nurture self-determination and encourage client's personal responsibility for health care decisions. This includes informing clients of options and the reasoning behind all recommendations. Yet self-determination and personal autonomy at times are impermissible or even impossible. For example, society must impose restrictions on unacceptable client choices, such as child abuse and other abusive behaviors, or situations in which clients are not competent to exercise self-determination, as is true for certain levels of mental illness or dementia.

There are two situations in which self-determination should be restricted (Schreiber et al., 2018):

When some objectives of individuals are contrary to the public interest or the interests of others in society (e.g., endangering others with a communicable disease) When a person's decision-making is so defective or mistaken that the individual is deemed legally incompetent (i.e., the person cannot fully comprehend the options, the consequences of actions related to the options, and the true costs and benefits)

WellBeing Determining what constitutes health for people and how their wellbeing can be promoted often requires knowledge of clients' subjective preferences. It is generally recognized that clients may be inclined to pursue different directions in treatment procedures based on individual goals, values, and interests.

C/PHNs should develop an understanding of each client group's needs and develop reasonable alternatives for service from which clients may choose (Box 4-9). When individuals are not capable of making a choice, the nurse or other surrogate decision-maker is obliged to make health care decisions that promote the value of wellbeing. With shared decision-making, the nurse

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seeks not only to understand clients' needs but also to present the alternatives in a way that enables clients to choose those they prefer. Wellbeing and self-determination are two values that are intricately related when providing community/public health nursing services (Klausen, 2018; Sexton, O'Donovan, Mulryan, McCallion, & McCarron, 2017).

BOX 4-9 STORIES FROM THE FIELD A FAMILY LIVING IN POVERTY Contrasting value systems may be seen in many community/public health practice settings. Andrea Vargas, a C/PHN, experienced such a contrast on her first home visit to a family living in poverty. Referred by a school nurse for the children's recurring problems with head lice and staphylococcal infections, the family was living in a converted outbuilding on the outskirts of town.

Although basically clean and orderly, the living conditions were cramped, inadequate, and unsafe. Three hammocks were strung, stacked one upon the other, across the far corner of the room to accommodate the three younger children (out of a total of six). The older two children slept on the couch and the floor, while the baby slept with the single mother in the small bed. There was an old gas stove for cooking, and it was currently being used to heat the room, as the wall heater did not work. The mother did not know why it was no longer working. She seemed “stuck”—unable to muster the effort to talk with the landlord about the lack of a working heater. Even though using a gas stove to heat the room was dangerous (because of carbon monoxide), it seemed to her to be the easiest way to deal with the problem.

Andrea knew that landlords were sometimes slow to respond to the needs of low-income renters and she saw this as unjust. The mother's main pleasure in life was watching soap operas on television, and Andrea felt that the mother seemed disinterested in trying to improve her circumstances. The nurse interpreted the situation through the framework of her own value system, in which health and safety were priorities, and justice was an instrumental value. Yet the mother, who might have shared those values in the past, appeared to be incapable of advocating for her family, no longer able to cope with her situation. It is possible that environmental influences reordered the family's value system priorities. Rather than imposing her own values, Andrea chose to determine the priorities of the family, assess their needs, and begin where they were.

1. Will she have a greater chance at success by doing this?

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2. What needs can you identify with this family? 3. Where could you find assistance for this family in your community?

Equity The third value that is important to decision-making in health care contexts is the value of equity or justice, which means being treated equally or fairly. The principle of equity implies that it is unjust (or inequitable) to treat people the same if they are, in significant respects, unalike. Equity generally means that all individuals should have the same access to health care according to benefit or needs (Box 4-10). However, effectively applying this value is often a complex enterprise and fraught with difficulties (Saniford, Vivas Consuelo, Rouse, & Bramley, 2018).

BOX 4-10 Levels of Prevention Pyramid Distributive Justice for Battered Women and Children SITUATION: Provide distributive justice for battered women and children by changing a proposed state law that would eliminate funding for shelters for battered women and children to a law that preserves resources for this population. GOAL: Using the three levels of prevention, avoid or promptly diagnose and treat negative health conditions and restore the fullest possible potential.

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The major problem with this definition of equity is that it assumes that an adequate level of health care can be economically available to all citizens. In times of limited technical, human, and financial resources, it may be impossible to fully respect the value of equity (Cohen & Marshall, 2017; Krisberg, 2018). Choices must be made and resources allotted despite professional practice values that create ethical dilemmas that seem impossible to resolve. Many of these conflicts are reflected in current health care reform efforts that focus on access to services, quality of services, and ways to control rising costs. We also have many new genomics issues with access to care paramount in equity decisions (Rogowski & Schleidgen, 2015). The following list represents some of the most pressing aggregate health problems related to inequities in the distribution of and access to health and illness care facing patients worldwide.

Too many women go without preventive care. The overall rate of infant mortality (all infant deaths before 1 year of age) is 5.1 per 1,000 in the United States. Although this rate is lower than previous rates, the disparities between the rates for populations of color and those for White non-Hispanic and White Hispanic populations remain high (Kaiser Family Foundation [KFF], 2017b).

Unintended pregnancies are much higher among populations of color than among White populations. Poverty is strongly related to difficulty in accessing family planning services (Snow, Laski, & Mutumba, 2015). Health care system factors such as access to care, patient preferences, and provider-related factors also impact the lack of preventive care.

Immunization rates for children entering kindergarten are an example of how public health works. The median vaccination coverage among kindergarteners from 2017 to 2018 was 94.3% for measles, mumps, and rubella; 95.1% for diphtheria, tetanus, and acellular pertussis; and 93.8% for two doses of varicella (Mellerson, 2018).

Compliance with scheduled vaccines, which is generally high, and consistently high rates of immunization against common childhood communicable diseases are required for achieving community or herd immunity (Oxford Vaccine Group, 2018). Without high vaccination rates, we will lose the benefit of herd immunity and

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diseases will return, as happened in Japan in 1979 when only 10% of children were vaccinated and 13,000 cases of whooping cough and 41 deaths were reported (CDC, 2018). Childhood immunization rate disparities have been dramatically reduced through multiple interventions and a strong infrastructure of vaccine services (Walsh, Doherty, & O'Neill, 2016). However, exemptions (medical, religious, personal) have been rising, with Oregon having the highest level at 7.6% and Mississippi the lowest at 2.2%. Personal belief exemptions, often related to antivaccination influence, were highest in Oregon (7.5%) and lowest in California (2.0%), where these exemptions are no longer permitted (CDC, 2018). See Chapters 8 and 20.

Disparities in immunization rates exist for adults along racial and ethnic lines, as well as by poverty level. In a study comparing adults, the rate of influenza vaccination during the 2018-2019 flu season for non- Hispanic Whites was 48.7%, but for non-Hispanic Blacks and Hispanics the rates were 39.4% and 37.1%, respectively (CDC, 2019a). This may be due to the following among the Black population: lower knowledge levels about the flu vaccine, distrust of the vaccine, and barriers or missed opportunities to receive the vaccine (Quinn, 2018). The uninsured are likely to go without physician care. Differences in access to expensive, discretionary procedures emerge according to health insurance status, race, and ethnicity, as well as other sociodemographic factors.

The Affordable Care Act has helped to improve the numbers of previously uninsured in America, but those remaining uninsured are the working poor. Over half of those without health insurance live at 200% below the poverty level, with White non-Hispanic Americans remaining more likely to be insured than people of color (Kaiser Family Foundation, 2017a).

Environmental hazards threaten global health. Global trade, travel, and changing social and cultural patterns make the population vulnerable to diseases that are endemic to other parts of the world, as well as to previously unknown diseases.

Past influenza pandemics have highlighted the need for better preparation for future pandemics, and the novel coronavirus pandemic (COVID-19) has further emphasized that need (Desmond-Hellmann, 2020). (Patel et al., 2017). Pollution of air, water, and soil to support industry contributes to pathogen mutations and threatens public health (Yu, Gunn, Wall, & Fanning, 2017).

Equity is tied to social justice (see below) and can be a difficult concept to truly grasp.

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People are socialized to see the world through the eyes of their own experience. Once we can “unpack” how race, gender, income, education, age, and sexual identity influence equity and social justice, we then become allies to those who lack privilege (Adams et al., 2018).

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Application of Values to Ethical Decision-Making in Community/Public Health Nursing These key values of self-determination, wellbeing, and equity influence nursing practice in many ways (Ryan & Deci, 2017). The value of self- determination has implications for how C/PHNs regard the following:

The choices of clients Privacy Informed consent Diminished capacity for self-determination

The value of wellbeing has implications for how C/PHNs seek to:

Prevent harm and provide benefits to client populations Determine effectiveness of nursing services Weigh costs of services against real client benefits (Ryan & Deci, 2017)

The value of equity has implications for community/public health nursing in terms of its priorities for:

Distributing health goods (macro-allocation issues) Deciding which populations will obtain available health goods and services (micro-allocation issues) Which individuals or groups have access to genetic tests (Ryan & Deci, 2017)

When a decision is based on only one value, it is more likely that conflict will emerge due to competing values. For example, deciding primarily on the basis of client wellbeing may conflict with decisions made on the basis of self-determination or equity. How C/PHNs balance these values may even conflict with their own personal values or the professional values of nursing as a whole. In these situations, values clarification techniques used with an ethical decision-making process may assist in producing decisions that promote the greatest wellbeing for clients without substantially reducing their self-determination or ignoring equity.

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Ethical Principles Based in patient-centered practice, fundamental ethical principles along with context and the nurse's knowledge provide guidance in making decisions regarding clients' care: respect, autonomy, beneficence, nonmaleficence, justice, veracity, and fidelity (Butts & Rich, 2019; Husted et al., 2015).

Respect Respect refers to treating people as unique, equal, and responsible moral agents (Butts & Rich, 2019):

Emphasizes one's importance as a member of the community and of the health services team Acknowledges community clients as valued participants in shaping their own and the community's health outcomes Includes treating clients as equals on the health team and holding them, as well as their views, in high regard (Akrami, & Abbasi, 2018)

Autonomy Autonomy means freedom of choice and the exercise of people's rights (Butts & Rich, 2019). Autonomy:

Is related to individualism and self-determination dominant values underlying this principle (Husted et al., 2015) Promotes individuals' and groups' rights to and involvement in decision- making as those decisions enhance their wellbeing and do not harm the wellbeing of others Requires nurses to make certain that clients are fully informed and that the decisions are made deliberately, with careful consideration of the consequences (Box 4-11)

BOX 4-11 STORIES FROM THE FIELD AN OLDER CLIENT GIVES UP Tom Hardwick, PHN, has been assigned to monitor Mr. Jackson, an older man who was diagnosed with tuberculosis (TB; positive skin test, positive sputum and x-ray). Mr. Jackson's wife unexpectedly died recently, and he is depressed and wants to “join her.” He is not eating or sleeping much. He refuses to take TB medications or his eight other

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medications for heart disease, thyroid insufficiency, type 2 diabetes, glaucoma, high cholesterol and triglycerides, and hypertension.

He has consistently refused any of Tom's suggestions or assistance. He does not want to see a mental health counselor, and Tom wonders if he should continue to make home visits. He has a busy caseload and needs to focus on the most pressing cases. Mr. Jackson's children feel that his depression and refusal of medications are a “temporary condition” in response to his wife's death and have asked for Tom's assistance in keeping their father healthy.

1. Why is this an ethical dilemma? 2. What are the ethical principles involved? 3. What does Mr. Jackson value? What are his children's values?

What are Tom's values? 4. Prioritize your values. What are the possible actions you could

take?

Beneficence Beneficence means doing good or benefiting others. Is the promotion of good or taking action to ensure positive outcomes on behalf of clients (Robichaux, 2017). Involves, in C/PHN, making decisions that actively promote clients' stated interests and their view of wellbeing (Husted et al., 2015).

Nonmaleficence Nonmaleficence means avoiding or preventing harm to others as a consequence of a person's own choices and actions (Butts & Rich, 2019; Robichaux, 2017): Involves taking steps to avoid negative consequences Examples include:

Encouraging providers to prescribe opioids within the newest guidelines Promoting legislation to protect young people from e-cigarette (vaping) use

Justice The principle of justice refers to treating people fairly (Butts & Rich, 2019; Husted et al., 2015).

This includes the fair distribution of both benefits and costs among society's members

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Examples: Equal access to health care Equitable distribution of services to rural as well as urban populations Fair distribution of resources after a disaster

Within this principle are three different views on allocation, or what constitutes the meaning of “fair” distribution.

Distributive justice is the view that benefits should be given first to the disadvantaged or those who need them most (Box 4-10). Decisions based on this view particularly help the needy, although it may mean withholding goods (e.g., food stamps, Medicaid) from others who may also be deserving, but less in need (Robichaux, 2017). Egalitarian justice promotes decisions based on equal distribution of benefits to everyone, regardless of need (e.g., Medicare). See Box 4-12. Restorative justice determines that benefits should go primarily to those who have been wronged by prior injustice, such as victims of crime or racial discrimination (Robichaux, 2017).

BOX 4-12 What Do You Think?

Predatory Drug Pricing Other developed countries pay markedly less than the United States for prescription drugs (i.e., Japan 70%, France 59%, Denmark 29%). The prices of prescription drugs in the United States are expected to rise 6.3% per year between 2016 and 2025. The U.S. government paid about 43% of the cost of all prescriptions in 2015, yet when Medicare D (prescription drug coverage) was enacted, the legislation barred Medicare from negotiating with pharmaceutical companies to get lower costs (Olson & Sheiner, 2017).

Drug companies influenced this and other legislation that prohibits negotiating prices on drugs and medical devices, having spent over $2.5 billion over the past 10 years funding lobbyists and politicians in Congress. In fact, lobbyists outnumber the members of Congress 2 to 1 (McGreahl, 2017).

Drug manufacturers are protected by U.S. patent and intellectual property laws to protect their investment in developing a new drug— estimated as high as $2.5 billion. And they have learned to game the generic drug laws that were enacted to promote competition (i.e., antitrust laws). When their patents are about to expire, they simply make a very

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minor adjustment and re-patent the medication, thus avoiding generic competitors and allowing increased prices. Legislative attempts to legalize the importation of lower-price drugs from outside the United States, to reverse the ban on the government negotiating drug prices, and on increasing Medicare rebates on generic drugs have failed (Walsdorf, 2018). Our “multiple, overlapping health care systems,” with government, private insurance, and private payors, have also made it difficult to maintain a consistent method of drug pricing and purchasing, making it easier for drug companies to limit access to specific medications leading to price spikes (Marciarille, 2017, p. 46).

The result of these policies and practices became very apparent when prices began to soar beginning in 2015:

The price of an established drug, Darprim to treat toxoplasmosis (often associated with HIV/AIDS patients), rose 5,000%—from $13.50 to $750 per pill (Pianin, 2016). Two pharmaceutical companies—Retrophine Inc., and Rodelis Therapeutics—raised prices on some drugs 2,000% (Pianin, 2016). Valeant raised prices on two long-standing drugs to treat Wilson's disease, from a 30-day cost of $500 to over $24,000 (Peterson, 2016). The cost of a lifesaving medication for those with serious allergic reactions, EpiPens, rose to over $600 in the United States, while the United Kingdom was able to negotiate a $70 price tag (McGreahl, 2017). Mylan, a drug company making EpiPens, gave their CEO an increase in salary from $2.5 million to $18.9 million between 2007 and 2016 (Babcock, 2017). In the midst of a serious U.S. opioid crisis, naloxone (Narcan—used to reverse opioid overdose), in all forms except nasal spray, increased between 469% and 2,281% between 2006 and 2017. Because of drug shortages due to only one drug company selling the 0.4-mg single- dose product, sustained and dramatic price increases have resulted (Rosenberg, Schick, Chai, & Mehta, 2018). From 2002 to 2013, insulin prices more than tripled—from $40 to $130 a vial (Pearl, 2018). A survey of type 1 or type 2 diabetics found that 26% had used less than their prescribed insulin dose due to rising costs, and that almost half had intermittently gone without diabetes treatment (“High Cost Has 1 in 4 Diabetics,” 2018; Upwell Community, 2019).

It may now be important to not only consider side effects and effectiveness of a medication but the negative impact of excessive cost. This may enable Medicare and other insurers to consider cost as well as quality in deciding which drugs to include in their formularies. For instance, physicians at Memorial Sloan-Kettering Cancer Center refused to

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put a new, very high-priced drug for colon cancer (Zaltrap) on their formulary because it was too expensive, and they encouraged other physicians to examine the financial strain to their patients in their decision-making process. After some publicity, the pharmaceutical company dropped the price by 50% (Buck, 2017).

1. Do you think drug prices are problematic? State the ethical principles involved.

2. Do both sides of the argument have merit (drug company's costs, a consumer's inability to pay)?

3. Does this situation constitute an ethical dilemma? 4. How could you go about resolving this? Consider the rights of a few

versus the rights of many. 5. Apply Iserson's (1999) three tests (under heading Decision-Making

Frameworks). Source: Babcock (2017); Buck (2017); “High Cost Has 1 in 4 Diabetics” (2018); Marciarille (2017); McGreahl (2017); Olson & Sheiner (2017); Peterson (2016); Pianin (2016); Rosenberg et al. (2018); Upwell Community (2019); Walsdorf (2018).

Social justice refers to the fair and equitable distribution of wealth, economic opportunity, and access to privileges in society and is tied to human rights (Adams et al., 2018). The ANA (2016) clearly articulates the duty of nurses to ensure that client care is socially just. See Chapter 23 for more on social justice.

Veracity The principle of veracity refers to telling the truth (Butts & Rich, 2019; Robichaux, 2017). This:

Includes giving community/public health clients accurate information in a timely manner Involves treating clients as equals Expands the opportunity for greater client involvement Provides needed information for decision-making (Husted et al., 2015)

Fidelity Fidelity means remaining true to your word or keeping promises (Butts & Rich, 2019; Oana, 2017). It:

Allows people to count on commitments being met, to which they have a right

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Results in the nurse earning the client's respect and trust When bidirectional, influences the quality of the nurse's relationship with clients, who then are more likely to share information Involves building trust and leads to improved decisions and better health When lacking, can cause community members to lose faith and interest in participation

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Ethical Standards and Guidelines As the number and complexity of ethical decisions in community health increase, so too does the need for ethical standards and guidelines to help nurses make the best choices possible.

The ANA's Code for Nurses with Interpretive Statements (2015) provides a helpful guide. The Association of State and Territorial Directors of Nursing (n.d.), a public health nursing organization, published a text on how to incorporate ethical principles into local health department processes and provide guidelines for the C/PHN role in eliminating health inequalities. More health care organizations are using ethics committees or ethics rounds to deal with ethical aspects of client services (Hajibabaee, Joolaee, Cheraghi, Salari, & Rodney, 2016). Ethics committees also function in a variety of community/public health care settings. In public health agencies, cases of clients with complicated communicable disease diagnoses and health care provider concerns are discussed as they relate to policy, protocols, and the health and safety of the broader population (Santos et al., 2017).

Ethics and research (or EBP) are intertwined. All nurses need competency in both areas to provide quality care to those they serve.

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SUMMARY

Implementation of EBP enables C/PHNs to promote health and prevent illness among at-risk populations and to design and evaluate community-based interventions. EBP is essential to ensuring economical and effective interventions for our clients. Systematic reviews can provide direction for those who have developed a “burning clinical question.” Research and application of EBP have a significant impact on community/public health and nursing practice by providing new knowledge that helps to shape health policy, improve service delivery, and promote the public's health. It offers the potential to enhance nursing's status and influence through documentation of the effectiveness of nursing interventions and broader recognition of nursing's contributions to health services. Nurses must learn to evaluate evidence critically, assessing the validity and applicability to their own practice. Nurses should search for current evidence and discuss EBP initiatives with colleagues and supervisors. A commitment to use and conduct research will move the nursing profession forward and enhance its influence on the health of at-risk populations. Values and ethical principles strongly influence C/PHN practice and ethical decision-making. Values are lasting beliefs that are important to individuals, groups, and cultures. A value system organizes these beliefs into a hierarchy of relative importance that motivates and guides human behavior. Values function as standards for behavior, as criteria for attitudes, and as standards for moral judgments, and they give expression to human needs. The nature of values can be understood by examining their qualities of endurance, their hierarchical arrangement, and their function as prescriptive–proscriptive beliefs and by examining them in terms of reference and preference. The nurse often is faced with decisions that affect client's values and involve conflicting moral values and ethical dilemmas. Understanding what personal values are and how they affect behavior assists the nurse in making ethical evaluations and addressing ethical conflicts in practice. Several frameworks for ethical decision-making that include the identification and clarification of values impinging on the making of

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ethical decisions were discussed in this chapter. Three key human values influence client health and nurse decision- making: the right to make decisions regarding a person's health (self- determination), the right to health and wellbeing, and the right to equal access and quality of health care. At times, these three key human values are affected by the value of self- interest on the part of another person or a system. Seven fundamental principles guide C/PHNs in making ethical decisions: respect, autonomy, beneficence, nonmaleficence, justice, veracity, and fidelity.

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ACTIVE LEARNING EXERCISES

1. As a C/PHN working in a big city, you encounter a large number of children with lead poisoning due to environmental contamination. You are interested in lead abatement programs. Where can you find evidence on successful programs/outcomes, cost–benefit analysis, and policies that have been implemented in other areas? Who would need to be involved in getting this type of program instituted?

2. Select a community/public health nursing systematic review or research article and analyze its potential impact on health policy and C/PHN practice. Critique the article, using the criteria presented in this chapter. What are the main findings? How can you apply this to your community setting? What policies could be affected and how?

3. You have just completed an EBP implementation study on the effectiveness of a series of birth control classes in three high schools, and the results show a reduction in the number of pregnancies over the last year. Is this enough information to declare it a success? What else could you do to strengthen your case? Describe three ways in which you could disseminate this information to your nursing colleagues and school officials.

4. Find a community/public health study that represents efforts to “Strengthen, Support, and Mobilize Communities and Partnerships” (1 of the 10 essential public health services; see Box 2-2 ) (e.g., community-based participatory research study). How would you apply the methods, interventions, and findings of that study to an issue in your community?

5. Describe where you stand on the following issues. For each statement, decide whether you strongly agree, agree, disagree, strongly disagree, or are undecided. Discuss your rationales and compare your results with a small group of classmates: a. Clients have the right to participate in all decisions related to their health care. b. Continuing education should not be mandatory to maintain

licensure. c. Clients always should be told the truth. d. Nurses should be required to take relicensure examinations every

5 years. e. Clients should be allowed to read their health record on request. f. Abortion on demand should be an option available to every

woman. g. Critically ill newborns should be allowed to die. h. Laws should guarantee health care for each person in this country.

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6. Search local or national news for stories involving ethical dilemmas. Pick one and describe which ethical principles were involved. How was the dilemma resolved? Or, how would you go about deciding on an equitable resolution?

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CHAPTER 5

Transcultural Nursing “People everywhere share common biological and psychological needs, and the function of all cultures is to fulfill such needs; the nature of the culture is determined by its function.”

—Bronislaw Malinowski (1884–1942), Cultural Anthropologist “Looking from… our high places of safety in the developed civilization, it is easy to

see all the crudity and irrelevance of magic. But without its power and guidance early man could not have mastered his practical difficulties …, nor

could man have advanced to the higher stages of civilization.”

—Horace Miner (1912–1993), Anthropologist

KEY TERMS Complementary and alternative medicine (CAM) Cultural assessment Cultural brokering Cultural diversity Cultural relativism Cultural self- awareness Cultural sensitivity Culture Culture shock Dominant values Enculturation Ethnic group Ethnicity Ethnocentrism Ethnorelativism Folk medicine Home remedies Indigenous Intraethnic variations Integrated health care Majority–minority Microculture Minority group Race Subcultures Transcultural (cross-cultural) nursing

LEARNING OBJECTIVES Upon mastery of this chapter, you should be able to:

1. Define and explain the concept of culture. 2. Discuss the meaning of cultural diversity and its significance for

community/public health nursing. 3. Describe the meaning and effects of ethnocentrism on community/public

health nursing practice. 4. Identify five characteristics shared by all cultures. 5. Conduct a cultural assessment. 6. Apply principles of transcultural nursing in community health nursing

practice.

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INTRODUCTION

The United States is a country of immigrants. People of many different cultural groups and races built this nation. For hundreds of years, people have seen this land as a refuge from political, religious, or economic strife. Indigenous (or native) people were present when the early settlers arrived on these shores and when people were brought here in slavery. Refugees, fleeing poverty and hunger, as well as war and oppression, flocked to this country over the next two centuries. The citizenship of most countries around the world is an amalgamation of people who have different values, ideals, and behaviors. Many people have chosen to discover their ancestry through DNA testing as a means of drawing families closer together. Do you know the story of how your ancestors came to your country?

Although Americans have many differences, they also have much in common. In the Western culture, an individual's work and creative achievements are applauded. There is respect for one another's personal preferences about food, dress, or personal beliefs. The right to be oneself— and thereby to be different from others—is even protected by state and federal laws. Although individuality is a cherished American value, there are limits to the range of differences most Americans find acceptable. People with behavior outside the acceptable range may be labeled as socially nonconforming. For example, the US culture approves of moderate alcohol intake but not alcoholism.

The beliefs and sanctions of the dominant or majority culture are called dominant values. In the United States, the majority culture is non-Hispanic Whites, whose dominant values have largely included the work ethic, thrift, success, independence, initiative, privacy, cleanliness, attractive appearance, and a focus on the future. Dominant values reflect the cultural power differentials and the unearned, frequently unrecognized privileges held by Americans with White social identities (Holm, Rowe, Brady, & White- Perkins, 2017).

Awareness of dominant values is important in community/public health nursing because the values shape people's thoughts and behaviors; this awareness helps nurses answer questions such as the following:

Why are some client behaviors acceptable to health professionals and others not? Why do nurses have difficulty persuading certain clients to accept new ways of thinking and acting?

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Explanations for such questions can be found by examining the concept of culture, especially its influence on health, health behaviors, and community/public health nursing practice. For example:

An emphasis on the need for milk in the diet may reflect cultural blindness, considering that people from diverse ethnic groups are often lactose intolerant and that food allergies affecting the quality of life for minority children appear to be understudied and undiagnosed (Widge, Flory, Sharma, & Herbert, 2018). Regardless of their own cultural backgrounds, nurses are generally educated to believe that the biomedical model is the best framework, and dominant social values are often reinforced.

However, these dominant values can and do change as a result of changing demographics and population shifts (Fig. 5-1). Current research on this issue reveals areas of concern (Box 5-1).

FIGURE 5-1 In 109 counties, White population share fell below 50% between 2000 and 2018: US Counties in which the non- Hispanic White share of the population fell below 50% from 2000 to 2018. (Reprinted with permission from Krogstad, J. M. (August 21, 2019). Reflecting a Demographic Shift, 109 US Counties have become majority nonwhite since 2000. Washington, D.C.: Pew Research Center. Retrieved from https://www.pewresearch.org/fact-tank/2019/08/21/u-s-counties- majority-nonwhite/ft_19-08-21_majorityminoritycounties_in-109- counties-white-population-share-fell-below-50-percent-2000- 2018_2/)

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BOX 5-1 What Do You Think?

Transition to a Majority–Minority Nation According to projections from the U.S. Census Bureau, in a seminal article by Perez and Hirschman (2009), we will become a majority– minority nation by mid-century, as current minority groups gain in population while the existing majority non-Hispanic White population decreases. This is manifesting in an uneven fashion across the 50 states with the growth of the Hispanic population, especially children ages 0 to 4 (Murdock, Cline, Zey, Perez, & Wilner Jeanty, 2015). Even though some disagree with the methods used to calculate these results (Alba, 2016), research conducted by Craig and Richeson (2014) predicts that this census report about the change to majority–minority standing may lead to anxiety about “group status” threats within the former majority population and “a widening partisan divide” (p. 1189). This phenomenon is not unique to one racial or ethnic group, however, as the researchers found similar results with other groups who perceived a loss of status —such as Black Americans perceiving Hispanic/Latino population growth as threatening to their status (Richeson & Grossman, 2016). Four studies conducted by Craig and Richeson (2017) found that access to information about this demographic shift led the

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majority group to believe that they will encounter greater discrimination while the minority groups may encounter less discrimination. Other researchers have noted that socioeconomic status is also associated with perceived discrimination in health care and note that resolving systems barriers and widespread inequities would be helpful in addressing this issue (Stepanikova & Oates, 2017).

1. Have you noticed demographic changes in your area? How do you feel about these changes?

2. Do you see any signs of dominant group anxiety and perceived threats to group status? How might they affect health care in the coming decades?

3. Have you experienced or observed discrimination in health care settings?

Source: Alba (2016); Craig and Richeson (2014); Craig and Richeson (2017); Murdock et al. (2015); Perez and Hirschman (2009); Richeson and Grossman (2016); Stepanikova and Oates (2017).

Awareness of dominant culture and values helps us better understand political, socioeconomic, and health care outcomes.

Because the powerful exert control over political, economic, and social structures that influence all members of society, laws are in place prohibiting discrimination based on “race, color, religion, national origin, and sex,” as well as disability (U.S. Equal Employment Opportunity Commission, n.d., para. 1). Governments' political decisions affecting the health of populations, beginning with deregulation and reductions in government spending in this country, have led to increased rates of poverty, inequality, incarceration, obesity, and other conditions tied to the social determinants of health (Nadasen, 2017). Culture so strongly influences community/public health nursing practice that the Quad Council of Public Health Nursing Organizations (which is now the Council of Public Health Nursing Organizations) incorporated it into the competency domains for community/public health nursing practice. Domain 4, cultural competency skills, focuses on individual and community needs, actions to support a diverse workforce, an

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organization's cultural competence, and the effect of public health policies/programs on diverse populations (Quad Council Coalition Competency Review Task Force, 2018). See Chapter 2 for Quad Council Competencies.

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THE CONCEPT OF CULTURE

Culture refers to the beliefs, values, and behaviors that are shared by members of a society and provide a template or “road map” for living.

Culture tells people what is acceptable or unacceptable in a given situation. Culture dictates what to do, say, or believe. Culture is learned. As children grow up, they learn from their parents and others around them how to interpret the world. In turn, these assimilated beliefs and values prescribe desired behavior. We think of this as learned behavior, but can culture actually impact your neurobiology (Box 5-2)?

BOX 5-2 EVIDENCE-BASED PRACTICE Can Culture Affect Your Neurobiology?

Research into the neuroscience of culture examines the interplay between culture, biological factors, physiological processes, and genetic influences.

Researchers in a 19-site longitudinal cohort study, the Adolescent Brain and Cognitive Development (ABCD) Initiative, are measuring a range of biological and behavioral processes at a time of marked change

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in the human brain's structure and networks (Luciana et al., 2018; Zucker et al., 2018). Over 11,000 children, ages 9 to 10 years, are enrolled in this study, which explores how neurologic developmental processes interact with culture and environment in areas such as risk taking and substance abuse. Preliminary results indicate that culture and environment have major roles influencing behavioral and neural development (Luciana et al., 2018; Zucker, et al., 2018).

Recent evidence converges to suggest that the neuropeptide oxytocin facilitates empathy, a key social cognitive capacity that affects interpersonal functioning. Culture is thought to influence the behavioral effects of oxytocin in both Chinese and Caucasian populations. In a study of 132 healthy Chinese adults, intranasal oxytocin was found to facilitate emotional empathy, similar to prior research with Caucasians (Geng et al., 2018). In another study, oxytocin was found to influence social connections and empathy with others but had a different effect in collectivistic versus individualistic cultures (group orientation vs. individual orientation). In this research, differences were noted across genders, as males were more influenced by oxytocin than females (Xu et al., 2017). This evidence is important as impaired empathy has been identified as a component of schizophrenia, autism, and personality disorders, and the oxytocin connection is of interest internationally (Montag et al. 2018).

Lastly, differences between Western and Asian cultures have been explored from a neuroscience standpoint. In a quantitative meta-analysis of 35 functional magnetic resonance imaging (fMRI) studies, researchers concluded that distinct neural networks do mediate cultural differences in both social and nonsocial processes (Han & Ma, 2014).

1. What are your impressions of these findings? 2. How can this information be useful to you as a nurse working

with different cultural groups? 3. Can this research impart a risk of stereotyping people from

different groups?

Source: Geng et al. (2018); Han and Ma (2014); Luciana et al. (2018); Montag et al. (2018); Widge et al. (2018); Wood et al. (2018); Xu et al. (2017); Zucker et al. (2018).

Culture is a multifaceted concept, a way of organizing and thinking about life. Culture includes customs, law, morals, beliefs, knowledge, and habits practiced by members of a group or society. It is all of the socially inherited characteristics of a group, comprising everything that one generation can tell, convey, or hand down to the next generation. Scholars from many disciplines have defined culture in these ways:

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Learned, shared, and transmitted values, beliefs, and norms held by a group of people that guide their actions (McFarland & Wehbe-Alamah, 2018) A patterned response of behavior that develops from the impact of social and religious structures in a community over time, from infancy through old age, and can be apparent in a community's intellectual and artistic achievements (Giger, 2017) A mediating or moderating variable in business, human relations, psychology, and most human endeavors (Coyle, 2018) A historically transmitted pattern of meanings, closely tied with religion and ethics; an identification of those people or behaviors outside the cultural bounds (Forbes & Mahan, 2017)

Anthropologists describe culture as systems of beliefs, values, and norms of behavior found in all societies. More than simply custom or ritual, it is a way of organizing and thinking about life. It gives people a sense of security about their behavior; without having to consciously think about it, they know how to act. For example, Spector (2017) notes that culture:

Determines the value placed on achievement, independence, work, and leisure Forms the basis for the definitions of gender roles Influences a person's response to authority figures Dictates religious beliefs and practices Shapes child-rearing

Every community and social or ethnic group has its own culture; individual members act based on what they have learned within their culture. As anthropologist Edward Hall (1959) noted over a half-century ago, culture controls our lives and influences even the smallest elements of everyday living. It is the knowledge people use to design their own actions and, in turn, to interpret others' behavior (Spradley, McCurdy, & Shandy, 2016). For example, culture:

Determines the appropriate distance for two people to stand when speaking to each other: non-Hispanic White Americans tolerate at least 2.5 ft, whereas Latin Americans prefer a shorter distance, as little as 18 in. Influences one's perception of time: non-Hispanic White Americans may expect people to be on time for appointments and think it inconsiderate to keep someone waiting, whereas those from Vietnamese, Native American, and Hispanic cultures have a more elastic perception of time and do not interpret lateness for appointments as thoughtlessness

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The concept of culture must be distinguished from two other related but different concepts:

Race refers to a biologically designated group of people whose distinguishing features, such as skin color or facial characteristics, are inherited. Ethnic group is an assemblage of people with common origins and a shared culture and identity; they may share a common geographic origin, race, language, religion, traditions, values, and food preferences (Spradley et al., 2016).

Race and ethnicity are factors influencing social inequality, and ultimately morbidity and mortality. See Figure 5-2.

FIGURE 5-2 A public health framework for reducing health inequities. (Used with permission from Bay Area Regional Health Inequities Initiative, with updated graphics by California Department of Public Health. Retrieved from http://barhii.org/framework/)

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Cultural Diversity Cultural diversity, or cultural plurality, refers to the coexistence of a variety of cultural patterns within a geographic area. This diversity can occur both between and within countries and communities. Cultural diversity within communities has unique advantages and challenges. Language barriers and misunderstanding of cultural values can occur, whereas cultural practices, celebrations, and food traditions can enrich the community.

A major driver of cultural diversity in the United States has been immigration. Cultural diversity in the United States began when Native Americans were challenged by early foreign settlements. Before the mid- 20th century, settlers came primarily from European countries, peaking in numbers just after the turn of the 20th century, with about 9 million immigrants admitted in the first decade. During much of that time, especially during the late 1600s through the early 1800s, Africans were enslaved and brought to the United States against their will, mostly to Southern states, where they were sold to plantation owners as property in order to labor on large plantations and farms. Slavery and cultural oppression engendered profound effects for many generations (Bellagamba, Greene, & Klein, 2017).

Immigration stayed high during the early 1900s and then dropped sharply from the 1950s to 1980s. It has risen more significantly since 2000. Immigration from non-European regions, such as Asia and South America, then steadily increased. Batalova, Blizzard, and Bolter (2020) note that the total number of immigrants from all countries in the 1990s actually exceeded the number who arrived during the first decade of the 20th century, when immigration was formerly at its peak (Fig. 5-3).

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FIGURE 5-3 Foreign-born population and percent of total population, in the United States: 1850 to 2010. (Reprinted from Grieco, E. M., Trevelyan, E., Larson, L., Acosta, Y., Gambino, C., de la Cruz, P., … Walters, N. (October 2012). The size, place of birth, and geographic distribution of the foreign-born population in the United States: 1960-2010 (p. 19). Retrieved from https://www.census.gov/content/dam/Census/library/working- papers/2012/demo/POP-twps0096.pdf)

Current trends in US immigration include the following:

A large, undocumented foreign-born population, which is difficult to count in a population census due to such factors as English language ability, literacy skills, understanding of the census, residential attachment, and legal status, which can contribute to coverage error (Jensen, Bhaskar, & Scopilliti, 2015) Immigrants from all regions of the world, in greater numbers from some areas than others (Fig. 5-4), becoming lawful permanent residents and, in due course, US citizens (Witsman, 2018) (Fig. 5-5) The fastest growing group of immigrants being people reporting two or more races, growing from 8 million in 2014 to a projected 26 million in 2060 (Fig. 5-4) The second-fastest growing group of immigrants being Asians, growing from 5.4% of the total population in 2014 to a projected 9.3% of the total population in 2060 (Colby & Ortman, 2015) Rapid growth in the Hispanic/Latino population (Box 5-3 and Table 5- 1)

BOX 5-3 Hispanic Population Trend in the United States

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According to the U.S. Census Bureau, people of Hispanic origin identify with “Cuban,” “Mexican,” “South American,” “Central American,” or “all other Hispanic or Latino origin,” regardless of race (U.S. Census Bureau, 2020, para. 1). Our Hispanic population is growing, from 12.5% of the population in the 2000 census to our most recent 2010 census figures of 16.3% of the population (Table 5-1). The 2019 population estimate for Hispanics/Latinos is 18.3% (U.S. Quick Facts, n.d.). The change in population numbers is only part of the story. The Hispanic population born in the United States is increasing, as portrayed in the figure in this box. Being first or second generation born in the United States and other factors such as intermarriage contribute to the increase in percentage of adults with Hispanic ancestry who self-identify as American. This indicates they feel a common identity with other Americans. The number of Hispanic cultural activities is diminishing, as adults reporting childhood experiences with Latino/Hispanic cultural are in decline across the generations as displayed below (Lopez, Gonzalez-Barrera, & López, 2017). Lopez et al. report that 11% of American adults with Hispanic heritage no longer identify themselves as Hispanic. Source: Lopez et al. (2017); U.S. Census Bureau 2020, para. 1; U.S. Quick Facts (n.d.). Figure reprinted with permission from Lopez, M. H., Gonzalez-Barrera, A., & Lopez, G. (December 20, 2017). Hispanic identity fades across generations as immigrant connections fall away. Washington, D.C.: Pew Research Center. Retrieved from https://www.pewresearch.org/hispanic/2017/12/20/hispanic-identity-fades- across-generations-as-immigrant-connections-fall-away/

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FIGURE 5-4 Percent distribution of foreign-born population by region of birth in the United States, 2010 Census. Total foreign- born population living in the United States in 2010 was 12.9% of population. These individuals are young, mostly from Latin America or Asia, and often settle in Southern or Western states. (Source: Grieco, E. M., Trevelyan, E., Larson, L., Acosta, Y., Gambino, C., de la Cruz, P., … Walters, N. (October 2012). The size, place of birth, and geographic distribution of the foreign-born population in the United States: 1960-2010. Retrieved from https://www.census.gov/content/dam/Census/library/working- papers/2012/demo/POP-twps0096.pdf)

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FIGURE 5-5 Sikh family now US citizens.

Undocumented or illegal immigration continues to be a controversial topic in this country. Plans to end the flow of illegal immigrants across our southwestern border include building a 700-mile border wall and legislation that penalizes employers of undocumented workers. Concerns include the following:

In the past 20 years, many thousands of migrants are estimated to have died while crossing illegally into this country; there were 230 confirmed deaths during the first 9 months of 2014, with likely many more that were unknown (Brian & Laczko, 2018). Social justice is an important issue in community/public health nursing, and the national debate does not often consider the economic desperation and security concerns that drive people to put themselves in such jeopardy (see Chapters 23 and 27).

Immigration patterns are strongly influenced by immigration laws established since the 1800s:

In 1891, medical and economic inspections were ordered at all major entry points as an influx of poor immigrants mostly from Europe led to fears of disease and contagion. The Immigration Act of 1924 limited immigration and allowed consideration of national origin in an effort to slow the influx of immigrants from Eastern and Southern Europe. Immigration has steadily trended upward since 1945, partly explained by changes in immigration laws. In 1965, quotas were ended that limited immigration of certain groups, and family-sponsored immigration, known as family migration, was officially endorsed.

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The Immigration Reform and Control Act of 1986 (Public Law 99-603) “legalized 2.7 million undocumented immigrants,” and the Immigration Act of 1990 (Public Law 101-649) set numerical ceilings on certain immigrant groups, in part due to the AIDS crisis, and authorized increases for highly skilled workers or specific family members of aliens (Fairchild, 2018).

The terrorist attacks in 2001 led US President George W. Bush to suspend all immigration for 2 months. Suspicion about people from Middle Eastern countries permeated the nation—and worsened the social climate for immigrants. More recent trends include the following:

Political upheaval, crime, and war precipitating the migration of refugees and migrants from the Middle East, South Asia, and Africa into Europe and of Central Americans into the United States, with no comprehensive effort to quickly find placements for the continual stream of people as all countries wrestle with the social and political issues A social climate in the United States and other countries is often characterized by ambivalence about accepting refugees and immigrants and ambiguity about their status, such that newcomers find an environment that is both welcoming and hostile Law enforcement practices related to immigration that result in involuntary separation of parents and children at the US border, with negative and persistent effects on the health and well-being of both children and adults (Gubernskaya & Dreby, 2017) Increased staffing for both border and immigration officials, broader use of drones, an average of almost one death per day at the border with Mexico, and, from 1993 to 2020, a 10-fold increase in the budget for border protection (American Immigration Council, 2020)

Although broad cultural values are shared by most large national societies, those societies contain smaller cultural groups called subcultures.

Subcultures:

Are developed and preserved over time to meet the unique needs, values, and beliefs of people (McFarland & Wehbe-Alamah, 2018) Are aggregates of people within a society who share separate distinguishing characteristics, such as:

Ethnicity (being a member of a social group with a common racial, national, or cultural background, such as African American, Hispanic American [Merriam Webster Dictionary, 2020]) Occupation (e.g., farmers, physicians) Socioeconomic status (e.g., working class, middle class)

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Religion (e.g., Catholics, Muslims) Geographic area (e.g., New Englanders, Southerners) Age (e.g., older adults, school-age children) Gender (e.g., women, men) Sexual preference (e.g., gay, lesbian)

Contain even smaller groups known as microcultures, consisting of people who share specific experiences or practices and who hold a special cultural knowledge unique to the subgroup, which they share with others in the community (Spradley et al., 2016), such as:

Recent African refugees sharing resources and housing Syrian refugees (see Fig. 5-6) seeking business and entrepreneurial opportunities Hmong immigrants from Southeast Asia adopting selected aspects of US culture Third-generation Norwegians sharing unique food, dress, and values

Retain some characteristics of the society of origin, as noted by the eminent anthropologist Margaret Mead (1960), such as beliefs and practices, foods, language spoken at home, holiday celebrations, and treatment of illness Include Native Americans, Mexican Americans, Irish Americans, Swedish Americans, Italian Americans, African Americans, Puerto Rican Americans, Chinese Americans, Japanese Americans, Vietnamese Americans, and many other ethnic groups

FIGURE 5-6 Syrian refugees in Turkey looking back at their burning homes.

Furthermore, many microcultures exist in groups on the margins of mainstream culture, and acquire their own sets of beliefs and patterns for

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dealing with their environments. They have distinctive ways of defining the world and coping with life, such as:

Narcotics users and transient alcoholics Gangs, criminals, and terrorist groups Appalachian people living in the mountains of Kentucky, West Virginia, Tennessee, and Virginia Migrant farm workers Urban homeless families

TABLE 5-1 US Population by Race and Hispanic/Latino Origin, Census 2000 and 2010

Adapted from Humes et al. (2011).

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Ethnocentrism There is a difference between a healthy cultural or ethnic identification and ethnocentrism. Anthropologists note that ethnocentrism is a preference for one's own culture and belief that one's culture of origin is the best approach to life (Spradley et al., 2016). Ethnocentrism can inhibit a person's capacity for effective communication in a culturally diverse environment (Young, Haffjee, & Corsun, 2017). In turn, this can cause serious damage to interpersonal relationships and interfere with the quality and effectiveness of nursing interventions (McFarland & Wehbe-Alamah, 2018).

As shown in Figure 5-7, people can experience a developmental progression along a continuum from ethnocentrism, feeling one's own culture is best, to ethnorelativism—seeing all behavior in a cultural context (Blair, 2019). Some people may stop progressing and remain stagnated at one step, and others may move backward on the continuum. The left side of the continuum represents the most extreme reaction to intercultural differences: refusal or denial. On the right side is the characterization of people who show the most sensitivity to intercultural differences: incorporation.

FIGURE 5-7 Cross-cultural sensitivity continuum.

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CHARACTERISTICS OF CULTURE

In their study of culture, anthropologists and sociologists have made significant contributions to the field of community/public health. Their findings shed light on why and how culture influences behavior. Five characteristics shared by all cultures are especially pertinent to nursing's efforts to improve community health: culture is learned, it is integrated, it is shared, it is tacit, and it is dynamic.

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Culture Is Learned Patterns of cultural behavior are acquired, not inherited. People are not born with a cultural belief system but gain it through enculturation, the process of learning one's culture (Fig. 5-8). Aspects one learns through enculturation include (Kottack, 2017; Spradley et al., 2016):

FIGURE 5-8 Family enculturation helps children acquire shared values and attitudes.

Beliefs Dress Diet Language Expressions of emotions such as sadness, grief, joy, and happiness Smiling, laughter, and humor

Although culture is learned, each individual may experience life in a singular way, which affects the process and results of that learning. For example, rigid gender roles may be culturally taught, but an individual may approach life as transgender (Andrews, Boyle, & Collins, 2020). Because culture is learned, parts of it can be relearned. People might change certain cultural elements or adopt new behaviors or values. Some individuals and groups are more willing and able than others to try new ways and thereby influence change.

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Culture is Integrated Culture is a functional, integrated whole, not merely an assortment of customs and traits. As in any system, all parts of a culture are interrelated and interdependent. The components of a culture, such as its social norms or religious beliefs, perform separate functions but come into harmony with each other to form an operating and cohesive whole. Therefore, each component should be viewed in light of its connection to other components and to the whole, not independently.

To provide effective nursing care, nurses may find their own cultural beliefs, and practice systems need to be adjusted or reintegrated to accommodate the cultural beliefs and practices of others. For example, a nurse may promote the need for eating three balanced meals each day based on social and cultural beliefs and values that are related to good nutrition. This is necessary for health, and health is essential for productivity in work and career, quality of life, and achieving life goals. A client's beliefs and values in these areas may not be completely congruent with the nurse's (Box 5-4).

BOX 5-4 Recognizing and Respecting the Integrated Nature of Culture in Nursing Below are some examples of clients whose beliefs and practices may prove challenging for the nurse to respect and accommodate if not viewed in the context of their culture:

Parents who are Jehovah's Witnesses may refuse a blood transfusion for their child. This refusal may appear irrational or uninformed to those who do not understand their religious view of accepting blood and the need for bloodless procedures. The single behavior of refusing blood transfusions, when viewed in context, is part of a larger belief system and a basic component of the family's culture (Campbell, Machan, & Fisher, 2016). A Muslim woman may ask to be examined by a person of the same sex. Separation of genders is integral to her cultural beliefs, and it may be uncomfortable or even traumatic to receive care from a person of the opposite sex (Mujallad & Taylor, 2016).

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A member of a Native American community may be unable to adhere to appointments for renal dialysis. Although such a client may appear to be noncompliant with care, rigid appointment scheduling may require the client to reframe the client's concept of time, violating concepts of patience and pride (Spector, 2017).

Source: Campbell et al. (2016); Mujallad and Taylor (2016); Spector (2017).

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Culture is Shared Culture is the product of aggregate behavior, not individual habit. Certainly, individuals practice a culture, but customs are phenomena shared by all members of the group. About 50 years ago, anthropologist George Murdock explained this idea as follows (1972, p. 258): Culture does not depend on individuals. An ordinary habit dies with its possessor, but a group habit lives on in the survivors… transmitted from generation to generation…. From earliest childhood behavior is conditioned by the habits of those around him. He has no choice but to conform to…. his group.”

Involving the ideas of what is good, right, just, and fair, a culture's values are among its most important elements. A value is a notion or idea designating relative worth or desirability. The normative criteria by which people justify their decisions are based on values that are more deeply rooted than behaviors and, consequently, more difficult to change. Each culture classifies phenomena into good and bad, desirable and undesirable, and right and wrong. When people respond in favor of or against some practice, they are reflecting their culture's values about that practice.

Examples of values include:

Desirable traits: honesty, loyalty, and faithfulness Undesirable traits: lying, stealing, and cheating Eating meat: desirable and healthy versus sacrilegious or unhealthful Response to pain or grief: loud, vocal expressions versus silence and stoicism Speed and efficiency versus patience and thoughtfulness

No matter the culture, shared values give people in a specific culture stability and security and provide a standard for behavior, helping them know what to believe and how to act (Andrews et al., 2020). See Chapter 4 for more on values and ethics.

When community/public health nurses (C/PHNs) know that culture is shared, their understanding of human behavior expands, and their ability to provide effective care to members of specific cultures increases. For example, it was found that women from the Hmong culture were reluctant to get a Pap test for cervical cancer because they had to be in the lithotomy position, which they (along with women from other cultures) perceived as immodest. Realizing that this impacts women's access to cancer screening, researchers have developed a urine test that can detect cervical cancer at early stages, similar to the Pap test, making screening more accessible to underserved populations (Guerrero-Preston et al., 2016; Wood, Loftres, &

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Vahabi, 2018). This demonstrates that focusing on one individual's behavior may be less effective than working within the culture to promote well-being (Box 5-5).

BOX 5-5 STORIES FROM THE FIELD Being Sensitive to Cultural Beliefs and Practices In some rural American communities, the use of catnip tea is highly valued for reducing colic in babies. Kayla, a C/PHN, was concerned about a baby not consuming enough infant formula because the mother, Josie, was giving so much catnip tea to the baby based on her friends and family having successfully used it to reduce symptoms of colic. Realizing that culture is shared, Kayla worked through informal cultural leaders—the elder women. She contacted the oldest woman in the community and discussed the cultural practice. The elder shared the group's beliefs that catnip tea is vital to the well-being of infants for the first 6 months. Together with other women in the community, they discussed concerns and babies' need for nutrients and relief from colic pain. The elders acknowledged that only 1 or 2 oz of catnip tea are needed for pain relief. This was shared with young mothers in the community, and the mothers gradually reduced the amount of tea given to their infants. This helped infants consume more formula and gain weight. Josie learned that she could give less tea and more formula, resulting in less pain and

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more weight gain for her baby. The C/PHN worked within the bounds of cultural tradition, and the health of the infants improved (Spector, 2017).

1. Can you think of a similar cultural practice in your community that you may be able to approach in the same way as this C/PHN?

2. How would you go about researching the tradition and finding ways to incorporate the practice into your plan of care?

Source: Spector (2017).

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Culture is Generally Tacit As a guide for human interaction, culture can be tacit, mostly unspoken and unexpressed at the unconscious level. Members of a cultural group, without the need for discussion, know how to act and what to expect from one another. Culture provides an implicit set of cues for behavior, not a written set of rules. Spradley et al. (2016) explained that culture often lies below a conscious level because it is such a regular and pervasive part of the daily environment. It is like a memory bank in which knowledge is stored for recall when the situation requires it, but this recall process is mostly unconscious.

Culture:

Teaches the proper tone of voice to use for each occasion Prescribes how close to stand when talking with someone familiar or unfamiliar Guides how one should appropriately respond to elders and based on one's gender, role, and status

All of these attitudes and behaviors become so ingrained—so tacit—that they are seldom, if ever, discussed.

Because culture is mostly tacit, realizing which of one's own behaviors may be offensive to people from other groups is difficult. It also is difficult to know the meaning and significance of other cultural practices.

Silence is valued and expected by many Native Americans and Islamic women but may make others uncomfortable. Offering food to a guest in many cultures is not merely a social gesture but an important symbol of hospitality and acceptance; to refuse it, for any reason, may be an insult and a rejection. Touching or calling someone by their first name may be viewed as a demonstration of caring by some groups but could be seen as disrespectful and offensive to others.

C/PHNs have a twofold task in developing cultural sensitivity: we must try to learn clients' cultures and also must try to make our own culture less tacit and more explicit. Nurses bring both their professional and personal cultural history to the workplace, often developing unique values not shared with others who are not in the profession (Blais & Hayes, 2016). Cross- cultural tension can be resolved through conscious efforts to develop awareness, patience, and acceptance of cultural differences.

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Culture is Dynamic Every culture undergoes change; none is entirely static. Each culture is an amalgamation of ideas, values, and practices from many sources. This dynamic process is related to exposure to other cultural groups, and every culture is in a dynamic state of adding or deleting components. Functional aspects are retained; less functional ones are eliminated. Individuals may generate innovations within a culture and some members see advantages to changing behaviors, being willing to adopt new practices. This is important when working with communities to use new resources, such as access to the yearly flu vaccine.

When people enter a new culture, such as Sudanese refugees resettling in the United States (see Fig. 5-9), anxiety and frustration can occur. Nothing may be familiar; foods, language, expectations for dress, gestures, and even facial expressions may be misunderstood. This lack of familiarity can result in conflicted feelings that have been termed culture shock, leading to difficulty with interactions in the new culture (Spradley et al., 2016). Culture shock can develop with nurses providing care in unfamiliar countries and is known to affect international students studying in the United States or American students studying abroad. Serious difficulties can arise when members of a culture do not adapt to change or when culture shock is pervasive in a community (Box 5-6).

FIGURE 5-9 Sudanese man now living in the United States.

BOX 5-6 Evidence-Based Practice

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Cultural Identity and Outcomes Southeast Asian Hmong teenagers are among the first generation to be raised in the United States. Their parents had high hopes for them to restore honor and pride to a displaced people, but the teens struggle to balance their American lifestyle with Hmong traditions. They can feel overwhelming stress resulting from the generational and cultural gaps between themselves and their parents. Hmong community leaders, community health workers, school districts, law enforcement, and Hmong families have joined together to develop interventions to address these issues. A longitudinal study of Asian Americans found that 48% chose that label most of the time and that this “American identity” was often tied to positive academic and psychological adjustment (Kiang & Witkow, 2018, p. 64). Cheon, Bayless, Wang, and Yip (2018) examined ethnic/racial self-labeling among a diverse group of adolescents and noted differing patterns tied to contextual and individual influences.

1. Can you identify a group in your community with similar issues to the Hmong parents and children?

2. Has your community provided any services to assist families in acculturating or adapting to their cultural change?

3. If you are a C/PHN working with this group, what types of assessment and interventions would be helpful?

Source: Cheon et al. (2018); Kiang and Witkow (2018).

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Cultural adaptation is the successful adjustment to cultural changes and often follows the process of culture shock. Examples of cultural adaptation can range from something as simple as learning to use a knife and fork to the complexities of becoming fluent in a new language. C/PHNs can facilitate cultural adaptation by explaining practices and expectations of the American health care system in the context of the original culture of their clients. For example, nurses working with recent African immigrants can explain to them the need for general health exams for all children entering school and that this does not mean their children are “in trouble.”

Community/public health nurses must remember the dynamic nature of culture for several reasons.

Cultures and subcultures change over time; patience and persistence are key attributes when working toward improving health behaviors. Cultures change as their members see greater advantages in adopting “new ways.” Describing the changes in language and context acceptable to the culture is essential. Successful nurses understand their clients' culture when delivering culturally competent care (Andrews et al., 2020). Within a culture, change may occur because of certain key individuals who are receptive to new ideas and are able to influence their peers. Key individuals can adapt suggested changes to fit the cultural and group values. The health care culture is dynamic; Westerners are beginning to appreciate the validity of non-Western practices such as acupuncture, meditation, and the use of therapeutic herbs and spices such as turmeric and fenugreek (Canizares, Hogg-Johnson, Gignac, Glazier, & Badley, 2017). Our national health-related goals, the Healthy People initiative, change every 10 years. Healthy People 2030 includes a focus on eliminating health disparities and improving health literacy (Office of Disease Prevention and Health Promotion, 2019). See Box 5-7.

BOX 5-7 HEALTHY PEOPLE 2030 2030 Objectives with Statistically Significant Racial/Ethnic Disparities in Leading Health Indicators at Healthy People 2020 Midcourse Review

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Reprinted from U.S. Department of Health and Human Services (USDHHS). (2020). Browse 2030 objectives. Retrieved from https://health.gov/healthypeople/objectives-and-data/browse- objectives

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ETHNOCULTURAL HEALTH CARE PRACTICES

Throughout history, people have relied on natural elements to treat misfortunes, illness, or injuries experienced by family, clan, tribe, or community members. Specialized knowledge about practices and substances (e.g., rituals, incantations, berries, plants, barks) is often held by one person in the group. This revered community leader, known as a medicine man/woman, healer, or shaman, may acquire the skills through apprenticeship or is believed to be born with them (McFarland & Wehbe- Alamah, 2018; Spector, 2017).

In this section, we present:

An overview of the three views of health care: biomedical, magicoreligious, and holistic Selected folk medicines and home remedies, such as herbs, teas, and poultices Over-the-counter (OTC) drugs and patent medications Complementary or alternative therapies Recently developed, expensive medications Various self-care practices

This section concludes with the C/PHN's role and responsibilities to provide culturally competent care in relation to caring for, respecting, teaching, and treating clients from different cultures.

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The World Community Beliefs about the causes and effects of illness, health practices, and health- seeking behaviors are all influenced by a person's, a group's, or a community's perception of what causes illness and injury and what actions can best treat or cure the health problem. The three major views in the world community are biomedical, magicoreligious, and holistic health beliefs (Andrews et al., 2020).

Biomedical View Common in Western societies, the biomedical view theorizes that all aspects of health can be understood through the sciences of biology, chemistry, physics, and mathematics. Furthermore, there is the belief that life can be manipulated by humans through physical and biochemical processes (Andrews et al., 2020). Examples of this viewpoint include:

Disease is the breakdown of the human machine through stress, injury, pathogens, or genetic/structural changes. Disease causes illness, which has a specific cause and a set of treatment requirements. Treatments can be aggressive including medication, surgery, and even genetic engineering.

Many health care professionals, including C/PHNs, believe this biomedical model is the only and best approach. As a result, they may have trouble understanding diverse cultures that incorporate the holistic or magicoreligious views, and clients may not receive culturally competent care. To be effective with diverse clients, C/PHNs must be knowledgeable about and accepting of a range of cultural health practices (Murcia & Lopez, 2016; Patwardhan, Mutalik, & Tillu, 2015).

Magicoreligious View Many cultural beliefs are grounded in the magicoreligious approach, which focuses on control of health and illness by supernatural forces.

Diseases are thought to originate from intrusion of a malevolent spirit, punishment for the deeds of ancestors, and other indications that God, the gods, or other supernatural forces are in control. Health is seen as a spiritual gift or reward and illness as an opportunity to be resigned to God's will (Andrews et al., 2020). Prayers for healing or well-being of self and others, participation in prayer groups, and requests for prayer are effective (Baldwin,

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Velasquez, Koenig, Salas, & Boelens, 2016; Levin, 2016). Death rituals connected with religious faith are designed to ease human departure from this life and help others cope with grief and loss (Roberson, Smith, & Davidson, 2018). Health and illness belong first to the community and then to the individual; communal activities are viewed as helpful (Andrews et al., 2020). Ceremonies, wearing special garments, and work with spiritual healers are important.

Religious beliefs, an individual's spirituality, and how these factors interface with wellness and healing practices are important to clients and cannot be separated from their culture. Community/public health nurses who are familiar with and respect the magicoreligious viewpoint offer culturally competent care.

Holistic View Approaching health from a holistic standpoint, the world is viewed as seeking harmonious balance; imbalance of natural forces can create chaos and disease. Many cultural groups use a holistic approach in tandem with biomedical and magicoreligious beliefs. In this belief system, for an individual to be healthy, all facets of the individual's nature—physical, mental, emotional, and spiritual—must be in balance (Eliopoulos, 2018). The holistic viewpoint can be expressed by:

Use of specific foods, beverages, and herbs to balance hot or cold disease states The Chinese concept of yin and yang, in which forces of nature are balanced Considering that infectious disease such as tuberculosis is not only caused by an organism but also by the environment, malnutrition, and poverty (Andrews et al., 2020; Eliopoulos, 2018)

Folk Medicine and Home Remedies All cultures have home remedies and aspects of folk medicine. Many of us remember our mothers giving us hot herbal tea with lemon or using ointments and piling on blankets to relieve symptoms of a mild illness. Treatments as part of folk medicine are verbally passed down from generation to generation and began when access to medical care was limited. Some clients may never plan to seek Western medical treatment but may share with you, the C/PHN, a practice they are using to treat a family member. Your response and actions may mean the difference between health and illness or injury. Folk practices are common in maternal and child health;

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some that may be encountered include (Andrews et al., 2020; Spector, 2017) the following:

Pregnant women not reaching above their head, as doing so will cause the umbilical cord to strangle the baby Taping coins over a newborn's umbilical area to prevent hernias Giving catnip tea to infants because it soothes them Holding a baby upside down by the heels to “wake up the liver” Not letting a cat be near a sleeping baby, because it will “suck the life” out of the baby Using vinegar to relieve hypertension and skin irritations (Quandt, Sandberg, Grzywacz, Altizer, & Arcury, 2015)

Home remedies are individualized caregiving practices, often used before people seek advice from health care professionals. Each of us has a set of home remedies our parents used on us that we are likely to use on ourselves or our own children before or instead of calling the pediatrician. Examples include using baking soda paste on a bee sting, ice on a “cold sore,” or cranberry juice to prevent a urinary tract infection.

Herbalism Use of herbs to treat illness is a centuries-old practice that is gaining popularity in our American culture (Fig. 5-10). Clients may not consider the use of herbs to be a “medical treatment” and may not tell health care professionals about their use (Donoghue, 2018). Textbooks and other books for the general public have been published on medicinal herbs (Chevallier, 2016; Kennedy, 2017; Pizzorno, Murray, & Joiner-Bey, 2016). In an increasingly multicultural society, the source, form, and identity of many herbs, roots, barks, and liquid preparations are difficult for most C/PHNs to distinguish. A book with pictures and descriptions, botanical form, purported indications and uses, and implications for nursing management of herbs is an important tool to keep handy when interacting with clients (Barrett, 2015). Basic safety questions that C/PHNs should answer about an herb when teaching or interacting with families include:

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FIGURE 5-10 A Chinese herb store.

Is the herb contraindicated with prescription medications the client is taking? Is the herb harmful? Does it have negative side effects? How often is it used? Is the client relying on the herb, without positive health changes, and neglecting to get effective treatment from a health care practitioner?

Just because herbs are not regulated as drugs, they are not risk-free. Variations in quality, strength, processing, storage, and purity may occur, leading to unpredictable effects. For these reasons, herbs must be used only in moderation and with caution, preferably with guidance by a health care practitioner (Donoghue, 2018). Examples of potentially harmful herbal supplements include Ephedra, Ginko, and Goldenseal for those persons with cardiac conditions, as these herbs can increase blood pressure and heart rate, as well as heighten the risk of bleeding (Cleveland Clinic, 2018).

Prescription and OTC Drugs

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The cautions mentioned about herbs can also apply to most dietary supplements and OTC preparations. Additional concerns with these drugs include:

Dietary supplements and OTC drugs undergo a less rigorous process of review and testing by the U.S. Food and Drug Administration than do prescription medications (USFDA, 2015). Many OTC drugs were once available only by prescription and remain powerful medicines. Herbal or dietary supplements do not have to be FDA -approved before manufacturers can sell them (USFDA, 2017). All drugs can have major side effects, may be contraindicated in people with certain conditions, and may not be safe to use in combination with certain other drugs. Many new prescription medications are so expensive that clients cannot afford to take them as prescribed. Often, older, less expensive, and more frequently used drugs work as well as the newer, more expensive ones, which are heavily marketed by drug companies to health care practitioners and consumers.

Community/public health nurses who see clients over time can assist them through medication review and instruction, advocating for them to receive a less expensive form of the same medication and reporting on the effectiveness of newly prescribed medications. Many pharmaceutical companies now have low-cost prescription assistance programs for those in need (Partnership for Prescription Assistance, 2018).

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Integrated Health Care and Self-Care Practices Complementary and alternative medicine (CAM), a multibillion-dollar industry in the United States, includes a broad array of healing resources (Donoghue, 2018). Self-care activities may include CAM, other medications, and spiritual and cultural practices.

These widely varied approaches are designed to promote comfort, health, and well-being and may include

Therapies and treatments (juice diets, fasting, coffee enemas, and biofeedback) Exercise activities (T'ai chi, yoga, and dance) Exposure (aromatherapy, music therapy, and light therapy) Manipulation (acupuncture, acupressure, chiropractic, cupping ([Fig. 5- 11], and reflexology).

FIGURE 5-11 Cupping has been used by many cultures.

Complementary therapies are often used in conjunction with Western medicine, an approach known as integrated health care, such as for pain relief during labor (Vitale & Jenner, 2018) and to improve sleep in the intensive care unit (Cho, Lee, & Hur, 2017). Complementary therapies have become so commonplace that some have suggested developing policies and guidelines for their use.

The C/PHN should be aware of the variety of therapies available and how to get information for clients while remaining objective and supportive of the client's choices. When a therapy contradicts the recommendations of the client's health care practitioner, the nurse may be able to provide the pros and cons of continuing the complementary therapy. Also, the nurse may be

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able to suggest therapy forms that would complement Western medicine for the client, such as music to promote relaxation and reduce stress or biofeedback for chronic pain management. Complementary and self-care practices should be uniquely chosen for each individual within the context of the client's cultural group (Lindquist & Tracy, 2018). The culturally competent nurse respects these decisions, while promoting client health.

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ROLE AND PREPARATION OF THE COMMUNITY/PUBLIC HEALTH NURSE

As a C/PHN, for you to be an effective health care advocate for clients from different cultural groups, you must be prepared to:

Speak knowledgeably about health care practices and choices Assess the client or family adequately, to know what belief system motivates their choices Teach clients about the limits and benefits of cultural health care practices Individualize assessment and caregiving for the client within the client's culture, not generalize about the client based on cultural group norms

Preparation to work effectively with clients in the area of cultural health care involves developing cultural awareness and promoting sensitivity to the differences among people from diverse ethnocultural groups. You, the nurse, can prepare by:

Performing a cultural self-assessment to identify your own beliefs and biases Learning from peers who are from the same cultural group as the clients Attending workshops or conferences on cultural topics, transcultural nursing, and cultural ethics Reading books on ethnocultural and alternative health care practices Talking with clients about their views and practices and learning from them Keeping an open mind and being curious about various practices Attending community cultural events, such as Native American powwows (Fig. 5-12), ethnic food and cultural festivals, or Cinco de Mayo celebrations

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FIGURE 5-12 Nevada Paiute tribe powwow.

There are textbooks, novels, and articles about cultures in the community in which one practices. For example, the classic book The Spirit Catches You and You Fall Down (Fadiman, 1998) describes a Hmong child, her American doctors, and the collision of two cultures in California. The experience of public health nurse Karin Urso, who worked with people from many different countries and cultures, illustrates the benefits of being open-minded (Box 5-8).

BOX 5-8 PERSPECTIVES

Learning About Other Cultures I was always interested in learning about other countries and cultures. However, I didn't realize that an overseas assignment would teach me so much about myself in addition to other cultures and ways of living. The lessons were sometimes difficult but always rewarding. I knew that my expectations would not always be met, yet it did surprise me how different the experience was from what I had imagined it

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would be. My job assignment, location, and team members changed frequently. Flexibility, comfort with ambiguity, a sense of humor, a deeper reliance upon my faith, patience when results were not forthcoming, trust in others, and the ability to cross multiple cultures with some degree of ease were all skills that I developed over time. Most important to being successful at my job was to maintain the attitude of a “learner,” not a “solver of problems” or “the person with all the answers.” I made friends with people from all over the world who graciously accepted me into their lives, thus enriching mine. I learned that we all are different, but that every behavior has a reasonable explanation when you take the time to listen with your heart as well as with your ears. I found that I actually preferred other ways of doing and being while still maintaining those parts of my identity that were valuable to me. When I returned home, I found that my newly developed skills were still necessary—because I had changed and had to adjust to reentry into my home culture!

Karin Urso, PHN

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TRANSCULTURAL COMMUNITY/PUBLIC HEALTH NURSING PRINCIPLES

Culture profoundly influences thinking and behavior and has an enormous impact on the effectiveness of health care. Just as physical and psychological factors determine clients' needs and attitudes toward health and illness, so too can culture.

About 50 years ago Kark emphasized that “culture is perhaps the most relevant social determinant of community health” (1974, p. 149). Culture determines how people rear their children, react to pain, cope with stress, deal with death, and value the past, present, and future. Culture influences diet and eating practices, which can be difficult to change due to culture's impact (McFarland & Wehbe-Alamah, 2018; Spector, 2017).

Despite its importance, the client's culture is often misunderstood or ignored in the delivery of health care (McFarland & Wehbe-Alamah, 2018). Cultural diversity is increasing in our world, and it is essential that health care professionals are prepared to effectively work with diverse health care team members and clients (Andrews et al., 2020). Effective and culturally competent care involves:

Avoiding ethnocentric attitudes Bridging cultural differences Developing knowledge and skill in serving multicultural clients Placing clients' responses to care within the context of their lives

Avoiding ethnocentrism requires the nurse to be willing to examine one's own culture carefully and to become aware that alternative viewpoints are possible. The nurse attempts to understand the meaning other people derive from their culture and appreciate their culture as important and useful to them (McFarland & Wehbe-Alamah, 2018). Ignoring consideration of clients' different cultural origins often has negative results.

Culture is a universal experience; each person is part of some group, and that group helps to shape the values, beliefs, and behaviors that make up their culture. Even within fairly homogeneous cultural groups, subcultures and microcultures have distinctive characteristics.

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Further differences, often due to social class, socioeconomic status, age, or degree of acculturation, can be found within microcultures. These latter differences, called intraethnic variations, only underscore the range of culturally diverse clients served by C/PHNs.

Community/public health nursing practice with cross-cultural groups, known as transcultural nursing, means providing culturally sensitive nursing service to people of an ethnic or racial background different from the nurse's (Andrews et al., 2020; McFarland & Wehbe-Alamah, 2018). Principles of transcultural nursing practice can guide C/PHNs (Box 5-9):

BOX 5-9 Cross-Cultural Guidelines 1. C/PHNs should strive to ensure all population members receive care and

services that are respectful and sensitive to their client's cultural beliefs and practices.

2. Be aware of your own belief system and values; understand and acknowledge that cultural differences may exist.

3. Develop a basic understanding and knowledge of other cultures, but do not use generalizations about other cultures to stereotype or oversimplify your ideas about another person or group. Remember there are differences within each cultural group that are influenced by individual characteristics and geographical location; therefore, never assume you understand what a person from another culture thinks or feels.

4. Demonstrate a genuine interest in the client's personal circumstances and seek to establish trust. Suspend judgments and respect the opinion of others.

5. Be aware of power imbalances and the effect on communication. Identify members who are accorded higher status and authority in family or group and respect the status hierarchy. Respect gender and age differences.

6. Do not assume that there is only one way (yours) to communicate. Keep working on ways to improve your cross-cultural communication skills. For example, avoid using jargon or slang that may not be understood cross-culturally. Use very clear and simple English.

7. Unspoken communication can be powerful; be aware and use appropriate body language.

8. Practice active listening. Try to put yourself in the other person's shoes, especially when another person's ideas or perceptions are different from your own. Be willing to step outside your comfort zone.

9. Do not assume that just because clients say they understand the information that they really do. Clarify questions and statements. Seek feedback by reframing the question in a different form to ensure understanding.

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10. Apologize for cultural mistakes. Admit your own limitations and state willingness to learn from others. Show appreciation for the opportunity to learn from others.

11. Easily understood information and services should be delivered in the preferred language of the population served. Whenever possible, use interpreters who are trained in culturally competent care, and if possible, avoid using family members or friends to interpret. Look directly at the client, not the interpreter, when speaking.

12. Assess immigration history and refugee stress or trauma; with children and adolescents, assess gaps in acculturation and potential family conflicts and cause of health problems and health beliefs; assess if they have experienced discrimination, racism, or bias.

13. Practice—we get better at cross-cultural collaboration when we practice it.

Source: Douglas et al. (2014); Douglas, Pacquiao and Purnell (2018); Underwood and Kelber (2015).

Develop cultural self-awareness. Cultivate cultural sensitivity. Assess the client group's culture. Show respect and patience while learning about other cultures. Examine culturally derived health practices.

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Develop Cultural Self-Awareness To avoid stereotyping, prejudice and racism, ethnocentrism, cultural imposition, and cultural conflict (a perceived threat arising from a misunderstanding of expectations between clients and nurses when either group is not aware of cultural differences), self-awareness is crucial for the nurse working with people from other cultures (Andrews et al., 2020; McFarland & Wehbe-Alamah, 2018). Cultural self-awareness means recognizing the values, beliefs, and practices that make up one's own culture and becoming sensitive to the impact of one's culturally based responses.

Although C/PHNs may think they are being helpful when operating from their own sets of cultural values and practices, doing so may actually have negative consequences and even cause damage to relationships with clients when cultural values differ. The nurse who has expectations for prenatal weight gain and values actions to limit weight could cause damage to a therapeutic relationship if the nurse does not take into account cultural expectations about diet during pregnancy to assure a healthy infant. To develop awareness, nurses can complete a cultural self-assessment by analyzing their own:

Influences related to racial and ethnic background Verbal and nonverbal communication patterns Values and norms (expected cultural practices or behaviors) Health-related beliefs and practices

Because culture is mostly tacit, it takes conscious effort and hard work to develop true awareness of one's own cultural biases or influence. A nurse can ask selected clients to critique nursing actions in light of the clients' own culture. Developing this awareness will reward you with a more effective understanding of self and an enhanced ability to provide culturally relevant service to clients (Andrews et al., 2020; Spector, 2017). See Box 5-10 and Table 5-2.

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TABLE 5-2 Cultural Assessment Guide

BOX 5-10 Cultural Self-Assessment Think about the culture of your family (parents and grandparents). Answer the following questions about your own cultural background:

Relationship to the dominant culture—Does the dominant culture have any stereotypes, misconceptions, suspicions, or historical issues related to your family's culture? If a minority culture, what is your family's view of the dominant culture? What cultural stereotypes does your family express?

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Verbal—What is the dominant language of your family's culture? How does your family share information and feelings, explain the meaning of terms, use proverbs, and incorporate direct questioning versus silence and passivity? Nonverbal—Describe your family's use of eye contact, facial expressions, body movements, and touch. Perception of time—Is your family's culture future, present, or past oriented? Personal space—Describe your family's concepts of boundaries and interpersonal distance. Perception of family roles and organization—Who is responsible for care of the children in your family? Who makes financial and health care decisions? Describe gender roles. Biological variations—Describe your family's skin and hair color, susceptibility to disease, enzymatic differences, and typical growth and development. Diet—What are typical meals in your family? How food is used (celebrations, fasting, healing, etc.)? Education—Describe your family's typical learning style (visual, auditory, psychomotor; formal/informal education). Spirituality—What are your family's spiritual beliefs and values, spiritual practices and support, rituals and taboos? Health beliefs—Describe your family's understanding of the meaning of health and illness (e.g., cause, perception of symptoms/intensity, seriousness, expression of illness, need for medical attention); beliefs about death and dying; beliefs about pregnancy, labor and delivery, postpartum period, and childcare. Health behaviors—What activities does your family do to promote health and prevent disease? Describe their help-seeking behaviors and use of home remedies, traditional or folk healers, and magicoreligious practitioners. What status is given to health care providers?

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Cultivate Cultural Sensitivity Nurses should be aware of the significant impact of culture on behavior. Cultural sensitivity requires recognizing that culturally based values, beliefs, and practices influence people's health and lifestyles and need to be considered in plans for service (Browne, Hackett, & Burger, 2017; Darnell & Hickson, 2015; McFarland & Wehbe-Alamah, 2018). It also first demands self-reflection about personally held stereotypes and biases, along with self- assessment of one's own cultural influences (Marion et al., 2017). Some hints to ensure culturally sensitive care include:

View culture as an enabler rather than a resistant force. Recognize feelings and reinforce dignity and worth as an individual or group. Take time for a pleasant conversation and build rapport. Involve significant family members in care. Reassure the client regarding confidentiality. Be aware of cultural diversity within the same ethnic group. Communicate openness, acceptance, and willingness to learn. When a cultural practice is unknown, ask the client to detail preferences, and then provide respectful care. Incorporate cultural beliefs into the plan of care.

A client's cultural values and health practices may sharply contrast with those of the nurse. Failure to recognize this contrast can lead to a communication breakdown and ineffective care. Once differences in culture are recognized, it is important to accept and appreciate them. For example, a nurse visiting a new immigrant family can avoid the dangerous ethnocentric trap of assuming that the nurse's way is best and consequently develop a more trusting and effective relationship with the clients. As a part of developing cultural sensitivity, nurses need to understand clients' points of view. By listening, observing, and learning about other cultures, the nurse can use culturally sensitive strategies for care and avoid ethnocentrism. Nurses who attempt to understand the feelings and ideas of their clients, establish a trusting relationship and open the door to the possibility of their clients' adopting new healthy behaviors. The American Nurses Association's (2015) Nursing: Scope and Standards of Practice outlines a set of competencies for culturally congruent practice. See Table 5-3 for culturally related competencies for registered nurses.

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TABLE 5-3 Cultural Competence

Source: Douglas et al. (2014).

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Assess the Client Group's Culture Learning the culture of the client first is critical to effective nursing practice. During a cultural assessment (Giger, 2017), the nurse obtains health-related information about the values, beliefs, and practices of a cultural group. There usually is a culturally based reason for clients to engage in (or avoid) certain actions. Instead of making assumptions or judging clients' behavior, the nurse first must learn about the culture that guides that behavior. For example, a client might severely limit the foods she allows her child to eat, believing that many from her culture have food allergies (Widge et al., 2018).

Interviewing members of a subcultural group can provide valuable data to enhance understanding (Andrews et al., 2020). The concept of cultural diversity can be understood in a general way, but each individual group should be appreciated within its own cultural and historical context. It is not practical to deeply study all cultural groups the nurse encounters. Instead, a general cultural assessment can be accomplished by questioning key informants, observing the cultural group, and reading current professional literature. These six categories comprise a general cultural assessment:

1. Ethnic or racial background: Where did the group originate, and how does that influence their status and identity?

2. Language and communication patterns: What language is preferred, and what are the group's culturally based communication patterns?

3. Cultural values and norms: What are the values, beliefs, and standards regarding family roles education, child-rearing, work and leisure, aging, dying, and rites of passage?

4. Biocultural factors: What unique physical or genetic traits predispose this group to certain conditions or illnesses?

5. Religious beliefs and practices: What are the common religious beliefs, and how do they influence roles, health, and illness?

6. Health beliefs and practices: What are the beliefs and practices regarding illness prevention, causes, and treatment?

In practice, a thorough cultural assessment may be too time-consuming and costly. Instead, the two-phase assessment process may be used, as outlined in Table 5-4. Categories to explore in the assessment include values, beliefs, customs, and social structure components.

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TABLE 5-4 Two-Phase Cultural Assessment Process

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Show Respect and Patience While Learning About Other Cultures When learning about other cultures, key behaviors are to demonstrate respect and to practice patience. Some behaviors that help the nurse overcome language barriers include:

Allow enough time for communication. Maintain a relaxed and unhurried attitude. Arrange for an interpreter when needed (Fig. 5-13). Speak to the client, not the interpreter. Use simple language and avoid slang and jargon. Watch for verbal and nonverbal cues. Ask open-ended questions. Validate feelings and understanding. Use any words you know in the client's language.

FIGURE 5-13 Hearing-impaired client helped by interpreter using sign language.

A nurse shows respect when involving a women's group in decisions and offering them choices about health topics to cover. Respect is evident when a nurse gives positive recognition to the importance of a client's culture. Attentive listening is a way to show respect and to learn about a client's culture. The nurse arranging for an interpreter to assist with a language barrier shows respect, including for those with hearing impairment. See

for best practices for working with interpreters. A minority group is part of a population that differs from the majority

and often receives different and unequal treatment. A message may be

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conveyed that their ways are inferior to those of the dominant culture, and it can be difficult for them to retain pride in their lifestyles or in themselves (McFarland & Wehbe-Alamah, 2018; Spector, 2017). This message may be implied or unintentional. In interacting with clients from a minority group, the nurse should:

Provide personal attention: some clients may perceive efficiency and less personal attention as disrespect, which could impair their trust in health care professionals. Show respect: this can help break down barriers in cross-cultural communication. Practice cultural relativism: cultural relativism is recognizing and respecting alternative viewpoints and understanding values, beliefs, and practices within their cultural context (Spector, 2017). Be patient: it takes time to establish the nurse–client relationship, especially when working with two different cultures. Trust must be earned, and that may take weeks, months, or years. Time must be allowed for both nurse and clients to learn how to communicate with one another, to test one another's trustworthiness and to learn about one another.

Cultural brokering involves mediating or building connections between those from different cultural backgrounds to promote change (Douglas et al., 2014; Jang, 2017). Aspects of both the nurse's and the clients' cultures can, and probably will, change. When working with a family from an unfamiliar cultural background, for example, you can explain your usual method of working with clients and may modify some usual practices to adapt them to the family's culture. The family, in turn, may begin to assume the nurse's recommended health care practices. This process of building trust and rapport with your client may take several months, but time, respect, and patience all help to break down cultural barriers (Fig. 5-14).

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FIGURE 5-14 Building trust and rapport with your client is essential.

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Consider Culturally Derived Health Practices Some traditional practices, such as customary diet, birth rituals, and certain folk remedies, may promote both physical and psychological health. Other practices, neither harmful nor health promoting, are useful in preserving the culture, security, and sense of identity of a cultural group. Some traditional practices may be directly harmful to health.

Examples of harmful practices include:

Sole use of herbal poultices to treat an infected wound when antibiotics are needed “Burning” the abdomen to compensate for heat loss associated with diarrhea The use of Greta or Azarcon (common Hispanic home remedies for stomach discomfort), which contain lead (CDC, 2019; McFarland & Wehbe-Alamah, 2018)

Cultural health practice and aggregate health assessment can be combined to preserve accepted practices while incorporating Western medicine for full treatment efficacy. If a group has a high incidence of low- birth-weight babies, pregnancy complications, skin infections, mental illness, or other health problems, it may be helpful to learn more about the group's cultural health practices. Practices clearly damaging to health can be discussed with group leaders and healers. Knowing the group's norms for authority and decision-making can be helpful to achieve improvements while respecting traditional health practices. An example of the consequences of not clearly understanding cultural norms is found in Boxes 5-11 and 5-12.

BOX 5-11 STORIES FROM THE FIELD The Importance of Cultural Sensitivity In a foreign country, well-intentioned government officials, including representatives of the health ministry, identified problems related to substandard housing among a particular aggregate of native people. To assist this community, the officials spent a great deal of time, energy, and finances planning and

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building homes for the native group. The homes were small but modern and offered many of the conveniences that officials believed would improve the quality of life for the community.

The members of the native group were appreciative of the group's efforts and moved into their new homes. Before long, however, officials realized that one by one the community members were moving back to their “substandard” housing. When asked about their lack of appreciation for the improved lifestyle, the group informed the officials that their watering hole was their lifeline and that the houses were not only uncomfortable to them but were too far from their watering hole. Soon, all the native families had returned to living on the land, and the homes were part of a veritable ghost town in the middle of nowhere.

1. Was the native community truly “poor,” as the officials seemed to think?

2. Discuss your perception of the following issues: cultural imposition, cultural poverty, dignity, and spirit.

3. Debate with a fellow student the pros and cons of trying again to improve the native people's quality of life.

BOX 5-12 STORIES FROM THE FIELD Emily's New Clients As she drove down the dirt road and parked her car next to the reservation community hall, Emily Josten felt apprehensive. The previous C/PHN had alerted her about the “difficulty of working with this population” and that she had “never gotten anywhere with them.” Only through the urging of Mrs. Brown, a community aid, had a group of the women reluctantly agreed to meet with the new nurse. They would see what she had to say.

Emily walked to the far corner where a group of women sat silently in a circle. Only their eyes turned; their faces remained impassive. Mrs.

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Brown introduced her to the group. Emily smiled. She told them of her background and explained that she had not worked with people on the reservation before. There was a long silence. No one spoke. Emily continued, “I'd like to help you if I can, maybe with problems about care of your children when they are sick or questions about how to keep them healthy, but I don't know what you need or want.” Silence fell again. She would like to learn from them, she repeated. Would they help her? Again, Emily felt an uncomfortable silence.

Then one woman began to speak. Quietly, but with deep feeling, she described several bad experiences with the previous nurse and the county social worker. Then others spoke up: “They tell us what we should do. They don't listen. They say our way is not good.” Seeing Emily's interest and concern, the women continued. One of their main issues was their children's health. Another was the high incidence of accidents and injuries on the reservation. They wanted to learn how to give first aid. Other concerns were expressed. The group agreed that Emily could help them by teaching a first-aid class.

In the weeks that followed, Emily taught several classes on first aid and emergency care. She then began a series of sessions on child health. Each time, she asked the women to choose a topic or problem for discussion and then elicited from them their accustomed ways of dealing with each problem; for example, how they handled toilet training or taught their children to eat solid foods. Her goal was to learn as much as she could about their culture and to incorporate that information into her teaching, which preserved as many of their practices as possible. Emily also visited informally with the women in their homes and at community gatherings.

She learned about their way of life, their history, and their values. For example, patience was highly valued. It was important to be able to wait patiently, even if a scheduled meeting was delayed as much as 2 hours. It also was important for others to speak, which explained the women's comfort with silences during a conversation. Honesty, reliability, and generosity were viewed as important standards of behavior. These were some of the values by which they judged Emily and other professionals. Emily's honesty in keeping her promises enabled the women to trust her. Her generosity in giving her time, helping them occasionally with some household task and arranging for childcare during classes, won their respect.

The women came to accept her, and Emily was invited to eat with them and share in tribal gatherings. The women corrected and advised her on acceptable ways to speak and act. Her openness and patience to learn and her respect for them individually, and as a people, had paved the way to improving their health. At first, she felt that her progress was

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slow, but this slowness was an advantage. She had built a solid foundation of cross-cultural trust, and in the months that followed she saw many changes in her clients' health practices.

1. What actions did Emily take that were culturally sensitive? Discuss ways in which you can incorporate these actions into your client care.

2. Discuss with another student the reasons you think the first C/PHN failed to make progress with this group of women.

3. Did Emily complete a cultural assessment? If your answer is “no,” why not? If “yes,” describe how this was done.

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SUMMARY

Culture refers to the beliefs, values, and behaviors that are shared by members of a society and provide a template or “road map” for living. Culture has five characteristics:

1. It is learned from others. 2. It is an integrated system of customs and traits. 3. It is shared. 4. It is tacit, mostly unspoken.5. It is dynamic.

Cultural diversity, or cultural plurality, refers to the coexistence of a variety of cultural patterns within a geographic area, either between cultures or within a given culture; smaller culturally distinctive groups may exist within a culture and are known as subcultures and microcultures. The increasing number of clients from different cultures requires that community health nurses should understand and appreciate cultural diversity. Ethnocentrism, or a bias toward one's own ethnic group, can create serious barriers to effective nursing care. Understanding cultural diversity and being sensitive to the values and behaviors of cultural groups often is the key to effective community health intervention. To gain acceptance, nurses strive to introduce improved health practices presented in a manner consistent with clients' cultural values. Nurses should be aware of and respect the three major views of health care in the world—biomedical, magicoreligious, and holistic. Nurses should be able to identify CAM treatments, such as folk medicine, home remedies, herbs, and other therapies; assess their clients' use of them; and, when appropriate, recommend their use. Five transcultural nursing principles, drawn from an understanding of the concept of culture, can guide community/public health nursing practice:

1. Develop cultural self-awareness. 2. Cultivate cultural sensitivity. 3. Assess the client group's culture. 4. Show respect and patience while learning about other cultures. 5. Examine culturally derived health practices.

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ACTIVE LEARNING EXERCISES

1. Pair up with another student from a different culture. Have a conversation about your own cultural practices (e.g., food, health, values, holidays). Complete a cultural interview and assessment of each other using a guide from this chapter. What similar patterns or themes do you notice? What are the differences? What was something new about this culture that you discovered?

2. Complete a cultural assessment of one of your clients and share the findings with your class. How do cultural values influence health behaviors, parenting, diet, social interaction, and other areas of life? How can you incorporate this information into your plan of care?

3. Consider health concerns or issues with a cultural group in your community. How could you apply 3 of the 10 essential public health services (see Box 2-2 ) in resolving this issue? Explain the rationale for your choices. What interventions would be most helpful? How would you ensure cultural competence and sensitivity?

4. Consider a recent high-profile event (e.g., Puerto Rico or Bahamas hurricanes, mass shooting in El Paso, TX) or a similar local event. Debate with other students whether ethnocentrism, stereotyping, and/or racism were influential factors, and give your rationale.

5. Find out if you have refugee populations in your area or state. Talk with program staff or the refugees themselves. Or, if this does not apply in your area, talk with two people from an unfamiliar cultural group. What caused them to move here? What assistance or resources are provided to them? How are they learning English? How are they finding housing and jobs? What are their hopes for the future? Have they felt welcomed or experienced discrimination? Describe four ways that C/PHNs can provide care and assistance for refugee populations.

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UNIT 2 Community/Public Health

Essentials

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CHAPTER 6

Structure and Economics of Community/Public Health Services

“The success or failure of any government in the final analysis must be measured by the well- being of its citizens. Nothing can be more important to a state than its public health; the state's paramount concern should be the health of its people.”

—Franklin Delano Roosevelt (1882–1945)

KEY TERMS Adverse selection Capitation Cost sharing Cost shifting Cross subsidization Diagnosis-related groups (DRGs) Economics Exclusive provider organization (EPO) Fee-for-service (FFS) Health–income gradient Health maintenance organization (HMO) Health reimbursement accounts (HRAs) Health savings accounts (HSAs) High-deductible health plans (HDHPs) High-deductible health plans with a savings option (HDHP/SOs) Macroeconomic theory Managed care Managed competition Medicaid Medical home Medicare Microeconomic theory Moral hazard Point-of-service (POS) plan Preferred provider organization (PPO) Prospective payment Retrospective payment Risk averse Single-payer system Supply and demand Third-party payments Underinsured

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Uninsured Universal coverage

LEARNING OBJECTIVES Upon mastery of this chapter, you should be able to:

1. Describe the current organizational structure of the United States' health care system, including public health.

2. Explain the influence of selected legislative acts in the United States on shaping current health care policy and practice.

3. Compare and contrast different payment systems for health care services, including managed care, fee-for-service, and single-payer systems.

4. Analyze the trends and issues influencing health care economics and delivery of public health services.

5. Discuss potential health care reform measures and the potential impact on community/public health nursing.

6. Describe how health care system funding and financing influences community/public health nursing practice.

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INTRODUCTION

In the United States, two systems address the health of the people who live here: the health care system and the public health system (American Public Health Association [APHA], 2019a). The United States' health system is often described as a “crazy quilt.” This type of quilt is not planned; rather, it develops from scraps of fabric that are collected over many years. Similarly, health care and public health services in the United States are provided through a mix of private and public programs and institutions; each of these was created to meet specific needs at different times in history. The substantial gaps in the U.S. systems, or tears in the quilt, are intermittently patched with new programs, institutions, or funding streams. Each patch makes a complicated system even more difficult to navigate.

Nurses preparing for population-based practice need to be familiar with both systems (health care and public health): their organization, operation, and financing. To understand financing, community/public health nurses must be familiar with the economics of health care and the influence of politics on public health services. The structure and economics of community/public health care are intertwined.

Health care economics is a specialized field of economics that describes and analyzes “value and behavior in the delivery and consumption of…. healthcare” (American Academy of Pediatrics, 2019, para. 1). Economic analysis evaluates the effects of health policy (Bernell, 2016). The goal of health care economics, much like that of public health, is to overcome scarcity by making good choices while providing essential services.

This chapter begins with a review of significant events that influenced the current U.S. health system. It then provides an overview of health care economics, including different payment systems used in the United States and sources of public and private funding for health care and community health services.

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HISTORICAL INFLUENCES ON HEALTH CARE

For centuries, humans have battled disease. As in current times, travel historically provided an exchange of goods and knowledge; however, it also has spread disease. For instance, trade between Europe and Asia, military conquests, and Christian crusades to the Middle East brought diseases to European cities.

The bubonic plague, known as the Black Death during the mid-1300s, was a devastating epidemic, reportedly killing between 50 and 60 million people (about 60% of the population in Europe) (Benedictow, 2005; Rosen, 2015). The plague “returned periodically” for almost 500 years (Cohn, 2008, p. 74). Venice and other port cities created quarantine areas outside of the city. Travelers were required to stay in these areas for a length of time, until city officials determined they were free of disease (Rosen, 2015). During the periods of Colonialism, Imperialism, and the Triangle Trade, extended influence furthered global health impacts (Bivins, 2007). Later, regulations developed to protect health, such as safety rules for miners and concern with sailors' health. Reforms during the Enlightenment period were influenced by a growing emphasis on human dignity, human rights, and the search for scientific truth (Erwin & Brownson, 2017b). Social and sanitary reforms increased, such as vaccination stations in London and establishment of a General Board of Health in the mid- 1800s (Lewis, 1952; Richardson, 1887). See Chapters 3 and 7.

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Development of the U.S. Health Care System Early health care in the American colonies consisted of private practices, with occasional (but infrequent) governmental action for the public good (Erwin & Brownson, 2017b). Physicians had few tools at their disposal and could do little to change the course of illness (Hoffer, 2019a & Rosen, 2015).

Until the mid-1800s, hospitals were places for the very poor to receive care, and the patients often died; those who could afford it had physicians visit them at home. During the late 1800s, scientific advances, including germ theory and sterilization, made hospitals safer, whereas industrialization led to more people living in cities and away from family members who could provide care (Kisacky, 2019). An emphasis on improved sanitation and working conditions stemmed from landmark reports, like Shattuck and Griscom. The professionalization of nursing care also occurred at this time, further contributing to the move from home-based to hospital-based care (see Chapter 3).

Early public health actions were isolated, local responses to specific problems (Rosen, 2015). The first federal public health action occurred in 1878, when the U.S. Congress created a federal quarantine system, enforced by the Marine Hospital Service (National Institutes of Health [NIH], 2017). With increasing travel between cities and states, local quarantines became ineffective. The coordinated strategy was successful; epidemics were quickly checked, and communities recognized the benefits of federal government action, resulting in continued growth. (See http://thepoint.lww.com/Rector10e for a table of historical milestones and legislation.)

The Marine Hospital Service eventually became the U.S. Public Health Service, one of the seven uniformed services of the United States (USDHHS, n.d.a). Their first lab in a New York hospital grew into the National Institutes of Health, headquartered in Bethesda, Maryland—which now includes more than 75 institutes supporting scientists conducting research activities in every state and globally (NIH, 2019). Since 1854, when President Pierce vetoed legislation to address “indigent insane,” many presidents, from Theodore Roosevelt to Franklin D. Roosevelt and from Richard Nixon to William Clinton, have sought some type of universal health coverage (Manchikanti, Helm, Benyamin, & Hirsch, 2017, p. 107).

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In 1900, the average amount spent on health care by individual Americans was $5 a year, which would equal just over $128 in 2020 economy. Compare that to the $11,172 spent in 2018 (Blumberg & Davidson, 2009; Centers for Medicare & Medicaid Services [CMS], 2019e; Saving.org, 2020).

Over time, events and insights contributed to improved programs and services, along with a broader recognition that individual health was affected by the health of the wider community. Our current public health system is not really a single entity, but more of a loosely affiliated network of federal, state, and local health agencies that have been chronically underfunded (Erwin & Brownson, 2017b).

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Early Health Insurance Starting in 1929 with Baylor University Hospital in Texas, hospitals offered prepayment plans for hospital services to teachers as a way to increase hospital use. They had already been marketing the benefits of hospital childbirth to fill beds. Soon after, physician groups developed similar plans. These became known as Blue Cross (hospital) and Blue Shield (physician) plans, the beginning of modern insurance companies. The first government involvement in health insurance was in 1965, when Medicare and Medicaid were created—providing insurance for older adults and families living in poverty (Blumberg & Davidson, 2009).

Over the next five decades, in addition to the prior public health actions, legislation passed addressing health care services for targeted groups. (See http://thepoint.lww.com/Rector10e for a table of important public health actions, reports, and legislation from 1647 to 2020.) In recent years, health care reform has focused on regulating the health insurance industry, including the price for insurance and the services that are covered (Shi & Singh, 2019).

The Patient Protection and Affordable Care Act or ACA, improved access to care by making insurance available to people who were considered “uninsurable” due to preexisting health conditions (Healthcare.gov, 2010). The ACA expanded Medicaid in a number of states, extending coverage to low-income individuals and families. In addition, the ACA required insurance companies to cover preventative health care visits without a copay and to cover those with preexisting conditions, improving access to care for those with insurance. The number percentage of uninsured (those lacking health insurance) had been 18% before passage of the ACA but dropped to a low of 10.9% by 2016 (Witters, 2019). In recent years, political disagreements about the ACA have led to weakening of some protections. Despite this, federal surveys revealed a fairly stable national rate of uninsured between 2016 and 2017 at 8.8%. However, states that did not participate in Medicaid expansion had higher rates, averaging 12.2% (Keith, 2018). At the end of 2018, a Gallup poll reported that the uninsured rate had increased to 13.7% (Witters, 2019). From 2016 to 2018, the number of uninsured Americans grew by 1.2 million (KFF, 2019d).

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Recent Calls to Action Formerly known as the Institute of Medicine (IOM), the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine is an independent, nongovernmental, nonprofit organization that researches health care and public health problems (NASEM, 2017). Established in 1970, it has produced many groundbreaking reports that have advanced health care and public health services. Table 6-1 describes several of these reports.

TABLE 6-1 Selected Reports of the Institute of Medicine (Now the National Academy of Medicine)

Source: National Academies Press (2020).

The Healthy People initiative established science-based, 10-year goals and objectives for improving the health of everyone in the United States (Office of Disease Prevention and Health Promotion, 2019; USDHHS, 2020a). Each decade since 1979, the Healthy People goals and objectives have directed research and grant dollars to support activities that improve

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health. In comparison to Healthy People 2020, fewer, more targeted topics and objectives are found in Healthy People 2030 (USDHHS, 2020a). See Chapters 1 and 2 for more on the development of Healthy People initiatives.

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HEALTH CARE ORGANIZATIONS IN THE UNITED STATES

A blend of private and public agencies provides oversight for both the health care and public health system in the United States. The actions of these agencies often complement each other, and in recent years, the roles of private groups and government agencies have become increasingly interdependent (Turnock, 2016b).

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Private Health Sector Organizations Private groups include professional associations and nongovernmental organizations (NGOs) focusing on health-related issues. Health-related professional associations influence the quality and type of community/public health services available in the United States through the promotion of standards, research, information, and programs. Many also lobby legislators. These organizations are funded primarily through membership dues, bequests, and contributions (U.S. Department of State, n.d.).

Health issues focused NGOs (e.g., American Cancer Society, American Diabetes Association) supply funds for research, to lobby legislators, and to educate the public. Funding is through private contributions. Others, such as the National Society for Autistic Children, Planned Parenthood Federation of America, and the National Council on Aging, focus on the needs of special populations. Some NGOs provide services and health care. These include Habitat for Humanity, the American Red Cross, and the Public Health Institute (Anbazhagan, 2016; Yale School of Public Health, 2019). A few agencies focus on disease prevention, such as the Trust for America's Health and the Prevention Institute. Many foundations provide grant support for health programs, research, and professional education as part of their mission (e.g., Robert Wood Johnson Foundation, Bill and Melinda Gates Foundation, National Philanthropic Trust, 2018).

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Health-Related Professional Associations Many health-related professional associations, like the National Organization for Public Health Nursing (1912–1952), have influenced the quality and type of community/public health services delivered (Bekemeier, Walker Linderman, Kneipp, & Zahner, 2015; Quad Council, 2018). See Chapter 3. Others include the following:

American Public Health Association (APHA, 2019a), founded in 1872, maintains a prominent role in the dissemination of public health information, influence on health policy, and advocacy for the nation's health. Other nursing and community health organizations that have promoted quality efforts in community/public health include (APHN, n.d.; Nurse.org, 2019) the following:

Association of Public Health Nurses (APHN) (formerly the Association of State and Territorial Directors of Nursing) Association of State and Territorial Health Officers (ASTHO) National Association of County and City Health Officials (NACCHO) Association for Community Health Nursing Educators (ACHNE) Public Health Nursing Section, American Public Health Association (APHA) Alliance of Nurses for Health Environments (ANHE)

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Public Health Agencies Public health agencies perform a wide variety of activities, some requiring legal authority to ensure enforcement (e.g., environmental pollution, communicable disease control, food handling). These agencies provide important data, including the collection and monitoring of vital statistics and communicable diseases. They also conduct research, provide consultation, and sometimes financially support other community/public health efforts. These activities can be grouped under one of the three core public health functions: assessment, policy development, and assurance (CDC, 2019).

Core Public Health Functions Public health agencies perform a wide variety of activities, organized around the three core public health functions of assessment, policy development, and assurance (CDC, 2019; Table 6-2). As discussed in Chapters 1 and 2, C/PHNs practice as partners with other public health professionals within these core functions.

TABLE 6-2 Core Public Health Functions Applied to Populations and People at Risk

Source: Centers for Disease Control and Prevention (CDC) (2019).

Table 6-3 describes the actions of some federal agencies in relation to the three core functions. States retain the primary responsibility for their citizens' health and are responsible for implementing federal policies. At the local level, a city government health agency, a county agency, or a combination of both assess, plan, and serve the health needs of their community (Goldsteen, Goldsteen, & Goldsteen, 2017). Table 6-4 compares the public health

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responsibilities of federal, state, and local governments related to the 10 Essentials of Public Health Services.

TABLE 6-3 Examples of Federal Government Agencies' Actions Related to the Three Core Public Health Functions

TABLE 6-4 Federal, State, and Local Activities Related to the Ten Essential Public Health Services

Source: Centers for Disease Control and Prevention (CDC) (2020); Public Health Law Center (n.d.).

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Federal Public Health Agencies The federal public health responsibilities include the following:

Policymaking and implementing legislation Financing public health through health care services, grants, contracts, and reimbursements to states and local public health agencies Protection of public health and prevention activities through surveillance, research, and regulation Collecting and disseminating data (national data, health statistics, surveys, research) Acting to assist states in mounting effective responses during public health emergencies (e.g., natural disaster, bioterrorism, emerging diseases) Developing public health goals in collaboration with state and local governments and other relevant stakeholders (e.g., Healthy People 2030) Building capacity for population health at federal, state, and local levels by providing resources and infrastructure Directly managing health care delivery through categorical grant programs (maternal–child health programs, Medicaid, Medicare, community health centers) and services (public health laboratories, Indian health clinics) (CDC, 2013; IOM, 2002)

At the national level, public health organizations can be clustered into four groups of government agencies:

U.S. Public Health Service (USPHS) is staffed by the Commissioned Corps, which consists of over 6,700 uniformed health professionals (see Chapter 28 for more on the Commissioned Corps). Employees of the USPHS work in many different federal agencies (USDHHS, n.d.a). See Chapter 28. The U.S. Department of Health and Human Services (USDHHS), including the Centers for Disease Control and Prevention (CDC). Federal departments that oversee areas impacting health, such as the Departments of Labor, Education, Environmental Health, Agriculture, and Transportation, among others. Federal agencies that focus on international health concerns, such as the U.S. Agency for International Development (USAID) and the Office of International Health Affairs, are under the auspices of the U. S. Department of State (Turnock, 2016a). See Chapter 16.

Table 6-5 provides a selected list of federal agencies related to public health. Figure 6-1 represents the organizational chart for the USDHHS.

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TABLE 6-5 Selected Federal Public Health Agencies of the U.S. Department of Health and Human Services

Source: USDHHS (n.d.c, n.d.d, 2015).

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FIGURE 6-1 Department of Health and Human Services organizational chart: January 2020b. *Components of the Public Health Service. (Reprinted from U.S. Department of Health & Human Services. (2020). HHS organizational chart. Content created by Assistant Secretary for Public Affairs (ASPA). Last reviewed January 13, 2020. Retrieved from https://www.hhs.gov/about/agencies/orgchart/index.html)

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State Public Health Agencies The state health department (SHD) is responsible for providing leadership in and monitoring of comprehensive public health needs and services in the state. SHDs promote population health, focusing on prevention and protection. They also administer federally funded programs.

General functions of SHDs include (CDC, 2013; Erwin & Brownson, 2017b) the following:

Statewide health planning Intergovernmental and other agency relations Intrastate agency relations Certain statewide policy determinations Standards setting Health regulatory functions State laboratory services Surveillance and epidemiology Training and technical support

The Association of State and Territory Health Officials (ASTHO) surveys SHDs; the latest published data were collected in 2019 and 2016. The structure of SHDs is described in Figure 6-2. The person in charge of the SHD is generally appointed by the governor and is, most often, a physician. In fact, 64% of state health officials have a medical degree. In 2016, the leaders of four SHDs (Maryland, North Carolina, North Dakota, and Oregon) were nurses (ASTHO, 2017). By March 2020, 36 SHDs had achieved initial accreditation by the Public Health Accreditation Board (PHAB, 2020).

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FIGURE 6-2 Organizational chart of a state public health department.

Marked changes occurred between 2007 and 2016. Responsibility for substance abuse programs increased from 32% to 76%, while number of SHDs that provided long-term care services decreased from 79% to 57% (ASTHO, 2017). SHDs most often provide training to local health departments (LHDs) in chronic disease and tobacco prevention and control (88%), as well as preparedness and maternal–child health (84%). Priorities also included health disparities/minority health initiatives (86%), and 59% of agencies promoted rural health programs (ASTHO, 2017).

Between 2010 and 2019, state health agency workforce dropped by 15.3%. The largest losses were among administrative and business/finance employees. As of 2020, 25% of employees are

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projected to be eligible for retirement; in some states, it is as high as over 40%. Public health nurses comprise 7.8% of the state health agency workforce, compared to 0.1% of physician assistants/nurse practitioners and 0.6% of public health physicians. Other employees include epidemiologists/statisticians, environmental health and laboratory specialists, nutritionists and dental health professionals, as well as informatics and public information specialists. The largest group of employees (26.8%) work within the financial/business and administrative categories (ASTHO, 2020).

Local Public Health Departments The primary responsibilities of LHDs are to assess the local population's health status and needs, determine how well those needs are being met, and take action toward satisfying unmet needs. Specifically, they should fulfill these core functions as follows (Erwin & Brownson, 2017b):

Monitor local health needs and the resources for addressing them. Develop policy and provide leadership in advocating equitable distribution of resources and services, both public and private. Evaluate availability, accessibility, and quality of health services for all members of the community. Keep the community informed about how to access public health services.

The National Association of City and County Health Officials (NACCHO, 2017) identified 2,800 LHDs in the United States in 2016; about 90% of these had significant local governance. Most LHDs (62%) serve populations of <50,000 people. A few (6%) serve over half of the U.S. population (each catchment area serves between 50,000 and 500,000 people). A review of an earlier NACCHO report separated out data from the 20 largest LHDs in the United States (Leider, Castrucci, Hearne, & Russo, 2015). These 20 LHDs represented 1% of all LHDs but served 15% of the population.

LHDs primarily report to local government (77%), while about 16% are a unit of the SHD and 8% have a shared governance structure. Figure 6-3 shows a typical organizational chart for a LHD.

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FIGURE 6-3 Organizational chart of a city public health department.

LHDs provide public health clinical programs to help people lead healthy lives and specific population-based health services within their jurisdictions. Table 6-6 lists clinical programs and services reported by more than 50% of LHDs (NACCHO, 2017). The most commonly provided clinical services were as follows:

TABLE 6-6 Services Offered by Local Health Departments

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Source: NACCHO (2017).

Adult and childhood immunizations (90%, 88%) TB screening and services (84%, 79%) Women, Infants, and Children (WIC) services (66%) Screening for HIV and other STDs (62%, 65%) Blood lead screening (61%) Home visits (60%)

The most common population-based programs provided include the following:

Adult and childhood immunizations (90%, 88%) Communicable/infectious disease (93%) Environmental health (85%) Family planning (53%) and WIC program (66%) Syndromic surveillance (61%) Primary preventive programs for nutrition (74%), tobacco (74%), and physical activity (60%)

In the area of regulations or inspections, food service establishments (79%), schools/day care (74%), recreational water (68%), septic systems (65%), and private drinking water (60%) were most commonly reported. Food safety education (77%), nuisance abatement (76%), and vital records (62%) were also listed (NACCHO, 2017).

Where a board of health exists, it holds the legal responsibility for the health of its citizens. More than three quarters of LHDs report to a local board of health; this is more common for small health departments compared to medium and large departments (NACCHO, 2017). Unlike SHDs, nearly one third of directors of LHDs are nurses, including 40% of small LHDs and 47% of rural LHDs. Nurses are less likely to lead large (9%) and urban (16%) LHDs. As of March 2020, 255 LHDs and 3 tribal health agencies had received initial accreditation by PHAB (2020). However, a majority of LHDs were completing prerequisite activities required by the PHAB (i.e., community health assessments and improvement plans) indicating continuing interest in accreditation (Robin & Leep, 2017). As in SHDs, LHDs have also experienced a decrease in staffing in the past decade. Between 2008 and 2016, LHDs employed 23% fewer people. Workforce reduction in large LHDs has declined more than in small LHDs, at a rate of almost double the number of employees per 10,000 population (NACCHO, 2017). A slight gain of 850 jobs nationwide between 2015 and 2016 was reported (Robin & Leep, 2017).

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Budgets and Funding for Public Health The U.S. public health system has been “starved for decades” (Weber, Ungar, Smith, Recht, & Barry-Jester, 2020, para. 1), and the sudden appearance of SARS-CoV-2 only further demonstrated how “hollowed-out state and local health departments” have become and how poorly equipped they were to manage the onslaught of COVID-19 cases (para. 7). The entire system, beginning with the CDC, was found in an investigative report to be “underfunded and under threat, unable to protect the nation's health” (para. 5). What had been considered a premier public health system, envied by other countries around the world, struggled to meet the crushing demands of a once-in-a-century pandemic on top of an already overworked and underfunded reality. Further, the degree to which the pandemic was politicized resulted in public health workers being “disrespected, ignored, and even vilified,” leading to resignations, retirements, and occasional firings (Weber et al., 2020, para.8). In some states, as the pandemic worsened and the economy and tax revenues dwindled, workers were furloughed, had their hours cut, or their pay frozen. See What Do You Think? (Box 6-1).

BOX 6-1 What Do You Think?

Service Over Salaries An investigative report found that 20% of public health employees (excluding large health departments) had salaries of $35,000 or less in 2017. Well-educated employees (i.e., those with bachelor's, master's, or PhDs) can earn substantially more working in the private sector. At times, some workers actually qualify for the very programs that they oversee, like WIC. For instance, a disease intervention specialist at the Kentucky state health department, tirelessly working to keep HIV and syphilis from spreading, found that her salary was so low that she and her three children qualified for Medicaid. Boston's 2018 budget for the police department was five time higher than

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its city public health department; Boston offered to move $3 million dollars from a police overtime fund to help with public health staffing and immunization clinics (Weber et al., 2020).

How can residents ensure that public health is adequately funded? What percentage of your city or county budget goes to public health compared to other services? Source: Weber et al. (2020).

Funding for public health peaked at 3.2% of total health expenditures in 2002 after the 9/11 attacks and again in 2008 but decreased to 2.65% in 2014. While overall health spending is projected to increase by an average of 6% per year over the next 10 years, funding for public health has continued to decrease from its peak to a projected low of 2.4% by 2023 (Himmelstein & Woolhandler, 2016a). In 2016, the CDC's budget was $22.26 per person, and state public health agencies budgeted an average of $31.26 per person (Trust for America's Health [TFAH], 2019). In 2018, total U.S. health care spending was $11,172 per person and 2019 projections showed an increase to $11,559 (CMS, n.d.b, 2019e; Himmelstein & Woolhandler, 2016b). When you compare this to the per person budget of the CDC and state public health agencies, you get a real sense of the very small percentage given to public health in comparison to overall health costs.

According to CMS (2017a), although U.S. government public health spending represented only 2.5% of total health spending in 2016, this number may actually be artificially overestimated. Recent research indicates that CMS inflates public health spending by including spending on behavioral health care, community health clinics, and disability-related services among other nonpublic health activities (Leider, 2016; Leider, Resnick, Bishai, & Scutchfield, 2018). Determining the amount of government spending on public health is difficult as the sources of funding are varied and not coordinated across levels of government (TFAH, 2019).

Federal public health agencies are largely funded by the federal government, but about 75% of that funding ends up at the state and local levels, along with other private and public organizations. At the state level, federal grants and monetary support, along with state tax dollars, fund programs.

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The majority of federal grant money is provided by the Prevention and Public Health Fund created by the ACA. From its 2018 budget, $586 million of the total $800 million budget went to state and LHDs (Johnson, 2019). The money that makes its way to LHDs often comes through competitive grants and block grants; it is supplemented by local taxes (Congressional Research Service, 2018; Leider et al., 2018; TFAH, 2019).

The lack of consistency and transparency limits public health officials' ability to defend public health programs when budget cuts are threatened. Given that public health agencies are vital safety net services, the decreases in budgets and staffing are very challenging (Bekemeier, Singh, & Schoemann, 2018).

The proposed 2020 federal budget originally included a 12% cut to the U.S. Department of Health and Human Services, as well as $750 million in cuts to the CDC, and cuts of almost $1 billion to the Health Resources and Services Administration were also included. There was also a 31% cut to the Environmental Protection Agency. These budget cuts, adding to reductions from prior years, were strongly opposed by public health organizations (APHA, 2019b).

Both ASTHO and NACCHO collect information on public health spending by state and LHDs. In 2015, federal dollars in state health agency budgets totaled $14.3 billion; the range of dollars per state was as small as $26 million and as high as $1.8 billion (ASTHO, 2017).

About 80% of state health agencies derive 40% of their funding from federal sources. As of 2016, 56% of state health agencies were accredited. LHDs also receive federal funding, a portion of which are “pass through dollars,” meaning the state receives the funding from the federal government but sends the money on to LHDs who provide the services.

Figure 6-4 shows the percent of state health agencies' budgets derived from state and federal sources.

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FIGURE 6-4 Funding sources for state health agencies. (Data from Association of State and Territorial Health Officials (ASTHO). (2017). ASTHO profile of state public health: Volume four. Retrieved from https://www.astho.org/Profile/Volume- Four/2016-ASTHO-Profile-of-State-and-Territorial-Public-Health/)

In 2015, over one third of state health agency grants, awards, and contracts were shared almost evenly between independent LHDs and community-based nonprofit agencies (ASTHO, 2017). In 2016, an average of 30% of LHD funding came from local taxes (NACCHO, 2017). Figure 6-5 highlights the sources of funding for LHDs.

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FIGURE 6-5 Funding sources for local health departments. (Data from National Association of County and City Health Officials (NACCHO). (2017). 2016 national profile of local health departments. Retrieved from http://nacchoprofilestudy.org/wp- content/uploads/2017/10/ProfileReport_Aug2017_final.pdf)

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For-Profit and Not-for-Profit Health Agencies Health agencies and hospitals may be for-profit or not-for-profit. For-profit agencies “benefit from investors' money” and may make decisions about services offered in a way that benefits their bottom line. They also pay their investors a portion of the money they earn. Not-for-profit agencies make money, but profits are used to offset the cost of other services that do not generate income or to improve the infrastructure of the agency's facilities, as they must “serve the health care needs of the community” and maintain prices at an affordable level to keep tax their exempt status. They do not pay federal, state, or county taxes (Masterson, 2017, para. 7). Both for-profit and not-for-profit health agencies receive payments from Medicare, Medicaid, private insurance companies, and out-of-pocket payments from clients.

There are 2,968 nonprofit and 1,322 for-profit hospitals in the United States (American Hospital Association, 2019). And, a recent study of hospital profitability found that 7 out of 10 of the most profitable U.S. hospitals were nonprofits, including Gundersen Lutheran Medical Center, Stanford Hospital and Clinics, and Louisville's Norton Hospital (Bai & Anderson, 2016). In a study of hospital profitability, Bai and Anderson (2016) found that 45% of hospitals were profitable, although the median hospital lost $82 per discharge. The top 10 hospitals earned over $163 million in total profits from patient care, and only 3 were for-profit. Nonprofits used their money to expand services, fund research, or build capital projects. Hospitals with the highest prices generally earned greater profits, making the case for a need to curb excessive fees (Belk, 2019).

Forty years ago, hospital payments were more closely aligned with billing. In 2015, U.S. hospitals billed “an average of 3 l/2 times what they received in payments” (Fig. 6-6), receiving <30% of billings on average (Belk, 2019, para. 1). Yet, profit margins over the past few years have averaged 8%. Private health insurance companies pay higher proportions of overbilling than do Medicaid or Medicare, thought to be a driver of increasing costs for policies, copayments, and deductions (Belk, 2019; Woodworth, Romano, & Holmes, 2017). Hospital payment-to-cost ratios reveal that for private insurers, hospitals average about 145% of cost, but for Medicaid and Medicare, the ratios are 88.1% and 86.8% of hospital cost (Gee, 2019).

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FIGURE 6-6 U.S. hospital overbilling, 1996 to 2014. (Reprinted with permission from Belk, D. (2019). Hospital financial analysis: Print section. True Cost of HealthCare. Retrieved from http://truecostofhealthcare.org/hospital_financial_analysis)

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INTERNATIONAL HEALTH ORGANIZATIONS

International cooperation in health dates back to early concerns for epidemics. Besides important humanitarian and moral concerns, there are pragmatic reasons for addressing health issues at the international level. Today, health—along with politics and economics—has become a global issue, as the COVID-19 pandemic exemplifies. The modern era of collaboration truly began with the development of the World Health Organization, an agency of the United Nations. Formed in 1948, in the aftermath of World War II, the WHO currently has 194 member nations (WHO, 2020). International health agencies focus on issues of global concern, setting policy, developing standards, and monitoring health conditions and programs (see Chapter 16).

It may not seem possible that the health of a resident of a country 9,000 miles away can affect anyone in the United States or vice versa. However, the reality of international air travel means that illness in one part of the world can quickly move to another. Over one billion people traveled internationally during 2014, with 80 million international visitors to the United States in 2018, and travel/tourism accounted for 10.3% of global GDP in 2019 (World Travel & Tourism Council, 2020). Despite close scrutiny of airline passengers for passports, visas, customs regulations, weapons, drugs, and even symptoms such as cough and fever, how can anyone know if someone sitting next to them on a plane or in an airport is carrying a deadly, communicable disease on their journey? As described in Chapters 7 and 8, during early 2020, travelers did bring a novel coronavirus (COVID-19) to the United States and a pandemic ensued (CDC, 2020a; Gan, Xiong, & Mackintosh, 2020; Lovelace, 2020; Schuchat, 2020).

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DEVELOPMENT OF TODAY'S HEALTH CARE SYSTEM

Many of the historical influences on health care, public health, and advancements in health and social systems were brought about through legislative efforts and influenced by market forces.

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Significant Legislation In comparison to earlier history, more recent history demonstrates an ever- widening sense of responsibility for citizen's health leading to the passage of expanded health-related legislation. This legislation was not always focused on providing care but eventually promoted disease prevention. For example, the Sheppard–Towner Maternity and Infancy Act in 1921 funded education about prenatal and infant care (Shi & Singh, 2019).

During the Great Depression, the U.S. government enacted the first significant legislation that affected the health and well-being of a wide range of citizens, the Social Security Act of 1935 (Rosen, 2015; Social Security Administration, n.d.a).

This law ensured greater public health programs and provided retirement income to participating workers aged 65 years and older (SSA, n.d.a). The act included aid to dependent children, unemployment insurance, and supported educational programs similar to those in the Sheppard–Towner Act.

Later legislation (e.g., Hill-Burton) provided federal support for expansion of hospitals; care for individuals with developmental delays; research and support for heart disease, cancer, and stroke; and training for health care personnel. The landmark Medicare and Medicaid legislation in 1965 moved the federal government deeper into the role of financing health care, especially for many older adults and people living in poverty, who, prior to this time, either could not get services or had to rely on charity care (CMS, 2019c). Health care legislation in the 1980s sought to contain health care spending, ensure the quality of health care, promote national health objectives, and facilitate data collection and research. President Bill Clinton made an unsuccessful attempt at universal health care during his first term in office. However, in 1997, the State Children's Health Insurance Program (SCHIP) was created to expand coverage to uninsured children at no or low cost, and this coverage was extended in 2009 under President Barak Obama (Brooks, 2018; CMS, n.d.a). The Medicare Modernization Act of 2003, signed into law by President George W. Bush, added prescription drug benefits and disease screening to Medicare and promoted health savings accounts. More recent laws have protected the confidentiality of health records and made it easier for workers to continue insurance coverage after being laid off. The ACA is the most recent legislation to impact health care financing in the United States (Knickman & Kovner, 2019),

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although efforts to repeal the act are ongoing as of 2020 (Frommer, 2018; Jost, 2019; Simmons-Duffin, 2019). (See http://thepoint.lww.com/Rector10e for a table of historical milestones.)

The ACA provided expanded health insurance for Americans, in an effort to bring the United States more in line with other high-income countries. See Chapter 13 for more information on legislation, policy, and advocacy.

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Our Current Health Care System Americans like to believe that ours is the best health care system in the world, but we have much to learn from other countries (Pross, Geissler, & Busse, 2017). Health care in the United States is very expensive.

Health spending in 2018 was estimated at 17.7% of the U.S. gross domestic product (GDP)—the total amount of goods and services produced within a year (Centers for Medicare & Medicaid [CMS], 2019c). To put that in perspective, only 5.0% of GDP in 1960 was spent on health care (Catlin & Howard, 2015). CMS 2019b, (n.d.b) predicts that health care spending will grow 0.8% faster than the U.S. GDP and increase to 19.6% of U.S. GDP by 2027— meaning that almost one fifth of all goods and services produced in the United States will go toward health care. Total spending on health care services was $3.6 trillion in 2018 and is predicted to grow to more than $5 trillion in 2024. If viewed as a separate economy, the U.S. health care system would be the fifth largest economy in the world (CMS, 2019d, 2019f). The United States per person spending was $10,739 in 2017, about twice the average of comparable countries. This represented 17.1% of GDP, compared with an average of 10.6% in comparable countries (American Health Rankings, 2019).

Are we getting commensurate value in exchange for our expensive health care system? When overall U.S. health spending and outcomes are matched against comparable countries, the results are startling:

The United States ranks 33rd out of 36 countries on infant mortality rates, with 5.9/1,000 live births compared to an average of 3.9 (America's Health Rankings, 2019). U.S. maternal death rate in 2015 was 26.4/100,000 live births, about 4 times the rates of 6.4 in Japan and 7.3 in Canada (Hoffer, 2019b). Average life expectancy in the United States is 78.6 years, compared to an average of 82.2 years, and this gap has been widening in recent years. Spurred by substance abuse and injuries, disease burden (a measurement of quality of life and longevity) is 31% higher in the United States, also demonstrating a widening gap. Rate of death responsive to health care is ranked on a scale from 0 to 100, and the United States falls behind at 88.7 compared to an average of 93.7. Preventable hospital admission rates are 143% higher for asthma, 55% higher for heart failure, and 38% higher for diabetes patients in the

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United States versus comparable countries (Kamal, Cox, McDermott, Ramirez, & Sawyer, 2019). In 2015, the United States had 7.9/1,000 practicing nurses versus a median of 9.9 when compared to other Organization for Economic Cooperation and Development (OECD) countries. The comparison for practicing physicians was 2.6 versus a median of 3.2 per 1,000 population (Anderson, Hussey, & Petrosyan, 2019). While high-quality new medications are often introduced in the United States, compared to four comparison countries, there is statistically significant evidence that “low-quality drugs diffuse more quickly” in the United States than those of higher quality (Kyle & Williams, 2017, p. 5). The United States ranks 11th out of 11 countries in health system effectiveness, a measure of access, equity, quality, efficiency, and healthy lives (Schneider, Sarnak, Squires, Shah, & Doty, 2017).

The U.S. health care system, in comparison to other countries, is often found lacking. In a study examining the quality of primary care coordination in 11 countries, the United States had the highest level of poor performance at 9.8% compared to the overall average of 5.2% (Penn, MacKinnon, Strakowski, Ying, & Doty, 2017).

The recent comprehensive evaluation of performance by Penn and colleagues (2017) examined five main indicators:

Care process—including care coordination, preventive, and self-care, along with patient preference and engagement Access—encompassing promptness of care and affordability Administrative efficiency—effective use of time needed to complete administrative duties like processing insurance, prescriptions, mandated reports Equity—problems with care or prompt access related to lack of money/insurance, lack of providers Health care outcomes—measures of population health (e.g., life expectancy, infant mortality), mortality responsive to health care, health outcomes related to specific diseases (e.g., cancer survival rates, mortality 30 days after MI or stroke)

A Commonwealth Fund comparison of the United States and 10 other high-income countries (Box 6-2) noted that the United States ranked highest on health care spending (% of GDP) and last in overall performance, access, equity, and health outcomes (Schneider et al., 2017). This was also the case in an earlier study by the Commonwealth Fund in 2014. The United States was 10th in administrative efficiency and our highest ranking was 5th in care

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process (Fig. 6-7). You can examine the performance scores in more detail at https://interactives.commonwealthfund.org/2017/july/mirror-mirror/.

BOX 6-2 Comparison of Health Systems in the United Kingdom, Australia, and The Netherlands United Kingdom National Health Service (NHS) began in 1948, largely organized and care delivered by the national government, it is supported by taxes. Public hospitals and government staff employees are part of the NHS, but most primary care practices are independent and privately owned. Health care in the United Kingdom is more centrally managed, making accountability more governmentally driven than in the United States. About 10% of people purchase voluntary private health insurance, which excludes mental health, emergency care, and maternity care but does provide convenient and prompt access to care (Commonwealth Fund, n.d.; Schneider et al., 2017).

Australia Medicare is the public insurance covering every citizen in Australia. It is paid for by taxes, and care is often available at private hospitals. About 50% of Australians also purchase private health

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insurance for access to care outside the Medicare system, but coverage is weighted higher among those with higher incomes. Coverage includes dental and vision care, along with other services. This system is similar to the U.S. Medicare system (Commonwealth Fund, n.d.; Schneider et al., 2017). The Netherlands Private health insurers cover the Dutch population. Funding is from payroll taxes and community-rated insurance premiums similar to the ACA insurance marketplaces. A standard benefit policy is available to everyone, with subsidies for low- income citizens, and those not enrolling in the plans being fined. The yearly deduction is around $500, and patients share some costs related to ambulance service and medical devices, for instance. Private

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providers are most common, and about 84% of people purchase additional voluntary insurance to cover dental, vision, and prescription drug copayments (Commonwealth Fund, n.d.; Schneider et al., 2017).

More comparisons of health care systems and statistics are available at https://international.commonwealthfund.org/countries/united_states/. Source: Commonwealth Fund (n.d.); Schneider et al. (2017).

FIGURE 6-7 Health care system performance compared to spending, OECD countries. Note: Health care spending as a percent of GDP. Sources: Spending data are from OECD for the year 2014, and exclude spending on capital formation of health care providers; Commonwealth Fund analysis. (Reprinted with permission from Schneider, E. C., Sarnak, D. O., Squires, D., Shah, A., & Doty, M. M. (July, 2017). Mirror, mirror 2017: International comparison reflects flaws and opportunities for better U.S. health care. Commonwealth Fund. Retrieved from https://interactives.commonwealthfund.org/2017/july/mirror- mirror/assets/Schneider_mirror_mirror_2017.pdf (Exhibit 5).)

Out of 11 high-income countries in this analysis, only the United States is without universal health care. Even after increased access to care with the

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ACA, we remained last in access and equity. The highest-ranking countries overall were the United Kingdom, Australia, and The Netherlands.

Statistical analysis of survey data comparing the United States with other high-income countries found that Americans are concerned about our current health care system, especially related to access to care and being able to receive preferred care. There are also profound concerns about health “insurance-related economic security” (Hero, Blendon, Zaslavsky, & Campbell, 2016, p. 507). A 2020 survey found that most Americans, regardless of their political views, want “substantial changes” to our health care system; goals include greater affordability, as well as coverage for preexisting conditions and long-term care (Public Agenda, 2020, para. 4).

Medicare for All, a public option plan, a market-based method, and a plan to give states wider health care responsibilities were offered as potential options; the market-based method and public option were the most widely accepted. Protection for those with preexisting conditions had the strongest support among all participants, despite political preference (Public Agenda, 2020).

Dissatisfaction with the U.S. health care system has resulted in various proposals for national health plans (e.g., universal coverage, Medicare for All) and closer examination of issues such as competition, managed care, and health care rationing (Darvas, Moes, Myachenkova, & Pichler, 2018). To gain a deeper understanding, an examination of some basic economic concepts can provide a broader perspective on health care financing and issues with health care access and coverage.

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THE ECONOMICS OF HEALTH CARE

Economics is defined as the science of making decisions regarding scarce resources. It is concerned with the “production, distribution, and consumption of services” (Rambur, 2015, p. 8).

Economics permeates our social structure—it affects and is affected by policies. Consequently, health is closely tied to economic growth and development, in that a healthy population is necessary for adequate national productivity. A nation with a healthy population has better worker productivity; longer life expectancies provide an incentive for investment in education and innovation. These factors encourage income growth and higher GDP. For instance, an increased adult survival rate of 10% has been shown to increase labor productivity by over 9% (Bloom, Canning, Kotschy, Prettner, & Schunemann, 2018).

Ample evidence exists for a health–income gradient, as personal income (specifically poverty) is linked to health status; people with lower incomes report poorer health and greater prevalence of diseases than those with higher incomes. They also live shorter lives (Urban Institute & Virginia Commonwealth University, 2015). Public health policies and programs that promote health and wellness can impact economic development by improving health outcomes, often on a more cost-effective basis than other interventions (APHA, 2020; Bloom et al., 2018).

Economic methods commonly employed by public health include analysis of (CDC, 2020b):

Regulatory impact (How will this new law effect costs and behaviors?) Budget impact (How cost-effective is a new program or intervention?) Cost–benefit analysis (How much will a disease outbreak investigation cost, and how many lives will it benefit?) Decision modeling (How can mathematical models help determine cost- effectiveness of vaccine programs, pandemic spread, disease management, and injury prevention programs?)

Health economics can be better understood by examining the two basic theories underlying the science of economics: microeconomics and

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macroeconomics. In addition, concepts of health care payment must be understood.

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Microeconomics Microeconomic theory is concerned with supply and demand.

Supply is the quantity of goods or services that providers are willing to sell at a particular price. Demand denotes the consumer's willingness to purchase goods or services at a specified price (Kramer, 2019).

In our free-market–driven economy, supply and demand is a key concept. Economists use microeconomic theory to study the supply of goods and services: how we, as consumers, allocate and distribute our resources, and how those marketing goods and services compete. They also examine how allocation and distribution affect consumer demand for these goods and services.

The concepts of supply and demand are influenced by each other and, in turn, affect prices (Kramer, 2019). In a simplified example, an increase in, or oversupply of, certain products usually leads to less overall consumption (decreased demand) and lowered prices (Fig. 6-8). The opposite also is true. Limited availability of desired products means that supply does not meet demand, and when something needed is in short supply, prices usually increase (Kramer, 2019).

FIGURE 6-8 Supply and demand explained.

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As an example, let's look at the price of a gallon of gasoline. When demand for oil is high and supply begins to dwindle, the prices go up. When demand drops and supplies become more plentiful, prices go down to attract more purchasers. This occurs as long as there are no monopolies to artificially control prices or only a few choices for goods and services that inhibit competition. Because most people need gasoline for their cars, they are more likely to continue to buy it even when the price is high. The same is true for health care.

In health care economics, demand-side policies are enacted to reduce the demand for health care (e.g., raising insurance deductibles and copayments), and supply-side policies restrict the supply of resources (e.g., denial of coverage for specific services, utilization of preferred providers who practice within boundaries set by insurance companies, information overload for consumers) (Babaloa, 2017). Microeconomic theory is useful for understanding how prices are set and resources allocated. It comes into play when health care competition increases, because the success of the supply-and-demand concept depends upon a competitive market (Nicholson & Snyder, 2017).

Under the ACA, some traditional demand-side policies were removed to improve access to care. For example, preventive services must now be offered without deductibles or copayments, and insurance companies are limited in their ability to deny coverage for preexisting conditions (Healthcare.gov, 2019; Shaw, Asomugha, Conway, & Rein, 2014).

Issues such as cost containment, competition between providers, accessibility of services, quality, and need for accountability continue as areas of major concern. Several ACA provisions address these issues as well (Healthcare.gov, 2019):

The law established the Centers for Medicare & Medicaid Innovation, which tests ways to improve quality and efficiency of care. Payments to hospitals and physicians increase or decrease based on the quality of care provided, and all hospitals must publicly report several indicators of quality.

Evaluation of how these provisions affect the supply and demand for health services is ongoing. Search for projects in your state at their Web site https://innovation.cms.gov.

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Macroeconomics Macroeconomic theory is concerned with the broad variables that affect the status of the economy as a whole, such as production, consumption, investment, international trade, inflation, recession, and unemployment on an aggregate level (Rice University, 2017). The focus is on the big picture, or larger view of economic stability and growth, and it is useful for providing a global or aggregate perspective of the variables affecting the total economic picture and subsequent economic policy development (Ross, 2018; Walsh, 2014).

The economics of health care encompasses both microeconomics and macroeconomics and an intricate and complex set of interacting variables. Health care economics is concerned with supply and demand, as well as the big picture: Are available resources sufficient to meet the demand by consumers and are the resources expended achieving the desired outcomes?

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Supply and Demand in Health Care Economics We have all learned first-hand about supply-and-demand economics. For instance, when you buy textbooks, you—as the purchaser—are able to determine the best value for your money (generally based on price, availability, and condition of the book) and you have choices of vendors (e.g., college bookstore, online bookseller, other students) and formats (e.g., print book, eBook). As a student, you know when you will need specific textbooks, but as a health care consumer, do you always know when you will need health care services? Is health care a competitive free market?

How does a patient determine what services are needed, where to buy them, and how to evaluate the quality of the goods and services? With health care, this is seldom the case; health care is typically unpredictable and often difficult to research (Hero et al., 2016). Even choosing a health insurance plan can be overwhelming considering the types of plans, the choices, the complexity, and one's level of health literacy (Taylor et al., 2016).

With health insurance companies and managed care, different prices are often paid for the same service, and consumers have little information as to the costs. Hence, health care purchases are not easily understood. In a free-market system, competition is an important factor, but is competition truly possible with employer-based or government health insurance that limits the choice of plans and providers?

In 1963, economist Kenneth Arrow wrote an influential article about health care economics detailing the lack of information in the medical marketplace (reprinted as (Arrow, 2004). The main points of the article still apply; Arrow noted that risk and uncertainty prohibit a true market economy in health care because consumers:

Do not know when or if they will become ill, but they know they will need and want medical treatment—thus the demand for health insurance. Do not know what services will be needed and what works best for their condition—thus the need for health care providers. Do not know about the quality of health care good and services—thus the need for government regulation (e.g., licensing, certification) and malpractice lawsuits. Are subject to an asymmetric level of information, compared to the insurer, about the likely demand for health care services. This can result in adverse selection (e.g., high-risk patients are denied insurance or care, smokers have higher health insurance premiums) and market failure (e.g., inefficiencies, lack of appropriate competition)—although

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this is less severe in large group insurance plans that spread out the risk (Mankiw, 2017).

Health care is an “opaque market” that keeps consumers in the dark about actual costs of services and medications due to confidential negotiations, discounts, and rebates (Walker, 2018, para. 3). For example, if you need an oil change for your car, the price is often clearly posted or advertised in advance, but are you aware of how much a chest x-ray or a vaccination will cost before you get one?

Market consolidation (e.g., hospitals that monopolize a geographic area, buy up competitors) allows them to bargain for higher compensation from health insurance companies (Wolfe & Pope, 2020). A large study found that hospital billing for private insurance patients was 10.7% greater than those without coverage; Medicare patient billing was 8.9% higher (Woodworth et al., 2017). Consumers with health insurance are shielded from a typical business relationship with a provider or hospital. Costs have been the driver, not excess use of the health care system, and costs have risen faster than inflation since the mid-1960s. The multiple types of health insurance (variety of private companies and government plans like Medicare and Medicaid) in the United States lead to higher costs (Hoffer, 2019a).

For instance, the United States had the highest administrative costs when compared with seven peer countries; currently estimated costs are between 12% and 25% of national health care expenditures (Frakt, 2018; Hoffer, 2019a, 2019b).

Health jobs grew faster than manufacturing jobs in 2008, and they surpassed retail sector jobs in 2017. Health care company revenues encompassed 16% of total revenues of firms on the S&P 500, increasing from just 4% in 1984. Since 1998, in an effort to sway policy decisions, twice as much money has been spent by health care companies on lobbying when compared to other businesses (Walker, 2018).

Waste is another factor in our high cost of health care. Cutler (2018, p. 494) estimated that as much as “one third of medical spending is wasteful,” and 25% to 50% of our health care dollar “is not associated with improved health” outcomes. When interventions are not clinically sound, that wasteful spending makes it more difficult to sustain preventive measures.

As far as supply and demand are concerned, Indresano (2016) noted that these factors are at play:

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Higher demand due to an aging population. The number of people over 65 is roughly 52 million (with 85.6% having one or more chronic health conditions) and is projected to almost double by 2060. More people now have health insurance thanks to the ACA, estimated at about 20 million, and they have added to the demand. There is a projected physician shortage (about 90,000 doctors by 2025), just as demand for health care services skyrockets. Supply could be increased by hiring more nurse practitioners and increasing the number of medical residency slots available. Fully utilizing telemedicine would help extend care, especially into rural areas experiencing provider shortages (Mather, Scommegna, & Kilduff, 2019; National Center for Health Statistics, 2015).

Because traditional market forces of supply and demand work differently in health care, consumers are not solely responsible, as “government, insurers, employers, and providers themselves have a major role to play in controlling costs and ensuring access to care” (Meyer, 2016, para.15). Some governments and employers have taken action to control costs. Maryland's system of hospital rate setting is a broad-based approach to regulation, and Massachusetts has set spending growth targets on all health care spending, not just public plans. Target growth is in line with state GDP, and this program has helped them move from among the highest states in health care spending growth at the onset of the program in 2012 to one of the lowest states (Altman & Mechanic, 2018).

Consumers seek value and convenience in health care. An example of this is the case of urgent care clinics and retail clinics (Heath, 2017). These are now more prevalent than ever, with five times more retail clinics (i.e., low-cost, no appointment clinics in retail stores) in 2018 than in 2010. Younger people, generally in good health, are most often using them, even though 90% have health insurance and a medical home (coordinated care from a primary practice physician or nurse practitioner). The most common reasons for visits are minor illness or injury (40%) and vaccinations (30.9%). High-deductible health plans (deductible for individual $1,350 and family $2,700 or more) and convenience are drivers for this increased use; however, overutilization of retail clinics cancels out cost-savings and can boost health care costs (Bresnick, 2018; Heath, 2017).

There are, however, rare areas of health care where supply and demand works without any interference. These health care services are generally paid out-of-pocket, with direct interaction between the patient/consumer and the provider, as insurance does not cover them. Cosmetic procedures are a good example. Between 1998 and 2018, prices for overall U.S. medical care services increased by 109.8%, and costs for hospital and related services jumped 201.6%. Overall, consumer prices for health-related services

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increased 54%, following a steady pattern since 1998 of 3.8% per year for medical and 5.7% for hospital services, even though inflation averaged only 2.2% per year. Over almost 60 years, consumers actually paid fewer health- related costs out-of-pocket (47.6% in 1960 vs. 10.5% by 2017).

Elective cosmetic procedures are an area where prices are more transparent because costs are paid by the consumer and not usually by insurers. Therefore, consumers are cost conscious and providers operate in a competitive marketplace with more transparent pricing.

Between 1998 and 2018, the average cost of 19 common cosmetic procedures and surgeries rose 34.3%, much less than the over 100% to 200% increases in medical and hospital services. Three of the most popular nonsurgical cosmetic procedures Botox injections, laser hair removal, and chemical peels actually dropped by 26.7%, 47.3%, and 15.6%, respectively (Perry, 2017). While elective procedures (e.g., cosmetic or LASIK surgery) demonstrate market influences, they are not typical of most health care expenditures. They also represent a select portion of the population— individuals who can afford them (Morelli, 2016).

Health Insurance Concepts People are generally risk averse, meaning that they do not like uncertainty, and this is seen often in relation to health care. Conventional economic theories hold that people will pay small premiums monthly to offset the risk of large medical bills should they become seriously ill. This represents an indemnity policy (much like car or homeowners' insurance), and this was the type of health insurance first offered in the United States. In the past, patients could choose any doctor or hospital and submit the providers' bills to the insurance company for payment (Eeckhoudt, Fiori, & Gianin, 2018).

Moral hazard is the term used by economists to explain how health insurance changes the behavior of people, resulting in more risk-taking and wasteful actions. They liken it to fire insurance without a deductible, noting that a person may be less careful about clearing brush from a house or may even resort to arson if it costs the owner nothing to have the home replaced. If a person has health insurance, many economists hypothesize, they are less likely to take good care of themselves, and if they do not pay for their health care (through premiums, copayments, and deductibles), they are more likely to overuse it, although empirical evidence of this is sparse (Nickitas, Middaugh, & Feeg, 2020). In other words, economists theorize that insurance has a paradoxical effect and may lead to wasteful or risk-taking behaviors. In this

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scenario, patients will demand expensive health care, even if it provides only the smallest benefit. The concept of moral hazard is a driver for larger deductibles and copayments; these are used to control waste and overuse.

A more recent viewpoint notes that consumers purchase health insurance not to avoid risk but to earn a claim for additional income (i.e., insurance paying for medical care) when they become ill and that copayments and managed care actually work against the system by reducing the amount of income transferred to ill persons or limiting their access to needed services. Think about what would happen if you or your loved one were to suddenly need an expensive heart surgery or lengthy cancer treatment—without health insurance. You would want health insurance to protect against this possibility —to be able to pay medical bills without losing your assets (e.g., home, car).

For instance, Rose-Jacobs et al. (2019) found that families of children with special health care needs who were without government-sponsored insurance had significantly greater odds of missing rent or mortgage payments, moving frequently, and homelessness than did similar families who had this insurance. Families may face a genuine risk of financial disaster when confronted with a serious medical emergency or long-term illness, and this is why some economists argue that a focus on moral hazard in the health insurance industry is too limiting. Some suggest that it is also important to examine provider actions in forecasting health care costs (Einav & Finkelstein, 2018).

Moral hazard alone doesn't easily apply to health insurance because its effects may not be as predictable as in other instances of indemnity. Individuals who gain access to health insurance will use it, but there are still constraints (e.g., high deductibles, high copays) that moderate use and can be harmful to families who may have to choose between care for a sick child and rent or food (Einav & Finkelstein, 2018). The case can surely be made that even those with unlimited insurance coverage don't just “check into the hospital because it's free” as noted in a classic article by Gladwell (2005, para. 11). For example, most people do not seek infinite numbers of colonoscopies, root canals, or other invasive procedures or surgeries just because they are well insured.

Adverse selection, however, is a concern for health insurance companies when sick individuals seek insurance because they have an urgent need for health care, while healthy people do not want to buy it because they have no pressing health concerns (Smith & Yip, 2016). This imbalance is not cost-effective, yet a key feature of the ACA is for insurers to provide coverage for people with preexisting conditions

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(without charging them outrageous prices), which was formerly a common practice. This was initially balanced out by requiring that everyone get insurance (Center on Budget & Policy Priorities, 2020a).

Cost sharing, which includes copayments and deductibles, divides the cost of health care services between insurance companies and patients. Insurance companies use cost sharing to prevent overuse of health services. The amount of a copayment or deductible may change for some types of care, such as a visit to the ED.

In a systematic review of current “methodologically rigorous studies,” Argawal, Mazurenko, and Menachemi (2017, p. 1762) found that newer high-deductible health plans (HDHPs) not only reduced costs but also led to a reduction in office visits and preventive care. The majority of studies reflected a decline in the use of preventive health care and medication compliance. A large study covering 42 states and the District of Columbia found that underinsured and uninsured adult women were significantly less likely to receive recommended screenings for colorectal, cervical, and breast cancer compared with those having adequate health insurance coverage (Zhao, Okoro, Li, & Town, 2018). Generally, the earlier a health problem is found, the less expensive the treatment and the better the patient outcomes.

Balancing the cost reduction against the lack of preventive care (that could eventually lead to more cost savings) is an important consideration. Also, the effect of cost sharing on use of services is not equal. Individuals with low incomes decrease their use of medications and services more than those with higher incomes. The ACA limited cost sharing for people with low or moderate incomes, in plans offered by employers and plans purchased through the marketplace (Healthcare.gov, 2019).

For some people, the cost-sharing component of their health insurance is so high that they are considered underinsured. To be underinsured, one must have a deductible that is 5% of income or out-of-pocket costs in excess of 10% of income (not including premium costs). Individuals and families often exhaust their savings, run up credit card debt, or else delay necessary medical care to avoid going into debt (Collins, Rasmussen, Beutel, & Doty, 2015). The numbers are rising:

In 2018, 29% of American adults who reported having health insurance for the entire year were considered underinsured, compared to 23% in 2014 (Commonwealth Fund, 2019).

Of that group, 28% had employer-sponsored health insurance, up from 20% in 2014. But, 42% of those with individually purchased

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insurance were most likely to be inadequately covered. Delayed care (41%) and problems paying medical bills (47%) were more common among underinsured than the insured population (23%, 25%). A 2018 survey revealed that 55% of adults with employer-based health insurance reported being very confident that they could afford health care based on their coverage, while only 31% with individual market policies were very confident (Collins, Gunja, Doty, & Bhupal, 2018).

Employer-Sponsored Health Insurance Employer-sponsored health insurance is the leading source of coverage for nonelderly U.S. citizens. A total of 49% of Americans had this type of insurance in 2017. Medicare, Medicaid, and other government plans provided coverage to 36%, while 7% purchased policies directly from insurers (Kaiser Family Foundation [KFF], 2019c).

The flaws in this system were blatantly exposed during the COVID-19 pandemic, as millions of Americans filed for unemployment when businesses shutdown, causing them to lose access to health care (Brown & Nanni, 2020). One example of the trickle-down effects of unemployment is the loss of reproductive health care for millions of women (Sonfield, Frost, Dawson, & Lindberg, 2020). About 56% of total jobs lost early on during the pandemic were among women, often those working in retail, education, and restaurant jobs. Black, Latina, and women with disabilities had the highest rates of unemployment. It is estimated that 40% of people losing employer- sponsored health insurance “will remain uninsured”; states without Medicaid expansion will be even harder hit (Sonfield et al., 2020, para. 6). Loss of access to contraceptive and preventive women's health care will place greater demands on publicly funded clinics that are continually underfunded and result in unplanned pregnancies or late diagnoses of cervical cancers and other health conditions.

How did the United States end up with this system of health insurance? Historically, employers became the leading source of coverage because of three policy decisions in the 1940s and 1950s.

1. During World War II, wage controls did not apply to health insurance, so employers used health insurance to lure workers from their competitors during wage freezes.

2. The U.S. government determined that health insurance could be part of collective bargaining.

3. In 1954, the IRS exempted health insurance premiums paid by employers from federal income tax (Rook, 2015).

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A 2019 annual survey revealed that 57% of all U.S. employers offered health insurance to their workers and 99% of large companies offered coverage (KFF, 2019b). Small businesses may not offer employee health insurance because of the high cost and fewer employees (Fig. 6-9).

FIGURE 6-9 Average annual worker and employer contributions to premiums and total premiums for single and family coverage, by firm wage level, 2019. *Estimate is statistically different between All Small Firms and All Large Firms estimate (p <.05). (Reprinted with permission from Kaiser Family Foundation. (2019). Employer health benefits 2019 annual survey. Retrieved from http://files.kff.org/attachment/Report-Employer-Health-Benefits- Annual-Survey-2019)

The average annual costs for employees in 2019 were $7,188 for individual and $20,576 for family health insurance coverage (Fig. 6-10). This represents 4% and 5% increases, respectively, over 2018; however, family premiums are 22% higher than 5 years ago and 54% higher than 10 years ago. Wages increased only 1.4% above inflation from 2018 to 2019 (KFF, 2019b). Keep in mind that the median U.S. income in 2019 was just over $63,179; the employee cost for a family policy would represent almost one third of that year's wages (Rothbaum & Edwards, 2019).

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FIGURE 6-10 Average Worker Premium Contributions Paid by Covered Workers for Single and Family Coverage, 1999–2017. *Estimate is statistically different from estimate from the previous year (p <.05). (Reprinted with permission from Kaiser Family Foundation and Health Research & Educational Trust. (2017). Employer health benefits: 2017 annual survey. Retrieved from http://files.kff.org/attachment/Report-Employer-Health-Benefits- Annual-Survey-2017)

The percent of employers offering health insurance decreased somewhat after the ACA went into effect but increased in 2017; the first time an increase was noted since 2008 (Joszt, 2018). However, employers are continuing to pass along some of the higher costs of health insurance to employees in the form of higher employee premiums, deductibles, copayments, and stricter enrollment requirements.

The number of workers with insurance that includes an annual deductible has increased from 55% in 2006 and 70% in 2010 to 81% in 2015. Similarly, the percentage of covered workers enrolled in employer health plans with a deductible of $1,000 or more for single coverage increased from 10% in 2006 and 27% in 2010 to 46% in 2015 (KFF, 2019c).

Those people whose employers do not offer health insurance coverage or who are self-employed can purchase nongroup health insurance. However, premiums are greater than the worker's share of employer group coverage. The ACA has made purchasing a nongroup policy easier and subsidizes the

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premiums for eligible people. Even in states that did not expand Medicaid, a greater number of people with lower incomes purchased insurance on the federal marketplace (Blumenthal & Abrams, 2020; Sommers, Blendon, & Orav, 2016). Problematic changes in affordability and availability of ACA health plans, resulting in “churning and switching among enrollees,” have been noted (McKillop et al., 2018, para. 4). Variation in costs has not been eliminated with the ACA's community rating, but the variation is geographical; specifically, costs vary by location, not within one location (Fehr & Cox, 2020; Gabel et al., 2016; Healthcare.gov, n.d.a).

For persons earning incomes “at or below 400% of the federal poverty level” ($103,000 per year for a family of four), premium subsidies are provided for those purchasing on the insurance “marketplaces.” This keeps buyers from spending more than a “fixed percentage” of income (2.06% at the lowest level and 9.78% at the highest level) on health care premiums (Blumenthal, Collins, & Fowler, 2020, p. 964). Some “cost-sharing assistance” is available to subsidize private insurers, although it is only for those at lower income levels (100% to 250% of the federal poverty level, or $25,750 to $64,375). It is expected that about 94% of potential costs for a “moderately generous” plan will be covered for those receiving this benefit (Blumenthal et al., 2020, p. 964).

A study of coverage gains, from 2014 to 2015, found that about 40% was because of premium subsidies, and 60% was due to enrollment in Medicaid (Frean, Gruber, & Sommers, 2017).

The cost of health insurance is a deterrent for many people. “In 2018, 45% of uninsured adults” stated that insurance costs were too high and that this was the reason they remained without it (Tolbert, Orgera, Singer, & Damico, 2019, para. 4). Prior to the ACA, only 4% to 11% of those at the lower-income levels purchased nongroup health coverage (Bernard, Banthin, & Encinosa, 2009). Although coverage levels generally increase as income rises, only 25% of those earning 10 times the poverty level purchased health insurance.

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SOURCES OF HEALTH CARE FINANCING: PUBLIC AND PRIVATE

Financing of health care significantly affects community/public health nursing practice. It influences the type and quality of services offered, as well as the ways in which those services are used. Sources of payment may be grouped into three categories: third-party payments, direct consumer payment, and private or philanthropic support.

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Third-Party Payments Third-party payments are monetary reimbursements made to providers of health care by someone other than the consumer who received the care. The organizations that administer these funds are called third-party payers because they are a third party, or external, to the consumer–provider relationship. Included in this category are four types of payment sources: private insurance companies, independent or self-insured health plans, government health programs, and claims payment agents (California Department of Insurance, n.d.).

Private Insurance Companies Payments from private companies make up approximately 34% of total health care spending (CMS, n.d.b). They market and underwrite policies aimed at decreasing consumer risk of economic loss because of a need to use health services.

There are three types of private insurers—commercial stock companies that maintain profit margins for stockholders (e.g., Anthem, Cigna), mutual companies owned by policyholders (e.g., MassMutual), and nonprofit plans (e.g., American Postal Workers Union) that must be approved by states (Miller, 2018). Today, about one third of Americans are covered by a health plan offered by the Blues (Blue Cross Blue Shield, 2019).

Maintaining profits for stockholders means that insurance companies must control the medical loss ratio or the money paid for health services. If they can reduce the amount paid for health care services, then profits increase, and the stock is more attractive to potential buyers (CMS, 2018b).

Four common ways to reduce the medical loss ratio include the following:

Reducing covered services Raising deductibles and copayments Excluding people with preexisting conditions Targeting marketing to young, healthy populations

The ACA has an 80/20 rule requiring that at least 80% of every premium dollar must be spent on patient care, leaving 20% to pay for administrative and other costs of business. It was designed to protect both consumers and insurers (CMS, 2018b; Day, Himmelstein, Broder, & Woolhandler, 2015; Hall & McCue, 2019; Healthcare.gov, n.d.b).

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Previously, insurers also resorted to rescission of coverage—or canceling coverage for failure to disclose a preexisting condition (often unrelated to the person's current health care problem) or some other means of disqualifying coverage after large medical claims have been filed (Healthcare.gov, n.d.c). However, the ACA made this practice illegal, except in cases of consumer misrepresentation or fraud. A more recent trend in private insurance is the move to high-deductible health plans with a savings option (HDHP/SOs) such as health savings accounts (HSAs)—created and paid for by employees, or health reimbursement accounts (HRAs)—established and funded by employers (U.S. Office of Personnel Management [USOPM], n.d.b). About 28% of employers offered this type of plan (KFF, 2019f). Six times more common than HRAs, HSAs tied to HDHPs can be rolled over yearly and move with the employee. The high deductibles (minimum of $1,400 for an individual and $2,800 for a family) allow for lower premiums, but the attendant HSAs can only be used on medical expenses—nothing else—or tax-exempt status may be forfeited, and a penalty is incurred (KFF, 2019f; National Conference of State Legislation [NCSL], 2020). HRA funds are controlled by the employer and as the employee turns in medical bills; funds are released for payment. Generally, remaining HRA funds carry over to the following year but do not go with the employee when they leave the company (KFF, 2018a). Most plans require employees to pay coinsurance, a percentage of their total health costs (often 20% of charges)—rather than a fixed copayment per office visit or prescription as in many other plans. Most workers with employer-sponsored health insurance also have prescription drug coverage (more than 99%) with the most comprehensive health plan offered, and 83% of those covered have a plan with three or more tiers of cost sharing, such as copayment or coinsurance (KFF, 2018a).

For instance, the average prescription copayment with tier one medications is $11, and for the second tier, it is $31.Only about 3% of employers offer no cost sharing after deductible (KFF, 2018a).

While these copayments are used by insurance companies to reduce their costs, they can affect medication adherence. A systematic review of the literature concluded that lower (or no) copayments for medications not only improved adherence and patient outcomes but also decreased the use of other health care services and associated costs (Gourzoulidis et al., 2017; Kesselheim et al., 2015).

Independent or Self-insured Health Plans

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Independent or self-insured health plans underwrite the remaining private health insurance in the United States. These plans have been offered through a limited number of organizations, such as large businesses, unions, school districts, consumer cooperatives, and medical groups. Employers with self- insured plans take on all or a major part of the risk for health care costs of their employees. These plans may be self-administered or utilize third-party claims administrators. Minimum premium plans are another form of self- insurance for which employers pay medical costs up to an agreed-upon limit, and insurers assume responsibility for the excess claims (Bureau of Labor Statistics, n.d.).

About 61% of employees receiving employer health insurance benefits were covered in full or partly by self-insured plans in 2018 (remained the same in 2019), up from 51% in 1999. Employees of large firms are more likely to have self-funded plans than small firms (81% vs. 13%). Only 18% of large firms offering employee health benefits extend that benefit to retirees, significantly smaller than the 66% in 1988 or 34% in 2006 (KFF, 2018a, 2019b).

Government Health Programs Government health programs make up the “largest single payer of health care in the United States” (Troy, 2015, p. 1).

Federal sources comprised 28.3% of total payments from all sources in 2018. Spending for Medicaid rose by 3%, and growth in Medicare was 6.4% (CMS, 2020b). The U.S. government's four major health insurance programs are Medicare, Medicaid, the Federal Employees Health Benefits Plan, and the Civilian Health and Medical Program of the Uniformed Services. The VA (Veterans Administration) system is also part of the federal government, as are a few other specialized programs like Indian Health Services. The largest programs are Medicare and Medicaid.

Medicare Medicare, known as Title XVIII of the Social Security Act Amendments of 1965, has provided mandatory federal health insurance since July 1, 1966, for adults aged 65 years and older who have paid into the Social Security system (CMS, 2019a). It also covers certain people with disabilities (regardless of age). Medicare is administered by the Centers for Medicare & Medicaid Services (CMS) of the USDHHS.

In July 2019, Medicare covered more than 60.8 million people, the majority being aged 65 years or older (52.2 million), and paid health

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care costs of $618.7 billion (CMS, 2019e, f). In 2018, 21% of total federal spending was for Medicare ($750.2 billion), and it is expected to increase 7.6% per year between 2019 and 2028 (CMS, 2020b). Financing of Medicare is through general tax revenues (43%), payroll taxes (36%), premiums from beneficiaries (15%), and other sources (KFF, 2019a). Out-of-pocket spending for Medicare beneficiaries was $5,460 in 2016, almost equally divided between medical/long-term care and premiums (CMS, 2017; Cubanski, Neuman, & Freed, 2019). Individuals with multiple chronic diseases and poor health spent more than their healthier counterparts (Cubanski, Koma, Damico, & Neuman, 2019).

About 85% of beneficiaries were over the age of 65; the remaining beneficiaries qualified for Medicare 24 months after they became eligible for Social Security Disability Insurance (SSDI). These recipients are younger than age 65 and permanently disabled or chronically ill, including those with end-stage renal disease.

In 2017, almost 51 million Americans were aged 65 and older; by 2060, that number is expected to almost double, at 94.7 million (Administration for Community Living, 2018).

Although there are financial challenges facing Medicare and Social Security, both program trust funds have sufficient resources to pay full costs and benefits, without any adjustments, through 2035. The disability insurance trust fund will be intact till 2052. Reforms enacted with the ACA, and other actions, extended the life of these trust funds (Zallman et al., 2016). Even after those funds have been spent, both programs can continue to pay 75% to about 90% of benefits using only their yearly tax revenues (Broaddus & Aron-Dine, 2019).

There are four parts to Medicare (Fig. 6-11):

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FIGURE 6-11 Medicare coverage: Parts A to D. Figure concept by Claire Lindstrom; used with permission. (Data from www.medicare.gov (2020).)

Part A of Medicare, the hospital insurance program, covers inpatient hospitals, limited-skilled nursing facilities, home health, and hospice services to participants eligible for Social Security Disability Income (Medicare.gov, n.d.a).

The 2020 deductible per benefit period for inpatient hospitalization, including inpatient mental health, is $1,408. Patients in a skilled nursing facility pay $176 per day after day 20 and assume all costs if care is needed longer than 100 days (Medicare.gov,

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n.d.c). Information on hospice and home health can be found at https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a- glance.

Part B of Medicare, the supplementary and voluntary medical insurance program, primarily covers necessary services to diagnosis or treat health issues and preventive services such as influenza vaccines (Medicare.gov, n.d.a).

The 2020 annual deductible is $197, and recipients pay 20% of services once the deductible is met. No out-of-pocket charges are applied for annual wellness visits or preventive services that are rated “A” or “B” by the U.S. Preventive Services Task Force (USPSTF). Monthly premiums vary depending on yearly income ranging from $144.60 to $491.60 (Medicare.gov, n.d.c).

Part C Medicare plans, also called Medicare Advantage, are private plans subsidized by the federal government.

Medicare Advantage plans are not supplemental to Part A and Part B— they take the place of Part A and Part B. Some may also cover vision, dental, and prescriptions (National Council on Aging, n.d.). Unlike traditional Medicare, Part C plans use provider networks, which limit the choice of physicians or hospitals. They are regional, which may be problematic for seniors who want to spend winters in Florida and summers in Montana, for instance.

Seniors can change their Part C plan during open enrollment periods or revert to traditional Medicare Part A and Part B.

In 2018, 24 million Medicare participants had Part C plans (KFF, 2019a). Other types of Medicare plans include Medicare Medical Savings Account (MSA) plans, Medicare cost plans, Programs of All- Inclusive Care for the Elderly (PACE), and Medication Therapy Management (MTM) program; these are not available in all areas.

In 2018, over 14 million Medicare beneficiaries had supplemental coverage through a private company or employer retiree health insurance plans—known as Medigap coverage—added to Medicare Part A and Part B (American Association for Medicare Supplement Insurance [AAMSI], 2019). Changes in Medigap coverage for new enrollees began at the start of 2020. Part B deductibles are no longer covered under Medigap and Plans C and F are not allowed. However, these changes do not affect those enrolled prior to January 1, 2020 (Medicare.gov, n.d.g).

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People with Medigap coverage through their employers' retiree health plan generally pay lower premiums than people with coverage through a private company. With rising costs of health care coverage, companies are increasing premium costs for retirees, offering new options, such as Medicare Advantage to replace traditional health plans, or paying only a set amount for health coverage and leaving retirees to purchase their own insurance (AAMSI, 2020).

Part D is a volunteer prescription drug plan for those on Medicare or Medicare Advantage. The member can sign up for a Medicare Part D plan or an Advantage plan with medication coverage (KFF, 2019a: Medicare.gov n.d.b). Costs vary based on state of residence. Plans differ in coverage, so clients should be encouraged to research the plans to determine if their medications are included in the plan's formulary. See Box 6-3.

BOX 6-3 Deductibles, Copays, and the Donut Hole Deductible Phase

While plans vary, most have an annual deductible that must be met before the prescription drug plan takes effect. Medicare caps the deductible at $435, and some plans do not have a deductible (Medicare.gov, n.d.g; Social Security Administration [SAS], 2019).

Initial Coverage Phase When the deductible is met, members are responsible to pay a copayment (a set amount) or coinsurance (a percent of the price of the medication), with Medicare covering the rest of the cost (Medicare.gov, n.d.h; SSA, 2019). The monthly premium depends on the type of plan chosen and the income of an individual or family. Individuals may pay nothing over their plan premium up to a monthly fee of $76.40 plus plan premium. Costs vary based on state of residence as well (Medicare.gov, n.d.f).

Donut Hole The Bipartisan Budget Act of 2018 limits what members pay. Members pay no more than 25% of the brand name or generic cost, and the manufacturer pays 95% of the cost. When the combined

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paid amount is $4,020 out-of-pocket, the catastrophic coverage phase begins. Items that are included in the coverage gap are the deductibles, copayments and coinsurance, and what is paid in the gap (Medicare.gov, n.d.c; MedicareAdvantage.com, 2020; SSA, 2019).

Catastrophic Coverage Phase Between the initial coverage and the coverage gap, a total of $6,350 has been paid, at which time the member is only responsible for a small copay or coinsurance (Medicare.gov, n.d.d; SSA, 2019).

Source: Medicare.gov (n.d.c, n.d.d, n.d.e, n.d.f, n.d.g, n.d.h); Medicare Advantage.com (2020); SSA (2019).

Supplemental security income and social security disability insurance Supplemental Security Income (SSI) and SSDI are federally funded programs to assist seniors and/or those with disabilities that have financial needs. Seniors and individuals with disabilities, regardless of age, with limited incomes can receive SSI. SSDI, however, is only available for those with disabilities that “have a qualifying work history” (Bauer, 2017, para. 3; SSA, 2019, 2020). Eligibility for health care benefits differs between the two programs as well (Fig. 6-12).

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FIGURE 6-12 Supplemental Security Income and Social Security Disability Insurance coverage. Figure concept by Claire Lindstrom; used with permission. (Data from www.ncoa.org (2017); www.disabilitysecrets.com (2019); https://www.ssa.gov/redbook/eng/overview-disability.htm (2020). For additional information and updates, see https://www.ssa.gov/benefits/disability/)

Medicaid benefits are immediate for SSI recipients, whereas most individuals receiving SSDI can qualify for Medicare after 24 months

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(Bauer, 2017). To be eligible for SSI, an individual's income must be <$1,260 a month. In 2020, the highest amount individual SSI recipients receive is $783 a month (Social Security Administration, n.d.b). However, SSDI assistance is not based on income or severity of disability. Rather, the monthly amount is based on the person's income prior to the disability. The average monthly income from SSDI is $800 to $1,800 and a maximum monthly payment of $3,011 (Laurence, 2019).

Medicaid Medicaid, known as Title XIX of the Social Security Amendments Act of 1965, provides medical assistance for children, pregnant women, parents with dependent children, seniors, and people with severe disabilities (Medicaid.gov, 2020).

About one in five Americans are covered by Medicaid (Rudowitz, Garfield, & Hinton, 2019). Medicaid is an optional program for states, but all states currently participate. Over time, the scope of Medicaid increased, and states opting to provide Medicaid were required to implement each increase—or lose their federal Medicaid funding (Cubanski et al., 2015). Medicaid covered over 70 million people in January 2020 (Medicaid.gov, 2020). Between October 1, 2017, and September 30, 2018, Medicaid spending was over $592 billion (KFF, 2018b). As the importance of social determinants of health gains wider acceptance, more states are requiring Medicaid managed care organizations (MCOs) to screen for determinants and provide social services, such as housing and nutrition assistance (Hinton, Rudowitz, Diaz, & Singer, 2019). Because Medicaid covers so many people, many of whom have complex health needs, it represents a significant proportion of health care spending in the United States (Rudowitz, Orgera, & Hinton, 2019).

In 2016, Medicaid covered 39% of all U.S. children and 77.9% of children living in households earning <$25,000 per year (Murphy, 2017). Medicare beneficiaries comprised 15% of Medicaid enrollment (Musumeci, 2017). Medicaid pays for 62% of individuals living in nursing homes, with the average yearly cost for nursing home care in 2016 topping $82,000 (KFF, 2017). About 33% of adults turning 65 will require nursing home care during the remainder of their lives (KFF, 2017).

Prior to the ACA, childless adults without disabilities were not eligible for Medicaid. Under the ACA, Medicaid was expanded to all nonelderly

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adults with incomes up to 138% of the FPL, or $17,236 for an individual in 2019 (Garfield, Orgera, & Damico, 2020). Other changes made through the ACA were to extend Medicaid coverage for children in foster care until age 26—equal to the requirement that private plans allow dependent children to remain on a parent's plan until that age. States also needed to make the Medicaid application process easier (Congressional Research Service, 2018; Manatt, Phelps, & Phillips, 2019).

The ACA initially required all states to expand Medicaid. This was legally challenged by several states, leading to a Supreme Court case— National Federation of Independent Business v. Sebelius (KFF, 2012). The Medicaid expansion was ruled to be unconstitutional because it was highly coercive and the Medicaid expansion became optional for states.

Currently, 37 states have expanded Medicaid coverage (KFF, 2020). However, a gap in coverage exists in states choosing not to expand Medicaid coverage (Fig. 6-13); Medicaid eligibility is 40% of the federal poverty level ($8,532 for a family of three in 2019). According to the Center on Budget and Policy Priorities (CPPB), since expanded Medicaid coverage was implemented, over 19,00 lives have been saved. Whereas, in states that have not expanded Medicaid, roughly 15,500 lives have been lost (Aron-Dine, 2019). The largest portion of Medicaid spending goes toward people with disabilities (40%) and older adults (21%), but these two groups comprise only 23% of Medicaid enrollees (Rudowitz, Orgera, et al., 2019).

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FIGURE 6-13 Gap in coverage for adults in states that do not expand Medicaid under the Patient Protection and Affordable Care Act. (Reprinted with permission from Garfield, R., Orgera, K., & Damico, A. (January 14, 2020). The coverage gap: Uninsured poor adults in states that do not expand Medicaid. Kaiser Family Foundation. Retrieved from https://www.kff.org/medicaid/issue- brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not- expand-medicaid/)

Medicaid is jointly funded between federal and state governments to assist the states in providing adequate medical care to eligible persons. The federal government matches state Medicaid spending, and this is the largest source of federal funding for states. The federal government pays a portion of the costs, called the Federal Medical Assistance Percentage (FMAP), at 50% to 76%. Historically, the FMAP was around 62% (Schneider, 2019).

The funding model for Medicaid has both benefits and problems. There isn't a limit on federal spending, so as states expand their Medicaid programs, more federal funding flows to states (Paradise, Lyons, & Rowland, 2015). This allows Medicaid to expand during epidemics or pandemics (e.g., COVID-19), natural or man-made disasters, or short economic downturns. At the same time, when the economy contracts, as in the 2008 recession, many more people become eligible for Medicaid at a time when state and federal funds were decreasing (Cutler, 2018).

The states have some discretion in determining which population groups their Medicaid programs cover and the financial criteria for Medicaid eligibility, as well as the scope of services, rate of payment, and how the program will be administered, so long as they meet the minimum requirements set by the federal government (Paradise et al., 2015).

Medicaid mandatory services include the following (Medicaid.gov, n.d.a):

Outpatient and inpatient hospital services Early childhood screenings and well-child checkups (to age 21) Physician and nurse practitioner/certified nurse midwife services Lab and x-ray services Family planning services Tobacco cessation counseling for pregnant women Home health care and nursing home services for those over age 21 (including rehabilitation centers) Federally qualified health center and rural health clinic services Transportation to medical care

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As with Medicare, Medicaid programs moved to a managed care concept following mandates within the Balanced Budget Act of 1997, in an attempt to restrain costs (Paradise et al., 2015).

In July 2017, more than 66% of Medicaid beneficiaries were covered by managed care programs (Hinton et al., 2019), with nearly 50% of the Medicaid budget going to managed care programs (Rudowitz, Orgera, et al., 2019). In some states, a managed care plan is required. In states with lower per capita income, there are higher federal matches. Medicaid beneficiaries are economically disadvantaged, frequently reside in medically underserved areas, and often have more complex health and social needs than other adults with higher incomes do. They often must choose between multiple plans, fewer providers, and may need to drive long distances to see specialists. Some managed care plans lack sufficient oversight, leading to fragmented services and poor health outcomes (Rudowitz, Orgera, et al., 2019).

Medicaid is also a source of innovation in health care. States implemented medical homes, care coordination, integration of physical and mental health care, and other “new” services earlier than private health plans. The flexibility built into the federal requirements for Medicaid, Medicaid rule waivers to test ideas, and the new Innovation Center in CMS (part of the ACA) allow states to develop new models of health care delivery (CMS, 2019g; Paradise et al., 2015).

Patient advocates (e.g., physicians, nurses, community leaders) often express concerns that many Medicaid managed care plans (or state administrators) are more focused on keeping their costs down than on improving patient care. The system has wide variability in cost-effectiveness and quality (Paradise et al., 2015). Ensuring access and quality of care in a managed care environment will require fiscally solvent plans, established provider networks, and awareness of the unique needs of the Medicaid population (CMS, 2020a; National Conference of State Legislatures, 2017). Also, both providers and beneficiaries need more education about managed care.

A key factor to Medicaid's future success is reimbursements to providers, both the amount of payments and administrative delays. Medicaid has historically reimbursed providers at a lower rate than Medicare, and other insurance programs and filing for reimbursement can be onerous. In 2016, Medicaid fees paid were an average of 72% of those paid by Medicare. In states where the fee ratio was above the median, physicians accepted Medicaid patients at higher rates than for those

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below the median (Holgash & Heberlein, 2019). This is problematic for C/PHNs who may have difficulty finding a health provider for clients. States may also take a long time to make the reimbursement payment. These issues create burdens for clinics and private physician offices, leading to a lack of provider participation—and a lack of access to care for enrollees. When state resources are strained, provider reimbursement rates are often cut. This leads to fewer providers willing to take Medicaid patients—it is estimated that about 30% of physicians in the United States will not accept Medicaid patients (Cutler, 2018). Despite these issues, Medicaid provides societal benefits. Medicaid coverage is associated with reduced rates of infant mortality, especially in African American infants (Bhatt & Beck-Sagué, 2018). In addition, providing coverage to children early in life leads to higher educational achievement, higher income, and decreased use of public programs (Manatt, Phelps, & Phillips, 2019; Robert Wood Johnson Foundation, 2019).

Although there are access and quality problems with Medicaid, one large study examining differences between an uninsured population and those with Medicaid found that patients with Medicaid were more likely to see a physician at least once annually. Among low-income populations with high blood pressure, those with Medicaid had greater awareness and control of hypertension, although this was not the case for those with high cholesterol or diabetes (Christopher et al., 2016).

Children's Health Insurance Plan Enacted as part of the Balanced Budget Act in 1997, the Children's Health Insurance Plan (CHIP) provides health coverage to uninsured children under age 19 for families caught in the gap between Medicaid and affordable health insurance (Healthcare.gov, n.d.d). Funding is provided from both federal and state budgets, and CHIP is a capped program; some states offer the program to pregnant women and their unborn child (Medicaid and CHIP Payment and Access Commission [MACPAC], 2018). In 2017, federal funding for this program lapsed, and it took 114 days to regain funding that is now good through 2023 (Mitchell, 2018).

In 2018, 9.6 million children were enrolled or had been previously enrolled during the 2018 fiscal year (Medicaid.gov, n.d.b). While states differ on some services provided, all states must cover routine checkups and doctor checks, dental and vision care, hospital services, immunizations, prescriptions, and emergency services. The program is free in many states, but premiums or enrollment fees vary by state; children up to the age of 19 are covered for families of

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four making up to $50,000 per year (InsureKidsNow.gov, n.d.).

Federal Reimbursements for Disproportionate Share Hospitals In addition to payments from Medicare and Medicaid, the U.S. government reimburses safety net hospitals and other entities involved in care of the uninsured, known as designated Disproportionate Share Hospitals (DSH). The American Hospital Association (2018) reported a total of $38.3 billion in uncompensated care in 2016; this is an increase over 2015 figures of $35.7 billion. Although taxpayers help pay for uninsured patients, it does not fully cover costs of care.

Camilleri (2018, p. 1562) examined national data on uncompensated care after the first year of ACA Medicaid expansion among hospitals with a “disproportionate share of low-income patients” and found significant reductions in the amount of uncompensated care for those participating in expansion.

DSH hospitals had greater reductions than non-DSH hospitals, and the differences in levels of uncompensated care for expansion and nonexpansion states were noticeably wider. The recent rash of hospital closures throughout the United States, mostly in rural and suburban areas and often safety net hospitals, has led to remaining hospitals being responsible for those patients (Khullar, Song, & Choski, 2018).

In states with ACA-related Medicaid expansion, safety net hospitals had “improved operating margins” and those without expansion demonstrated declining operating margins (Dobson, DaVanzo, Haught, & Phap-Hoa, 2017, p. 1).

If Medicaid expansion were extended to those states, costs of uncompensated care are projected to drop by over $6 billion (Dranove, Gartwaite, & Ody, 2017).

Other Government Programs In addition to third-party reimbursement, the government offers some direct health services to selected populations, including Native Americans, military personnel, veterans, merchant marines, and federal employees. Government support, largely through grants administered through the CDC, provides immunizations and well-child visits, as well as prenatal care and other programs at the state and local level.

Retrospective Payment

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Reimbursement for health care services generally has been accomplished through one of two approaches: retrospective or prospective payment. A traditional form of reimbursement for any kind of service, including health care, is retrospective payment, which is reimbursement for a service after it has been rendered (Torrey, 2020). A fee may or may not be established in advance. However, payment of that fee occurs after the fact, or retrospectively, termed fee-for-service (FFS).

In health care, limited accountability in the use of retrospective payment has created several problems (Hodgin, 2018).

With third-party payers (e.g., insurance companies, the government) serving as intermediaries, neither consumers nor providers of health services were accountable for containing costs (Hodgin, 2018). As more advanced technology and new medications became available, costs increased. Third-party reimbursement also increased, along with other factors, to create an inflationary spiral of escalating costs. FFS promoted sickness care rather than wellness services. Providers were rewarded financially for treating illness and for providing additional tests and services. There were few incentives for prevention or health promotion (Hodgin, 2018).

Although retrospective payment worked well in other industries, from a cost-containment as well as a public health perspective, it has not worked well in health care and is now rarely used.

Surprise Medical Billing “Surprise medical bills” occur when an individual is caught unaware that a provider is not in-network and receives a bill (Pollitz, 2016, para. 2). For instance, a visit to an emergency department is in-network hospital yet the ED physicians are contracted employees and out-of-network. A scheduled surgery at a hospital is covered under the plan yet the assistant surgeon, anesthesiologist or radiologist are not part of the plan.

More than 42% of patients hospitalized or seen in emergency rooms at in-network hospitals received surprise bills in a recent study, with bills doubling or tripling between 2010 and 2016 (Kaiser Health News, 2019). Another study in New York found the average emergency care bill for out-of-network patients was $7,006. Despite efforts to address this common problem, it will most likely persist, especially with narrower networks of providers found with newer health insurance policies (Pollitz, 2016).

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Prospective Payment Prospective reimbursement, although not a new concept, was implemented for inpatient Medicare services in 1983, in response to the health care system's desperate need for cost containment (Rambur, 2015). It has since influenced the Medicaid program, as well as private health insurers. The prospective payment form of reimbursement has virtually eliminated the retrospective payment system (Nickitas et al., 2020). Prospective payment is a payment method based on rates derived from predictions of annual service costs that are set in advance of service delivery. Providers receive payment for services according to these fixed rates, set in advance. Payments may be in the form of premiums paid before receipt of service or in response to fixed-rate (not cost) charges. To correct unlimited reimbursement patterns and counteract disincentives to contain costs, prospective payment involves four classic steps (Dowling, 1979; Longest, 2016):

1. An external authority is empowered (by statute, market power, or voluntary compliance by providers) to set provider charges, third-party payment rates, or both.

2. Rates are set in advance of the prospective year during which they will apply and are considered fixed for the year (except for major, uncontrollable occurrences). The provider accepts the assignment of fees.

3. Patients, third-party payers, or both pay the prospective rates rather than the costs incurred by providers during the year (or charges adjusted to cover these costs).

4. Providers are at risk for losses or surpluses. Prospective payment imposes constraints on spending and provides

incentives for cutting costs. The federal government, as mentioned earlier, enacted a prospective payment plan (The Social Security Amendments Act of 1983; see Significant Legislation, above).

The plan is a billing classification system known as diagnosis-related groups (DRGs). The system is based on about 500 diagnosis and procedure groups. It provides fixed Medicare reimbursement to hospitals based on weighted formulas. Flat rates of payment are based on average national costs for a specific group, adjusted annually, with some regional variations accounting for higher wages and other costs (Longest, 2016). This system was enacted to curb Medicare spending in hospitals and to extend the program's solvency period. It was designed to create incentives for hospitals to be more efficient in delivering services. The prospective payment system reduced Medicare's rate of increase for inpatient hospital spending and increased hospital productivity by

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reducing hospital stays and unnecessary admissions, according to Clifton (2009) and Rambur (2015). The system, however, led to DRG creep or “upcoding” (i.e., classifying patients into more lucrative categories) and patient dumping (i.e., transferring patients whose reimbursement is expected to be lower than actual costs of services) in an effort to counteract the losses in revenue and in some circumstances make hefty profits.

The CEO of Prime Health Services and 14 of the company's hospitals settled a $65 million settlement for “upcoding,” a practice in which patients are assigned a DRG requiring a higher level of care than what the patient needs (U.S. Department of Justice [USDOJ], 2018).

In a classic article, Kinney (2013) calculated that the three major concerns faced by Medicare (and the ACA) are “cost and volume inflation, quality assurance, and fraud and abuse” (p. 253).

Cost inflation was addressed by DRGs and other measures; CMS has mechanisms in place to investigate fraud or abuse. Quality was addressed in October 2008, when Medicare began withholding payments to hospitals for preventable errors in an effort to provide an incentive to prevent avoidable mistakes and improve patient care. There are 29 preventable errors (often called “never events”) grouped into 7 categories (Agency for Healthcare Research and Quality [AHRQ], 2019b). Appropriate mechanisms must be in place to provide accountability and take action when needed—as when billing and other fraud is prosecuted (Smith & Yip, 2016; USDOJ, 2018, 2019). Cutler (2018) estimated that overall health care fraud for public and private payers may be as high as 10% of total costs.

These changes were instituted at the request of Congress, and initially, many hospitals complained that their payments would be substantially reduced, especially for complicated patients.

“Never events” are medical errors or adverse events that never should happen and are largely preventable (Patient Safety Network 2019; AHRQ, 2019b). An expanded list of 24 never events for hospitals—serious incidents that could have been prevented—was approved for nonpayment by Medicaid beginning in July 2012 for all states. The goal was to reduce serious medical errors and preventable infections that should reduce costs and improve patient care (AHRQ, 2019a). Progress toward this goal of improved quality of care is evident by saving the lives of 8,000 people and saving close to $3 billion (CMS, 2018a). However, never events still occur. In 2017, there were 95 surgical events, 37 criminal events, and 89 patient protection events

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(Knowles, 2018). Medical errors account for 100,00 deaths and costs 20 billion a year. In addition, there are 4,000 surgical errors reported yearly (Rodziewicz & Hipskind, 2020). The ACA includes incentive payments to primary care providers who meet quality goals. Nursing instituted the QSEN initiative (QSEN Institute, 2020).

Debate continues about nonpayment outside of hospital settings and about which conditions should be included in the list of never events (Box 6- 4).

BOX 6-4 What Do You Think?

Nonpayment for Preventable Medical Errors What if you were to hire a glass company to replace a broken windshield in your car, and while completing the repair, they accidentally broke off your rearview mirror. Would you expect them to pay for that mistake? Or would you just absorb the cost yourself?

In the past, we the taxpayers have been paying Medicare payments to hospitals and physicians who have made serious errors that have led to adverse events, spiraling costs, and resulted in poor patient outcomes. Congress and others feel that this is unfair and have enacted legislation to stop paying for these types of errors or preventable events.

Do you think this is fair? Can these conditions always be prevented? Are there extenuating circumstances that should be taken into account? Are there benefits to patients and taxpayers from holding health care providers accountable for errors and inadequate care?

Capitation A more vigorous version of prospective payment is capitation. Capitation refers to a fixed fee per person that is paid to a MCO for a specified package of services. Fees remain in effect until renegotiated, regardless of the number of services provided. Because profit margins are very tight, utilization, quality, and costs are carefully monitored (Nickitas et al., 2020).

The prospective payment concept has proved useful from a public health perspective. Prepaid services create incentives for providers to

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keep their enrollees healthy, thus reducing provider costs. A potential, indirect benefit from fixed rates and reduced costs is that prevention programs may capture a larger share of the health care dollar.

Claims Payment Agents Claims payment agents administer the process for government third-party payments. That is, the government contracts with private fiscal agents to handle the claims payment process and function as an intermediary between them and the health care provider. As an example, Blue Cross Blue Shield, in addition to serving as a private insurance company, has also served as claims payment agent for Medicare since its inception (Blue Cross Blue Shield, 2019).

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Direct Consumer Reimbursement or Out-of-Pocket Payment Another source of health care financing comes from direct fees paid by consumers. This refers to individual out-of-pocket payments made for several different reasons, such as:

Payments made by individuals who have no insurance coverage (fees must be paid directly for health and medical services) Payments for limited coverage, insurance caps, and exclusions (services for which the consumer must bear the entire expense)

For example, some individuals carry only major medical insurance and must pay directly for physician office visits, prescriptions, eyeglasses, and dental care. In other instances, deductibles and coinsurance leaves individuals and families with health care insurance out-of-pocket costs, with payments ranging from $360 to $1,500; the highest being $7,000 or more (Hayes, Collins, & Radley, 2019). Roughly, 30% of Americans are worried about health care insurance premiums, deductibles, and out-of-pocket expenses (Kirzinger, Muñana, Wu, & Brodie, 2019).

Two important factors to consider in health care costs are cost shifting and cross subsidization.

Cost shifting consists of charging different prices for the same services, placing the burden of high cost of health care on others. The idea is that health care agencies and providers are able to make up for the lower reimbursements from Medicare and Medicaid by charging more to private payers (Feldhaus & Mathauer, 2018).

Over the past 20 years of research into cost shifting, it has been noted that, as Medicare and Medicaid decrease their payments to providers, this has not substantially increased costs to others. In fact, as government programs pay less, private insurance companies are charging less as well (Frakt, 2018).

Cross subsidization is the practice of adjusting revenues from a central pool of funds to an area with higher health care needs to help cut site costs. The health risks of an area are calculated based on population's age, gender, poverty level, chronic diseases and disabilities (Mathauer, Vinyals Torres, Kutzin, Jakab, & Hanson, 2020).

Cross subsidization is used in many countries with decentralized health care such as Germany, Japan, Spain, and Switzerland (Mathauer et al., 2020).

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Private and Philanthropic Support Private or philanthropic support, a third funding source, contributes both directly and indirectly to health care financing. U.S. charities received $427.71 billion in donations in 2018. Many private agencies fund programs, underwrite research, and provide benefits for people who otherwise would go without services. Roughly, $9 billion was donated to help pay for medications by providing lower costs or medications at no charge to those who could not afford prescription drugs (Giving USA, 2019).

In addition, volunteerism, the efforts of numerous individuals and organizations that donate their time and services (e.g., hospital guild members), provides tremendous cost savings to health care institutions.

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TRENDS AND ISSUES INFLUENCING HEALTH CARE ECONOMICS

The High Cost of Health Care in the United States As described earlier, the United States pays the most for what are often some of the worst health outcomes. Mossialos, Wenzl, Osborn, and Sarnak (2016) reported health care comparisons across OECD countries and found that the United States ranked last on amenable mortality levels (deaths prior to age 75 that may be prevented through effective, timely health care). A study comparing mortality between the United States and seven European countries found that greater U.S. social and educational disparities “explain why U.S. adults have higher mortality” (van Hedel et al., 2015, p. e112). The United States was

Among the lowest nations in the percentage of adults who smoke daily Among the lowest third of nations in cancer deaths In the lower half of countries on childhood vaccination rates but third highest on influenza vaccination rates Among the highest among nations on the percentage of adults who are obese Among the lower third of countries for life expectancy at birth (OECD, 2019)

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Controlling Costs The ACA has introduced many strategies to control the rise of health care costs, including increased funding for primary prevention strategies. A focus on primary prevention demands a paradigm shift in thinking about the practice and delivery of health care (see Chapter 1). It is one that fits more closely with the mission of public health. It expects that citizens are involved in their health care, are knowledgeable about their health status, can manage self-care practices, and can modify lifestyle behaviors to promote wellness. Our focus on illness and not health promotion or prevention has proven costly. Prevention should be at the forefront of a new era in health care. Trust for America's Health (TFAH, 2020) has developed 10 top priorities for a National Prevention Strategy:

1. Fighting the Obesity Epidemic 2. Thwarting the use or exposure to tobacco 3. Preventing/Controlling Infectious Diseases 4. Preparing for Possible Health Emergencies/Bioterrorism Attacks 5.

Acknowledging the Connection Between Health and U.S. Economic Competitiveness 6. Safeguarding Our Food Supply

7. Planning for Adapting Senior Health Care Needs 8. Improving the Health and Wellbeing of Low-Income/Minority Communities 9. Diminishing Environmental Threats

10. Advancing Prevention of Diseases (para. 1)

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Access to Health Services: The Uninsured and Underinsured Many services, preventive or illness focused, are not available to a large portion of our population.

The U.S. Census Bureau (2010) reported that 50.7 million people (16.7% of the population) were uninsured in 2009; the percentage of uninsured (those lacking health insurance) had been as high as 18% before passage of the ACA (Witters, 2019). The ACA (2010) improved access to care by making insurance available to people who were considered “uninsurable” due to preexisting health conditions. By 2014, the number of people who were uninsured decreased to 33 million or 10.4% of the population (U.S. Census Bureau, 2015).

The U.S. Census Bureau noted that 8.5%, approximately 27.5 million people, had no health insurance the entire year in 2018 (Berchik, Barnett, & Upton, 2019). The rate of those lacking health insurance varies by age group (Fig. 6-14). The uninsured rate in 2018 is highest for those living below the poverty level (7.8%) and higher for Hispanics (8.7%) and Blacks (4.6%), and similar for Asians (4.1%) compared to non-Hispanic Whites (4.2%).

The ACA expanded Medicaid in a number of states, extending coverage to low-income individuals and families. In addition, the ACA required insurance companies to cover preventative health care visits without a copay and to cover those with preexisting conditions. In recent years, political disagreements about the ACA have led to weakening of some protections. Despite this, federal surveys revealed a fairly stable national rate of uninsured between 2016 and 2017 at 8.8%. However, states that did not participate in Medicaid expansion had higher rates, averaging 12.2% (Keith, 2018).

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FIGURE 6-14 Percentage of people uninsured by age: 2017 and 2018. Note: population as of March of the following year.(From Berchik, E. R., Barnett, J. C., Upton, R. D., & for the U.S. Census Bureau. (November 2019). Health insurance coverage in the United States: 2018. Figure 4, p. 7. Retrieved from https://www.census.gov/content/dam/Census/library/publications/2 019/demo/p60-267.pdf)

At the end of 2018, a Gallup poll reported that the uninsured rate had increased to 13.7% (Witters, 2019). From 2016 to 2018, the number of uninsured Americans grew by 1.2 million. By the end of 20108, a Gallup poll reported that the uninsured rate had increased to 13.7% (KFF, 2019d; Witters, 2019).

Even those with Medicaid and Medicare can be underinsured or become uninsured.

It is estimated that almost 25% (11.5 million) of Medicare participants are underinsured, with state data varying from a low of 16% to a high of 32% (Schoen & Solis-Roman, 2016). The Kaiser Family Foundation estimated that between 1.4 and 4 million Medicaid recipients would lose their health care coverage in states where Medicaid work requirements are now being implemented (Fig. 6- 15). Between 62% and 91% will be disenrolled for not correctly reporting work hours or exemptions and between 9% and 38% for not meeting the work requirements (Garfield, Rudowitz, & Musumeci, 2018).

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FIGURE 6-15 Barriers to health care among nonelderly adults by insurance status, 2018. (Reprinted with permission from the Kaiser Family Foundation. (December 13, 2019). Key facts about the uninsured population. Retrieved from https://www.kff.org/uninsured/fact-sheet/key-facts-about-the- uninsured-population/)

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Medical Bankruptcies A wide variety of medical issues can lead to financial insecurity and bankruptcy. If you don't have health insurance and you undergo emergency surgery for appendicitis, it may take a great effort to pay off your medical debt (or you may turn to high-interest credit cards). Even if you have health insurance, long-term cancer treatments will likely mean large out-of-pocket costs—and your inability to work may lead to further financial problems. Bankruptcy has provided debt relief.

Bankruptcy filings reached their peak in 2010; about 50% fewer filings were noted by 2017 (United States Courts, 2018). Experts credit that downturn to expanded health coverage with passage of the ACA, along with an improved economy and the 2005 legislation revising bankruptcy laws (St. John, 2017). Medical bankruptcies are uncommon in most developed countries, but GoFundMe efforts to help families with unexpected, crushing medical bills are commonplace in the United States, with over a quarter million requests for assistance annually, raising over $650 million annually (Hiltzik, 2019).

Medical debt is thought to be a major contributor to personal bankruptcy filings. In a classic study, Himmelstein, Thorne, Warren, and Woolhandler (2009) reported in a five-state study that 62% of bankruptcy filings were associated with medical expenses. This number has been widely cited—in academic journals, in the media, and in political speeches. However, more recent studies have not found the same patterns.

Dobkin, Finkelstein, Kluender, and Notowidigdo (2018) examined credit records of a stratified random sample of over 500,00 adults between 2002 and 2011 who had a hospital admission between 2003 and 2007. They discovered that rate of bankruptcies dramatically increased at 1 year and 4 years postadmission. They posited that out-of- pocket health care costs, increased medical debt, and lost wages could lead to bankruptcies, although at a much lower percentage (under 10%) than reported in other studies using different samples. Medical debt that doesn't lead to bankruptcy is still problematic. Cutshaw, Woolhandler, Himmelstein, and Robertson (2016) studied medical causes and consequences of home foreclosures in Arizona and found that about 10% of those affected were uninsured and 28% reported a coverage gap within the previous 2 years. Medical debt or other medical causes were cited by 57%, and 54% stated that they incurred new debt in an effort to pay medical bills (10% had mortgaged homes). About 57% reported having a chronic condition, and over 50%

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had either delayed or missed medical visits. Five months after the first data collection, 33% reported that they could not afford food, and 63% had new medical debts. A few respondents were homeless. Medical debt redistributes income from the poor to wealthier individuals, and our health care system payment structure “exacerbates income inequality and impoverishes millions of Americans” (Christopher, Himmelstein, Woolhandler, & McCormick, 2018, p. 351). About 19% of people with employer-sponsored health insurance reported having been contacted by a collection agency within the last year because of unpaid health care expenses in a representative survey conducted by the Kaiser Family Foundation and the Los Angeles Times (Hamel, Munana, & Brodie, 2019). Over half of respondents reported skipping or postponing care. This is further evidence that the underinsured, along with those individuals without health insurance, are in danger of financial disaster when confronted with a serious medical emergency or long-term illness. Those with chronic health conditions, insured and uninsured, have even higher financial burdens from out-of-pocket health care expenses (Khera et al., 2018).

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Health Care Rationing In 2018, more than 30 million people, or 9.4% of the U.S. population, were uninsured (Cohen, Terlizzi, & Martinez, 2019). Health care in the United States is allocated based on price and the willingness and ability of patients to pay. In other words, patients are entitled to purchase a share of the medical services that they value. Social justice, in contrast, emphasizes the well-being of the community over the individual. Under this view, health care is regarded as a social good (as opposed to an economic good) that should be collectively financed and available to everyone regardless of ability to pay (APHA, 2020; Krau, 2015).

The concept of rationing in health care refers to limiting the provision of health care services. Rationing may occur according to a social justice or market justice model (Bowser, 2015). Rationing implies that resources are fixed or limited and, therefore, cannot meet every need. This is the case in health care—the need will always be greater than the resources (Pearl, 2017). Although Americans may not consider our current system as rationing, when an individual cannot afford health care or delays treatment because of copays, we begin to realize our current system actually is a form of rationing (Tikkanen & Osborn, 2019). Often insurance companies require preapproval prior to agreeing to cover an examination or procedure; this is also a form of rationing (Pearl, 2017). The United States rations health care chiefly by the high cost of health care and the lack of comprehensive insurance for all (Tikkanen & Osborn, 2019). Rationing occurs by your zip code of residence, physicians rationing their time per patient, and hospitals' ratios of beds per unit (Khetpal, 2017). When rationing is based on social justice principles, it is considered a rational, fair and equal distribution of resources according to a clinical need or potential for effectiveness and is not based on income or where one lives. In this way, rationing focuses on the needs of the population more than the individual (Bowser, 2015). Rationing may occur by restricting people's choices, by denying access to services, or by limiting the supply of services or personnel. It may be overt, as in the oft-cited government health system of the United Kingdom, or more covert, as practiced by some U.S. health plans. When rationing is based on market justice principles, limited resources are distributed based on the ability to pay (Bowser, 2015). Rationing may jeopardize the well-being of groups of individuals (Bowser, 2015; Physicians for a National Health Program, 2020a). With limited resources for health services delivery, the government, insurers,

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and providers of health care services make rationing decisions to contain costs (Pearl, 2017). This has included strict eligibility levels or monitoring the use of resources to ensure the most equitable distribution. In 2014, companies were no longer allowed to deny health coverage based on preexisting health issues (CMS, n.d.c). Prior to the ACA, millions of Americans were at risk of being charged higher rates for insurance, had limited coverage, or were denied coverage (CMS, n.d.a.). In the past, private insurers engaged in rationing by excluding enrollees who were at greatest risk for health problems—and, thus, higher expenditures (Rosoff, 2014). This practice is no longer allowed under the rules of the ACA (Box 6-5).

BOX 6-5 What Do You Think?

Rationing of Health Care Services When several individuals need an organ transplant and only one organ is available, what criteria should be used to select the recipient? It is now commonly accepted that certain lifestyle behaviors, such as smoking, alcohol consumption, or driving without restraints, create health risks. Should people who engage in these activities pay a higher price for health care or be excluded from certain services? Should a younger person needing specialized surgery take priority over an older person needing similar care?

There are no easy answers. At the height of the COVID-19 pandemic, health care systems in several countries were stretched beyond their means, and a form of triaging evolved out of necessity. Was this form of rationing used in your area? Or was it used in other areas of our country? Which strategies do you feel are the most effective for the United States in controlling costs and improving health outcomes?

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Managed Care The term managed care became popular in the late 1980s. It refers to systems that contract to coordinate medical care for specific groups in order to promote provider efficiency and control costs. Managed care is a cost- control strategy used in both public and private sectors of health care. Care is managed by regulating the use of services and levels of provider payment. This approach is utilized in HMOs, ACOs, EPOs, and PPOs. Roughly 70 million Americans are enrolled in HMOs, compared to 90 million enrolled in PPOs (NCSL, 2017).

Managed care plans operate on a prospective payment basis and control costs by managing utilization and provider payments. Because costs are tight, preventive services are generally encouraged, so that more expensive tertiary care costs can be avoided if possible (NCSL, 2017).

Health Maintenance Organizations Health maintenance organizations (HMOs) are systems in which participants prepay a fixed monthly premium to receive comprehensive health services delivered by a defined network of providers. In 2019, costs for employee health coverage were similar for HMO, PPO, and point-of- service plans with approximately a $500 difference for an individual and $2,000 for a family. Insurance premiums have continued to rise more than wage increases (KFF, 2019b).

HMOs are the oldest model of managed care. Several HMOs have existed for decades (e.g., Kaiser Permanente), but others have developed more recently. The unique set of properties of HMOs includes the following:

A contract between the HMO and the beneficiaries (or their representative), the enrolled population. Absorption of prospective risk by the HMO. A regular (usually monthly) premium to cover specified (typically comprehensive) benefits paid by each enrollee of the HMO. An integrated delivery system with provider incentives for efficiency. The HMO contracts with professional providers to deliver the services due the enrollees, and the basis for reimbursing those providers varies among HMOs (Estes, Chapman, Dodd, Hollister, & Harrington, 2013).

Some HMOs follow the traditional model, employing health professionals (e.g., physicians, nurses), building their own hospital and clinic facilities, and serving only their own enrollees. Other HMOs provide some services while contracting for the rest (Shi & Singh, 2019).

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HMOs have a 20% higher rate of consumer complaints than customers with PPO plans (State of California, 2017). In response to concerns from managed care clients, a patient bill of rights stipulating the patient's right to timely emergency services, respect and nondiscrimination, as well as participation in treatment decisions and a more consumer-friendly appeals process was developed (California Department of Managed Care, 2020).

Preferred Provider Organizations A preferred provider organization (PPO) is a network of physicians, hospitals, and other health-related services that contract with a third-party payer organization (health insurer) to provide health services to subscribers at a reduced rate. Employers with these plans offer medical services to their employees at discounted rates.

In PPOs, consumer choice exists. Enrollees have a choice among providers within the plan and contracted providers out of the plan. PPOs practice utilization review and often use formal standards for selecting providers (KFF, 2019e). In 2016, PPOs were the most common form of health insurance offered by employers—with 48% of workers able to choose this type of policy; companies with over 200 employees have the highest rate of PPO usage at 52% (KFF, 2016). However, enrollment in PPOs began to decline, and increases were noted in HDHP/SO policies (KFF, 2016). In 2019, 44% of workers had PPOs, and 30% had HDHP/SOs. About 19% were enrolled in an HMO (KFF, 2019b).

Point-of-Service Plans A variation on the plans described above is the point-of-service (POS) plan, which permits more freedom of choice than a standard HMO or PPO. Enrollees choose a primary physician from within the POS plan who monitors their care and makes outside referrals when necessary. At an extra cost, enrollees can go outside the HMO or PPO network of contracted providers unless their primary physician has made a specific referral (Downs, 2016). POS is a type of hybrid or combination of an HMO and PPO. In 2016, about 10% of employees were enrolled in POS plans and only 7% were in a POS plan in 2019 (KFF, 2016, 2019c). See Figure 6-16 for trends in types of health plan enrollment.

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FIGURE 6-16 Distribution of health plan enrollment for covered workers, by plan type, 1988–2019. (Reprinted with permission from the Kaiser Family Foundation and Health Research & Educational Trust. (2019). Employer health benefits: 2019 annual survey. Retrieved from http://files.kff.org/attachment/Report- Employer-Health-Benefits-Annual-Survey-2019)

High-Deductible Health Plans The high-deductible health plan (HDHP) is growing in popularity. Among employees in small and large size companies a high-deductible health plan with a saving option (HDHP/SO) is often favored over HMOs (Argawal et al., 2017). The plan has higher deductibles and out-of-pocket maximum limits. However, once these deductibles are met, the plan pays 100% of in- network health care. In addition, the HDHP plan is the only health plan that allows for money to be put aside pretaxed to be used to pay for deductibles and out-of-pocket expenses (USOPM, n.d.a.).

The average annual out-of-pocket cost in 2018 for high-deductible, high-premium HDHP-HSA plans were not to exceed $6,650 for single and $13,300 for family coverage (KFF, 2018a). Similar saving plans tied to HDHP plans vary in maximum costs. Deductibles have risen 212% between 2008 and 2018, and over a quarter of covered employees have plans with $2,000 deductibles (or more). For employers with <200 employees, 42% of covered employees have at least $2,000 deductibles (Tozzi, 2018). In 2018, 29% of employers offering HDHPs also included a savings plan option, either HSA or HRA (Tozzi, 2018). HDHPs are more often available with large firms than with small ones, 58% versus 27% (KFF, 2018a).

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Exclusive Provider Organizations Other than for medical emergencies, an exclusive provider organization (EPO) plan only covers services and providers within the network. Benefits of this type of plan are lower prices than an HMO and not needing a referral from a primary health care provider (Downs, 2016). However, if an individual goes out of network, 100% of the medical bill is owed by that person. A provider that was covered when you bought your policy may no longer be part of the plan the following year, and you will not necessarily know this until you are billed for the visit.

In 2016, there were projected to be about “60% more EPOs being sold through the federal insurance exchange” than the previous year (Zamosky, 2015, para. 13).

Competition and Regulation Often, competition and regulation in health economics have been viewed as antagonistic and incompatible concepts.

Competition describes a contest between rival health care organizations for resources and clients. Regulation refers to mandated procedures and practices affecting health services delivery that are enforced by law.

In a society in which there are long-held values of freedom of choice and individualism, competition provides opportunities for entrepreneurial endeavor, free enterprise, and scientific advancement. Yet, regulation also serves an important role in promoting the public good, overseeing equitable distribution of health services, and fostering community-wide participation (Smith & Yip, 2016).

Health care incorporates four major types of regulation—laws, regulations, programs, and policies (Longest, 2016; Young & Kroth, 2018).

Laws that regulate health care include any legislation that governs financing or delivery of health services (e.g., Medicare reimbursement to hospitals). Regulations guide and clarify implementation; they are issued under the authority of law and are part of most federal health care programs (e.g., CHIP eligibility requirements). Regulatory policies have a broader focus and involve decisions that shape the health care system by channeling the flow of resources into it and setting limits on key players' actions (e.g., state nurse practice acts, health manpower training, ACA rules on preexisting conditions) (Longest, 2016). Programs and policies are often developed in

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order to control costs and improve quality (e.g., HRRP, HIPAA). See Chapter 13.

In the early 1980s, government cost-control measures were greatly diminished as the Reagan era ushered in deregulation (Young & Kroth, 2018). The passage of the Omnibus Budget Reconciliation Act caused dramatic changes affecting health care. The federal government, having failed to contain rising health care costs, shifted responsibility for the public's health and welfare back to state and local governments. From all this grew the competition-versus-regulation debate (KFF, n.d.; Young & Kroth, 2018). The 1990s were characterized by numerous hospital mergers and movement from nonprofit to for-profit status. More than 86% of the population in 1991 was covered by some form of prepaid health insurance, largely due to the effects of Medicare and Medicaid (Levit, Olin, & Letsch, 1992).

The Clinton health plan failed to gain support and many hospitals downsized and reduced the number of nurses on staff. Managed care became more popular, but by the late 1990s, fears were raised about MCOs withholding necessary care and a consumer “backlash” resulted (Melnick, Fonkych, & Zwanziger, 2018).

Many states and the federal government enacted benefit laws between 1990 and 2008, in response to these concerns (KFF, n.d.). The ACA was passed into law in 2010 (KFF, n.d.). However, we still feel the results of decades of disjointed policies, and one of the most obvious consequences deals with competition in health care. Competition, its proponents say, offers wider consumer choice and positive incentives for cost containment and enhanced efficiency (Young & Kroth, 2018); that is, consumers are free to select among various health plans on the basis of cost, quality, and range of services. One downside is fragmentation of services, lack of coordination, and subsequent waste. Integrated delivery systems, such as Kaiser Permanente's fully integrated system, or more loosely organized public– private partnerships, could lead to improved quality, outcomes, and reduced costs (Enthoven & Baker, 2018).

Regulation advocates for almost 20 years have argued that there are at least four problems associated with the competition model: (1) consumers often do not make proper health care choices because they have limited knowledge of health services; (2) competition may discriminate against enrolling certain consumers, especially high-risk, high-cost patients, thus excluding those who may need services the most; (3) the competition model may not encourage enough teaching and research—expensive elements of

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our present system; and (4) quality may be sacrificed to keep costs down (Young & Kroth, 2018).

The following tenets often guide discussions on health care reform efforts (Fitzgerald & Yencha, 2019):

Reduction in health care prices occurs when there is more competition among hospitals and among insurers. Reducing government regulations will lead to lower health care prices. Higher prices can reflect higher-quality care. Higher provider costs are reflected in higher prices.

A study by Fitzgerald and Yencha (2019) examining outcome measures for those tenets among seven million hospital and patient interactions found the following:

Generally, the greater the competition among hospitals (more choice), the lower the prices. Depending upon the type of charge used (average total payment or “chargemaster” price), the price of average total payments is greater when there is more competition among insurers, and “chargemaster” prices (or the higher amount paid by those out of network or without insurance, like MSRP) increase when insurers are more concentrated, leading to fewer choices (p. 7). Regulation does not consistently affect health care prices; prices can increase or decrease depending upon the cost measure used. As hospitals gain in quality measures, their prices generally rise (both average and chargemaster); higher mortality rates were associated with lower prices. However, on two measures of quality, patient experiences and readmission rates, a negative relationship was found. Higher hospital costs are generally associated with higher prices. Regulation advocates conclude that standardization and controls are needed to guarantee quality and equal access (Longest, 2016). However, “regulation of prices and spending,” as done in other health care systems, has not always been popular among U.S. policymakers (Altman & Mechanic, 2018, para. 5). Regulations are often viewed as excessively restrictive and costly. For instance, the American Hospital Association claims that $39 billion per year is spent by hospitals, health systems, and postacute care providers on administrative costs involved in meeting regulatory requirements (AHA, 2020). However, over 4,800 community hospitals reported increasing profits, rising 43% from 2011 to 2017, and reaching over $76 billion (Bannow, 2018).

From 2001 to 2016, hospital revenue rose dramatically (238% price increase), while experiencing a 10% drop in total care volume for privately insured patients (Melnick et al., 2018).

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U.S. hospitals earned their highest level of profits post-ACA in 2016 (Altman & Mechanic, 2018).

California instituted a competitive model in an effort to control health care costs. This included promotion of competitive prices “through market- based, managed care policies” (Melnick et al., 2018, p. 1417). This model was successful until two emerging trends shattered competition: (1) hospitals were permitted by antitrust officials to merge into larger hospital systems (adding hospitals outside local markets) and (2) in order to adequately meet the demand for access to hospital emergency services, regulations were put in place that inadvertently gave hospitals new ability to gain an advantage in negotiations with health insurance companies. These actions led to a less competitive marketplace and the inability of health insurance companies to “leverage competition” to negotiate for lower costs and better benefits (Melnick et al., 2018, p. 1417).

Our capitalist system is driven by profits, and the profit motive in health care can lead to excesses and higher costs for taxpayers and patients. In 2019, first quarter reporting more than half of all profits in the health care sector went to the top 10 companies, and 90% of those were large pharmaceutical companies like Pfizer ($3.9 billion), Eli Lilly ($4.2 billion), and Johnson & Johnson ($3.7 billion). These high profits are occurring at a time when drug prices are escalating, with almost half of the U.S. population reporting use of a prescription medication in the last month. Currently, 44 states have “joined an antitrust lawsuit accusing 20 drug manufacturers, including Pfizer and Teva Pharmaceuticals, of fixing prices for more than 100 generic drugs” (Jaggannathan, 2019, para. 5). The argument often made by pharmaceutical firms that more money is needed for research and development of new drugs was recently invalidated by examining the costs for 10 pharmaceutical companies introducing newly developed cancer drugs (cost = $9 billion) while their revenues reached over $67 billion (Anderson et al., 2019).

As the ACA was enacted, concerns arose about the continued financial stability of health insurers participating in the ACA marketplace exchanges, but the five largest health insurers have continued to be profitable. These five companies represent about 43% of the nation's insured population.

Three of them have restricted or ended enrollment in ACA plans, but they have all benefited from growth in Medicare and Medicaid membership between 2010 and 2016, doubling from 12.8 million to 25.5 million. These companies now hold 52% of the Medicare Advantage market in 19 states. They have also moved to procuring more administrative

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service contracts, providing network and claims management for employers or entities who are converting from the usual health insurance policies to self-insurance plans. The five insurers report profit margins (some as high as 11% in 2017) and stock share prices have doubled or tripled from 2011 to 2016 (Schoen & Collins, 2017).

Leaders in the field have concluded that both competition and regulation are needed (Longest, 2016; Young & Kroth, 2018). With foresight, McNerney (1980) wrote, “It is rapidly becoming apparent that what we need is a proper balance between competition and regulation with more effective links [and] regulation [should be] used as a force to keep the market honest” (p. 1091).

Managed competition (market-based effort to provide wide access to health care while keeping costs down) and universal coverage (every person has health insurance), as well as single-payer systems (only one entity receives funds and pays for health care), have been part of the discussion around health care reform (Physicians for a National Health Program, 2020b). Two plans that are worth further review are managed competition and universal coverage, with and without a single-payer system. The benefits and drawbacks of each are discussed at http://thepoint.lww.com/Rector10e.

Drivers of Costs Drug spending is a “primary driver of higher cost” in the present U.S. health care system, and a continuing trend, with $1,011 per person spent on prescription drugs annually compared to $422 for other developed countries (Anderson et al., 2019, p. 12; Cox, Kamal, Jankiewicz, & Rousseau, 2016; NAHU, 2015).

While the U.S. Veterans Administration has a 30% discounted rate for prescription medications, the federal government is not allowed to negotiate drug prices for Medicare or Medicaid programs (Cai et al., 2020).

Other drivers of health care costs include the following: An aging population, new technologies, and biologics (e.g., biosimilars like synthetic insulin and monoclonal antibodies) Lifestyle/behavioral choices (about 70% of health care costs may be related to smoking, abuse of alcohol, and obesity), inefficient systems (e.g., duplication of services/procedures, preventable medical errors, unwarranted prescriptions/visits/treatments, spotty quality improvement) Medical malpractice costs, cost shifting, increased demand for health care, government regulations, and other market changes,

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like consolidations/monopolies (National Association of Health Underwriters, 2015)

We will need to decide how to move forward, either building on the ACA by offering a more meaningful public option and expanding markets while continuing to promote employer health insurance or making a significant shift to a single-payer system provided to all citizens.

With the lack of quality health outcomes in the United States, as described above, even if everyone received health insurance, how could quality be assured? Some believe that the overall performance of the health care system should improve as everyone gains access to care. However, some early evaluation of value-based incentive and penalty programs (e.g., Hospital Value-Based Purchasing Program, Hospital Readmission Reduction Program [HRRP]) reveal that they have not been “effectively calibrated” to achieve their expected results and need more fine tuning to produce better outcomes (Doran, Maurer, & Ryan, 2017, p. 464). A system that provides incentives to both providers and patients to use services efficiently and effectively may produce better results (Robinson, Brown, & Whaley, 2017). Another factor that may also improve outcomes is a means of providing health care consumers with pertinent, timely information so that they can be more active participants in their care. (See http://thepoint.lww.com/Rector10e for resources.)

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Changing Our Health Care System The cry for health care reform is not new. In a classic study, Perkins (1998) examined the work of the 1927 to 1932 Committee on the Costs of Medical Care. Almost 100 years ago, the committee defined costs as the major problem and business models of organization as the major solution.

An important health care reform element is a standard set of benefits, set by law and enjoyed by the entire population, regardless of age, health status, income level, and employment. Many countries have successfully implemented such a package under a plan called the statutory model. Various versions of this model have worked well in Austria, France, Belgium, Japan, Germany, Israel, Poland, The Netherlands, and Switzerland. In this model, health insurance falls under the rubric of social security and is funded through government-mandated payroll premiums or taxes. Payment is made to private sector health insurers, from a fund known in some countries as a sickness fund (Edwards & Dunn, 2019; IOM, 2013). Individuals can switch plans when desired. This statutory model eliminates the need for separate programs such as Medicaid and Medicare. It also provides uniform and comprehensive benefits (McClure, Enthoven, & McDonald, 2017).

Health reform must focus on the central question: Is there coverage for the promotion of health and prevention of illness or simply payment for the diagnosis and treatment of those who are already ill? Research has shown that public health interventions are consistently more cost-effective than medical services, yet past health reform has often paid minimal attention to this critical issue (Owen, Pennington, Fischer, & Jeong, 2019; Smith et al., 2019; Tanner, 2015). In addition, our frequent emphasis on medical care cost containment does not take into account the social determinants of health that need to be addressed outside the health care system (Beckfield & Bambra, 2016). C/PHNs can play an influential role in emphasizing health promotion services as being central to future health reform efforts through political involvement and policy development. With the successful passage of HR 3590 (Public Law [PL] 111–148), The Patient Protection and Affordable Care Act, on March 23, 2010, and the March 25 passage of HR 4872 (PL 111–152), Health Care and Education Affordability Reconciliation Act of 2010, amending HR 3590, the long journey toward health care system reform crossed a threshold. Both pieces of legislation are referred to as the Affordable Care Act (ACA). Although by no means a grand vision for change with its incremental implementation, it has been noted to be a significantly consequential

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achievement in reducing the number of uninsured Americans (Gaffney & McCormick, 2017; Woolhandler & Himmelstein, 2017). The ACA has been described as “consumer friendly” with coordination and seamless transition between programs as the goal, with exchanges given to power to remove insurers who abuse the system or provide inadequate service. Coordination between insurance exchanges, Medicaid, and CHIP provides for better coverage (MACPAC, 2018). The ACA encourages comprehensive case management of chronic disease as one way to decrease hospitalizations and the cost of care. New methods of determining cost-effectiveness are being utilized to determine the realistic impact of population interventions (Arbel & Greenberg, 2016).

Another component of the ACA, the Patient-Centered Outcomes Research Institute (PCORI) provides additional information on effectiveness of treatments and interventions, and the Innovation Center at CMS develops, evaluates, and tests new programs and policies that reduce cost and enhance care for Medicaid and Medicare patients (CMS, 2020c; Hoagland & Parekh, 2019; PCORI, 2017). Improved value and quality outcomes are the proposed benefits of these programs. For a summary of the ACA, see http://kff.org/health-reform/fact-sheet/summary-of-the-affordable-care-act/.

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EFFECTS OF HEALTH ECONOMICS ON COMMUNITY/PUBLIC HEALTH PRACTICE

Health economics has significantly affected community/public health practice by advancing disincentives for efficient use of resources, incentives for illness care, and conflicts with public health values.

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Overcoming Disincentives for the Efficient Use of Resources Public health has been affected in several ways. The trend of diminished federal and state allocations has had profound effects on community/public health programs, and severe budget cuts have affected even basic public health services, especially during the coronavirus pandemic.

Public health agencies and providers in Accountable Care Organizations are joining together for initiatives to improve quality along with cutting costs (e.g., Triple Aim, outcome accountable care). Public health professionals can offer their expertise in community assessment and design of population- based interventions. The 6/18 initiative follows the format of promoting population health by accelerating collaborative partnerships to implement 18 evidence-based interventions that target 6 high-cost, “high-burden, preventable conditions” in a community-integrated health care program (Hester et al., 2016, p. 4).

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Managed Care and the Future of Public Health Initially, managed care focused on event-driven cost avoidance (e.g., decreasing inpatient days and specialty physician use, using physician extenders). This evolved into a second stage, in which the principal objective was to control resource intensity and improve the delivery process. Now, emphasis has shifted to a focus on health promotion and population health. Community assessments are an important part of this approach, so that high- risk groups can be identified and provided early interventions. Case management of individuals with chronic illness is also a focus (Mendelson, 2019).

Community health assessments could become standard quality tools for not only public health interventions but also health care in general. The ACA requires hospitals to conduct regular community assessments, and many have partnered with LHDs to do so. This provides an opportunity for collaborative partnerships or “cross- sector collaborations” needed to improve population health and reach more community members. Health care reform legislation includes a requirement for community needs assessment every 3 years for state- licensed, tax-exempt health organizations such as hospitals and imposes a $50,000 annual penalty if this is not done. Prioritization of health needs and a description of community resources are to be included, as is input from those with expertise in public health (Adams, 2011; Erwin & Brownson, 2017a; Wahowiak, 2017, p. 1). While hospitals are required by the ACA to complete community health assessments, more research is needed to discover if intervention programs have been implemented to improve population health as a result (Cramer, Singh, Flaherty, & Young, 2017). See Chapter 15 for more on Community Assessment.

Improving the health status of a community mandates that health care agencies be actively involved in health teaching and health promotion, as well as developing community action plans to promote collaboration and focus on early intervention and treatment to improve health equity and health outcomes (National Academies of Sciences, Engineering, and Medicine, 2017). Are these not the proposals that public health advocates have been making for more than a century?

By partnering with hospitals on community assessment and research, these things, along with public health accreditation, may further improve the public health system (Wahowiak, 2017).

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Erwin and Brownson (2017a) described macro trends that will influence the future of public health. These include community health assessments in conjunction with hospitals, accreditation, and preparation for catastrophic weather events and other disasters related to climate change. The influences of Health in All Policies (HiAP, described in Chapters 13 and 16), informatics and social media, demographic trends (e.g., increased elderly and racial ethnic minority populations), and global travel will encourage C/PHNs to become more adept in these areas in order to meet the needs of their clients and communities. However, in some areas of the country, there is a decline in recruitment and retention of C/PHNs making it difficult to meet the coming challenges (Taylor, 2018). Public Health 3.0 is an initiative promoted by the U.S. Department of Health and Human Services (n.d.b) and amplified by leaders in the field of public health (Balio, Yeager, & Beitsch, 2019; DiSalvo et al., 2017).

Eight “strategic skill domains” were identified: “effective communication, data for decision-making, cultural competence, budget and financial management, change management, systems and strategic thinking, developing a vision for a healthy community, and cross-sector partnerships” (Resnick et al., 2019, p. 10).

Frieden (2015) called upon public health to join with clinical medicine, government agencies, health NGOs, private sector groups, and our communities to make our population healthier. He shared a powerful example from the United Kingdom.

Knowing that decreasing sodium intake would have great benefits for health outcomes (reduced hypertension, stroke, heart attacks), but recognizing that individual efforts are difficult due to the use of processed foods, the government partnered with the food industry to cut sodium in breakfast cereals by 57% and bread by 20%, along with many other foods. This caused a drop in the population average for sodium intake by 15% over 8 years and a 40% reduction in heart attack deaths and 42% drop in strokes.

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IMPLICATIONS FOR COMMUNITY/PUBLIC HEALTH NURSING

There are estimated to be over 47,000 public health nurses working in federal, state, and local public health agencies. A large number of nurses also work in educational community organizations. Together, they strive to promote and protect the health of individuals, families, and populations (Kub, Kulbok, Miner, & Merrill, 2017).

C/PHNs have had to adapt to a constantly changing system. They need the ability to assist their clients in accessing programs and services. Some of your clients may be able to access health care services through your LHD (e.g., immunizations, school physicals, women's health care), but others may need help in finding some type of health insurance to help pay for private health care services. Where do you begin? You will need the following information:

What type of care is needed (e.g., primary provider, specialist)? Who needs the care (e.g., child, older adult, family)? Employment/finances (e.g., unemployed/laid off, intermittent or steady employment without health insurance/income level, sources of income)?

See Box 6-6 for online resources for accessing programs and services.

BOX 6-6 Online Resources for Accessing Programs and Services Basic Information on Paying for Medical Care and Prescriptions

https://www.usa.gov/payingfor-medical https://www.verywellhealth.com/how-to-get-help-payingfor- health-insurance-1738500 https://www.thebalance.com/save-money-healthcare-insurance- 4124456 https://www.livestrong.org/we-can-help/insurance-and-financial- assistance/healthcare-assistance-for-uninsured

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Information Based on Income Levels If incomes are low, check for Medicaid and CHIP eligibility at https://www.healthcare.gov/medicaid-chip/getting-medicaid-chip/. For those with higher-income levels, check your state's health insurance marketplace at:

https://www.healthcare.gov/apply-and-enroll/get-help- applying/ https://www.npr.org/sections/health- shots/2020/04/03/826316458/coronavirus-reset-how-to-get- health-insurance-now

Information for Older Adults https://www.nia.nih.gov/health/paying-care https://www.payingforseniorcare.com/homecare/payingfor- homecare https://www.caring.com/senior-living/nursing-homes/how-to-pay/

Nurses working within the public health system have developed innovative modes of service delivery (Nolte, 2018).

One example of an innovative collaborative partnership is the inclusion of PHNs on case conference teams at Indianapolis health centers. The PHNs, with deep knowledge of their communities, help health center staff by following up on patients in their homes, and providing team members with information about available resources. In return, the public health department derives benefits from the health centers promoting population health (Vest et al., 2018). C/PHNs have recognized the importance of outcomes research to document the value of nursing interventions with at-risk populations (Christian, 2016; DiClemente, Nowara, Shelton, & Wingood, 2019; Hill, Penrod, & Milone-Nuzzo, 2014). An examination of 20 years of studies that focused on “health education, behavior change, and screening” demonstrated effective outcomes in almost 50%, but limitations included a need to “strengthen methods for documenting effectiveness of PHN practice” (Swider, Levin, & Reising, 2017, p. 324). The effectiveness of the PHN interventions in Nurse–Family Partnership research is well documented and extends over many years, taking place in many settings. See Chapter 4.

Utilizing collaborative skills and knowledge of their communities, they can work with partners to meet the challenges of Public Health 3.0 and

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provide services needed for the vulnerable populations in our future health care system (Kulbok, Kub, & Glick, 2017; Swider, Levin, & Kulbok, 2015; Swider et al., 2017).

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SUMMARY

Many factors and events have influenced the current structure, function, and financing of community/public health services. Understanding this background gives the C/PHN a stronger base for planning for population health. Historically, health care has progressed unevenly, marked by numerous influences. The Middle Ages saw a serious health decline in Europe, with raging epidemics leading to extensive 19th century reform efforts in England and, later, in the United States. Public health problems prompted the gradual development of official interventions. Quarantines to control the spread of communicable disease, sanitary reforms, and establishment of public health departments were discussed. By the early 1900s, the federal government had assumed a more active role in public health, with a proliferation of health, education, and welfare services. Efforts to address community/public health needs have been made by public agencies and private individuals. They work together to promote an emerging health care system.

The public arm includes all government, tax-supported health agencies and occurs at local, state, national, and international levels. A different structure and set of functions are found at each level.

Public health services include three core public health functions: assessment, policy development, and assurance. Inadequate funding has been problematic for the public health system, especially during the recent pandemic.

Private health services are the unofficial arm. They include voluntary nonprofit agencies as well as privately owned (proprietary) and for-profit agencies. They often supplement and complement the work of official agencies.

The delivery and financing of community/public health services have been significantly affected by various legislative acts.

These include such innovations as health insurance and assistance for people who are poor, elderly, or disabled; money to train health personnel and conduct health research; standards for health planning and delivery; health protection for workers on the job; and the financing of health services.

Health care economics studies the production, distribution, and consumption of health care goods and services to maximize the use of

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scarce resources to benefit the most people. The health care system is influenced by microeconomics (supply and demand) as well as macroeconomics.

Health care is funded through public and private sources, which fall into three categories: third-party payers, direct consumer payment, and private support. Health care services have been reimbursed either retrospectively, typical of FFS plans, or prospectively, typical of most managed care plans. Several trends and issues have influenced community/public health care financing and delivery, including cost control, financial access, managed care, health care rationing, competition and regulation, managed competition, universal coverage, calls for a single-payer system, and health care reform. The changing nature of health care financing has adversely affected community/public health by promoting incentives to focus on illness care, and the competition model has generated a conflict with the basic public health values of health promotion and disease prevention for all persons. Health care reform has reduced the number of uninsured Americans, but access for many people is still difficult.

The United States remains the only industrialized nation without some type of universal health coverage. It also ranks significantly lower than most other developed countries on health indicators, such as infant mortality and life expectancy, and we spend the highest percentage of GDP on health care.

C/PHNs can lead the effort in making health care more accessible to all citizens and encourage policies and practices that promote health. C/PHNs should prepare for future changes in public health.

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ACTIVE LEARNING EXERCISES

1. Explain how social, economic (e.g., Great Depression), political (e.g., WWII), and legislative actions have shaped our current health care system, public health system, policies, and practices. Give examples of legislation or policy that incorporates each of the three core public health functions (assessment, policy, and assurance) and identify which of the 10 essential public health services are implicated.

2. Describe an every-day life example of supply and demand. Summarize three exceptions to the law of supply and demand in health care economics. How can this promote rising health care costs? Form two teams and debate the advantages and disadvantages of managed competition as opposed to mandatory universal coverage.

3. Compare the United States with other similar countries. Where do we rank in spending on health care? Identify five measures (e.g., life expectancy) in which the United States has more negative outcomes. What health care system approach, that is common in all other high- income countries, does the U.S. lack? What are the advantages and disadvantages of a single-payer system? Debate with a classmate if further health care reform is feasible in the United States. What is the most efficient way of ensuring universal coverage, as evidenced by examples from other countries outlined in this chapter?

4. Debate the pros and cons of universal health care as outlined by Blumberg and Holahan (2019) at http://thepoint.lww.com/Rector10e. Describe three key potential benefits and the three most serious potential negative consequences. Talk with your classmates and other students at your university about their access to health care and if they have some type of health insurance. If they do not, explore the reasons for this. Does your campus have a student health center? What services are offered there? What are the average costs to students?

5. Interview two consumers about their perception of the problems and strengths of our health care system. What are their thoughts and feelings about our current health care system and availability of health insurance? Have they, or others they know, had problems with health care or health insurance coverage during the pandemic? Select people who represent distinctly different age groups and life situations, such as a single 25-year-old mother of three children making minimum wage and a 75-year-old widower; compare and contrast their responses.

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thePoint: Everything You Need to Make the Grade!

Visit http://thePoint.lww.com/Rector10e for NCLEX-style review questions, journal articles, supplemental materials, and more!

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CHAPTER 7

Epidemiology in the Community "Epidemiology dates back to the Age of Pericles in 5th Century B.C., but its standing as a ‘true’ science in 21st century is often questioned. This is unexpected, given that epidemiology directly impacts lives and our reliance on it will only increase in a changing world" (p. 1).

—Epidemiology is a science of high importance [Editorial]. (2018). Nature Communications, 9(1703), 1–2.

KEY TERMS Association Causal matrix Causality Chain of causation Epidemic Epidemiologic triangle Epidemiology Immunity Incidence Morbidity rate Mortality rate Natural history Nosology Pandemic Prevalence Reservoir Risk Vectors Web of causation

LEARNING OBJECTIVES Upon mastery of this chapter, you should be able to:

1. Discuss key highlights of the history of epidemiology. 2. Apply the epidemiologic triangle (host, agent, and environment model)

to a common public health problem. 3. Describe theories of causality in health and illness. 4. Define immunity and compare and contrast passive, active, cross-, and

herd immunity. 5. Explain how epidemiologists determine populations at risk. 6. Identify the four stages of a disease or health condition. 7. Describe sources of information for epidemiologic study, including

existing data, informational observational studies, and scientific studies. 8. Discuss the types of epidemiologic studies that are useful for researching

aggregate health and the process for conducting epidemiologic research.

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INTRODUCTION

Epidemiology is the scientific discipline that seeks to describe, quantify, and determine how diseases occur in populations and aid in developing methods of controlling those diseases (Friis, 2018). The term is derived from the “Greek words epi (upon), demos (the people), and logy (study of)”; the knowledge or study of what happens to people (Friis, 2018, p. 6).

Purposes of epidemiology include the following:

To examine determinants and distribution of diseases, disabilities, morbidity, and mortality, as well as health To provide a body of knowledge through research on which to base practice and methods for studying new and existing problems To provide C/PHNs with a methodology for assessing the health of aggregates To offer a frame of reference for investigating and improving clinical practice in any setting

Characteristics of epidemiology include the following:

Is data driven Relies on an unbiased and systematic approach to collecting, analyzing, and interpreting data Draws on methods and principles from biostatistics, informatics, biology, and the social, economic, and behavioral sciences

Epidemiologists are considered “disease detectives” as they search for causes of illness and outbreak (Centers for Disease Control and Prevention [CDC], 2016, para. 1). Epidemiologists ask such questions as:

What is the occurrence of health and disease in a population? Has there been an increase or decrease in a health state over the years? Does one geographic area have a higher frequency of disease than another? What characteristics of people with a particular condition distinguish them from those without the condition? What factors need to be present to cause disease or injury? Is one treatment or program more effective than another in changing the health of affected people? Why do some people recover from a disease and others do not?

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As an example of epidemiology serving as a frame of reference, imagine that a county health department public health nurse's (PHN's) goal is to lower the incidence of sexually transmitted diseases (also referred to as sexually transmitted infections [STIs]) in a given community. Such a prevention plan would require information about population groups. The nurse would need to ask questions such as:

How many STD cases have been reported in this community over the past year? What percentage of these are drug resistant (e.g., drug- resistant gonorrhea)? What is the expected number of STD cases (the morbidity rate)? Which members of the community are at highest risk of contracting STDs?

In fact, to be effective, any program of screening, treatment, or health promotion regarding STDs must be based on this kind of information about population groups.

Whether the PHN's goals are to improve a population's nutrition, control the spread of tuberculosis (TB), deal with health problems created by a flood, protect and promote the health of battered women, or reduce the number of automobile crash injuries and fatalities at a specific intersection, epidemiologic data are essential.

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HOW EPIDEMIOLOGY SUPPORTS THE TEN ESSENTIALS OF PUBLIC HEALTH SERVICES

Assessment Monitor Health: by gathering vital and disease statistics, provides data necessary to define the scope of disease and health and visually trend disease spread Diagnose and Investigate: by providing population health and disease data to determine whether new diseases are spreading into new segments of the population and providing the basis for launching epidemiologic investigations

Policy Development Inform, Educate, and Empower: by providing statistical reports of the status of disease spread, investigations, and their progress so policy makers can inform and educate the public about health factors and empower the public to address them Mobilize Community Partnerships: by sharing community epidemiologic data so stakeholders can collaborate in addressing health issues that affect their constituents Develop Policies: by providing health data to community planning agencies and organizations so policy makers can develop more informed strategies to address issues affecting the community

Assurance Evaluate: by providing population health data that can be used as objective measures to evaluate the effectiveness of health programs in reducing morbidity and mortality (CDC, 2020)

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HISTORICAL ROOTS OF EPIDEMIOLOGY

Most of the early contributions to epidemiology were made by physicians who sought the cause of disease through methodical observation and conducting experiments to test their theories of new treatment methodologies. The work of these physicians formed the basic concepts that served as a foundation for the science of epidemiology.

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Early Physician–Epidemiologists The roots of epidemiology can be traced to Hippocrates (460 to 375 BC), a Greek physician who is sometimes referred to as the first epidemiologist.

Hippocrates:

Explained disease occurrences from a rational, rather than a supernatural, viewpoint. In his essay, “On Airs, Waters, and Places,” suggested that environmental and host factors (e.g., lifestyle behaviors) influence disease development (Bryant & Rhodes, 2018). Introduced observations of how diseases spread and affect populations. Considered diseases in relation to time and season, place, environmental conditions, and disease control.

Table 7-1 summarizes the contributions of the early physician– epidemiologists to the field of public health. Figure 7-1 shows an example of a spot map early epidemiologist John Snow used in tracking cholera cases.

TABLE 7-1 Physician–Epidemiologists and Their Contributions to Epidemiology

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Source: Lilienfeld (2007); Merrill (2017).

FIGURE 7-1 A spot map John Snow used to track cholera cases. Note the location of water wells/pumps (blue). (Reprinted with permission from Wilson, R. (2012). John Snow's famous cholera analysis data in modern GIS formats. Robin's Blog. Retrieved from http://blog.rtwilson.com/john-snows-famous-cholera-analysis-data- in-modern-gis-formats/)

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Florence Nightingale: Nurse Epidemiologist Nursing's epidemiologic roots can be traced to Florence Nightingale (1820 to 1910). Nightingale advocated training in science, strict discipline, attention to cleanliness, and the development of empathy for patients. She also established a nursing school at London's St. Thomas Hospital and is commonly referred to as “The Lady with the Lamp,” a designation given to her by soldiers during the Crimean War as she ministered to them during the night. Queen Victoria recognized Nightingale's contributions to nursing and epidemiology. She was awarded the highest civilian medal, the Order of Merit, and was the first woman to receive it (Florence Nightingale Museum, 2018). Her contributions include:

Monitoring disease mortality rates to improve hospital sanitary methods that decreased death rates Using a research perspective to conducting systematic descriptive studies of the distribution and patterns of disease in a population (detailed records and descriptions of health conditions, morbidity [sickness] statistics) Using applied statistical methods to visualize data (shaded and colored wedge-shaped graphs) as a new way to improve medical and surgical practices Using published statistical reports to gain the attention of politicians and powerful people (i.e., William Farr) to bring about hospital and public health reforms that created changes in hygiene and overall treatment of patients (Schiotz, 2015)

Nightingale's contributions to nursing are further explored in Chapter 3.

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Eras in the Evolution of Modern Epidemiology Modern epidemiology can be described as having four distinct eras, each based on causal thinking: (1) sanitary statistics, (2) infectious disease epidemiology, (3) chronic disease epidemiology, and (4) eco-epidemiology. Table 7-2 summarizes these four eras in the evolution of modern epidemiology. Below, each is described in detail.

TABLE 7-2 Eras in the Evolution of Modern Epidemiology

Source: Susser and Susser (1996a, 1996b); Susser and Stein (2009).

Sanitary Statistics Early causal thinking was dominated by the miasma theory, which had its origins in the work of the Hippocratic School and was formally developed in the early 1700s. This theory held that a substance called miasma was composed of malodorous and poisonous particles generated by the decomposition of organic matter and was the cause of disease. Prevention based on this theory attempted to eliminate the sources of the miasma or polluted vapors.

Despite the faulty reasoning, this type of prevention had positive consequences because it made people aware that decaying organic matter can be a source of infectious diseases. This theory dominated until the first half of the 19th century, when environmental sources and the idea that sanitary conditions were linked to disease led John Snow to identify the source of cholera (Rosen, 2015; Schiotz, 2015).

Infectious-Disease Epidemiology The era of infectious-disease epidemiology was dominated by the contagion theory of disease, which developed during the mid-19th century. Due to development of increasingly sophisticated microscopes, this theory attempted to identify the microorganisms that cause diseases as a first step in

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prevention. It inspired various theories of immunity, and even prompted some initial attempts at vaccination against smallpox.

Additionally, once an agent had been identified, measures were taken to contain its spread. Fumigating ships to kill rats, protecting wharf buildings and human habitations from rats, and removing rat food supplies from easy access were all measures taken to protect the public by further preventing the spread of plague bacilli. Based on the work of Louis Pasteur, Jakob Henle, and Robert Koch, the contagion theory was refined and became best known as the germ theory of disease, which was predominant from the late 19th century through the first half of the 20th century (McKenzie, Pinger, & Seabert, 2018; Merrill, 2017; Rosen, 2015).

In the era of infectious disease epidemiology, scientists viewed disease in terms of a simple cause-and-effect relationship. Finding a single cause (e.g., plague bacilli) and attacking it (e.g., eliminating rats) seemed to be the solution for preventing many diseases. In the case of bubonic plague, this approach appeared to be quite effective (Merrill, 2017).

However, scientific research eventually revealed that disease causation was much more complex than first suspected. For example, although most members of a group might be exposed to the plague, many did not contract it. With bubonic plague, as with many other infectious diseases, host characteristics can determine both the spread of the disease and its individual impact. Lessons learned from the bubonic plague include the following:

Not everyone in a population is at equal risk; it is now known that untreated bubonic plague has a case fatality rate of 40% to 70%, meaning that about half of those who contract the disease and are not treated will eventually die. The agent and course of transmission can be quite complex. Although a flea carries the bacilli from rats to humans in bubonic plague, many infectious diseases spread directly from one human being to another. The environment must be considered as part of the cause of disease. Evidence suggests that the plague originated in the high plains of Asia and spread to other parts of the world. However, questions remain as to whether the bacillus spread from rats to ground squirrels or had always been part of the squirrels' ecology (CDC, 2015).

After World War II, the causative agents of major infectious diseases were identified, methods of prevention were recognized, and antibiotics were added to the arsenal to fight communicable diseases.

Chronic Disease Epidemiology

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The focus then became understanding and controlling the new chronic disease epidemics, ushering in the era of chronic disease epidemiology. Researchers completed case–control and cohort studies, to be discussed more fully later, that linked the causative factors of cholesterol levels and smoking with coronary heart disease and associated smoking with lung cancer.

According to the CDC (2018a), noninfectious diseases are the major causes of mortality in the United States (Fig. 7-2). As you can see, infectious agents are not to blame for most of today's major health problems. See more in Chapters 21 and 22.

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FIGURE 7-2 Ten leading causes of death by age group, United States: 2018. (Reprinted from National Vital Statistics System, National Center for Health Statistics. Retrieved from https://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_ by_age_group_2018-508.pdf)

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Eco-epidemiology We are now in the new era of eco-epidemiology, distinguished by transforming global health patterns and technological advances. New and emerging global infections, such as the COVID-19 pandemic in 2020, are now a concern, as is the spread of medication-resistant diseases (see more in Chapters 8, 9, and 16). The West Nile virus (WNV), sudden acute respiratory syndrome (SARS), influenza A (H1N1), multidrug-resistant TB, HIV, Zika, and Ebola virus disease illustrate this transformation.

In most cases, causative organisms and critical risk factors are known, yet diseases occur, spread, and suddenly appear in countries or regions previously free of them (Abubakar, Stagg, Cohen, & Rodrigues, 2016; Bain & Awah, 2014). For example, we know how to prevent the transmission of HIV, yet 1.8 million new cases worldwide were reported in 2016 (HIV.gov, 2018). How can preventive practices be promoted among populations at risk for communicable diseases? The same situation is true for many current chronic diseases. For instance, how many nurses smoke? Do you exercise as often as you know you should? Do you know your cholesterol level and eat healthy foods? Do you regularly use sunscreen? What are we missing to effectively change social behaviors? See Chapter 11.

Technological developments drive research, primarily in biology and biomedical techniques and in information system capabilities. The science of genetics is useful in modern epidemiology. For example, genetic influence in some cases of insulin-dependent diabetes is linked to human leukocyte antigens, and particular combinations of this gene variant can predict risk of type 1 diabetes, whereas other combinations either cause no problems or may be protective (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDKD], 2016). HIV, TB, and other infections can be tracked from person to person through identifying the molecular specificity of the organisms.

About 12% of women in the general population will develop breast cancer sometime during their lives, whereas about 72% of women who inherit a harmful BRCA1 mutation and about 69% of women who inherit a harmful BRCA2 mutation will develop breast cancer by the age of 80 years. About 1.3% of women in the general population will develop ovarian cancer sometime during their lives, whereas about 44% of women who inherit a harmful BRCA1 mutation and about 17% of women who inherit a harmful BRCA2 mutation will develop ovarian cancer by the age of 80 years (National Cancer Institute [NCI], 2018).

On a broader scale, using new technology, we can examine the geographic distribution of disease and correlate those data with other important health risks. For instance, using these geocoding systems, overweight and obesity in children can be correlated with other factors, such

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as after-school recreation opportunities, distribution of fast food restaurants, farmer's markets, or socioeconomic status. (See Chapter 10 for more on technology in public health). The possibilities of learning through technology have just begun in this current epidemiologic era.

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Epidemics An epidemic refers to a disease occurrence that clearly exceeds the normal or expected frequency in a community or region. When an epidemic, such as the bubonic plague (also called pneumonic plague or the Black Death) or HIV/AIDS, is worldwide in distribution, it is known as a pandemic. When a disease or infectious agent is continually found in a particular area or population, it is considered to be endemic (American Academy of Pediatrics, 2018).

Epidemic and pandemic diseases prompted the development of epidemiology as a science. Epidemiology became a distinct branch of medical science and provides public health with the tools to investigate disease outbreaks, as well as controlling disease to prevent future outbreaks. Despite hundreds of years of experience with disease outbreaks, new diseases arise all the time, such as COVID-19; see Box 7-1 for its epidemiology, and for information on its background, transmission, symptoms, and testing. New diseases challenge us to come up with new methods. Eradication would be ideal, but sometimes it may take a long time, or it may not happen at all. Read about smallpox eradication in Chapter 8.

BOX 7-1 Epidemiology and COVID-19 To control the spread of epidemics or pandemics, the following measures and terminology are useful to consider:

The S-I-R model—This model is a mathematical model of spread that places the population into three categories: (1) “susceptibles”—those who do not have the disease yet; (2) “infectives”—those have contracted the disease; (3) “removed”— those who have had the disease and recovered and are now immune, or those who have died, and no longer spread the disease. The model supports the importance of social isolation of those infected to prevent the spread to those susceptible (Smith & Moore, 2020; Yates, 2020). R0 (pronounced “R-nought” or “R-zero”)—Whether an outbreak spreads or dies depends on the basic reproduction number. This is the average number of previously unexposed individuals infected by a single, freshly introduced disease. If a disease has an R0 <1 (each infected person on average gives it to less than one other person), then the infection will die out quickly.

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The outbreak cannot sustain its own spread. If R0 is larger than one, then the outbreak will grow exponentially (Yates, 2020).

The early estimates of the R0 for COVID-19 was at least 2 (varying between 1.5 and 4). This means the first person with the disease spreads it to two others, who each, on average, is spreading the disease to two others and then to two others each, and so on. The rate at which “susceptibles” become infected (the force of infection), and the rate of recovery or death from the disease can increase the R0, while increasing recovery rate will reduce it. The bigger the population and the faster the disease spreads between individuals, the larger the outbreak is likely to be. The quicker individuals recover, the less time they have to pass on the disease to others and, the easier it will be to bring an outbreak under control. The “effective reproduction number” is the average number of secondary infections caused by an infectious individual at a given point in the outbreak's progression. If, by intervention, the effective reproduction number can be brought to below one, then the disease will die out (Yates, 2020, para. 19). The fraction of the population that needs to be immune to protect the rest depends on how infectious the disease is. The basic reproduction number, R0 can be used to determine the proportion of the population that will need to be immune. The higher the R0, the higher the immune proportion of the population needs to be. If the Ro is 4, then three-quarters of the population must be immune. If R0 is 1.5 then only one- third of the population must be immunized to protect the remaining two-thirds (Yates, 2020).

Case fatality rate—R0 does not capture the seriousness of the disease for an infected individual. The proportion of infected people who ultimately die from a disease is known as the case fatality rate. A high case fatality rate means that a high number of those who get the disease usually die from the disease. Diseases with high fatality rates are less infectious because those who are ill die quickly, thus reducing the chances of infecting others (Yates, 2020).

Early estimates indicate that the case fatality rate of COVID- 19 is between 0.25% and 3.5%. This low fatality rate can end up killing more people because more people can become infected from those who are presymptomatic or have mild cases of the disease.

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Case fatality rates for COVID-19 vary significantly with the age of the patient, with the elderly being worst affected. Older people are more likely to die from COVID-19 than the population as a whole (Yates, 2020). Current estimates of the death rate of COVID-19 found that globally, the case fatality rate for those under age 60 was 1.4%. For those over age 60, it was 4.5%. For those 80 and over, the case fatality rate was 13.4% (Resnick, 2020).

Source: Resnick (2020); Smith and Moore (2020); Yates (2020).

Historically, as the threat of the great epidemic diseases declined, epidemiologists began to focus on other infectious diseases, such as diphtheria, infant diarrhea, typhoid, TB, and syphilis. They also studied diseases linked to occupations, such as scurvy among sailors and scrotal cancer among chimney sweeps (Remington & Brownson, 2011). In recent years, epidemiologists turned to the study of major causes of death and disability, such as cancer, cardiovascular disorders, AIDS, violence, mental illness, accidents, arthritis, and congenital defects (Meier, Sandler, Simonsick, & Parks, 2016).

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Opioid Epidemic: A 21st Century Public Health Epidemic The current, ongoing opioid epidemic is an example of how epidemiology has helped define the scope of the problem and how this knowledge impacts public health policies in addressing the epidemic. Public health surveillance of drug use has helped to better define who are most affected by the opioid epidemic by monitoring who is dying from drug overdoses. The latest compilation from the U.S. Department of Health and Human Services (USDHHS) about the opioid epidemic show the following (USDHHS, 2018a):

115 people die every day from opioid-related overdoses (Fig. 7-3) Opioid overdose deaths increased fivefold from 1999 to 2016 New hepatitis C infections tripled from 2010 to 2016 Hepatitis B and C and other infections associated with the injection of opioids increased in communities hardest hit

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FIGURE 7-3 Opioid epidemic by the numbers. (Updated October 2019). Retrieved from https://www.hhs.gov/opioids/sites/default/files/2019- 11/Opioids%20Infographic_letterSizePDF_10-02-19.pdf

Mapping the statistically significant rise in overdose death rates shows how rapidly the opioid epidemic is spreading across various states (CDC, 2017a). This is why continuous monitoring over time is important to identifying trends (Fig. 7-4).

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FIGURE 7-4 Age-adjusted rates of overdose deaths by state, US 2018. (Reprinted from CDC. (December 19, 2017). Opioid overdose: Drug overdose death data. Retrieved from https://www.cdc.gov/drugoverdose/data/statedeaths/drugoverdose- death-2018.html)

In 2016, drug overdose deaths totaled 63,632, increasing significantly from 2015 at a rate of 16.3 to 19.8 per 100,000. Opioids were involved in 66.4% of total deaths (CDC, 2017a). The most recent overdose death data indicate that different drugs are responsible for the rise in opioid deaths (Fig. 7-5). Between 2000 and 2016, deaths due to heroin steadily rose, to be overtaken by deaths from synthetic opioids (National Institute on Drug Abuse [NIDA], 2018a).

FIGURE 7-5 National drug overdose deaths by specific category —number among all ages, 1999–2018. (National Institute on Drug

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Abuse (NIDA). (2020). Overdose death rates. Retrieved from https://www.drugabuse.gov/drug-topics/trends-statistics/overdose- death-rates)

In August 2017, the CDC showed that opioid overdose deaths were occurring in three waves (CDC, 2017c; Fig. 7-6):

FIGURE 7-6 Three waves of opioid overdose deaths. (Reprinted from CDC. (2020). Opioid overdose: Understanding the epidemic. Retrieved from https://www.cdc.gov/drugoverdose/epidemic/index.html)

Wave 1: Rise in prescription overdose deaths (1990s) Wave 2: Rise in heroin overdose deaths (2010 to now) Wave 3: Rise in synthetic overdose deaths (2013 to now)

Trends in opioid abuse include the following:

Prescription opioid use is a risk factor for heroin use, with nearly 80% of heroin users in 2013 reporting using prescription opioids prior to heroin (NIDA, 2018b). Initiation into nonmedical use of opioids was through three main sources: family, friends, or personal prescriptions (NIDA, 2018b). Drug overdoses of cocaine, heroin, and OxyContin are occurring because popular illicit drugs are being laced with synthetic opioids (e.g., fentanyl; Fig. 7-7).

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Deaths due to fentanyl have not been well documented because they are usually mixed in with other drugs (Frankel, 2018). By July 2018, the CDC reported that drug deaths from fentanyl and fentanyl analogs were responsible for the growing opioid deaths seen in the United States (CDC, 2018b; Fig. 7-8). First responders are dying from accidental exposure to fentanyl, including nurses (Evans, 2017) and police dogs (Cima, 2018).

FIGURE 7-7 Fentanyl: Overdoses on the rise. (Reprinted from CDC. (2017). Opioid overdose: Fentanyl. Retrieved from https://www.cdc.gov/drugoverdose/opioids/fentanyl.html)

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FIGURE 7-8 Percentage of opioid overdose deaths testing positive for fentanyl and fentanyl analogs, by state (10 states). (Reprinted from O'Donnell, J. K., Halpin, J., Mattson, C. L., Goldberger, B. A., & Gladden, R. M. (2017). Deaths involving Fentanyl and Fentanyl analogs, and U-47700—10 states, July-December 2016. Morbidity & Mortality Weekly (MMWR), 66(43), 1197–1202. Retrieved from https://www.cdc.gov/mmwr/volumes/66/wr/mm6643e1.htm)

In July 2018, the CDC reported overdose deaths from fentanyl analogs in 10 states and viewed the rising deaths to be alarming (CDC, 2018b; Fig. 7-9). Fentanyl analogs are illicitly manufactured forms of fentanyl (i.e., carfentanil, acetylfentanyl, furanylfentanyl, U-47700). The rise of fentanyl and its analogs in drug overdose deaths is the result of the high profit margin for drug traffickers (CDC, 2017b). One kilogram of fentanyl powder can yield hundreds of thousands of counterfeit pills that can be sold for millions of dollars in profit. Fentanyl is manufactured in clandestine labs found in Mexico and China (U.S. Drug Enforcement Administration, n.d.; EPR, 2018).

FIGURE 7-9 Number of overdose deaths with carfentanil and any fentanyl analog detected*—Ohio and nine other SUDORS states, July 2016–June 2017. (Reprinted from O'Donnell, J., Gladden, M., Mattson, C. L., & Kariisa, M. (2018). Notes from the field: Overdose deaths with Carfentanil and other Fentanyl analogs detected—10 states, July 2016-June 2017. Morbidity and Mortality Weekly (MMWR), 67(27), 767–768. Retrieved from https://www.cdc.gov/mmwr/volumes/67/wr/mm6727a4.htm)

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Trends in rates of serious infection and associated costs with opioid abuse/dependence were not investigated until 2016. At that time, research found hospitalizations related to opioid abuse/dependence both with and without associated serious infection significantly increased from 2002 to 2012, from 301,707 to 520,275, and from 3,421 to 6,535, respectively (Ronan & Herzig, 2016).

The rise in HIV and hepatitis outbreaks, along with the dramatic increase in Staphylococcus aureus infections (often MRSA), have been linked to this epidemic. S. aureus can damage heart valves, and a North Carolina study found a 13-fold increase in endocarditis between 2007 and 2017 among those abusing drugs (Reardon, 2019; National Academies of Science, Engineering, and Medicine, 2018; USDHHS, 2018b). Inpatient charges for both types of hospitalizations quadrupled for the same time period. In all, almost $15 billion was paid for hospitalizations related to opioid abuse/dependence and more than $700 million for those related to associated infections in 2012 (Ronan & Herzig, 2016).

In 2017, the USDHHS declared a public health emergency (USDHHS, 2018a) and announced a 5-point strategy to combat the opioid crisis (USDHHS, 2017a):

1. Improving access to treatment and recovery services 2. Promoting use of overdose-reversing drugs 3. Strengthening our understanding of the epidemic through better public health surveillance 4. Providing support for cutting-edge research on pain and addiction 5. Advancing better practices for pain management

Fortunately, epidemiological data were used to develop new guidelines for treating those who are brought in for treatment and provide data to drug enforcement agencies to develop strategies to reduce the trafficking of illegal drugs that will save lives in the long run.

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CONCEPTS BASIC TO EPIDEMIOLOGY

The science of epidemiology draws on certain basic concepts and principles to analyze and understand patterns of occurrence among aggregate health conditions.

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Disease Etiology In 1856, John Stuart Mill formed three methods of hypothesis formulation for determining disease etiology. These methods include method of difference, method of agreement, and method of concomitant variation.

In 1965, Sir Austin Bradford Hill proposed expanding on Mill's postulates about causality by developing nine criteria to evaluate the relationship between environmental exposure and potential health outcomes. The criteria can be used with infectious disease as well as noninfectious disease. These elements are:

1. Strength of Association: The ratio of the rate of a disease in those with a suspected causal factor to the rate of the disease in those without it: a higher rate in the group with the factor than in the group without it indicates a strong association.

2. Consistency of Association: An association is demonstrated in varying types of studies among diverse study groups (i.e., replication).

3. Specificity: A cause leads to one effect (not always the case in noninfectious diseases).

4. Temporality: Exposure to the suspected factor must precede the onset of disease (i.e., time order or time sequence).

5. Biological Gradient: This relationship is demonstrated if, with increasing levels of exposure to the factor, there is a corresponding increase in occurrence of the disease (i.e., dose–response relationship).

6. Biological Plausibility: The hypothesized cause makes sense based on current biologic or social models (i.e., it is possible).

7. Coherence of Explanation: The hypothesized cause makes sense based on current knowledge about the natural history or biology of the disease (i.e., scientific knowledge).

8. Analogy: Similarities between the association of interest and others (e.g., potential links to birth defects from new drugs is a concern because we already recognize this potential from the use of the drug thalidomide during the 1950s and early 1960s).

9. Experimental Evidence: Experimental and nonexperimental studies support the association (e.g., reduced tobacco use in a population should lead to reduced lung cancer rates; Merrill, 2017).

The elements described by Hill are still used by epidemiologists and provide the fundamental principles C/PHNs can use to evaluate evidence of disease causation in all types of published reports, both scientific and lay.

In health education, these principles can be used to teach disease causation risk, especially when the evidence is not yet complete. For instance, a pregnant teen asks a nurse if she should drink diet soda while she is pregnant. The nurse can share with her that the evidence to date supports

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the safety of artificial sweeteners for most adults (experiment), but that it is probably not wise to drink diet soda while pregnant. When she asks why (because there isn't any reported risk), the nurse can respond that any chemical has the potential to cause harm (plausibility and analogy), and the effects on a growing fetus (biologic gradient) are often unknown until decades later (temporality and experiment).

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Epidemiologic Triangle or Host, Agent, and Environment Model Through their early study of infectious diseases, epidemiologists began to consider disease states in terms of the epidemiologic triangle, or the host, agent, and environment model, shown in Figure 7-10. Interactions among these three elements explained infectious and other disease patterns.

FIGURE 7-10 Epidemiologic triangle.

Host The host is a susceptible human or animal who harbors and nourishes a disease-causing agent. Many physical, psychological, and lifestyle factors influence the host's susceptibility and response to an agent (Friis, 2018):

Physical factors: age, sex, race, socioeconomic status, and genetic influences Psychological factors: outlook and response to stress Lifestyle factors: diet, exercise, and other healthy or unhealthy habits

The concept of resistance is important for community/public health nursing practice. People sometimes have an ability to resist pathogens, which is called inherent resistance. Typically, these people have inherited or acquired characteristics, such as the various factors mentioned earlier, that

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make them less vulnerable. For instance, people who maintain a healthful lifestyle may not contract influenza even if exposed to the flu virus. Resistance can be promoted through preventive interventions that improve one's immunity system and support a healthy lifestyle.

Such healthy habits include not smoking, eating more fruits and vegetables, exercising regularly, maintaining a healthy weight, drinking alcohol in moderation, getting adequate sleep, washing hands frequently, cooking meals thoroughly, and minimizing stress (Harvard Health Publishing [HHP], 2018).

Agent An agent is a factor that causes or contributes to a health problem or condition (Friis, 2018). Causative agents can be factors that are present (e.g., bacteria that cause TB, rocks on a mountain road that contribute to an automobile crash) or factors that are lacking (e.g., a low serum iron level that causes anemia or the lack of seat belt use contributing to the extent of injury in an automobile crash).

Agents vary considerably and include five types: biologic, chemical, nutrient, physical, and psychological:

Biologic agents include bacteria, viruses, fungi, protozoa, worms, and insects. Some biologic agents are infectious, such as influenza virus or HIV. Chemical agents may be in the form of liquids, solids, gases, dusts, or fumes. Examples are poisonous sprays used on garden pests and industrial chemical wastes. The degree of toxicity of the chemical agent influences its impact on health. Nutrient agents include essential dietary components that can produce illness conditions if they are deficient or are taken in excess. For example, a deficiency of niacin can cause pellagra, and too much vitamin A can be toxic. Physical agents include anything mechanical (e.g., chainsaw, automobile), material (e.g., rockslide), atmospheric (e.g., ultraviolet radiation), geologic (e.g., earthquake), or genetically transmitted that causes injury to humans. The shape, size, and force of physical agents influence the degree of harm to the host. Psychological agents are events that produce stress leading to health problems (e.g., war, terrorism).

Agents may also be classified as infectious or noninfectious. Infectious agents cause communicable diseases, such as influenza or TB—that is, the disease can be spread from one person to another. Certain characteristics of infectious agents are important for C/PHNs to understand:

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Exposure to the agent Pathogenicity (capacity to cause disease in the host) Infectivity (capacity to enter the host and multiply) Virulence (severity of disease) Toxigenicity (capacity to produce a toxin or poison) Resistance (ability of the agent to survive environmental conditions) Antigenicity (ability to induce an antibody response in the host) Structure and chemical composition (Friis, 2018)

Chapter 8 examines the subject of communicable disease in greater depth. Noninfectious agents have similar characteristics in that their relative abilities to harm the host vary with type of agent and intensity and duration of exposure (Szklo & Nieto, 2019).

Environment The environment refers to all the external factors surrounding the host that might influence vulnerability or resistance and includes physical and psychosocial elements (Friis, 2018):

The physical environment includes factors such as geography, climate and weather, safety of buildings, water and food supply, and presence of animals, plants, insects, and microorganisms that have the capacity to serve as reservoirs (storage sites for disease-causing agents) or vectors (carriers) for transmitting disease. The psychosocial environment refers to social, cultural, economic, and psychological influences and conditions that affect health, such as access to health care, cultural health practices, poverty, and work stressors, which can all contribute to disease or health (Szklo & Nieto, 2019).

Interaction of the Host, Agent, and Environment Host, agent, and environment interact to cause a disease or health condition. For example, WNV is spread to people by mosquito bites and occurs during mosquito season (summer through fall). There are no vaccines to prevent or medications to treat WNV. Most people infected have no symptoms, but about 20% develop a fever and other symptoms. Around 1 out of 150 infected people develop a serious, sometimes fatal, illness. The risk of WNV can be reduced by using insect repellent and wearing long-sleeved shirts and long pants to prevent mosquito bites (CDC, 2018c). WNV, which was widespread in Africa and the Middle East, arrived in the United States in 1999 and spread throughout the continental United States. Mapping the distribution of infectious diseases (Fig. 7-11) helps authorities know where to make resources and aid available.

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FIGURE 7-11 West Nile Virus incidence by State—United States. (Source: CDC. (2018). West Nile virus neuroinvasive disease incidence reported to ArboNET, by state, United States, 2018. Retrieved from https://www.cdc.gov/westnile/resources/pdfs/data/WNV-Neuro- Incidence-by-State-Map-2018-P.pdf)

Another mosquito-borne viral illness, eastern equine encephalitis (EEE) virus, has recently gained attention. EEE cases are rare in humans, usually no more than 5 to 10 annually in the United States. However, about 30% of cases can be fatal; as of October 1, 2019, there have been 10 deaths reported from EEE virus, and patients are often left with neurological problems (Almasy, 2019; CDC, 2019a).

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Causality Causality refers to the relationship between a cause and its effect. As scientific knowledge of health and disease has expanded, epidemiology has changed its view of causality. The following section discusses some of those changes in thinking, which began in the 1960s and continue today.

Chain of Causation As the scientific community is thinking about disease causation and the epidemiologic model (host–agent–environment) grew more complex, epidemiologists began to use the idea of a chain of causation (Fig. 7-12).

FIGURE 7-12 Chain of causation.

The components of the chain of causation include:

Reservoir (i.e., where the causal agent can live and multiply). With plague, that reservoir may be other humans, rats, squirrels, and a few other animals. With malaria, infected humans are the major reservoir for the parasitic agents, although certain nonhuman primates also act as reservoirs (Heymann, 2014). Portal of exit from the reservoir, which can be a mode of transmission. For example, the bite of an Anopheles mosquito provides a portal of exit for the malaria parasites, which spend part of their life cycle in the mosquito's body; the mosquito in this case is the mode of transmission. Agent itself. Malaria, for example, actually consists of four distinct diseases caused by four kinds of microscopic protozoa (Heymann, 2014).

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Portal of entry. In the case of malaria, the mosquito bite provides a portal of exit as well as a portal of entry into the human host.

Basically, by breaking the chain of causation at any link, the spread of disease will be prevented.

Web of Causation In the 1960s, the concept of multiple causation emerged to explain the existence of health and illness states and to provide guiding principles for epidemiologic practice. A causal paradigm that gained attention was referred to as the web of causation. The implication was that an intervention (or breaking of the web at any point nearest to the disease) could profoundly impact the development of that disease (Merrill, 2017; Szklo & Nieto, 2019).

This was a significant shift in thinking about disease and health, positing that the combination of multiple factors was the deciding influence in the development of poor outcomes. This refinement in causal thinking also provided opportunities for health care interventions at a variety of levels. Another common term used for this approach is causal matrix.

Using the multiple causation approach, Figure 7-13 depicts a causal matrix for infant mortality. Data from birth and death certificates were used to identify the complex interactions among multiple causal factors that produce a negative health condition leading to infant mortality. Another example (Fig. 7-14) shows a web of causation for automobile crashes. All of the numerous factors involved must be considered when diagramming a web of causation. Speed, faulty equipment, heavy traffic, confusing traffic patterns, road construction, poor visibility, weather conditions, driver inexperience, and drinking or drug use, in any combination, can cause an automobile crash.

FIGURE 7-13 Web of causation for infant mortality.

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FIGURE 7-14 Web of causation for automobile crashes.

All health conditions can be diagramed to depict a matrix of causation. A communicable disease that has one clearly identified organism as the agent has the ability to be diagramed based on factors such as availability of emergency services (treatment), diagnostic skill of health professionals (early diagnosis), availability of medications and vaccines to treat the disease (reduced morbidity), and community communication networks (public awareness). Any of these factors could greatly influence the progression of disease within the community.

Association is a concept that is helpful in determining multiple causalities. Events are said to be associated if they appear together more often than would be the case by chance alone (see Box 7-10 later in this chapter). Such events may include risk factors or other characteristics affecting disease or health states. Examples are the frequent association of cigarette smoking with lung cancer, obesity with heart disease, and severe prematurity with infant mortality. The study of associated factors suggests possible causalities and points for intervention.

Contemporary epidemiologists continue to explore new and more comprehensive ways of viewing health and illness. The associations among lifestyle, behavior, environment, and stress of all kinds and the ways in which they affect health states are gaining importance in epidemiology (Szklo & Nieto, 2019).

Causation in Noninfectious (Noncommunicable) Disease With the availability of vaccines and antibiotics by the mid-20th century to thwart most infectious diseases in the United States and the developed world, attention shifted to the causes of noninfectious diseases such as cancer and

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diabetes. A new causal paradigm was clearly needed. The linear thinking embodied in models such as the chain of causation was insufficient in understanding the causes of these emerging health threats.

The web of causation model, which previously was used to study infectious diseases and which encompasses multifactorial causes of health problems and issues, has therefore been adapted to study the causation of noninfectious (noncommunicable) diseases. One such adaptation of this model, proposed by Egger in 2012, explains the rise of chronic, noncommunicable diseases, for which there is no single underlying etiology, as the result of the body's reaction to its surrounding ecological environment. According to this model, the body develops systemic and chronic inflammation (metaflammation) at the molecular level to inducers (anthropogens) that are associated with lifestyles and modern built environments (Fig. 7-15).

FIGURE 7-15 Anthropogen-induced metaflammation as the cause of chronic diseases. (Reprinted from Egger, G. (2012). In search of a germ theory equivalent for chronic disease. Preventing Chronic Disease, 9, e110301. Retrieved from https://www.cdc.gov/pcd/issues/2012/11_0301.htm)

Thus, preventive approaches to improving the health of those with chronic disease that are based on this model focus on reducing this inflammatory process through lifestyle changes (Straub & Schradin, 2016). Such preventive approaches are being taken today to address the top two

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leading causes of death—heart disease and cancer—and include modifying lifestyle and addressing environmental factors.

Examples of disease that can be studied using this model include:

Air pollution, which has been identified as an independent risk factor for cardiovascular morbidity and mortality due to direct toxicity to the cardiovascular system or indirect injury by inducing systemic inflammation and oxidative stress in the peripheral circulation (Du, Xu, Chu, Guo, & Wang, 2016). Another example is how gene changes that alter cell function cause cancer. Genetic changes can occur naturally during the process of cell division, while others are the result of environmental exposures that damage the DNA. Such environmental exposures include tobacco smoke chemicals and ultraviolet radiation (NCI, 2020).

Another aspect of this transition in focus from infectious to noninfectious disease is a shift from concern with individual susceptibility to the vulnerability of an entire population to chronic disease as a result of exposure to common environmental factors. Increasingly, public health workers came to realize the limitations imposed on individual control of health. After all, even individuals who are in the best of health may not withstand toxic agents in the workplace—for example, nuclear waste in the atmosphere from power plant accidents—or other debilitating conditions created by modern society. Therefore, more and more public health professionals are studying the environment and looking for methods to change conditions that contribute to illness in populations rather than just in individuals (see Chapter 9).

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Immunity Immunity refers to a host's ability to resist a particular infectious disease– causing agent. This occurs when the body forms antibodies and lymphocytes that react with the foreign antigenic molecules and render them harmless (Friis, 2018).

For community/public health nursing, this concept has significance in determining which individuals and groups are protected against disease and which may be vulnerable. Four types of immunity, seen in Box 7-2, are important in community health: passive, active, cross, and herd. Herd immunity is covered in greater detail in Chapter 8.

BOX 7-2 Basic Principles of Immunity Immunity Self versus nonself Protection from infectious disease Usually indicated by the presence of antibody Generally specific to a single organism

Active Immunity Protection produced by the person's own immune system Often lifetime Passive Immunity Protection transferred from another animal or human Effective protection that wanes with time Cross Immunity Immunity to one bacteria or virus is effective in protecting the person against an antigenically similar but different organism (e.g., cowpox vaccination protects against smallpox) Antigen A live (e.g., viruses and bacteria) or inactivated substance capable of producing an immune response Antibody Protein molecules (immunoglobulins) produced by B lymphocytes to help eliminate

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an antigen Source: Centers for Disease Control & Prevention (CDC) (2018d); Merriam Webster Dictionary (n.d.).

Herd Immunity Herd immunity or community immunity describes the immunity level that is present in a population group (USDHHS, 2017b). A population with low herd immunity is one with few immune members; consequently, it is more susceptible to a particular disease. Nonimmune people are more likely to contract the disease and spread it throughout the group, placing the entire population at greater risk.

Conversely, a population with high herd immunity is one in which the immune people in the group outnumber the susceptible people; consequently, the incidence of a particular disease is reduced. The level of herd immunity may vary with diseases. For instance, a level of community immunity of between 83% and 85% may be necessary for rubella, but for pertussis (whooping cough) 92% to 94% may be needed to be effective (Merrill, 2017). Mandatory preschool immunizations and required travel vaccinations are applications of the herd immunity concept. Figure 8-10 in Chapter 8 provides more information and a depiction of herd immunity.

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Risk Epidemiologists are concerned with risk, or the probability that a disease or other unfavorable health condition will develop. For any given group of people, the risk of developing a health problem is directly influenced, either positively or negatively, by such factors as their biology or inherited health capacity, living environment, lifestyle choices, and system of health care (McKenzie et al., 2018). When such factors are negative influences, they are called risk factors. The degree of risk is directly linked to susceptibility or vulnerability to a given health problem (Box 7-3).

BOX 7-3 Risk in Epidemiology Epidemiologists study populations at risk. A population at risk is a collection of people among whom a health problem has the possibility of developing because certain influencing factors are present (e.g., exposure to HIV) or absent (e.g., lack of childhood immunizations, lack of specific vitamins in the diet), or because there are modifiable risk factors present (e.g., cardiovascular disease). Epidemiologists measure this difference using the relative risk ratio, which statistically compares the disease occurrence in the population at risk with the occurrence of the same disease in people without that risk factor.

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If the risk of acquiring the disease is the same regardless of exposure to the risk factor studied, the ratio will be 1:1, and the relative risk will be 1.0. A relative risk >1.0 indicates that those with the risk factor have a greater likelihood of acquiring the disease than do those without it; for instance, a relative risk of 2.54 means that the exposed group is 2.54 times more likely to acquire the disease than the unexposed group (Merrill, 2017).

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Natural History of a Disease or Health Condition Any disease or health condition follows a progression known as its natural history, which refers to events that occur before its development, during its course, and during its conclusion. This process involves the interactions among a susceptible host, the causative agent, and the environment. The natural progression of a disease occurs in four stages in terms of how it affects a population: (1) susceptibility, (2) preclinical (subclinical) disease, (3) clinical disease, and (4) resolution (Fig. 7-16). The last stage, resolution, includes recovery, disability, or death (Friis, 2018). As shown in Fig 7-16, the stages may be grouped into two phases: phase I (prepathogenesis), which includes stages 1 and 2, and phase II (pathogenesis), which includes stages 3 and 4. Each stage is briefly described below.

FIGURE 7-16 Natural history of stages of a disease. (Source: Centers for Disease Control and Prevention (CDC). (2012a). Lesson 1: Introduction to epidemiology. In Principles of epidemiology in public health practice (3rd ed.). Retrieved from https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section9.html)

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1. Susceptibility Stage: The disease is not present, and individuals have not been exposed, but host and environmental factors influence their susceptibility. If a pathogen invades and the immune system's response is effective, then the infection is eliminated or contained and the disease does not occur (History of Vaccines, 2018).

2. Subclinical Disease Stage: Individuals have been exposed to a disease but are asymptomatic. In infectious diseases, it includes an incubation period of hours to months (or years, in the case of AIDS), during which the organism multiplies to sufficient numbers to produce a host reaction and clinical symptoms. In noninfectious disease, it includes an induction or latency period, which is the time from exposure to the onset of symptoms and is often years to decades (e.g., up to 40 years from exposure to asbestos and development of lung cancer).

3. Clinical Disease Stage: Signs and symptoms of the disease or condition develop, and diagnosis may occur. Early signs may be evident only through laboratory test findings (e.g., premalignant cervical changes evident on Papanicolaou smears), whereas later signs are more likely to be acute and clearly visible (e.g., enterocolitis in a salmonellosis outbreak; Heymann, 2014).

4. Resolution or Advanced Disease Stage: Depending on its severity, the disease may conclude with a return to health, a residual or chronic form of the disease with some disabling limitations, or death (Merrill, 2017).

C/PHNs can intervene at any point during these four stages to delay, arrest, or prevent the progression of the disease or condition. Primary, secondary, and tertiary prevention can be applied to each of the stages. However, primary prevention through health promotion and education strategies and health protection policies is the best and most cost-effective approach to ensuring population health (Box 7-4).

BOX 7-4 Levels of Prevention Pyramid SITUATION: Apply the levels of prevention during the four stages of the natural history of a disease to eradicate or reduce risk factors (examples of potential conditions provided). GOAL: Using the three levels of prevention, avoid or promptly diagnose and treat negative health conditions, and restore the fullest possible

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potential.

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Epidemiology of Wellness Epidemiology has moved from concentrating only on illness to examining how host, agent, and environment are involved in wellness at various levels. In response to an escalating need for improved methods of health planning and health policy analysis, epidemiology has developed more holistic models of health (Kiefer, 2017).

These evolving epidemiologic models are organized around four attributes that influence health:

1. The physical, social, and psychological environment 2. Lifestyle, with its self-created risks 3. Human biology and genetic influences 4. The health care system

In the United States, Healthy People 2030 (USDHHS, 2018c) and greater recognition of the importance and cost-effectiveness of illness prevention and health promotion are driving new efforts to develop policy and research initiatives that can improve the public's health (Box 7-5). There is also growing recognition of the impact of social determinants of health on health outcomes and conditions, not merely an individual role in one's health. Social determinants of health are “conditions in the environments in which people are born, live, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks” (CDC, 2018h, para. 6). Population disparities result when these social determinants disproportionately impact individuals owing to race/ethnicity, socioeconomic status, gender, age, disability status, sexual orientation, and geographic location (USDHHS, 2018c). See Chapter 11 on health promotion and Chapters 15, 23, and 25 for more on this.

BOX 7-5 SELECTED HEALTHY PEOPLE 2030 OBJECTIVES

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Reprinted from U.S. Department of Health and Human Services (USDHHS). (2020). Browse objectives: Public health infrastructure. Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives/publichealth- infrastructure

Wellness models that at first focused on individual behavior now include approaches that encompass aggregates, including:

Seniors (see Chapter 22) Workers (i.e., in occupational health settings; see Chapter 29) Students (i.e., children and teens at schools with wellness programs; see Chapter 20) Beginning and growing families (see Chapter 19)

Programs designed for aggregates focus on a wellness approach to growth and development, such as those for pregnant teens and infant and child development (e.g., Healthy Start, Head Start). Societal changes, such as the aging population, the technological revolution, the global economy, environmental threats, health care reform with its focus on prevention, and the health and wellness movements, are driving these new approaches (see Chapter 6).

Another approach to wellness is applying the four stages of the natural history of disease to wellness states:

Susceptibility: People are amenable (“vulnerable”) to healthier practices and improved health system organization. Subclinical: A community is exposed to these health-promoting behaviors. Clinical: Signs of adoption of beneficial policies and activities are evident in the community.

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Resolution: The community fully adopts the beneficial policies and activities and achieves a higher level of well-being.

This approach has important implications for preventive and health- promotion practices in community/public health nursing as it can play a primary role in the investigation and identification of factors that not only prevent illness but also promote health. This means sharpening skills in epidemiologic research to uncover the factors that contribute to a full measure of healthful living. The time for an epidemiology of wellness has come (Merrill, 2017).

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Causal Relationships One of the main challenges to epidemiology is to identify causal relationships in disease and health conditions among populations. Causal inference is based on consistent results obtained from many studies. Frequently, the accumulation of evidence begins with a clinical observation or an educated guess that a certain factor may be causally related to a health problem (Friis, 2018). In epidemiological research, the types of studies to research causal relationships include:

Cross-sectional study: Explores a health condition's relation to other variables in a specified population at a specific point in time and can show that the factor and the problem coexist (e.g., using the “broken window index” to correlate poor housing quality, public school deterioration, and the presence of abandoned cars, graffiti, and trash with crime and social isolation in neighborhoods [Aiyer, Zimmerman, Morrel-Samuels, & Reischl, 2015] and, by extension, perceived sexual partner risk level or other risk behaviors [Haley et al., 2018]) Retrospective study: Looks backward in time to find a causal relationship, allowing a fairly quick assessment of whether an association exists. Such studies use existing data that have been recorded for reasons other than research and are generally less expensive and less labor intensive. One disadvantage is that the data may not be collected with a research outcome in mind. An example is a study of a giardia outbreak in a suburb of Boston caused by infection in a kiddy pool and then person-to-person spreading (Adam, Yoder, Gould, Hlavsa, & Gargano, 2016). Prospective study: Looks forward in time to find a causal relationship that is crucial to ensure that the presumed causal factor actually precedes the onset of the health problem (e.g., The Nurses' Health Study, with over 280,000 participants, related to women's health [NHS, 2018]). Experimental study: Controls or changes factors suspected of causing the condition and observes results, which are then used to confirm the associations obtained from observational studies (e.g., an experimental trial for a dengue virus vaccine in which 21 volunteers received the vaccine and 20 received a placebo injection; National Institutes of Health [NIH], 2016).

Epidemiologically, a causal relationship may be said to exist if two major conditions are met: (1) the factor of interest (causal agent) is shown to increase the probability of occurrence of the disease or condition as observed

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in many studies in different populations and (2) evidence suggests that a reduction in the factor decreases the frequency of the given disease.

The synthesis of data begins by selecting as many of the various types of epidemiologic studies of the problem as possible and reviewing those that are sound. The goal of any epidemiologic investigation is to identify causal mechanisms that meet Hill's nine criteria for disease causation and to develop measures for preventing illness and promoting health (Celentano & Szklo, 2019). The C/PHN may need to gather new data for this type of investigation but should thoroughly examine pertinent existing data first.

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SOURCES OF INFORMATION FOR EPIDEMIOLOGIC STUDY

Epidemiologic investigators may draw data from any of three major sources: existing data, informal investigations, and scientific studies. The C/PHN will find all three sources useful in efforts to improve the health of aggregates. See Chapter 15 on community assessment for more on sources of data.

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Existing Data A variety of epidemiologic information is available nationally, by state, and by section (e.g., county, region, census tract, metropolitan statistical area). This information includes vital statistics, census data, and morbidity statistics on certain communicable or infectious diseases. Local health departments often can provide these data on request.

C/PHNs seeking information on communities may find local health agencies helpful. These agencies collect health information for groups of counties within states and interact with health planning authorities at the state level. They have access to many types of information and can give advice on specific problems. One newer source of data is social media (see Box 7-6).

BOX 7-6 POPULATION FOCUS Epidemiology and Social Media You probably use some form of social media. But, did you know that epidemiologists and C/PHNs have used Twitter and Yelp in foodborne illness investigations? Traditionally, most investigations begin with either a physician report to the local health department or a self- report called in by someone who became ill after eating out at a restaurant or a food truck. In most cases, people do not report when they have gotten ill when eating at restaurant, so food poisoning cases are underreported.

The Chicago Health Department used “FoodBorne Chicago” to track Twitter messages about food poisoning, leading to follow-up inspections of restaurants located within the city limits. Of the 133 Twitter-prompted health inspections, 20.3% identified at least one critical violation, compared with 16.4% of the 1,808 inspections initiated by usual methods. A total of 15.8% of restaurants failed inspection and were closed (Harris et al., 2014). Officials in St. Louis, Missouri, also instituted a Twitter message program of reporting foodborne illness and gathered 193 relevant tweets in 7 months. This

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method generated more reports than traditional mechanisms (Harris et al., 2017).

In New York City, health department staff noticed patron restaurant reviews often included reports of illness after eating at the same restaurant they were investigating for a recent gastrointestinal disease outbreak; most of these had not been reported to the health department. Thinking that this might be a reliable source for population-based investigation into foodborne illnesses, the New York City Department of Health and Mental Hygiene worked with Yelp in using data mining software to download weekly data that met the following criteria: (1) symptoms occurred after a meal, (2) symptoms occurred within 4 weeks of the posted review, and (3) two or more people became ill (or one person with symptoms of severe neurologic illness). An epidemiologist specializing in foodborne illness reviewed 893 potential postings and discovered three outbreaks causing 16 illnesses (Harrison et al., 2014). Officials in San Francisco worked with Yelp on a predictive model for health code violations, and their pilot study of 440 restaurant reviews, Yelp stars, and price ranges successfully predicted 78% of restaurants that would receive serious health code citations. When including specific key word analysis of reviews and expanding to 1,542 restaurants, the model was even more effective. They included New York City and found good predictive accuracy there, as well (Schomberg, Haimson, Hayes, & Anton-Culver, 2016).

The Web site iwaspoisoned.com is a consumer-led lead initiative, founded in 2009, that permits people to report online when they experience food poisoning symptoms. This real-time information collected from online reports is shared by consumers, food authorities, restaurants, and industry. There is also an app that informs consumers of whether a restaurant they were planning on eating at has had a food poisoning report. It was found that the site correctly identified several outbreaks before local officials became aware of problems (Neimark, 2017). These are examples of how collaborations of online sources with local health authorities have helped to reduce the incidence of food poisoning. Crowdsourcing such as this has been used in many areas of health care, especially during disasters and other emergencies (Wazny, 2018). Source: Harris et al. (2014, 2017); Harrison et al. (2014); Neimark (2017); Schomberg et al. (2016); Wazny (2018).

Vital Statistics Vital statistics refers to the information gathered from the ongoing registration of births, deaths, adoptions, divorces, and marriages. Certified

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births, deaths, and fetal deaths are the most useful vital statistics in epidemiologic studies.

The PHN can obtain blank copies of a state's birth and death certificates to become familiar with the information contained in each (for links to standard birth and death certificates, see ). Death certificates report the fact and cause of death along with much more pertinent information. Birth certificates also can provide helpful information (e.g., weight of the infant, amount of prenatal care received by the mother), which can be used to identify high-risk mothers and infants.

However, nurses should note that the lack of standardization in collecting and reporting vital statistics data can lead to threats to reliability and validity. For example, if an agency changes the definitions for the categories used in grouping the data (reclassification), an inflation or deflation of the total of those affected can occur. Trending data over time would not be possible without including an explanation about the redefinitions used.

For example, according to the criteria of the 2017 AAP Clinical Practice Guideline, about one in seven U.S. youths aged 12 to 19 years reported having hypertension during the period from 2013 to 2016. Prevalence of hypertension varied by weight status, ranging from 2% among healthy- weight youths to nearly 14% among those with severe obesity. The new guideline used a lower threshold of hypertension and new percentile references. Compared with the former guideline, the new guideline would reclassify 2.6% of U.S. youths (or nearly an additional 800,000) as having hypertension (CDC, 2018e).

Sources for vital statistical information include state Web sites, local and state health departments, city halls, and county halls of records (see list of Internet resources on ). Statistics regarding general aggregate morbidity and mortality for specific states are available from the CDC and, at the national level, from the National Center for Health Statistics (NCHS). State statistics are obtained from state health departments, and county information (regarding specific cities or census tracts) can be obtained from either the state or the county health department.

Census Data Data from population censuses taken every 10 years in many countries are the main source of population statistics. This information can be a valuable assessment tool for the C/PHN who is taking part in health planning for aggregates. Population statistics can be analyzed by age, sex, race, ethnic background, type of occupation, income gradient, marital status, educational level, or other standards, such as housing quality.

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Analysis of population statistics can provide the C/PHN with a better understanding of the community and help identify specific areas that may warrant further epidemiologic investigation. Data from the 2020 Census can be found on the U.S. Census Bureau Web site (https://www.census.gov/) and is an easily accessed source of population-level data.

Reportable Diseases Each state has developed laws or regulations that require health organizations and practitioners to report to their local health authority cases of certain communicable and infectious diseases that can be spread through the community (Heymann, 2014). This reporting enables the health department to take the most appropriate and efficient action, for instance, in the case of foodborne illnesses. All states require that diseases subject to international quarantine regulations be reported immediately.

The World Health Organization (WHO, 2018a, 2018b) has numerous diseases under surveillance (e.g., TB, malaria, viral influenza) globally, and these must also be reported. Other reportable diseases (numbering between 20 and 40 in each state) are usually classified according to the speed with which the health department should be notified. Some should be reported by phone or e-mail, others weekly by regular mail. They vary in potential severity from varicella (chickenpox) to rabies and include AIDS, encephalitis, measles, meningitis, pertussis (whooping cough), syphilis, and toxic shock syndrome (MedlinePlus, 2017). The Laboratory Response Network (LRN) provides early response to biological and chemical agents involved in public health emergencies or bioterrorism (CDC, 2019b). See Chapter 16.

C/PHNs should obtain the list of reportable diseases from their local or state health department office. Following up on occurrences of these diseases is a task frequently assigned to PHNs working for local health departments. Chapter 8 includes more information on reporting and tracking communicable diseases at the local, regional, and national levels.

Disease Registries Some areas or states have disease registries or rosters for conditions with major public health impact. TB and rheumatic fever registries were more common when these diseases occurred more frequently. Cancer registries provide useful incidence, prevalence, and survival data and assist the C/PHN in monitoring cancer patterns within a community. Nurses can access these registries through federal and state health department Web sites.

Federal registries include:

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Agency for Toxic Substances and Disease Registry (ATSDR, 2016) maintains three registries of major public concern:

National Amyotrophic Lateral Sclerosis (ALS) Registry: A congressionally mandated registry for persons in the United States with ALS (Lou Gehrig's Disease). It is the only population-based registry in the United States that collects information to help scientists learn more about who gets ALS and its causes. Rapid Response Registry: A registry of persons who are exposed or potentially exposed to chemical and other harmful substances during catastrophic events to help local, state, and federal public health and disaster response agencies. World Trade Center Health Registry: A comprehensive and confidential health survey of those directly exposed to fallout and debris on September 11, 2001.

Surveillance, Epidemiology, and End Results Program of the NCI: An organization that collects and publishes cancer incidence and survival data from population-based cancer registries that cover a portion of the U.S. population (NCI, n.d.).

Surveillance Systems The CDC maintains various surveillance systems to monitor diseases so it can develop and evaluate control strategies, including:

The Behavioral Risk Factor Surveillance System conducts an ongoing state-based telephone survey of the civilian, noninstitutional adult population. Data collected provide the prevalence of high-risk behaviors, such as excessive alcohol consumption, cigarette smoking, physical inactivity and lack of preventive health care, such as screening for cancer. Results are published on a periodic basis in the Morbidity and Mortality Weekly Report's CDC Surveillance Summaries and are available online at https://www.cdc.gov/brfss/. The Youth Risk Behavior Surveillance System monitors unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors that contribute to unintended pregnancy and STIs, unhealthy dietary behaviors, and physical inactivity, as well as the prevalence of obesity and asthma, in the national Youth Risk Behavior Survey. Results are available online at https://www.cdc.gov/healthyyouth/data/yrbs/index.htm (McKenzie et al., 2018). Pregnancy Risk Assessment Monitoring System (PRAMS) collects state- specific, population-based data on maternal attitudes and experiences before, during, and shortly after pregnancy. PRAMS surveillance currently covers about 83% of all U.S. births and the data can be used to

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identify groups of women and infants at high risk for health problems, to monitor changes in health status, and to measure progress toward goals in improving the health of mothers and infants (CDC, 2018f). U.S. Zika Pregnancy and Infant Registry was created in 2018 and is a collaborative system to learn about Zika virus infection during pregnancy and after birth. Information from the Registry is used to make recommendations for health care providers caring for families affected by Zika virus and plan for needed services (CDC, 2018g).

Environmental Monitoring State governments, through health departments or other agencies, now monitor health hazards found in the environment. Pesticides, industrial wastes, radioactive or nuclear materials, chemical additives in foods, and medicinal drugs have joined the list of pollutants (see Chapter 9 for a detailed discussion). Concerned community members and leaders may view these as risk factors that affect health at both community and individual levels. C/PHNs can also obtain data from federal agencies such as the Food and Drug Administration, the Consumer Product Safety Commission, the Environmental Protection Agency (EPA), and, as previously mentioned, the ATSDR (USEPA, 2018). The CDC's National Environmental Public Health Tracking Network monitors the air, soil and water for potential threats to human health, as well as trends in chronic and other health conditions. The EPA has compiled a list of agencies and organizations addressing environmental asthma (USEPA, 2018).

National Center for Health Statistics Health Surveys The NCHS furnishes valuable health prevalence data from surveys of Americans. Published data are also frequently available for regions. Examples are as follows:

The National Health Interview Survey (formerly known as National Health Survey), established by Congress in 1956, provides a continual source of information about the health status and needs of the entire nation based on interviews from approximately 43,000 households each year (NCHS, 2018a, 2018b). The National Nursing Home Survey, which primarily samples institutional records of hospitals and nursing homes, provides information on those who are using these services, along with diagnoses and other characteristics (NCHS, 2018a, 2018b). The National Health and Nutrition Examination Survey reports physical measurements on smaller samples of the population and augments the information provided by interviews. It also provides prevalence

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information on injuries, diseases, and disabilities that appear frequently in the population (NCHS, 2018a). The National Survey of Family Growth focuses on fertility and family planning as well as other aspects of family health (NCHS, 2018a).

Other studies investigate vital statistics events and characteristics of ambulatory patients in physicians' community practices. Each of these nationally sponsored efforts suggests ways in which nurses can examine health problems or concerns affecting their communities (see Box 7-7). Interviews, physical examinations of subsets of community members, and surveillance of institutions, clinics, and private physicians' practices can be carried out locally after needs are identified and funds made available. Other sources may be found in data kept routinely, but not centrally, on the health problems of workers in local industries or the health problems of schoolchildren; a key issue for many C/PHNs. Existing epidemiologic data can be used to plan parent education programs, health promotion among students, and almost any other type of service.

BOX 7-7 STORIES FROM THE FIELD How Public Health Nurses Make the Case Public health nurses working for a local or county health department often find themselves more involved with program planning than direct patient care. Often, they are asked to help develop a health education program based on what is affecting the community the most, limited by budgetary constraints while still meeting reporting requirements of grant funders.

Let's say your health department has been given the opportunity to apply for funding from three sponsoring organizations. The choices are to develop public health education programs about alcohol consumption, smoking cessation, and community HIV testing. In an upcoming department meeting you are asked to make a case for and against applying for the funding of each of these programs.

1. In preparing for this presentation, what specific types of data would you recommend to the department?

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2. What would be the sources of these data? Are those sources from local, state, or national resources?

3. How could Healthy People 2030 help frame this presentation?

Federal Public Health Agency Reports The CDC issues the Mortality and Morbidity Weekly Report. This publication presents weekly summaries of disease and death data trends for the nation. It includes reports on outbreaks or occurrences of diseases in specific regions of the country and international trends in disease occurrences that may affect the U.S. population.

Most health departments subscribe to this publication, which provides important information both for epidemiologists and PHNs. It is also available free online from the CDC at https://www.cdc.gov/mmwr/index.html.

The Community Preventive Services Task Force (CPSTF) maintains the Guide to Community Preventive Services Web site. It houses the official collection of all the CPSTF findings, and the systematic reviews on which they are based are offered as a free resource to help C/PHNs and other public health professionals choose programs and policies to improve health and prevent disease within the communities with whom they work (CPSTF, n.d.).

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Informal Observational Studies In addition to perusing existing data, the C/PHN can also gain epidemiologic data by engaging in informal observation and description. The C/PHN can perform such study on almost any client group the nurse encounters.

If, for example, the nurse encounters an abused child at a clinic, a study of the clinic's records to screen for additional possible instances of child abuse and neglect could lead to more case finding. If several cases of diabetes come to the attention of a nurse serving on a Navajo reservation, a widespread problem might come to light through informal inquiries about the incidence and age at onset of the disease among this Native American population. Informal observational study often raises questions and suggests hypotheses that form the basis for designing larger-scale epidemiologic investigations.

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Scientific Studies A third source of information used in epidemiologic inquiry involves carefully designed scientific studies. The nursing profession has recognized the need to develop a systematic body of knowledge on which to base nursing practice. Systematic research is becoming an accepted part of the C/PHN's role.

Findings from epidemiologic studies conducted by or involving nurses are appearing more frequently in the literature. The Cochrane Database of Systematic Reviews is the most popular resource for systematic reviews in health care and includes a section on public health. Its Web site is searchable by topic or Cochrane Review Group. Additionally, the Web site includes reviews, methods studies, technology assessments, and economic evaluations (Wiley Online Library, 2018; see Chapter 4). Systematic reviews can routinely be found in many professional journals and the aforementioned Community Guide. These can provide the C/PHN with valuable information that can be used to positively affect aggregate health.

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METHODS IN THE EPIDEMIOLOGIC INVESTIGATIVE PROCESS

The goals of an epidemiologic investigation are to identify the causal mechanisms of health and illness states and to develop measures for preventing illness and promoting health. Epidemiologists use an investigative process that involves a sequence of three approaches that build on one another: descriptive, analytic, and experimental studies. All three approaches have relevance for community/public health nursing (see Chapter 4 for a more detailed description).

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Descriptive Epidemiology Descriptive epidemiology includes investigations that seek to observe and describe patterns of health-related conditions that occur naturally in a population. At this stage in the epidemiologic investigation, the researcher seeks to establish the occurrence of a problem. Data from descriptive studies suggest hypotheses for further testing. Descriptive studies almost always involve some form of broad-based quantification and statistical analysis (Celentano & Szklo, 2019).

Descriptive studies can be retrospective (identify cases and controls, then go back to review existing data) or prospective (identify groups and exposure factors, and then follow them forward in time). In a descriptive study of child abuse, for example, the investigator would note the age, gender, race or ethnic group, and physical and emotional conditions of the children affected. In addition, the investigator would collect data that describe the economic status and occupation of parents, the location and setting of abusive behavior, and the time and season of the year when abuse occurred. In a retrospective study on reported varicella deaths, the investigators would describe the age, sex, ethnic background, and birthplace of victims and other information. Describing facets of these deaths provides information for further study and suggests avenues for intervention or prevention (Celentano & Szklo, 2019).

Counts The simplest measure of description is a count. For example, an epidemiologic study to assess the impact of the routine 2-dose varicella vaccination program on death due to the disease used calculated rates to compare the prevaccine and mature 1-dose varicella vaccination program eras. Authors concluded that the new 2-dose varicella vaccination program significantly reduced varicella disease burden (Leung, Bialek, & Marin, 2015).

Obtaining a count of this type always depends on the definition of what is being counted and when it was counted. This particular count, for example, uses a large database that takes time to be made public and therefore may not provide a current picture of actual deaths. When using this type of data, the C/PHN should always consider the time delay involved. If a C/PHN needs more current information within a specific community or state, hospital records or death certificates may be another source.

Rates Rates are statistical measures expressing the proportion of people with a given health problem among a population at risk. The total number of people

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in the group serves as the denominator for various types of rates. To express a count as a proportion, or rate, the population to be studied must first be identified. If those deaths are considered in relation to the total number of cases in the country, there will be one rate; if, however, those fatalities are considered in relation to the total population, there will be a quite different rate. It is important when reviewing rates that you understand which measures are being compared.

In epidemiology, the population represents the universe of people defined as the objects of a study. Because it is often difficult, if not impossible, to study an entire population, most epidemiologic studies draw a sample to represent that group.

Sometimes, it is important to seek a random sample (in which everyone in the population has an equal chance of selection for study and choice is made without bias). At other times, a sample of convenience (in which study subjects are selected because of their availability) is sufficient. In many small epidemiologic studies, it may be possible to study almost every person in the population, eliminating the need for a sample. Several rates have wide use in epidemiology (Merrill, 2017). Those most important for the C/PHN to understand are the incidence rate, the prevalence rate, and the period prevalence rate (see Box 7-8).

BOX 7-8 Incidence and Prevalence Incidence Not everyone in a population is at risk for developing a disease, incurring an injury, or having some other health-related characteristic. The incidence rate recognizes this fact. Incidence refers to all new cases of a disease or health condition appearing during a given time. Incidence rate describes a proportion in which the numerator is all new cases appearing during a given period of time and the denominator is the population at risk during the same period (Merrill, 2017).

Another rate that describes incidence is the attack rate. An attack rate describes the proportion of a group or population that develops a

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disease among all those exposed to a particular risk. This term is used frequently in investigations of outbreaks of infectious diseases such as influenza. If the attack rate changes, it may suggest an alteration in the population's immune status or that the disease-causing organism is present in a more or less virulent strain (Celentano & Szklo, 2019).

Prevalence Prevalence refers to all of the people with a particular health condition existing in a given population at a given point in time. The prevalence rate describes a situation at a specific point in time (McKenzie et al., 2018). If a nurse discovers 50 cases of measles in an elementary school, that is a simple count. When this number is divided by the total number of students in the school, the result is the prevalence of measles. For instance, if the school has 500 students, the prevalence of measles on that day would be 10% (50 measles/500 population).

The prevalence rate over a defined period of time is called a period

prevalence rate:

Source: Celentano and Szklo (2019); Merrill (2017).

Computing Rates To make comparisons between populations, epidemiologists often use a common base population in computing rates. For example, instead of merely saying that the rate of an illness is 13% in one city and 25% in another, the comparison is made per 100,000 people in the population. This population base can vary for different purposes from 100 to 100,000.

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To describe the morbidity rate, which is the relative incidence of disease in a population, the ratio of the number of sick individuals to the total population is determined. The mortality rate refers to the relative death rate, or the sum of deaths in a given population at a given time (Celentano & Szklo, 2019). Table 7-3 includes formulas for morbidity rates, and Box 7-9 includes formulas for computing mortality and other rates used frequently in community/public health.

BOX 7-9 Common Epidemiologic Mortality Rates A mortality rate is a measure of the frequency of occurrence of death in a defined population during a specified interval. Morbidity and mortality measures are often the same mathematically; it's just a matter of what you choose to measure, illness or death. The formula for the mortality of a defined population, over a specified

period of time, is: When mortality rates are based on vital statistics (e.g., counts of death

certificates), the denominator most commonly used is the size of the population at the middle of the time period. In the United States, values of 1,000 and 100,000 are both used for 10n for most types of mortality rates.

General Mortality Rates

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Specific Rates for Maternal and Infant Populations

Source: Centers for Disease Control and Prevention (CDC) (2012b).

TABLE 7-3 Frequently Used Measures of Morbidity

*Incidence refers to the occurrence of new cases of disease or injury in a population over a specified period of time. Although some epidemiologists use incidence to mean the number of new cases in a community, others use incidence to mean the number of new cases per unit of population.

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Reprinted from CDC. (2012b). Lesson 3: Measures of risk. Retrieved from https://www.cdc.gov/csels/dsepd/ss1978/lesson3/section2.html

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Analytic Epidemiology A second type of investigation, analytic epidemiology, goes beyond simple description or observation and seeks to identify associations between a particular human disease or health problem and its possible causes. Analytic studies tend to be more specific than descriptive studies in their focus. They test hypotheses or seek to answer specific questions and can be retrospective or prospective in design (Merrill, 2017). Analytic studies fall into three types: prevalence studies, case–control studies, and cohort studies.

Prevalence Studies When examining prevalence, it is helpful to remember that the health condition may be new or may have affected some people for many years. A prevalence study describes patterns of occurrence, as in the study of varicella-related deaths. It may examine causal factors, but a prevalence study always looks at factors from the same point in time and in the same population. Hypothesized causal factors are based on inferences from a single examination and most likely need further testing for validation. Intervening or confounding variables can lead to inaccurate assumptions about results, and studies must be carefully designed to avoid both falsely positive and falsely negative outcomes (Merrill, 2017). A recent international prevalence study found sociodemographic factors (e.g., education, gender) were moderators of the built environment (safety from crime) in meeting physical activity goals (Perez et al., 2018).

Case–Control Studies A case–control study compares people who have a health or illness condition (number of cases with the condition) with those who lack this condition (controls). These studies begin with the cases and look back over time (retrospectively) for presence or absence of the suspected causal factor in both cases and controls (Celentano & Szklo, 2019).

In a case–control study, Dabrera and colleagues (2015) explored whether maternal pertussis vaccination might prevent newborns younger than 8 weeks from being infected with pertussis. Cases included infants younger than 8 weeks who tested positive for pertussis infection with an onset of <8 weeks and healthy infants born subsequent to identified cases as controls. Mothers of 17% of the cases and 71% of the controls received pertussis vaccination during pregnancy. Vaccine effectiveness was 93%, and researchers concluded that maternal pertussis vaccine during pregnancy was effective in preventing infection of infants younger than 8 weeks (when they are too young to receive their own vaccination).

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Cohort Studies A cohort is a group of people who share a common experience in a specific time period. In epidemiology, a cohort of people often becomes a focus of study. Cohort studies, rather than measuring the relationship of variables in existing conditions, study the development of a condition over time.

A cohort study begins by selecting a group of people who display certain defined characteristics before the onset of the condition being investigated (Merrill, 2017). In studying a disease, the cohort might include individuals who are initially free of the disease but were known to have been exposed to a particular substance or risk factor. They would be observed over time to evaluate which variables were associated with the development or nondevelopment of the disease. These types of studies are often used with environmental hazard exposures, as with the Health Registry and the National Toxic Substance Incidents Program discussed earlier (ATSDR, 2016).

One workplace exposure study examined almost 48,000 employees who had contact with 11 toxins (e.g., dyes/inks, acids, paints, pesticides, metals, glues, petroleum products, soldering materials) and found that almost 2,000 cases of breast cancer were reported. They noted that premenopausal breast cancer was associated with exposure to soldering materials and that women with cumulative exposure to petroleum products at the highest level had 2.3 higher risk than those at the lowest level to for breast cancer and 2.5 higher risk for invasive breast cancer (Ekenga, Parks, & Sandler, 2015).

In 1993, the Women's Health Study, a 10-year national longitudinal, experimental, cohort study involving nearly 40,000 female health professionals was initiated (Harvard Medical School & Brigham and Women's Hospital, n.d.). Over the course of many years, significant findings regarding women's health issues were published (600+) and implemented to improve health outcomes.

In practice, the various types of studies just discussed are frequently mixed. A case–control study may include description and analysis with a retrospective focus; a cohort study may be conducted prospectively or retrospectively. The Women's Health Study is an example of a case–control study, a cohort study, and an experimental study. Flexibility is essential to allow the investigator as much freedom as possible in choosing the most useful methodology.

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Experimental Epidemiology Experimental epidemiology follows and builds on information gathered from descriptive and analytic approaches. In an experimental study, the investigator actually controls or changes the factors suspected of causing the health condition under study and then observe what happens to the health state (Merrill, 2017).

In human populations, experimental studies should focus on disease prevention or health promotion rather than testing the causes of disease, which is done primarily on animals. Experimental studies are carried out under carefully controlled conditions and must be approved by an Institutional Review Board. The investigator exposes an experimental group to some factor thought to cause disease, improve health, prevent disease, or influence health in some way (as in the Women's Health Study). Simultaneously, the investigator observes a control group that is similar in characteristics to the experimental group but without the exposure factor. See Chapter 4 for more on experimental research studies.

The C/PHN should be alert for opportunities to conduct experimental studies in the course of working with groups. A study need not be elaborate to provide important data for future nursing practice. For example, a C/PHN can provide focused instruction to 20 new mothers encouraging them to breastfeed and then compare the health outcomes of their infants with infants of 20 mothers in the same service area who use formula.

An expanding area of experimental epidemiology involves the use of computers to simulate epidemics. With mathematical models, it is possible to determine the probabilities of various aspects of disease occurrence (Yang et al., 2015). This approach is making an increased contribution to epidemiologists' knowledge of etiology and prevention.

Occasionally, an experiment occurs naturally, thus affording the researcher a chance to make important discoveries. John Snow discovered such a “natural experiment” in London in 1854 (as discussed earlier in the chapter). In his seminal study of an epidemic of cholera, he observed one group that contracted the disease and another that did not. Closer inspection revealed that the major difference between these groups was their water supply. See Chapter 9 for a more current example from Flint, Michigan's lead-contaminated water.

A community trial is a type of experimental study done at the community level. Geographic communities are assigned to intervention (experimental) or nonintervention (control) groups and compared to determine whether the intervention produces a positive change in the community (Merrill, 2017).

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Community trials can be extremely expensive and are not undertaken unless there is substantial evidence that the intervention will make a difference at the aggregate level. There are times when these community trials occur spontaneously, and it is important for the C/PHN to recognize these opportunities. For instance, one local public health department institutes an aggressive campaign to educate health care workers on the signs of elder abuse. Selecting a similar community where that level of training is not available, the PHN can then compare the rates of elder abuse reporting between these two communities. If you were conducting this research, what outcome would you expect in the community with the enhanced training? Where could you obtain this information? Think about what other measures you might also want to compare between these two communities.

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CONDUCTING EPIDEMIOLOGIC RESEARCH

The C/PHN who engages in an epidemiologic investigation becomes a kind of detective. First, there is a problem to solve, a puzzle to unravel, or a question to answer. The nurse begins to search for basic information, for clues that might help answer the question.

Information is never self-explanatory, and, like a detective, the nurse must analyze and interpret every additional clue. Slowly, there is a narrowing of possible suspects until the causes of a particular disease, the consequences of a prevention plan, or the results of treatment are identified. On the basis of this investigation, the nurse can draw further conclusions and make new applications to improve health services.

Epidemiologic studies are a form of research. The steps outlined here are similar to those discussed in Chapter 4. Epidemiologic research involves seven steps (Table 7-4). Everything from an informal study in the course of nursing practice to the most comprehensive epidemiologic research project can be undertaken with these steps. An example of conducting an epidemiologic investigation can be found in Box 7-10 and will be used as examples for each step.

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TABLE 7-4 Steps in Epidemiologic Research

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BOX 7-10 PERSPECTIVES: CONDUCTING AN EPIDEMIOLOGIC INVESTIGATION

Adult Lead Poisoning From the Use of an Asian Remedy for Menstrual Cramps—Example of an Epidemiologic Investigation During a free lead- screening event, sponsored by a nursing school community health promotion center, a 33-year-old Cambodian woman who brought her two children to the center to be tested for lead poisoning also participated in being tested. She was found to have an elevated blood lead level (BLL) of 44 μg/dL, and a confirmatory BLL 1 month later of 42 μg/dL. Any level above 10 μg/dL is considered abnormal. The children and her husband were found to have normal BLLs. This woman was referred to the Connecticut Department of Public Health for follow-up. As the Connecticut Adult Blood Lead Surveillance Program's Adult Lead Registry and Case Management Coordinator, I was responsible for compiling and analyzing BLL data from Connecticut laboratories performing these tests and following up on any reports of elevated lead levels, such as this woman who was identified through a community screening event sponsored by a nursing school.

After finding lead in the Koo Sar pills purchased in Connecticut, New York City and San Francisco and taken by the woman for menstrual cramps, public health department follow-up was conducted with the New York City and San Francisco health departments. Eventually it was determined that

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lead was not a listed ingredient of these pills but a contaminant during the manufacturing process. The investigation was considered significant and was reported in an issue of the CDC's Morbidity and Mortality Weekly Report ( CDC, 1999 ). As a result of this report, this case was further reported by various public health agencies to the public and their constituencies (Jung, 2018).

Lessons learned from this investigation:

Collaboration between health care providers and public health entities allowed for a broader approach to addressing health and environmental issues, such as lead poisoning. Detailed follow-up at various points of an epidemiologic investigation allowed for cross-state efforts to identify new sources of exposure. Dissemination of findings by the CDC (via MMWR) provided scientific evidence that enabled the implementation of legislation in other states other than where the exposure initially occurred. Public health education regarding lead contamination of consumer products was expanded to include unusual sources of exposures.Margie, case management coordinator

Source: Centers for Disease Control and Prevention (1999); Jung (2018); Poison Control (2018).

Margie, case management coordinator

Findings from epidemiologic investigations should be disseminated in forms that are easily understood by the general public, such as the flow chart developed during an outbreak investigation of coccidioidomycosis among solar farm workers (Wilkin et al., 2015). See Figure 7-17 for a flowchart of the sequence of investigation that took place and how cases were identified, as well as what was done.

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FIGURE 7-17 Flowchart of investigation of coccidioidomycosis among solar farm workers, San Luis Obispo County, CA, USA, October 2011 to April 2014. CDPH, California Department of Public Health; SLOPHD, County of San Luis Obispo Public Health Department. (Adapted from Wilkin, J. A., Sondermeyer, G., Shusterman, D., McNary, J., Vugia, D., McDowell, A., & … Materna, B. L. (2015). Coccidioidomycosis among workers constructing solar power farms, California, USA, 2011=2014. Emerging Infectious Diseases, 21(11). doi: 10.3201/eid2111.150129. Retrieved from https://wwwnc.cdc.gov/eid/syn/en/article/21/11/15-0129.htm)

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Figure 7-18 shows the impact of conducting investigations of multistate food outbreaks. Such outbreaks are becoming quite common because the manufacturing process of food products can affect people living in many states. It is vital that collaborative processes are in place in which all levels of public health agencies and health systems can communicate findings efficiently to prevent outbreaks as well as reduce morbidity and mortality.

FIGURE 7-18 Outbreak investigations help everyone make food safer. (Reprinted from CDC. (2015). Safer food saves lives.

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Retrieved from https://www.cdc.gov/vitalsigns/foodsafety- 2015/index.html)

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SUMMARY

Epidemiology is the study of the distribution and determinants of health, health conditions, and disease in human population groups. Epidemiology shares with community/public health nursing the common focus of the health of populations and provides a body of knowledge on which to base practice. Basic epidemiologic concepts the nurse should understand include:

The host, agent, and environment model Causality Immunity Risk The natural history of disease or health conditions Wellness Causal relationships

C/PHNs can use three sources of information when conducting epidemiologic investigations:

Existing epidemiologic data Informal investigations Carefully designed scientific studies

Epidemiology employs three investigative approaches: Descriptive studies Analytic studies Experimental studies

Epidemiologic research includes seven steps:

1. Identifying the problem, which is usually a threat to the population's health 2. Reviewing the literature to determine what other studies have found 3. Carefully designing the study

4. Collecting the data 5. Analyzing the findings 6. Developing conclusions and applications 7. Disseminating the findings

Thinking epidemiologically can significantly enhance community/public health nursing practice.

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ACTIVE LEARNING EXERCISES

1. Identify an aggregate-level health problem in your community (e.g., hypertension, homelessness). Using the host, agent, and environment model, explain: a. Who the host is? b. What the causative agents are? c. What environmental factors have promoted or delayed the

development of the problem? d. What vector control programs may be needed or enhanced?

2. Select an aggregate health (wellness) condition (e.g., preschoolers' normal growth and development, elders' healthy aging) and: a. List all the causal factors that might contribute to this healthy state. b. Plot these schematically in a diagram to show the web of

causation model for this condition. 3. Using the same health condition that you selected in the previous

exercise: a. Describe the natural history of this condition. b. Outline its four stages. c. Identify three preventive nursing interventions, one for each level

of prevention that could apply to this condition. 4. Select an article that reports an epidemiologic study from a recent

nursing or public health journal, and record your responses to the following questions: a. What prompted the study, and what was its purpose? b. Was it descriptive, analytic, or experimental research? c. Was the study design retrospective or prospective? d. Why did the investigators choose this design? e. What existing sources of epidemiologic data did this study use? f. List all sources specifically, such as Morbidity and Mortality

Weekly Report or incomes by household in census data. g. What were the study findings? Identify the population group that

will benefit from this research. 5. Interview one or more practicing C/PHNs in your community and

identify an aggregate-level problem that needs epidemiologic investigation. Propose a rough draft study design to research this problem. How many of the 10 essential public health services would you need to employ? In relation to your identified problem, describe which three would be most useful.

6. Search for local or national news regarding a new disease threat (e.g., tick-borne diseases, Zika virus, COVID-19), an example of a foodborne illness outbreak (e.g., bacterial contamination of produce), or another example requiring epidemiological investigation. Work

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with a small group of classmates to develop a hypothetical case investigation and a potential epidemiological plan for action. Are there specific environmental factors that should be considered? If possible, watch for the resolution of the issue (e.g., conclusions of the investigation, public health recommendations).

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CHAPTER 8

Communicable Disease “There are only two things a child will share willingly; communicable disease and its mother's age.”

—Benjamin Spock (1903–1998), Pediatrician and Author

KEY TERMS Active immunity Antigenic drift Antigenic shift Cocooning Communicable disease Direct transmission Disease control Fomites Herd immunity Immunization Incubation period Indirect transmission Infectious agent Isolation Novel Pandemic Passive immunity Quarantine Reservoir Ring vaccination Screening Surveillance Vaccine Vaccine hesitancy Vector

LEARNING OBJECTIVES Upon mastery of this chapter, you should be able to:

1. Define the nurse's role in communicable disease control. 2. Describe the three modes of transmission for communicable diseases. 3. Identify four major communicable diseases in the United States. 4. Differentiate the strategies used for the three levels of prevention in

communicable disease control.

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5. Explain the significance of immunization as a communicable disease control measure.

6. Delineate the major concerns of parents who choose not to vaccinate their children.

7. Explain the importance of herd immunity in controlling vaccine- preventable diseases.

8. Discuss legal and ethical issues affecting communicable disease and infection control.

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INTRODUCTION

In the United States, the highly contagious disease measles was eliminated in 2000. However, unvaccinated people and international travelers have been associated with outbreaks of this disease over the past few years. During 2019, there were 22 outbreaks and 1,249 confirmed measles cases, which is the highest annual number since 1992 (Patel et al., 2019). Imagine visiting Disneyland with your friends and family, only to learn that an infectious individual had been there on the same day. That occurred in 2019, and in 2014, “at least 131 California residents were infected with measles” in the state's most recent “large outbreak of measles” (California Department of Public Health, 2020, para. 3; Hassan, 2019). Communicable diseases pose a major threat to public health and are of significant concern to community/public health nurses. A communicable disease is caused by an infectious agent, such as a virus or bacteria, and can be transmitted from one source to another. Transmission to a susceptible host can occur directly either from person to person or animal to human, or transmission may occur indirectly through a reservoir such as contaminated water (Centers for Disease Control and Prevention [CDC], 2012; Heymann, 2015). Some noncommunicable diseases can also be caused by infectious agents, such as tetanus, but cannot be transmitted from one source to another (CDC, 2018a). Jurisdictional laws and regulations define the infectious and noninfectious diseases to be reported to local, state, and territorial public health departments. The National Notifiable Diseases Surveillance System allows sharing of notifiable disease information nationally and between jurisdictions for surveillance, control, and prevention purposes (CDC, 2018b).

Knowledge of communicable diseases is fundamental to the practice of community/public health nursing because these diseases typically spread through communities of people. It is essential for the nurse to understand the basic concepts of communicable disease control, which involves teaching important and effective preventive measures to community members, advocating for those affected, protecting the well-being of uninfected persons (including health care workers and nurses themselves), and controlling communicable disease in populations and groups (CDC, 2012).

In the last century, numerous changes occurred in the lives of people both nationally and globally related to issues of public health. Communicable disease control is recognized as one of the 10 great public health achievements of the 20th century (CDC, 2013). In the early 1900s, the top three causes of death were pneumonia, tuberculosis (TB), and diarrheal or enteric diseases. Then, control measures including improved sanitation and

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hygiene, vaccinations, and use of antibiotics and other antimicrobials, along with improved surveillance systems, have all contributed to a significant reduction of infant and child mortality and a nearly 30-year increase in life expectancy overall (Penn Wharton, 2016).

During the first decade of the 21st century, new vaccines reduced the number of serious illness and death due to pneumococcal infection and reduced rotavirus-related hospitalizations among children. Deaths related to other vaccine-preventable diseases (VPDs), including hepatitis A, hepatitis B, and varicella, were also reduced during this 10-year time period (Hinman, Orenstein, & Schuchat, 2011). In addition, improved public health infrastructure and changes in prevention strategies resulted in a 30% reduction in TB and a 58% reduction in bloodstream infections related to central lines. Improved testing has allowed more people with human immunodeficiency virus (HIV)/AIDS to be identified and receive lifesaving treatment earlier. Rabies control efforts have resulted in the elimination of canine rabies in the United States (CDC, 2018g). The CDC is charged to protect Americans against threats of disease, both in the United States and abroad (CDC, 2015a, 2019h). But, new challenges in communicable disease control have emerged:

Human migration, modern transportation, and globalization leading to the spread of new pathogens and vectors such as the H1N1 influenza pandemic in 2009 and 2010 and Zika and Ebola virus outbreaks in West Africa in 2014 and 2017– 2018 (CDC, 2016e, 2019h, 2019p, 2020f; Heymann, 2015; Moreno-Madriñán & Turell, 2018; Porse, et al., 2018). Diseases with epidemic potential due to little or no countermeasures being in place, such as Zika virus, Ebola virus, and Middle East respiratory syndrome coronavirus (CDC, 2019p; WHO, 2016a). The COVID-19 (SARS-CoV-2) outbreak brought that reality to life, as the initial epidemic in China spread around the world as a pandemic, infecting millions (Johns Hopkins University of Medicine, 2020). Climate variability and increased rate of urbanization affecting the transmission patterns of vector-borne diseases such as dengue and Zika virus diseases (Otmani del Barrio, Simard, & Caprara, 2018). Development of antibiotic-resistant strains of the bacteria Neisseria Meningitides, groups A and B Streptococcus, TB, and gonorrhea that threaten the public's health and pose significant occupational health risk for health workers (CDC, 2015d, 2018i, 2019d; WHO, 2018c). The threat of bioterrorism, which involves the use of biologic agents with the intent to cause harm (Heymann, 2015); see Chapter 17 for more on emerging infections and bioterrorism.

This chapter provides information to help you better understand communicable diseases in communities and around the globe. It describes

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ways to plan and implement appropriate prevention interventions, including immunization of children and adults, environmental interventions, community education, screening programs, and disease investigation and case/contact finding. Ethical issues of communicable disease control are also discussed. A list of communicable disease information sources useful to you, the C/PHN, are also provided.

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BASIC CONCEPTS REGARDING COMMUNICABLE DISEASES

Communicable diseases have challenged health care providers for centuries. Exposure to infectious agents can occur out in the community or within health care settings. The threat of these diseases has led to the development of important infection control measures over the last century (Heymann, 2015; Rosner, 2010):

Hand washing Use of personal protective equipment Safe handling of contaminated sharp equipment Appropriate disposal of potentially infectious materials Community sanitation Pest control Vaccines Antimicrobial medications

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Evolution of Communicable Disease Control Although communicable diseases are no longer the leading cause of death in the world, they continue to pose a serious threat. Three of the top ten causes of death worldwide continue to be infectious illnesses. In 2016, lower respiratory infections, as a group, were the fourth-leading cause, responsible for 3.0 million global deaths. Even though the worldwide number of deaths attributed to diarrhea and TB have declined, these diseases are still responsible for the deaths of 1.4 million and 1.3 million people, respectively (WHO, 2020h).

Bubonic plague, caused by Yersinia pestis, is one example of how communicable diseases have changed the course of history. The first documented pandemic plague occurred in 541 AD. The next 200 years saw outbreaks in Africa, Egypt, Istanbul, Europe, and across the Middle East, with over 100 million deaths due to plague (CDC, 2019k; Frith, 2012). In 1347–1352, the great plague pandemic, known as “Black Death,” killed 25% of the European population in the first plague and another 20% in the second one; it killed over 25 million people in Africa and Asia (Frith, 2012). Now, this deadly disease can be controlled through early identification and treatment with antibiotics. It may be transmitted when humans are bitten by infected fleas, when they come in contact with infected tissue or body fluids of an infected animal, or when droplets from a person infected with plague pneumonia are inhaled by another person. Y. pestis has been used as a weapon during wars over the centuries. Weaponization of Y. pestis remains a threat today (CDC, 2019k, 2019l).

Historically, as countries became industrialized, increased productivity, trade, and economic growth also brought on the four D's of disruption, deprivation, disease, and death. Industrialization brings large numbers of people close together in condensed living conditions. Trade brings populations together, exposing them to infectious agents they had not previously seen. These conditions, combined with poor sanitation leading to contaminated water supplies and infestation of disease-carrying insects or rodents, have all contributed to devastating epidemics in the past and continue to pose a threat today in developing countries (Boyce, Katz, & Standley, 2019).

To address this threat, the CDC is tasked with health promotion and disease prevention (see Chapter 6). It is recognized globally for its partnerships in disease surveillance, research, data collection, and analysis, as well as for responding nationally and globally with peer agencies to disease outbreaks (CDC, 2015a, 2020d). The World Health Organization (WHO) addresses communicable and noncommunicable diseases, working

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on emergency preparedness, surveillance, and response (WHO, 2018a, 2020a, WHO, 2020e). See more on global health in Chapter 16.

Smallpox, caused by the variola virus, is a classic example of a communicable disease control success story. The variola virus had been associated with devastating epidemics throughout the centuries. Smallpox became endemic in Europe in the 18th century and was responsible for 300 to 500 million deaths worldwide during the 20th century (Thèves, Biagini, & Crubezy, 2014). Smallpox first responded to a crude vaccine that was developed in the 18th century. The vaccine was studied and perfected and used globally for decades. A major worldwide eradication campaign began in 1967, under the direction of the WHO (Heymann, 2015). In 1980, the World Health Assembly declared the eradication of smallpox and made a call to cease smallpox vaccinations around the globe (WHO, 2014a). Outside of a small accidental laboratory-related outbreak in 1978, there have been no cases of smallpox since that time (Heymann, 2015).

Despite strides in controlling major disease outbreaks, nations and disease prevention organizations worldwide, such as the following, must continue to prepare for the future through collaboration, surveillance, and prevention (Heymann, 2015):

Global Health Security Agenda (2018), an international partnership among nearly 50 participating nations and nongovernmental stakeholders, strives to make the world safe and secure from biological threats. The National Notifiable Diseases Surveillance System electronically collects, analyzes, and shares data on over 120 diseases provided by local, state, and territorial public health departments as per mandated jurisdictional laws and regulations (CDC, 2018b). Global Health Security is part of the CDC's prevention effort to stop the spread of disease through prevention, surveillance, and rapid response to outbreaks as a result of globalization (CDC, 2020d).

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Community/Public Health Nurse's Role: Process of Investigating Reportable Communicable Diseases Health care providers, veterinarians, and laboratories are required to report certain diseases in humans to the local health authority and, in some cases, to the CDC (Heymann, 2015). Each state has a State Health Department, and some states have local sites, such as a county or city health department. Such departments are typically staffed by a combination of nurses, epidemiologists, and communicable disease investigators (CDC, 2019h). See Chapter 6.

The local health department or agency is the initial point of notification of a communicable disease investigation. If a person is identified in one jurisdiction but was exposed in another, the health agency receiving the report should notify the health agency where the exposure occurred, so an investigation can be conducted in the originating region (Heymann, 2015). In most states, reporting known or suspected cases of a reportable disease is generally considered to be an obligation of:

Physicians, dentists, nurses, veterinarians, pharmacists, and other health professionals Medical examiners Administrators of hospitals, clinics, nursing homes, schools, and nurseries

Some states also require or request reporting from:

Laboratory directors Any individual who knows of or suspects the existence of a reportable disease (County of Los Angeles Department of Public Health, n.d.; Heymann, 2015).

Figure 8-1 outlines the Notifiable Disease Surveillance process. Each state has a disease report form (see example on ), and the local health department or agency investigates a specific disease using a protocol set by the local, state, or federal public health official. Reportable diseases must be reported to the state health department. Notifiable diseases are voluntarily reported by the state to the CDC (CDC, 2020j). Individual citizens may also contact the CDC directly via mail, phone, or the Internet. You can reach them at:

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FIGURE 8-1 How we do notifiable disease surveillance. (Reprinted from Center for Disease Control and Prevention. (2018). Defending America from Health Threats. Retrieved from https://wwwn.cdc.gov/nndss/how-we-do.html)

Centers for Disease Control and Prevention 800-CDC-INFO (800-232- 4636); TTY: (888) 232–6348, 24 hours/every day E-mail: [email protected]; Website: https://www.cdc.gov/

Disease investigation requires a systematic approach. The nurse may be assigned to work on individual cases of a disease or several cases that make up a cluster or outbreak. Whether it is a single case of illness in a small town or a multijurisdictional outbreak, the nurse should follow similar steps (Heymann, 2015):

1. Identify additional people who might be infected (surveillance) 2. Determine the possible source of infection and means of transmission 3. Identify others who are at risk so screening and prevention measures can be implemented 4. Prevent further transmission

5. Monitor the response to these interventions

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In the event of an outbreak, the response should also include confirming the outbreak, establishing a task force to serve as the command-and-control center of the response, communicating with the public, managing care for those who are ill, and conducting an outbreak investigation (Heymann, 2015).

When investigating a disease outbreak, prior to contacting an individual for an interview:

Review the information received from the mandated reporter for completeness. Clarify whether the disease is suspect (meeting certain clinical criteria) or lab confirmed. Review the case definition (criteria an individual must meet to be considered to have the disease). Review the disease information (reservoir, incubation and infectious periods, symptoms, and treatment), know the methods of control, and be prepared to provide education to the client while also conducting the investigation. See Chapter 7 to review the natural history of a disease or health condition. Review the disease-specific questionnaire, if applicable, to better understand the intent of the investigation and to identify questions to ask the client, allowing you to focus and putting the client at ease. If no questionnaire exists, write a narrative report including the information related to onset of illness, symptoms, medical evaluation, treatment if received, recovery state, and individuals the person has been in contact with, depending upon the nature of the disease. (See

for a sample disease investigation form.)

When conducting the interview:

Maintain a neutral and nonjudgmental attitude to elicit information more readily, especially when discussing highly sensitive topics, such as a sexually transmitted infection (STI) Arrange to call or meet with the person (Fig. 8-2), depending on department protocol and/or disease being addressed Introduce yourself and explain the purpose of the confidential nature of the interview Elicit what the individual knows about the disease to assess knowledge base and guide education Gather information using a disease-specific questionnaire, if available, and note any possible sources of the disease or additional infected contacts

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FIGURE 8-2 PHN interviews a health center nurse during TB/HIV investigation.

After the interview, contact individuals identified as possibly infected, which may help establish whether an outbreak is occurring.

Surveillance of communicable diseases is the next step. The WHO has defined surveillance as the ongoing and systematic collection, analysis, and interpretation of health data. Surveillance allows for early identification of public health emergencies and evaluation of the effectiveness of public health interventions and is used to help inform policy changes (WHO, n.d). Contact tracing can identify additional people who are also affected. The nurse or other local investigator sends information obtained during the interview to the next higher level of government for analysis and interpretation. If an outbreak is occurring, properly addressing it may require assistance from the next level of government (Heymann, 2015).

Next is disease control. Disease control measures are determined by the characteristics specific to the disease. C/PHNs must understand the characteristics of the infectious agent so that appropriate control measures can be implemented. Prompt, appropriate action could minimize or even prevent an outbreak. Control measures may include testing, counseling, education, environmental modifications such as draining standing water, vaccination, treatment, or prophylaxis as appropriate (Heymann, 2015). Effective surveillance and control can lead to elimination and eradication of a disease in many cases. See Chapter 16 for more on global eradication of infectious diseases.

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Modes of Transmission Transmission of a communicable disease describes how disease is passed from person to person or from another source to a person. The spread can occur by direct transmission or indirect transmission methods (Heymann, 2015). Refer to Table 8-1, which summarizes the modes of infectious disease transmission. Two indirect modes of transmission particularly important for C/PHN, vector transmission and food and water transmission, are discussed in detail below. Chapter 9 describes both the government's role and the nurse's role in helping to prevent food and water contamination by infectious agents (Heymann, 2015).

TABLE 8-1 Modes of Infectious Disease Transmission

Source: CDC (2012).

Vector Transmission Vectors are living organisms that can transmit infectious diseases to humans. Insects, a common type of vector, carry disease on their feet or expel it through their digestive tract. This mechanical transmission does not require the infectious organism to multiply. Insects can also transmit disease when the infectious agent has propagated within the insect, which is known as biological transmission (Heymann, 2015). This requires an incubation period for the infectious agent to be passed to the host. These modes of transmission, together known as vector-borne transmission, involve the bite of the infected insect (e.g., mosquito) or animal (e.g., rat) or some other form of exposure to the infected animal's body fluids, such as contact with the urine from the Hantavirus-infected rodent (CDC, 2020a; Heymann, 2015). Box 8-1 provides an overview of vector-borne diseases that are a major public health concern and the most complex to prevent and control (CDC, 2018j, 2020a).

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BOX 8-1 Vector-Borne Diseases Diseases from mosquito, tick, and flea bites have increased threefold between 2004 and 2016. The United States has had outbreaks of Zika and Chikungunya viruses. The U.S. population is at risk of infection from seven new tick- borne germs. Commerce and travelers spread mosquitos, ticks, and fleas around the world. Over 80% of vector control organizations report a need for improved performance in core competencies, including pesticide resistance testing.

Mosquito-Borne Diseases

California serogroup viruses Chikungunya virus Dengue viruses Eastern equine encephalitis virus Malaria plasmodium St. Louis encephalitis virus West Nile virus Yellow fever virus Zika virus

Tick-Borne Diseases

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Anaplasmosis/ehrlichiosis Babesiosis Lyme disease Powassan virus Spotted fever rickettsiosis Tularemia

Flea-Borne Disease

Plague

Photo of mosquito reprinted from Centers for Disease control and Prevention. Public Health Image Library. Photo Image ID no. 23157—San Gabriel Valley Mosquito & Vector Control District (SGVMVCD), Pablo Cabrera. Retrieved from https://phil.cdc.gov/Details.aspx?pid=23157. Adapted from CDC (2018c).

Food-and Water-Related Illness Food-or water-related illness can be caused by bacteria (e.g., Salmonella, Shigella, Escherichia coli 0157, Listeria monocytogenes, and

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Campylobacter), viruses (e.g., norovirus, hepatitis A), or parasites (e.g., Cryptosporidium, Giardia; CDC, 2020c; Heymann, 2015). Toxins released in response to bacteria in the intestines can also result in severe illness. Ingestion of the pathogenic organism sets in motion the events of a food-or water-related intestinal illness or even death.

The contamination can occur:

At the source (e.g., animal waste being introduced into the food or water chain) Through unsanitary food handling or practices (e.g., ingestion of fecal material, fecal–oral route) Due to food storage at improper temperatures, allowing microorganisms to grow (2016d)

Most commonly, exposure to contaminated food or water results in symptoms related to gastrointestinal function, including diarrhea, nausea, vomiting, stomach cramps, and bloating. Fever may accompany these infections, as well. Onset of symptoms may occur within a few hours after exposure or not until days or even weeks later, depending on the microorganism. This time interval between exposure and onset of symptoms is called the incubation period.

Microorganism contamination of food resulting in human illness occurs as a result of either infection or intoxication (Heymann, 2015):

Infection: Ingestion of food contaminated with Salmonella, Shigella, E. coli, or other pathogen that has multiplied and grown in the food and that irritates the normal gastrointestinal mucosa Intoxication: Ingestion of food contaminated with a toxin, or by-product of the normal bacterial life cycle, rather than the microbe itself (e.g., heat-stable Staphylococcus toxin; the neurotoxin botulinum, produced by the bacterium Clostridium botulinum), which may be introduced to the food by bacteria in the food (e.g., cooked food left at room temperature) or living on the skin of a food preparer

This distinction is relevant because, compared with bacteria, toxins (Heymann, 2015):

Are difficult to isolate and identify, causing some foodborne illnesses to go unidentified Are stable at normal cooking temperatures and therefore can occur in thoroughly cooked food Typically require only supportive care to address, rather than medical treatment

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Food-and water-related outbreaks can impact large numbers of people. A famous historical example is Typhoid Mary. Mary Mallon was the “first identified healthy carrier of typhoid fever” who spread the bacteria (Salmonella typhi) in 10 outbreaks, resulting in 51 typhoid fever cases and three deaths (The College of Physicians of Philadelphia, 2019, para. 2). Such outbreaks serve to remind all C/PHP of the continuing need to teach and observe the most basic methods for preventing food and water contamination. Box 8-2 summarizes correct methods for maintaining the safety and cleanliness of food.

BOX 8-2 Correct Methods for Preserving the Safety and Cleanliness of Food

Before Handling Food Wash hands and all food preparation surfaces and utensils thoroughly with soap and water.

When Preparing Food

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Wash foods that are to be eaten raw and uncooked thoroughly in clean water. This includes foods that are to be peeled that grow on the ground or come in contact with soil. Cook all meat products thoroughly. Do not allow cooked meats to come in contact with dishes, utensils, or containers used when the foods were raw and uncooked.

When Storing Leftover Foods Cool cooked foods quickly; store under refrigeration in clean, covered containers.

When Reheating Leftover Foods Heat foods thoroughly. Bacteria contaminating food grow and multiply in a temperature range between 39°F and 140°F.

Source: U.S. Department of Agriculture (2015).

Investigating outbreaks involves three types of data: 1. Epidemiologic data:

Patterns in the geographic distribution, time of onset, and past incidents of illnesses Associated exposures to foods, infected people, or other sources of disease Clusters of unrelated sick people who share a common event (e.g., eating at the same restaurant, shopping at the same store, attending the same concert; CDC, 2019a)

2. Traceback data:

Common points of contamination in the distribution chain, identified by reviewing records collected from restaurants and stores where sick people ate or shopped Findings of environmental assessment in food production facilities, farms, and restaurants identifying food safety risks (CDC, 2016d)

3. Food and environmental testing data:

Specimens collected from suspected food items and sent to the lab for processing and identification of the organism (CDC, 2016d) Specimens processed through the CDC surveillance system, PulseNet, which is designed to identify organisms that may come from the same

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source, allowing outbreaks to be identified and sources to be eliminated (CDC, 2016h)

An example of one PulseNet success story occurred in 2014 when this system identified a rare fingerprint of Salmonella Newport in specimens from ill patients. This prompted multiple health departments to initiate an investigation (2016f). Chia powder used in people's smoothie drinks was determined to be the common source. Public health investigators included questions about Chia powder in their questionnaires and identified additional cases in the United States and in Canada. The product was pulled from shelves, eliminating the source from the food supply. A similar process occurred in 2019 with fresh basil from a company in Mexico when 132 lab confirmed Cyclospora infection cases were reported, and four people were hospitalized (CDC, 2019a, 2019i).

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MAJOR COMMUNICABLE DISEASES IN THE UNITED STATES

C/PHN encounter many communicable diseases in their practice, some reportable, some not, though equally transmittable. These diseases are frequently diagnosed and treated in the community care setting rather than the hospital. The following sections discuss some of the more common communicable diseases, excluding many that are reportable. Diseases are presented in groups by similarity, rather than by virulence or prevalence.

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Influenza (Seasonal or Novel) and Pandemic Preparedness Influenza (flu) is an acute communicable viral disease of the respiratory tract. Symptoms include fever, headache, myalgia, prostration, coryza, sore throat, and cough. Influenza derives its importance from the rapidity with which epidemics evolve, the widespread morbidity, and the seriousness of complications, specifically pneumonias (Heymann, 2015). The antigenic types of influenza virus are as follows:

Influenza A virus causes the most severe and widespread disease (pandemic) and undergoes minor genetic mutations from year to year, referred to as antigenic drift, and drastic transformations periodically, referred to as antigenic shift. Subtype description of proteins on the surface of the virus, hemagglutinin and neuraminidase antigens, are included in parentheses—A(H1N1), A(H3N2) (CDC, 2019o).

Most people around the world do not have antibodies to protect them from novel (new) strains, making them susceptible and increasing the risk of a pandemic. An explanation of differences between seasonal and pandemic flu is provided on .

Influenza B virus causes milder disease outbreaks, and they change or mutate at a slower rate. They are not categorized by subtypes but do have two lineages: Victoria and Yamagata (CDC, 2019o; Heymann, 2015). Influenza C virus is connected with only sporadic cases of milder respiratory disease (Heymann, 2015). Influenza D viruses do not cause illness in people but do affect cattle (CDC, 2019o).

Influenza is usually seasonal in nature, occurring in the winter months, but may be found year-round if testing is done. Each year, a vaccine is developed to prepare for the upcoming flu season. The strains used in the vaccine are based on those the WHO identifies through ongoing surveillance as currently circulating around the globe (CDC, 2019o; Heymann, 2015).

Influenza, an Italian word that means influence of the cold, has been recognized since 412 BC and was first described by Hippocrates (Heymann, 2015). It existed throughout the early centuries, and about 30 probable pandemics have been documented in the past 400 years. Three have occurred in the 20th century: in 1918, 1957, and 1968. The 1918 “Spanish flu” pandemic was the most devastating, with 20% to 40% of the world population affected and an estimated death toll of 50 million worldwide; in the United States, roughly 675,000 died (CDC, 2018d). The last pandemic occurred in 2009, when the novel strain, H1N1, emerged with infection rates

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ranging from 43 million to 89 million people and deaths from 8,868 to 18,306 (CDC, 2018d, 2019n) in the US.

C/PHN play a major role in primary prevention. Universal immunization is recommended for all people 6 months of age and older. “Immunization is the process whereby a person is made immune or resistant to an infectious disease, typically by administration of a vaccine” (WHO, 2020f, para. 1). In the elderly, immunization may be less effective in preventing illness but is still important because it may reduce the severity of disease. With immunization, the incidence of complications and death among the elderly is reduced. Children younger than 6 months cannot receive the flu vaccine, so they need to be protected by immunization of the individuals surrounding them. It is important that C/PHNs promote immunization of those who may have the poorest of outcomes and their caretakers, which include (CDC, 2018e, 2018f, 2020b):

Health care workers and personal care providers Children younger than 5 years, but especially those younger than 2 years, as they have the highest rate of infection Adults 65 years and older, as they account for 90% of deaths related to influenza and pneumonia Pregnant women Individuals with asthma Those with chronic disease of any organ system or on long-term medication for an illness

The injectable influenza vaccine is inactivated. The nasally inhaled version is a live attenuated vaccine and is licensed for use in people ages 2 to 49 years (Heymann, 2015). An adjuvanted and high-dose inactivated vaccine is recommended for those 65 years of age and older, whereas adults 18 to 64 years may receive a recombinant influenza (RIV) vaccine (CDC, 2019o; Fig. 8-3). The vaccine should be given every year before influenza is expected in the community. The season can begin as early as October, so vaccinating in September may be indicated, but usually it begins by the end of October in most of the United States. For those living or traveling outside the United States, timing of the immunization should be based on the seasonal patterns of influenza in the area to which they are traveling (Heymann, 2015). Influenza immunization clinics are frequently planned and organized by or with the local public health agency, with the injections usually administered by C/PHN. Flu shots are also available through major pharmacies.

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FIGURE 8-3 Administration of nasal spray flu vaccine. (Reprinted from Centers for Disease Control and Prevention. Public Health Image Library. Photo Image ID no. 11864—James Gathany.)

The 2009 H1N1 pandemic provides an example of the emergency response to a pandemic event. On April 15, 2009, the first case of H1N1 strain influenza was diagnosed in the United States. Ongoing cases of this novel strain were being reported across the United States and around the world into the summer of 2010. There was a rapid response by the WHO and the CDC in investigating, typing the strain, and initiating the production of a vaccine. Vaccine production began by April 21, and on April 26, the federal government declared a public health emergency (CDC, 2019j). Within 6 months, a monovalent (single-strain) vaccine was available to the public. Eighty million doses were administered during that first season, which minimized the impact of this pandemic event (CDC, 2019j). The pandemic response to COVID-19 has been much slower with testing and vaccine development, because this is a novel coronavirus with community spread by asymptomatic as well as symptomatic individuals (Johns Hopkins University of Medicine, 2020).

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The WHO's Global Influenza Surveillance and Response System (GISRS) program began in 1952 and now involves 144 institutions from 114 WHO member states. The mission of GISRS is to protect the world from the threat of influenza (WHO, n.d.).

FluNet is an Internet-based tool for worldwide influenza surveillance. This program allows for the electronic submission of influenza data from participating global laboratories. Real-time data can be accessed through this resource. As new data arrive and are verified, the maps and tables are revised to give users an up-to-date overview of the influenza situation. Data are provided remotely through the GISRS, the WHO regional databases, and other designated laboratories. Only designated users can submit data, but the results—graphics, maps, and tables of influenza activity on a global scale— are available to the general public. FluNet has expedited the sharing of information on influenza patterns and virus strains and is becoming an essential tool in preparing for and preventing influenza pandemics. Collaborating national influenza centers in 112 countries have created a task force of influenza experts to develop a plan for the global management and control of influenza pandemics (WHO, 2020d). Real-time surveillance is provided by self-report on the app Flu Near You, in the United States, and Flusurvey in the United Kingdom (Heymann, 2017; Polansky, Outin- Blenman, & Moen, 2016). See more on global disease surveillance in Chapter 16.

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Pneumonia Pneumonia is a pulmonary infection that causes inflammation of the lobes of the lungs, bronchial tree, or interstitial space. People most susceptible to pneumonia are infants, the elderly, and people with a history of chronic diseases, a compromised immune system, or any condition affecting the anatomic or physiologic integrity of the lower respiratory tract. Malnutrition and smoking also increase risk (Heymann, 2015; MedlinePlus, 2020).

Key facts:

Routes of transmission: droplet, direct oral contact, fomites (inanimate objects freshly soiled with respiratory discharges) Most common bacterial cause in the United States: Streptococcus pneumoniae (pneumococcus) Most common viral causes: influenza, parainfluenza, and respiratory syncytial viruses Symptoms: sudden onset with a shaking chill, fever, pleural pain, dyspnea, a productive cough of “rusty” sputum, and tachypnea Symptoms in older adults: less abrupt, including fever, shortness of breath, altered mental status Symptoms in infants and young children: initially, fever, vomiting, and convulsions Diagnosis: may require confirmation by radiographic studies (Heymann, 2015; MedlinePlus, 2020)

Community-acquired pneumonia is a significant cause of morbidity and mortality. The incidence of pneumonia is highest in winter. An increased incidence of pneumonia often accompanies epidemics of influenza. In the United States and Europe, morbidity rates range from 30 to 100 cases per 100,000 adults. Incidences are higher among people living in poverty or who have poor nutrition. Case fatality rates of pneumococcal pneumonia range from 5% to 35% and are 10% for children living in developing countries. Children under the age of 6 months who live in developing countries have a 60% fatality rate. Globally, pneumonia kills more than one and a half million children younger than 5 years of age each year. This is greater than the number of deaths from any other infectious disease, including AIDS, malaria, and TB (Heymann, 2015). Hospital admissions and mortality related to pneumonia are far more common among people older than age 65; the mortality rate is approximately 50%. Although this is not a reportable infectious disease, it can nevertheless have a great impact upon the community (Heymann, 2015).

Two vaccines are available to help protect against pneumonia. The pneumococcal protein–polysaccharide conjugate vaccine protects against 13

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of the most common pneumonia serotypes and is included as part of the routine vaccination schedule for infants. The 23-valent pneumococcal polysaccharide vaccine is available for those in high-risk groups who are 2 years or older, with the following recommendations:

High-risk groups: those with chronic diseases, immunosuppressing health conditions, or asplenia Reimmunization: recommended only for high-risk children or adults older than 65 years who received their first vaccine before age 65 and at least 5 years has passed since the previous vaccine Not effective in children younger than 2 years Not recommended for the healthy population between the ages of 2 and 65 years

For people who are not in a high-risk group, education about preventing pneumonia is a major part of the C/PHN role (Heymann, 2015).

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Hepatitis Of the five viral hepatitis infections that constitute serious liver disease, the three most commonly reported types are hepatitis A, B, and C. Infection with hepatitis is an ongoing global epidemic. Substantial progress is being made in the elimination of hepatitis viruses through the primary prevention practices of education and immunization with hepatitis A and B vaccines.

Hepatitis A Hepatitis A is caused by infection with the hepatitis A virus (HAV). It occurs worldwide and is sporadic and epidemic, with cyclic recurrences affecting children and young adults most frequently. Case rates are highest in areas with poor sanitation, which include Central and South America, the Caribbean, Mexico, Asia (except Japan), Africa, and southern and eastern Europe (Heymann, 2015).

Key facts:

Route of transmission: fecal–oral (person to person), with an incubation period of 28 days Risk factor: occupation as a food handlers or health care worker, due to increased risk of transmission (National Institutes of Health [NIH], 2019) Onset: 15 to 50 days after exposure to the virus Symptoms: abrupt, including fever, malaise, anorexia, nausea, abdominal discomfort, jaundice Symptoms in children: often asymptomatic Prognosis: self-limiting; does not result in chronic infection or chronic liver disease Duration: mild, 1 to 2 weeks; more severe, 1 month or longer Diagnosis: by the presence of immunoglobulin M antibodies against HAV in the serum of acutely or recently ill individuals Immunity: usually conferred by recovery from HAV Reporting: mandated for providers on diagnosis to the local health agency (Heymann, 2015; Mayo Clinic, 2020)

In areas of the world where environmental sanitation conditions are poor, endemic infection may exist and cause infection at an early age. In this setting, most adults have immunity due to previous exposure. In industrialized countries, cases tend to occur in the older population rather than children, in households of the infected, and among travelers returning from countries where the disease is endemic. At times, common-source outbreaks are related to contaminated water, food contaminated by infected

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food handlers, raw or undercooked shellfish harvested from contaminated water, or contaminated produce. Outbreaks of hepatitis A may warrant mass vaccination outreach with the hepatitis A vaccine or immunoglobulin (Heymann, 2015; USDA, 2015).

An inactivated hepatitis A vaccine has been available for use since 1995 (Hamborsky, Kroeger, & Wolfe, 2015; NIH, 2019). Administered in a two- dose series, these vaccines induce protective antibody levels in virtually all who are immunized. Ninety-five percent of immunized adults develop immunity after the first dose, and nearly 100% seroconvert after the second dose (CDC, 2015d). The vaccine is recommended as a routine vaccine for children and, as of 2005, was made available to children older than 12 months. C/PHN play an important role in the prevention and control of this disease. Vital to preventing and controlling this disease are offering hepatitis A vaccine to travelers, conducting case investigations, providing education, and identifying potential sources and exposed contacts who need referral or assistance in obtaining postexposure prophylaxis (PEP) and vaccination (CDC, 2016f; Hamborsky et al., 2015; NIH, 2019).

Hepatitis B Hepatitis B is both an acute and chronic serious disease and is a global problem. Approximately 257 million people are living with hepatitis B virus (HBV). Approximately 800,000 people die each year due to complications related to HBV (WHO, 2018d). Rates are highest in China, Southeast Asia, most of Africa, most of the Pacific Islands, parts of the Middle East, and in the Amazon basin (CDC, 2020f; WHO, 2019a).

Key facts:

Route of transmission: percutaneous or mucosal exposure to infected blood or body fluids (CDC, 2020f) Prognosis: a lifelong chronic infection (rarely resolving), possibly causing cirrhosis (scarring) of the liver, liver cancer, liver failure, and death (Heymann, 2015; NIH, 2017) Symptoms: range from unnoticeable to fulminating, including anorexia, fatigue, vague abdominal discomfort in the right upper quadrant, nausea and vomiting, light or gray stools, dark urine, fever, arthralgia, arthritis, and rash, often progressing to jaundice (Hamborsky et al., 2015; NIH, 2017) Symptoms in infants: rare Occurrence of jaundice: <10% of children and only 30% to 50% of adults (CDC, 2020f) Diagnosis: confirmed by the presence of specific antigens to HBV in serum (Heymann, 2015)

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Immunization is the most effective way of preventing HBV transmission. The hepatitis B vaccine has been available in the United States since 1981. Since then, rates of HBV infection in the United States have declined by 75% (CDC, 2020f). Almost all infections would be prevented if hepatitis B vaccines were administered to all newborns and infants (Heymann, 2015). After receiving the recommended three doses of vaccine, 95% of infants and children develop immunity, whereas only 90% of adults become immune. By age 65 years, only 75% become immune (CDC, 2020f). Infants born to HBV carrier mothers are at an extremely high risk for developing hepatitis B. Receiving the hepatitis B vaccination and one dose of hepatitis B immunoglobulin within 24 hours after birth in combination with completing the three-dose series at 1 to 2 months and at 6 months of age is 85% to 95% effective (CDC, 2020f). C/PHN have an important role in the prevention and control of hepatitis B by encouraging immunization compliance, particularly following up on immunization of infants born to mothers with chronic HBV status, and consistent adherence to universal precautions, especially for people in high-risk lifestyles or occupations.

Hepatitis C Hepatitis C virus (HCV) causes a complex infection of the liver and is one of the leading-known causes of liver disease in the United States. It was formerly known as hepatitis, non-A, non-B (NIH, 2016). Seventy-five to eighty-five percent of people with acute HCV develop chronic disease (Heymann, 2015). WHO estimates that in 2015, 71 million persons were living with chronic hepatitis C infection worldwide (WHO, 2018b). The Global Health Sector Strategy is to eliminate viral hepatitis as a public health threat by 2030, but funding is the “major hurdle” (Waheed, Siddiq, Jamil, & Najmi, 2018, p. 4959).

Key facts:

Route of transmission (most common): direct contact with infected blood via shared intravenous needles, reuse or inadequate sterilization of medical equipment, or transfusion of unscreened blood or blood products (WHO, 2018b) Routes of transmission (less common): direct contact with infected blood via tattooing; sexual contact; and vertical (from infected mother to infant) Symptoms: similar to those of hepatitis A and B; 80% are asymptomatic after initial infection (WHO, 2018b) Diagnosis: confirmed by the presence of HCV antibody (WHO, 2018b) Treatment: may not be required if immune response clears infection or chronic infection does not result in liver damage (WHO, 2018b, 2019b)

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Testing is recommended for those individuals at greater risk for HCV infection, as acute HCV infection is usually asymptomatic. These include:

People who have injected drugs, even if only once People who received transfusions or organ transplants before 1992 or blood from a positive donor People who received clotting factors before 1987, are undergoing chronic hemodialysis, or have persistently elevated alanine aminotransferase levels People diagnosed with HIV/AIDS People with symptoms of liver disease People exposed to HCV-positive sources, such as through needle sticks, sharps, or mucosal exposures People who are HIV positive Children born to HCV-positive mothers; testing should be done after the child is 18 months old to avoid detecting the mother's antibodies (CDC, 2020g, 2020h)

There is currently no vaccine for HCV. When treatment for chronic hepatitis C is required, the goal is to cure, and the success rate depends on the strain of the virus and the type of treatment given. Treatment is rapidly changing with the introduction of direct-acting antivirals (DAA) like Vosevi® (sofosbuvir/velpatasvir/voxilaprevir) that can be administered to all regardless of genotyping, advancement of disease, or prior failed DAA treatment (WHO, 2018d). Another treatment drug, glecaprevir/pibrentasvir (Mavyrett™), is administered for 8 weeks, thus increasing the chance for compliance and decrease of overall cost of treatment. DAA medications have a >90% cure rate for most patients (Alkhouri, Lawitz, & Poordad, 2017). Protease and polymerase inhibitors, which are also effective, work by blocking the needed physiological processes the virus requires (Healthline, 2020).

The C/PHN's role is primarily supportive, encouraging testing for people who identified as having HCV infection risk factors, referring individuals for care and treatment and to support/educational groups, and encouraging adherence to standard precautions in the home (CDC, 2020g; WHO, 2018b).

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HIV/AIDS HIV is a retrovirus that attacks the body's immune system. HIV is a global health issue affecting 37.9 million people at the end of 2018, with more than half of new HIV infections among individuals and their sexual partners within the following groups: injection drug users, transgender, men having sex with men, sex workers and clients, and those living in prisons/closed facilities. About 95% of this increase is found in central Asian, eastern European, north African, and Middle Eastern countries (WHO, 2019c).

Key facts:

Routes of transmission: direct contact with infected blood and body fluids via unprotected sex, sharing of needles, placental transmission from mother to fetus, or transfusion (WHO, 2019) Diagnosis: rapid diagnostic tests (RDTs), which can indicate the presence of HIV antibodies as early as 1 month after exposure (CDC, 2019e; WHO, 2019c) Symptoms (initial): none to flulike Symptoms (later): swollen lymph nodes, weight loss, diarrhea fever, and cough (WHO, 2019) Risk factors: having unprotected anal or vaginal sex; having another STI; sharing contaminated needles, syringes, or drug solution; using contaminated unsterile cutting or piercing equipment; and having an accidental needle stick injury, particularly among health workers. Transmission is through blood, semen/vaginal secretions, and breast milk/mother to baby (CDC, 2019e; WHO, 2019c). Prognosis: without treatment, AIDS can develop in 2 to 15 years after infection (WHO, 2019c)

Although there is no cure for HIV/AIDS, HIV infection is now treated with antiretroviral therapy (ART), which can reduce the viral load to the point that it is undetectable, thus reducing the risk of transmission of the virus by 96% (CDC, 2019f; WHO, 2019c). Antiretroviral (ARV) drugs are also being used for prevention of HIV. Preexposure prophylaxis (PrEP) drugs (e.g., ARVs) reduce the risk of infection by an HIV-negative partner when taken regularly. PEP is ART medication that is taken only in an emergency situation and within 72 hours after possible exposure to HIV (CDC, 2019f, 2019p; WHO, 2019c).

Acquired Immune Deficiency Syndrome (AIDS) is a severe, life- threatening condition, representing the late clinical stage of infection with HIV, in which there is progressive damage to the immune and other organ systems—particularly the central nervous system. AIDS has been delayed or deferred in many individuals by the use of medications during the HIV stage

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of the spectrum. AIDS reporting is obligatory in most countries (Heymann, 2015).

C/PHN interventions may include education about risk reduction behaviors for those who are at risk but not yet infected. For those who are infected, C/PHNs can provide education about treatment, noting that with early initiation of appropriate treatment, a person with HIV can expect to live almost as long as an uninfected person. Nurses can also play a role in promoting good health for those who are infected, helping them access care, and advising them on how to prevent transmitting the virus to others (CDC, 2019f).

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Tuberculosis TB is a disease primarily of the lungs and larynx, caused by the Mycobacterium tuberculosis (MTB) complex, M. africanum, M. tuberculosis, and M. canettii. These are all Gram-positive bacilli.

Key facts:

Routes of transmission: airborne and spread of droplet nuclei (e.g., via coughing, sneezing, laughing, yelling, singing), in which one inhales the bacilli exhaled by a person with viable TB bacilli in the sputum Sites of infection: apex of the lung (most common), kidney, brain, bone, lymphatic channels (Parmer, Allen, & Walton, 2017) Process: two basic stages, latent and active; classification according to symptoms (Table 8-2) Communicability: depends on duration of the exposure with the infected person as well as the proximity or closeness and ventilation within the space where the exposure occurred Incubation period: approximately 10 to 12 weeks (Heymann, 2015)

TABLE 8-2 Classification System for Tuberculosis

Reprinted from Centers for Disease Control and Prevention. (2013). Core curriculum on tuberculosis: What the clinician should know (6th ed.). Retrieved from http://www.cdc.gov/tb/education/corecurr/pdf/chapter2.pdf

Most individuals exposed to people with TB do not become infected. Of those who do, all but about 5% to 10% remain disease free. The remaining 90% harbor the organism in a latent stage; although not infectious, they represent a persistent pool of potential cases in a population (Heymann, 2015). Health factors such as poor nutrition or health status and chronic illness, such as diabetes, can inhibit the immune system's ability to prevent

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TB activation from the latent TB dormant state (Heymann, 2015). Figure 8-4 shows the geographic distribution of TB in the United States.

FIGURE 8-4 Reported tuberculosis (TB) case rates by states, United States, 2018. (Reprinted from Centers for Disease Control and Prevention [CDC]. (June 6, 2019). Tuberculosis in the United States, 1993-2018. National Tuberculosis Surveillance System (p. 5). Atlanta, GA: US Department of Health and Human Services. Retrieved from https://www.cdc.gov/tb/statistics/reports/2017/2017_Surveillance_ FullReport.pdf)

Once almost eradicated, TB has reemerged as a serious public health problem, with around one quarter of the world's population being infected with latent TB (WHO, 2020c). A total of 10 million cases of active TB were noted in 2018, and there were 1.5 billion deaths. TB is one of the ten leading causes of death globally (WHO, 2020h). The majority of new TB cases in 2018 (87%) were found in “high burden TB countries” (WHO, 2019d, para. 4). About 66% of these came from India, Pakistan, Bangladesh, China, Indonesia, the Philippines, South Africa, and Nigeria. The United States had a rate of 2.7 TB cases per 100,000 people in 2019. There are sharply disparate rates among racial/ethnic minority populations. In the United States, 87% of the reported TB cases in 2015 were among Hispanic, Black, and Asian individuals. In 2018, over 70% of reported TB cases were among individuals born outside the United States. Four states—California, Texas, New York, and Florida—reported 50.5% of the cases (CDC, 2019n).

The WHO describes global TB burden in three categories: TB, multidrug-resistant TB, and TB with HIV coinfection. HIV infection contributes dramatically to the development of active TB and is the leading

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killer of HIV-positive people (WHO, 2019d, 2020c). It is critical to rule out active disease before treating a person with HIV/AIDS for latent TB infection to reduce the risk of developing drug-resistant TB (CDC, 2014, 2020i; Heymann, 2015).

Screening TB infection can be detected by screening through either a skin test or blood testing. The tests can only be used to identify a person who has been infected at some point; they do not differentiate between latent and active disease.

The Mantoux tuberculin skin test (TST) can detect whether a person is infected with M. tuberculosis 2 to 8 weeks after infection (CDC, 2014). Using the Mantoux technique, the nurse injects 0.1 mL of 5 TU of purified protein derivative (PPD) solution via the intradermal route. The nurse must conduct the reading within 48 to 72 hours after the test was administered. Interpretation of the results is based on measurement of induration and recorded in millimeters. Induration is described as the raised, hard area (redness is not considered part of the reaction). Results are considered positive based on various factors (CDC, 2016h). See Figure 8-5 and Table 8- 3 for information on the correct administration, reading, and interpretation of TB skin tests.

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FIGURE 8-5 Mantoux tuberculin skin test. A: Inject 0.1 mL of purified protein derivative (5 tuberculin units) into the forearm between skin layers, producing a wheal (raised area) of 6 to 10 mm in diameter. B: After 48 to 72 hours, assess the reaction, measuring the diameter of the induration (not the area of redness surrounding the induration) across the forearm in millimeters.

TABLE 8-3 Interpreting the Mantoux Tuberculin Skin Test Reaction

Reprinted from Centers for Disease Control and Prevention. (2013). Core curriculum on tuberculosis: What the clinician should know (6th ed.). Retrieved from http://www.cdc.gov/tb/education/corecurr/pdf/chapter3.pdf

Special considerations: Nurses should not administer the TST to individuals who report a previous positive TST. The bacille Calmette-Guerin (BCG) vaccine, used in TB-endemic countries to protect infants and young

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children from life-threatening TB illness, may cause a reaction to the TST. The effect of BCG often wanes over time; however, repeated TSTs may boost the reactivity in a BCG-vaccinated person. The results should be interpreted based on risk stratification regardless of BCG history. Two-step TST testing may help to identify an infected person who might otherwise not be detected owing to a waning immune response because too much time had lapsed since a previous TST. The two-step approach allows the immune system to wake up and respond using a booster effect (CDC, 2014). The second test may be a blood test rather than another skin test (Lewinsohn et al., 2017).

Two different blood tests for interferon gamma release assays (IGRAs), the QuantiFERON test and the T-spot test, detect the immune response to TB proteins in the blood (CDC, 2016b).

Advantages of using an IGRA (CDC, 2016f, para. 5):

Necessitates only one visit to be tested Allows a 24-hour turnaround time on results Does not boost responses measured by subsequent tests Is not affected by a health care provider's interpretation of the results Causes no false-positive results from past immunization with BCG vaccine

Disadvantages and limitations of using an IGRA (para. 6):

Requires the blood sample to be processed within 8 to 30 hours after collection Can be less accurate due to errors in collecting or transporting the blood specimens or in running and interpreting the assay Lacks data supporting its use to predict who will progress to TB disease in the future Lacks data supporting its use for:

Children younger than 5 years Persons who were recently exposed to M. tuberculosis Immunocompromised persons People requiring serial testing

May be expensive

IGRAs are preferred for people who are not likely to return for reading of TST and people who have a history of receiving BCG vaccine. The TST is preferred for children under the age of 5 years (CDC, 2016b, 2020b).

Diagnosis of Active TB

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Diagnosis of suspected active TB disease is initially based on the presence of acid-fast bacilli in the sputum. Confirmation is determined by a culture that reveals MTB. The culture test also provides information about drug susceptibility that informs the decisions for treatment (CDC, 2016a, 2016h; Heymann, 2015). The nurse should conduct a full examination, including obtaining a chest x-ray and reviewing the person's history of risk factors and symptoms.

Prevention and Intervention The C/PHN can apply all three levels of prevention when working with clients with TB. According to the CDC Division of TB Elimination (CDC, n.d., 2016d), a well-functioning TB control program must focus resources on those at risk for TB exposure and treating those with latent or active TB.

The U.S. Preventive Services Task Force (USPSTF) issued new recommended guidelines (the first since 1996) on offering testing and treatment for latent TB infection, as outlined in Table 8-4 (USPSTF, 2016). The recommendations for C/PHNs are to increase surveillance and take every opportunity to educate and encourage at-risk patients to get tested or seek treatment. Above all it is crucial for C/PHNs to work closely with local and state TB control programs to learn about at-risk populations in their community (CDC, 2016c, 2018i; Parmer et al., 2017).

TABLE 8-4 Screening for Latent Tuberculosis Infection in Adults

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services. For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, please go to www.uspreventiveservicestaskforce.org.

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CDC, Centers for Disease Control and Prevention; USPSTF, U.S. Preventive Services Task Force (September 6, 2016). Reprinted from https://www.uspreventiveservicestaskforce.org/Page/Document/ClinicalSummaryFinal/latent- tuberculosis-infection-screening

Isoniazid therapy for individuals who are infected with TB but have no evidence of active disease has been shown to be highly effective in preventing progression to infectiousness and clinical symptoms. Isoniazid INH is a key component of the treatment for active disease (CDC, 2020i, 2020n; Heymann, 2015).

When candidates for drug therapy are identified, it is essential to provide program support to ensure that the maximum number of individuals comply with their medication regimen for the full duration of therapy. One of the most effective ways to achieve a high completion-of-therapy rate is through directly observed treatment (DOT). One variation of DOT is eDOT, which involves recording the patient taking the medication at home and review by trained staff. The eDOT method has a higher completion rate and is preferred over DOT as it costs 32% less than DOT (Garfein et al., 2018). eDOT and DOT are a public health strategy of delivering TB treatment and offer the benefits of timely completion of treatment, prevention of drug resistance, and prevention of further transmission (California Department of Public Health 2019). The DOT strategies have been demonstrated to work when they are implemented universally with all active TB patients within the county, and it is supported by the CDC and, in turn, by state and local health departments. It is not mandatory, but health officers may use the laws surrounding TB prevention and public protection to institute policy and statute to mandate its use. By using DOT with the client with active TB, providers can reduce ongoing potential sources of infection in the community (CDC, 2019; Zhang, Ehiri, Yang, Tan, & Li, 2016).

It is important to assess the patient to see what form of DOT therapy would work the best. The more difficult clients, such as alcohol and drug users, transient homeless people, and people stressed by socioeconomic problems, may benefit from DOT therapy, as it ensures that patients are often met where they are located (school, shelter, bar, or job). Implementation of an eDOTS program requires input from information technology and legal representatives to ensure that it complies with both state and federal laws and that clients' HIPAA rights are protected (CDC, 2019).

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Multidrug-Resistant TB Epidemiologists and communicable disease specialists cite a number of factors that contribute to the development and spread of TB strains resistant to one or more of the standard TB drugs. Strains now exist that are resistant to almost all of the standard anti-TB drugs and according to the WHO, one in four persons contracting extensively drug-resistant TB (XDRTB) dies rapidly, within months from the disease. Chief among the factors contributing to drug resistance seems to be the political and social response to declining rates of TB over past decades, which has resulted in funding cuts for surveillance, treatment, and research and a premature sense that TB was defeated. On an individual case basis, the most common means by which resistant organisms are acquired is by noncompliance with therapy for the full, recommended period (WHO, 2018d, 2020c). Figure 8-6 compares MDRTB rates among people born in the United States and those born in other countries now living in the United States.

FIGURE 8-6 Multidrug-resistant tuberculosis patterns: comparison of U.S.-born and non–U.S.-born persons, 1993 to 2017. (Reprinted from Centers for Disease Control and Prevention (CDC). (2018). Reported tuberculosis in the United States, 2017 (p. 119). Atlanta, GA: US Department of Health and Human Services, CDC. Retrieved from https://www.cdc.gov/tb/statistics/reports/2017/2017_Surveillance_ FullReport.pdf)

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Clients With HIV and TB HIV infection is associated with an increased possibility of developing primary TB after exposure to a source. The person living with coinfection of latent TB infection and HIV infection has a 50% higher risk of developing active TB than the immunocompetent individual (Heymann, 2015).

The HIV-positive client may not have the ability to react to a skin test for TB because of a weakened immune system. Therefore, other methods to determine TB status are employed. People with HIV infection and TB infection should be counseled about the benefit of preventive treatment and possibility of TB activation without treatment. These clients must be monitored closely for effectiveness of the preventive therapy and for tolerance to isoniazid. This drug has the capacity to develop adverse reactions or negative side effects such as hepatitis or damage to the liver, and regular follow-ups are necessary to detect early symptoms such as nausea, vomiting, abdominal pain, fatigue, and dark urine signifying bleeding are sufficient to initiate liver function tests (CDC, 2020l; Heymann, 2015).

If it is determined that TB disease is present, HIV-infected clients should begin a regimen of drugs according to the accepted national and global medication schedule used in their country. The client should be closely monitored for response to treatment; if they do not seem to be responding, they should be reevaluated. Drug sensitivity is key to correct and successful treatment (USDHHS, 2019).

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TB Case Management The functional aspect of the program should ideally strive for (CDC, n.d.):

Standardized public health practices for investigating, case and contact finding, as well as care and treatment. Case management of care and treatment of the individual with TB to ensure medication compliance and barriers to treatment completion are dealt with so treatment completion will occur. Close monitoring for sputum conversion in people with active disease, in order to adjust medication as necessary. A high completion-of-therapy rate within 1 year after diagnosis. Assurance of adequate funding and a dedicated TB control infrastructure.

C/PHNs have a responsibility to build a relationship of trust with individuals who have TB or latent TB infection which leads to seeking and adhering to treatment. It is also important to monitor for overall health and well-being, educating, and making referrals (CDC, 2016f; Parmer et al., 2017).

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Sexually Transmitted Infections

Chlamydia Chlamydia trachomatis (CT) infections are the most commonly reported notifiable STI in the United States (CDC, 2019b). In 2018, more than 1.8 million cases of Chlamydia were reported in the United States, with the highest proportion found in those ages 20 to 24. Disparities exist, resulting in infection rates among Black individuals that are 5.6 times higher than the rates of White individuals, even though between 2014 and 2018, there was a 17.6% increase in cases for Whites (CDC, 2019b).

Key Facts:

Route of transmission: sexual contact and maternal transmission to a newborn (CDC, 2019b) Symptoms: often asymptomatic, resulting in a greater risk for going undetected, resulting in serious complications:

Pelvic inflammatory disease (PID) Fallopian tube issues, including ectopic pregnancy and infertility Chronic pain in the pelvis (CDC, 2019b) Preterm delivery or complications for the newborn, including conjunctivitis or pneumonia (CDC, 2019b)

Diagnosis: highly sensitive nucleic acid amplification urine tests (CDC, 2019b) Treatment: either a 7-day treatment with the antibiotics azithromycin, doxycycline, levofloxacin, ofloxacin, and erythromycin or a single dose of antibiotic followed by 7 days abstaining from sexual activity Barriers to successful treatment:

Noncompliance with the 7-day treatment with antibiotics or abstaining from sex Stigma, costs of care, and treatment Side effects of medication, such as gastric upset for erythromycin Not treating infection of partner at the same time Not following up with retesting if patient did not adhere to treatment guidelines (CDC, 2019b)

Recommended screening guidelines: Yearly for all women who are sexually active and 25 years or younger For women older than 25 years who have a new sexual partner or multiple partners or a partner who has been diagnosed with an STI All pregnant women at their first obstetrical visit

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For men who have sex with men in settings with high rates of CT infection

Screening programs have been extremely effective in reducing the overall Chlamydia burden and reducing rates of PID in women (CDC, 2019b). As a result of increased screening efforts in many settings outside of the medical office, reported rates of Chlamydia continue to increase, especially in women aged 15 to 24 years (Fig. 8-7).

FIGURE 8-7 Chlamydia: rates of reported cases by age group and sex, United States, 2018. (Reprinted from Centers for Disease Control and Prevention. (September 30, 2019). Sexually transmitted disease surveillance 2018: Chlamydia. Retrieved from https://www.cdc.gov/std/stats17/figures/5.htm)

STI notification depends on the state health department, as some health departments use the Internet to anonymously notify partners of possible exposure to an STI, whereas others use patient-delivered partner treatment or expedited partner treatment (EPT; CDC, 2015d, 2019b). EPT treatment strategy is to give a prescription or medication to the infected patients to, in turn, give to their sex partners. This intervention has been shown to be more effective than encouraging the patient to notify the partner(s) to seek testing and treatment. Each state may have its own legal requirements related to this treatment option; nurses must review and understand their states' law (CDC, 2015d). With EPT, it is important to provide very specific written instructions that include self-administration of the medication, warnings about pregnancy and allergic reactions, when to seek medical care, and how to prevent reinfection. However, for men who have sex with men, this practice is not as customary, as there may be other coinfection issues needing

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evaluation and treatment, such as Haemophilus influenzae type b infection (CDC, 2015d).

Gonorrhea The causative agent of gonorrhea is the gonococcus bacteria—Neisseria gonorrhoeae. Gonorrhea is the second-most commonly reported notifiable disease in the United States, with 583,405 cases reported in 2018, although it is estimated that there are 1.4 million new gonorrheal infections yearly (CDC, 2019d). About half of the cases each year are among people 15 to 44 years old. Compared with the rate of reported cases of gonorrhea among Whites, the rate was 7.7 times higher in Blacks, 4.6 times higher in American Indian/Alaska Natives, 2.6 times higher in Native Hawaiians and other Pacific Islanders, and 1.6 times higher in Hispanics (CDC, 2019d).

Key facts:

Route of transmission: sexual contact and maternal transmission Symptoms (men): purulent drainage from the penis, accompanied by painful urination within 2 to 7 days after an infecting exposure Symptoms (women): asymptomatic; mild vaginal discharge or bleeding after intercourse (Heymann, 2015) Complications (women): if untreated, PID, infertility, or ectopic pregnancy Complications (dissemination): petechial or pustular lesions, requiring hospitalization for treatment and evaluation for complications such as endocarditis and meningitis Screening criteria: similar to those of Chlamydia; refer back to previous section on Chlamydia (CDC, 2015d, 2019b)

Antimicrobial resistance is a great concern when treating gonorrhea. In 2010, concerns over emerging resistant gonorrhea prompted the CDC to recommend dual therapy, combining cephalosporin with azithromycin or doxycycline. Resistance to cefixime, a third-generation cephalosporin, appeared in Asia, Europe, South Africa, and Canada, causing further changes in dual treatment guidelines advising the exclusive use of ceftriaxone and azithromycin (CDC, 2019b). Gonorrhea transmitted to neonates during delivery presents 2 to 5 days after delivery. This can result in ophthalmia neonatorum and sepsis. As a result, most states have a law that requires a prophylactic agent be given to all infants after delivery. Treatment during pregnancy is the best way to prevent gonorrhea infection in the newborn (CDC, 2019b).

Sex partners should be referred to a medical provider for testing and treatment, but if this is not possible, EPT can be used. This is not the preferred partner treatment course for men who have sex with other men

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owing to concerns of coexisting STD infection including HIV (CDC, 2015d). Once again, it is best to refer to your state's regulations regarding this method of treatment.

Syphilis Syphilis is a systemic infection caused by the spirochete Treponema pallidum. Prior to 2014, the incidence rate of syphilis had been decreasing, but starting in 2014, the incidence rate has been increasing. In 2018, reported cases of all stages of syphilis increased by 13.3% from 2017 (CDC, 2019m). Increased incidence has been seen among men who have sex with men and women. The highest rates of primary and secondary syphilis infections in 2018 occurred in the age range of 25 to 29 years for both men and women, with 55.7 cases per 100,000 for men and 10 cases per 100,00 for women ages 20 to 24 (CDC, 2019m). The incidence rate of congenital syphilis also increased 39.7% from 2017 to 2018. Past historical data indicate a correlation between primary and secondary syphilis infectious rates of women in their reproductive years (CDC, 2019m).

Key facts:

Routes of transmission: direct contact with a lesion; blood transfusion during the primary or secondary stage of the disease; maternal transmission (CDC, 2017g; Heymann, 2015) Process: Four distinct stages:

1. Primary: A primary lesion called a chancre appears as a painless ulcer at the site where the infection entered the body, lasts 3 to 6 weeks, and heals regardless of medical treatment.

2. Secondary: After 4 to 6 weeks, a more generalized secondary macular- to-papulosquamous skin eruption develops, classically appearing on the soles of the feet, palms of the hands, and trunk, often accompanied by fever, sore throat, lymphadenopathy, and fatigue. These secondary manifestations can resolve spontaneously within weeks or may persist up to 12 months.

3. Latent: By this phase, the spirochete has invaded the central nervous system but there may not be any signs or symptoms of infection for weeks to years.

4. Tertiary: One third of those infected who do not receive treatment progress to tertiary syphilis, associated with recurring lesions, severe systemic involvement, disability, abnormalities in the cerebral spinal fluid, deafness, meningitis, cranial nerve palsy, or even death (CDC, 2017g; Heymann, 2015).

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Complications (congenital syphilis): fetal death, premature birth, death of the newborn, failure to thrive, anemia, lesions, and central nervous system symptoms (CDC, 2017g; Heymann, 2015)

Penicillin is the treatment of choice for syphilis. The nurse should instruct patients to avoid sexual contact until the treatment is completed and the lesions have resolved and to encourage contacts to receive treatment. Contacts are defined as those with whom the patient had sex within the 3 months (for patients in the primary stage), 6 months (for patients in the secondary stage), or 1 year (for patients in the early latent stage) prior to the onset of symptoms or long-term sexual partners (for patients in the late latent stage (New York City Department of Health & STD Prevention Training Center, 2019). If an infant is diagnosed with congenital syphilis, all immediate family members should be treated. Anyone diagnosed with syphilis should also be evaluated for other STIs (Heymann, 2015).

Genital Herpes Genital herpes is an STI caused by the herpes simplex virus types 1 (HSV-1) and 2 (HSV-2) and is one of the most common STIs in the United States. Most genital herpes infections are caused by HSV-2; however, rates of HSV- 1 genital herpes are increasing among college students. HSV-1 is the virus that causes cold sores and spreads from the mouth to the genitals through oral sex. Most people with HSV-2 remain undiagnosed because of the symptoms being mild, causing the person to not recognize a need to seek medical care (CDC, 2017a).

Key facts:

Symptoms (initial): systemic, including fever and malaise, and bilateral lesions lasting 2 to 3 weeks on the cervix (women), external genitalia (men or women), or anus or rectum (those who engage in anal intercourse) (CDC, 2017a; Heymann, 2015) Symptoms (subsequent outbreaks): lesions in areas beyond the initial exposure site, which usually are unilateral, less severe, and less frequent and resolve more quickly than the primary lesion (Heymann, 2015) Diagnosis: by isolation of the virus, DNA detection through polymerase chain reaction (PCR) testing, or tests that detect HSV antigens, with viral isolates being typed to determine whether the infection is due to HSV-1 or HSV-2 (Heymann, 2015) Prognosis: there is no cure for HSV, and the infection can remain in the body indefinitely; however, antiviral medications can prevent or reduce the duration of an outbreak and can reduce the risk of transmission to uninfected sexual partners (CDC, 2015b, 2015d).

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If a pregnant woman becomes infected late in the pregnancy and has active lesions, delivery by cesarean section is often advised to reduce the risk of transmission to the neonate. Antiviral therapy can be given to the pregnant woman at 36 weeks of gestation to suppress the virus to help reduce the need for a cesarean section birth (Heymann, 2015).

Viral Warts Condylomata acuminata, verruca vulgaris, papilloma venereum, and the common wart are all forms of a viral disease caused by the human papillomavirus (HPV). More than 120 HPV types have been identified, at least 40 of which are sexually transmitted. HPV is a common STD, with most sexually active persons becoming infected with it at least once during their lifetime (CDC, 2015c, 2019c). It is estimated that around 79 million people in the United States have been infected with HPV; between 340,000 to 360,000 have genital warts. Yearly, over 34,800 men and women are diagnosed with some type of cancer caused by HPV (e.g., cervical, anal, oropharyngeal), but these are preventable with the HPV vaccine (Cameron et al., 2016; CDC, 2019g).

Key facts:

Routes of transmission: direct contact with fomites; sexual (skin-to- skin) contact; or transmission by a mother to a neonate during vaginal birth Process: incubation period of 2 to 3 months (Heymann, 2015) Symptoms: may include lesions on the skin or mucous membranes, including in the throat or respiratory tract (recurrent, respiratory papillomatosis) and in the genital region (condylomata acuminata, or genital warts); may include none (asymptomatic), with increased risk for lack of detection and diagnosis and ongoing transmission between or among sexual partners (CDC, 2019i; Heymann, 2015) Prevention: condoms are (not fully protective; CDC, 2019i) Prognosis: about 12,000 women are diagnosed with HPV-related cervical cancer each year, with oropharyngeal cancer being most common for men (CDC, 2019g) Vaccination: recommended for males and females against high-risk HPV (hrHPV) infection strains by the CDC, 2015e (Meites, Kempe, & Markowitz, 2016) as follows:

Routine vaccination is recommended for girls and boys at age 11 or 12 years.

Patients 9 to 14 years old: 2 doses, with 6 to 12 months between doses

Patients 15 to 26 years old: 3 doses, with at least 4 weeks between the first and second doses, 12 weeks between the second and third

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doses, and 5 months between the first and last doses Extended use of Gardasil-9 to the age of 45 years for males and females (as approved by the U.S. Food and Drug Administration [FDA], 2018)

The vaccine works best if given prior to being sexually active but can still be given to individuals already sexually active to protect against any hrHPV (high risk) strains they have not yet acquired. The National Cancer Institute (NCI) stresses the importance of increasing the numbers of people vaccinated “to reduce the prevalence of the vaccine-targeted HPV types in the population, thereby providing some protection for individuals who are not vaccinated” (NCI, 2019, para. 15).

There is currently no routine recommended screening test for HPV- associated diseases other than cervical cancer. The USPSTF (2018, para. 6) has issued the following recommendations for women 21 to 65 years of age, “regardless of sexual history, who have a cervix and show no signs or symptoms of cervical cancer”:

Women aged 21 to 29 years: cervical cytology screening alone every 3 years Women aged 30 to 65 years: cervical cytology screening alone every 3 years or hrHPV testing alone every 5 years or hrHPV testing in combination with cervical cytology screening (cotesting) every 5 years Women younger than 21 years: no screening recommended (USPSTF, 2018)

Treatment may include curettage, trichloroacetic acid, cryotherapy with liquid nitrogen, or surgical debulking for larger lesions. Patient-applied treatment may include immunomodulator creams or ointments, but topical treatments may not be appropriate for pregnant women (Heymann, 2015).

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Sexually Transmitted Infection Prevention and Control Minority populations, the poor, the medically underserved, and women and children, in general, experience a disproportionate amount of the STI burden (see Chapters 5 and 23). Women also have a higher risk of serious complications from STIs, including PID, sterility, ectopic pregnancy, and cancer associated with HPV. Children can also be affected by exposure to maternal STIs, resulting in fetal and infant death, birth defects, blindness, and intellectual disability. Undiagnosed and untreated STIs may play a role in infertility (CDC, 2019m). Nurses need to be involved in accomplishing the Healthy People 2030 goal of promoting healthy sexual behaviors, strengthening capacities within communities, and increasing access to quality services (ODPHP, 2020; see Chapter 21).

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Infectious Diseases of Bioterrorism The deliberate release of biological agents into the environment with the intent to cause harm is a real risk and can occur as an overt or covert event (Heymann, 2015). In the event of such a terrorist attack, C/PHNs can allay fears, provide the public with correct information, and promote and carry out immunization. Although many disease-causing organisms can be weaponized, only anthrax and smallpox, two biological agents that have a history of being used as terrorist weapons, are discussed here (see Chapter 17).

Anthrax Shortly after the terrorist attacks of September 11, 2001, the U.S. population was further terrorized by a deliberate release of anthrax agent into the postal service system. As a result, 22 people were infected, five died, and 32,000 were identified as having been potentially exposed and were treated with antibiotics as a precaution (Heymann, 2015; NPR, 2011).

Anthrax spores are found in nature in the digestive tracks of herbivores and can be found in the soil. Infection in humans is infrequent and sporadic in most developed countries (Heymann, 2015). It is an occupational hazard among workers who process animal hides, hair, bone and bone products, and wool in some countries, leading to it being referred to as woolsorter disease and ragpicker disease (Heymann, 2015).

In humans, anthrax is an acute bacterial disease that affects mainly the skin or respiratory tract. The two main forms—cutaneous anthrax and inhalation anthrax—account for most human anthrax cases. Cutaneous anthrax, which has a case fatality rate of 5% to 20%, manifests as itchiness on the skin where exposed, a lesion that progresses from papular to vesicular, and, in 2 to 6 days after exposure, a depressed black eschar surrounded by extensive edema. The infection may spread to the lymph system and cause septicemia. Inhalation anthrax, which has a case fatality rate of 85% (although antimicrobial and supportive therapy can reduce this rate), manifests initially as mild symptoms—including fever, cough, chest pain, and malaise—but can then progress to respiratory distress, fever, and shock (Heymann, 2015).

The causative organism Bacillus anthracis is a Gram-positive, encapsulated, spore-forming agent found in livestock and wildlife as the main reservoirs. The incubation period for cutaneous infection is 5 to 7 days but for inhalational anthrax is 1 to 45 days. Person-to-person transmission is rare, but articles and soil contaminated with spores may remain infective for decades, so these items must be appropriately disposed of (Heymann, 2015).

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A vaccine that protects against cutaneous and inhalational anthrax exists but is generally used only for those laboratory scientists handling anthrax specimens and some veterinarians who may have work-related exposure risk (Heymann, 2015).

Smallpox The variola virus causes smallpox and is transmitted from person to person. Initial symptoms of infection include a febrile prodromal period, which includes a fever of 104°F, malaise, headache, abdominal pain, and vomiting followed by the eruption of a deep-seated rash that transitions from macular to papular to vesicular to pustular (Fig. 8-8). Eventually, these scab over and fall off approximately 3 to 4 weeks after onset. It is passed from person to person through respiratory droplets or skin inoculation, most easily by droplet during the first week after the rash has developed, but airborne and contact precautions (personal protective equipment-PPE) are recommended for health care workers (CDC, 2016g; Heymann, 2015).

FIGURE 8-8 Maculopapular rash of smallpox. A smallpox patient in Cardiff, Wales during a 1962 epidemic. The lesions here upon his right hand were determined to be benign, semiconfluent focal variola eruptions. (Reprinted from Centers for Disease control and Prevention. Public Health Image Library. Photo Image ID no. 10375—Dr. Charles Farmer, Jr. Retrieved from https://phil.cdc.gov/Details.aspx?pid=10375)

Smallpox was declared globally eradicated in May of 1980. Officially, the smallpox virus presently exists at only two places: the CDC in Atlanta and the State Research Centre of Virology and Biotechnology in Koltsovo, Novosibirsk Region, Russian Federation. These samples remain available in the unlikely case of reemergence of smallpox disease (Heymann, 2015).

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A vaccine made from the vaccinia virus exists. The vaccinia virus, also known as cowpox, is a similar organism that confers protection to smallpox. In 1798, Edward Jenner was able to demonstrate that the vaccinia virus could be used to protect people from smallpox (WHO, 2014a). Smallpox vaccination has risks as it is a live virus. To avoid spreading the vaccinia virus, vaccinated people should not touch or cover the vaccination site with a gauze bandage and should follow care instructions. Serious complications include eye infection or blindness if the vaccinated person has the vaccine virus on the hand and touches the eye, severe rash leading to scarring or even death, encephalitis, and preterm birth or fetal demise if the virus becomes transmitted to a fetus during pregnancy (CDC, 2017e). Reactions are rare, with only 14 to 52 per 1 million people experiencing a life-threatening reaction (CDC, 2017e). Less severe but more common side effects include the formation of satellite lesions, regional lymphadenopathy, fever, headache, nausea, muscle aches, fatigue, and chills. In addition, the vaccine is contraindicated for those who are immunosuppressed, those with eczema, and pregnant women (Heymann, 2015; Fig. 8-9).

FIGURE 8-9 Smallpox inoculation of public health worker. (Reprinted from Centers for Disease Control and Prevention. Public Health Image Library. Photo Image ID no. 2825—James

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Gathany. Retrieved from https://phil.cdc.gov/Details.aspx? pid=2825)

Routine immunization against smallpox is no longer recommended for the general public because, at this time, the risk of harm from the vaccine is considered to be greater than the risk of contracting the disease. Laboratory workers who work in high-risk areas may still obtain the vaccine (Heymann, 2015).

The response plan for smallpox exposure may include the previously successful ring vaccination strategy—containing an outbreak by rapidly isolating and vaccinating people who have had close, face-to-face contact with the victim. This method refers to a ring of people around the exposed or ill person. Contacts would be monitored daily for fever and isolated if a fever develops (Heymann, 2015).

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PRIMARY PREVENTION

In the context of communicable disease control, two approaches are useful in achieving primary prevention: (1) education using mass media with targeted health messages to aggregates and (2) immunizations.

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Education Health education in primary prevention is directed both at helping individuals understand their risk and at promoting healthy behaviors. Chapter 11 deals more extensively with the concepts of learning theory and the variety of health education approaches and materials available to C/PHN today.

Targeting Meaningful Health Messages to Aggregates Marketing is based on the principles of exchange, paying a price for goods or services. The price may be money, effort, or time. The goods are the outcomes, such as good health. To effectively deliver a health promotion and disease prevention message, the following must be done (CDC, 2020e):

1. Identify the target (at-risk) market, a group of people who share common interests, needs, and behaviors.

2. Determine the target market's educational level, view of the salience of the issue, involvement with the issue, and access to media channels.

3. Consider the cultural, racial, and ethnic context of the target market and ensure that the message and educational materials are relevant to the needs and interests of the community and respect and reflect their values and traditions (Fig. 8-10).

4. Select or develop materials that relate to the delivery of health services that are available, accessible, and acceptable to the target population.

5. Pretest all materials and verify that they are attractive, comprehensible, acceptable, and persuasive to the target market and promote ownership.

6. Select or develop materials that are at the appropriate reading level for the intended audience.

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FIGURE 8-10 A targeted health message in Africa. A Stop Transmission of Polio (STOP) campaign volunteer's bicycle equipped with a vaccine-carrying satchel with the message “Kick Polio out of Africa.” (From Centers for Disease control and Prevention. Public Health Image Library. Photo Image ID no. 19436—Molly Kurnit, MPH. Retrieved from https://phil.cdc.gov/Details.aspx?pid=19436)

Ways to Communicate Social media, including Facebook, Instagram, YouTube, Snapchat, and Twitter, offers the ability to engage a large number of participants in an interactive, collaborative, and synchronous manner. It allows practitioners to reach populations that are diverse and that they might not easily arrange to meet face-to-face. It also makes sharing of information easier, through podcasts, YouTube, and blogs (CDC, 2020e); however, in using it, nurses must take care to maintain patients' privacy. This approach can also be integrated with other public health communication strategies. Public health organizations need to use social media engagement to its full potential (Andrade, Evans, Barrett, Edberg, & Cleary, 2018). Nurses can explore ways that social media can be used to augment current public health communication approaches. Chapters 10 and 12 have more information on social marketing and using technology to reach various populations.

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Immunization The extended life expectancy that has been enjoyed during the 20th century was largely due to the expansion of immunization programs that are provided to families. Immunizations are a cost-effective public health intervention that offers a high return on investment (see Fig. 8-11). Examples of the benefits gained through immunization programs include 92% to 100% drop in morbidity for ten communicable diseases including pertussis, polio, and smallpox, and preventing $14 million in lost income from disease while also saving $9.9 billion in health care costs and $33.4 billion in indirect costs (Ornstein & Ahmed, 2017; Vanderslott, Dadonaite, & Roser, 2019). Immunization and control of infectious diseases remain a national focus through Healthy People 2030 (ODPHP, 2018). Box 8-3 highlights select objectives related to immunization and infectious diseases.

FIGURE 8-11 The Vaccines for Children (VCF) program ensures that children from all communities and income levels will be able to get recommended childhood vaccinations, preventing these infectious diseases and their sequelae. (Reprinted from Centers for Disease Control & Prevention (CDC). (2019). Vaccines for Children Program (VCF). Retrieved from https://www.cdc.gov/vaccines/programs/vfc/protecting-

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children.html? CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fvaccines% 2Fprograms%2Fvfc%2F20-year-infographic.html)

BOX 8-3 HEALTHY PEOPLE 2030 Immunization and Infectious Diseases: Selected 2030 Objectives

Reprinted from U.S. Department of Health and Human Services (USDHHS). (2020). Browse 2030 objectives. Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives

Challenges still exist. Over 3 million people, half of them children, die worldwide each year from VPDs. Pockets of communities with low vaccination rates among the children exist across the country. In addition, new and emerging diseases may develop (e.g., COVID-19) for which a vaccine has not yet been developed (Children's Hospital of Philadelphia, 2018; USDHHS, 2020).

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The Advisory Committee on Immunization Practices (ACIP) reviews the schedule for administration of vaccines for various populations and age groups (CDC, 2020b). The ACIP provides vaccine recommendations based on research and scientific data related to vaccine safety and efficacy for adult and child vaccines. Recommendations include age when vaccines should be given, dosage, number of doses, time intervals between doses, and precautions and contraindications (CDC, 2020b). It also makes recommendations during times of disease outbreaks and vaccine shortages. An example is an outbreak of pertussis (whooping cough) in 2012. More than 14,000 people became infected and 14 babies died of pertussis. Given that young infants cannot receive the first dose of pertussis until they are 2 months old and their immunity would still be developing as they receive subsequent doses, ACIP recommends that pregnant women receive the vaccine to provide short-term protection, and the CDC encourages everyone close to the baby to receive an updated pertussis vaccine (CDC, 2017c, 2017f).

The majority of American society has accepted immunizations as a part of overall health care. However, some challenge the notion of immunizing their children for many reasons. Some oppose government mandates and the sheer number of vaccinations, whereas others want to veer from the recommended spacing schedule but plan to eventually complete the childhood series. Although all states have established laws requiring immunizations in certain situations (such as for attendance in public schools and childcare facilities and employment in health care facilities), many allow for exempting immunizations for various reasons, whether religious, philosophical, or medical (Boxes 8-4 and 8-5). In 2019, 15 states allowed for personal, moral, or other beliefs exemption (National Conference of State Legislatures [NCSL], 2019). The C/PHN should look to immunization agency of the state of practice for the accepted exemption criteria (Immunization Action Coalition, 2020). This subject is further discussed under the section Barriers to Immunization Coverage.

BOX 8-4 What Parents Should Know When Signing a Personal Beliefs Affidavit Exemption of Immunization

1. Please educate yourself to the symptoms and possible complications that can arise from a vaccine-preventable disease (VPD). Information for parents about these diseases may be found at the National Immunization Program site http://www.cdc.gov/nip/or by calling Insert Local County Public Health Department Name & Phone Number.

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2. Have a plan of care coordinated with your health care provider, to act upon the mildest to most severe symptoms of the disease.

3. It is the Parent/Guardian's responsibility to ensure an approved copy of the exemption is filed with the Child's school nurse.

4. An unimmunized child will be excluded from school by the County Health Officer when a VPD is identified in the school.

5. When a child is excluded from school, it is the responsibility of the parent/guardian to keep the child isolated 1 from the public at large to prevent spread of infection to the community.

6. VPDs are considered reportable communicable diseases under the Health and Safety Codes of Insert Local County Public Health Department. If your child contracts one of these diseases, a public health nurse will contact you. Be prepared to provide information about the illness to the investigator. This information is confidential.

7. The parent/guardian is also at risk of contracting any of these diseases when exposed to an ill child. If unimmunized, the parent or guardian will remain in isolation from the community through the incubation period.

8. The child who is exposed to the disease may be offered preventive medication or immunization to prevent the disease from occurring —either may keep the child from being excluded from school.

1The isolation time frame is determined by the county health officer. Isolation means that the exposed or ill child cannot leave home except for medical care. No social gatherings!

BOX 8-5 PERSPECTIVES

PHN: Personal Belief Exemption and Immunization A whooping cough (pertussis) outbreak occurred in a small rural community. The outbreak of pertussis occurred in a small charter school, where the majority of the children were unvaccinated for reasons of parental

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personal belief objections. Unfortunately, with a large unvaccinated population and with many in the community against vaccinating children, 22 cases were reported among children and family members. The school closed early to stop the spread of the disease. After meeting with parents, members in the community, and C/PHNs and school nurses, it was discovered that not all parents signed the personal belief exemption out of true conviction but instead signed them to stop the school staff from pestering them for not having the time to vaccinate their high-risk children.

The county's immunization coordinator, the community's immunization coalition, and the school nurses determined that the school secretaries were the most common point of entrance to school registration. It was discovered that these individuals needed an in-service on how to properly offer the exemption to a family and what information parents would need to make an informed decision before signing the exemption.

The immunization coordinator developed an education tool that explained to the parents their responsibility to the community at large if their child were to become ill with a vaccine-preventable illness. The Personal Beliefs Affidavit covered the points outlined in Box 8-4. The school secretaries were asked to give this document to parents who were interested in the exemption, as well as community resource information for families who may not have access to affordable immunizations.

The parents at the charter school were very accepting of the information on what to do for an ill child, and the school secretaries expressed relief regarding dealing with parents who may want to exempt out for convenience rather than conviction.

During the pertussis outbreak, as a C/PHN, what interventions would you direct to the parents who did not vaccinate their children due to true personal belief objections?

Ashley, PHN

At the time of this writing, data from the CDC's National Immunization Survey indicated the following (CDC, 2018c):

Children's data for 2016 showed >80% compliance in vaccination for the diphtheria and tetanus toxoids and acellular pertussis (DTaP);

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measles, mumps, and rubella (MMR); polio; Haemophilus influenzae type b (HIB); hepatitis B; varicella; and pneumococcal conjugate vaccines. Of adolescents (boys and girls 13 to 17 years of age), 48.6% were up to date on the HPV vaccine, with higher HPV vaccine rates in Hispanic girls than in White girls and in girls living in poverty than those living at or above the poverty line. Adult immunization rates showed a modest increase of 1% to 3% from 2010 to 2015 but did not meet the Healthy People 2020 immunization goals, except for the herpes zoster rate, which was 30%. Racial and ethnic differences persisted, with Asians, Blacks, and Hispanics having lower rates for recommended immunizations, with the exception of influenza vaccination. Higher immunization rates could also be seen in U.S.-born adults when compared with foreign-born adults, with the exceptions of the influenza and hepatitis A vaccinations.

Adults who reported having a regular place to seek medical care, regardless of health insurance coverage, had higher vaccination rates than those who did not have a regular place to seek medical care (Williams et al., 2017).

Health care providers, C/PHN, and school nurses are in positions to review records, educate families, and provide opportunities for a child and adult to obtain immunizations. Nurses need to be aware that individuals now more often obtain their medial information from online sources than from medical professionals (Hussain, Ali, Ahmed, & Hussain, 2018). These online sources include Internet searches and social media platforms such as Facebook, Twitter, and Instagram. This change has allowed for users of social media to produce and disseminate their content directly, leading to widespread digital misinformation and “echo chambers,” which has been listed as one of the main threats to our society (Schmidt, Zollo, Scala, Betsch, & Quattrociocchi, 2018, p. 3606). Researchers note that if parents are seeking information on the Internet about vaccination risks, they are likely to discover more Web sites perpetuating negative myths about and recommending against childhood vaccination than supporting it, according to a seminal systematic review by Kaufman et al. (2013). The viewing of antivaccination Web sites cannot be underestimated, as studies have found that the perception of vaccine risk is evident 5 months after parents viewed the misinformation, resulting in parents choosing to not fully vaccinate their child (Hussain et al., 2018).

Common questions parents ask about vaccines and recommended responses by nurses are as follows:

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Are the vaccines safe? Nurses can provide information about the safety trials that the vaccines undergo prior to release to the public and advise parents of possible side effects and how to care for the child if side effects do arise. I'm worried about giving so much at one time; how does that affect my child's immune system? Nurses can assure parents that the small dose in the vaccine is not nearly as much as children are exposed to in everyday life (Donovan & Bedford, 2013; Kumar, Chandra, Mathur, Samdariya, & Kapoor, 2016). Nurses can explain that although incidences of diseases have declined, other than polio, they still exist in the natural setting and can easily resurface and be life-threatening. Why are vaccines given at such a young age? Nurses need to explain that vaccines are given as early as possible to provide the child with protection as early as possible and that declining an immunization at the time the child is eligible for it leaves the child vulnerable to the disease until the series is completed (CDC, 2018h; Donovan & Bedford, 2013). Are preservatives or additives in the vaccine that will harm my baby? The nurse could explain why the preservative is added to the vaccine. C/PHNs should be aware of any state law prohibiting the administration of a vaccine that contains thimerosal to a newborn (CDC, 2018h).

Vaccine-Preventable Diseases Hepatitis A and B, H. influenza type b, measles, polio, diphtheria, pertussis, influenza, and chickenpox are examples of diseases that can be prevented through immunization, or VPDs. Immunization causes the body to become immune to an infectious agent by developing a defense against the invading infectious agent or antigen. The immunity allows the body to tolerate the presence of material that is foreign, such as a virus or bacterium (Hamborsky et al., 2015). Immunity may be either passive or active:

Passive immunity is short-term resistance to a specific disease-causing organism; it may be acquired naturally (as with newborns through maternal antibody transfer) or artificially through inoculation with pooled human antibody (e.g., immunoglobulin) that gives temporary protection. Active immunity is long-term (sometimes lifelong) resistance to a specific disease-causing organism; it also can be acquired naturally or artificially. Naturally acquired active immunity occurs when a person contracts a disease, whereas artificial immunity occurs when a person receives an inoculation of an antigen through a vaccine.

Both prompt an immune response that stimulates the development of long-lasting antibodies that provide immunity against future exposure to that

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antigen (Hamborsky et al., 2015). See Chapter 7. A vaccine is a preparation made from either a live organism or an

inactivated form of the organism. Live attenuated vaccines are made from weakened wild virus organisms that are able to replicate but generally do not make the person ill. It only takes a small amount to initiate an immune response, and the organisms must replicate to be effective. Inactivated vaccines are made from a viral organism that has been inactivated by heat or chemicals. These vaccines cannot replicate in the recipient (Hamborsky et al., 2015). Currently, measles, mumps, rubella, vaccinia, yellow fever, rotavirus, and intranasal influenza are all live attenuated vaccines (Hamborsky et al., 2015).

Schedule of Recommended Immunizations A schedule for the administration of childhood vaccinations, based on recommendations by the ACIP, the American Academy of Pediatrics, the American Academy of Family Physicians, and the CDC, is published annually (see https://www.cdc.gov/vaccines/schedules/hcp/imz/child- adolescent.html). The CDC also provides “catch-up” schedules for children not receiving their first immunizations at birth, according to the standard schedule. Current recommendations call for a child to receive 10 different vaccines or toxoids (many in combination form and all requiring more than one dose) in six or seven visits to a health care provider between birth and school entry, with boosters in the preteen to early teen years (Hamborsky et al., 2015).

Factors influencing the recommended age at which vaccines are administered include:

Age-specific risks of the disease Age-specific risks of complications Ability of persons of a given age to produce an adequate and lasting immune response Potential for interference with the immune response acquired from passively transferred maternal antibodies

In general, vaccines are recommended for the youngest age group at risk whose members are known to develop an acceptable antibody response to the vaccination (Hamborsky et al., 2015).

Recommendations for vaccine administration may be revised in certain circumstances. For example, it is now recommended that infants receive hepatitis B vaccine at birth, whether or not their mothers have a positive or negative response to the hepatitis B surface antigen. This approach will catch any infant born to mothers who lack prenatal testing or who may live in

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households with individuals with unknown hepatitis B status (Heymann, 2015).

Herd Immunity Herd immunity, or community immunity, is central to understanding immunization as a means of protecting community health. As described in Chapter 7, Herd immunity is the immunity level present in a particular group or community of people. If only a few immune persons exist within a community (i.e., if herd immunity is low), then the spread of disease is more likely (Fig. 8-12). However, if there are more individuals in the community who are immunized (i.e., if herd immunity is high), this helps minimize the chance that an unvaccinated person will become ill (Heymann, 2015).

FIGURE 8-12 Community immunity/herd immunity. (From National Institute of Allergies and Infectious Diseases (NIAID). Retrieved from https://twitter.com/niaidnews/status/1105879923535867910? lang=en)

The level of required herd immunity varies. For instance, a level of community immunity between 83% and 85% may be enough for rubella, but for pertussis (whooping cough), 92% to 94% may be needed to be effective (Merrill, 2017). Mandatory preschool immunizations and required travel vaccinations are applications of the herd immunity concept. An illustration of how herd immunity can cross all age groups is the Australian infant

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pneumococcal vaccination program, which created a herd immunity resulting in a 50% decline in hospitalization and deaths across all age groups over an 11-year period (Chen, 2018). See Box 8-6. An informative animation explaining herd immunity and how it varies depending on infectious agent can be found at: https://www.youtube.com/watch?v=XJFoOCmJsdg

BOX 8-6 Evidence-Based Practice Pertussis: New Preventive Strategies for an Old Disease In spite of high vaccination rates, pertussis outbreaks are occurring every 2 to 5 years in developed and developing countries. The population primarily being affected are infants <6 months of age followed by 10 to 14 years old who have yet to complete the vaccination series. The reasons may be due to the rising awareness of the disease, improved diagnostic tests, new strains of Bordetella pertussis not included in vaccine, asymptotic spread of B. pertussis in adolescents and adults or the decreased protection time of vaccine (Fernandes, Rodrigues, Sartori, De Soárez, & Novaes, 2018).

As a result, new strategies to protect against B. pertussis are under evaluation such as booster doses of vaccine to adolescents, adults, and pregnant women. Another method under evaluation is the practice known as cocooning. The goal is to immunize close family and friends or frequent contacts to reduce the risk of exposing the vulnerable person to these diseases (Di Mattia et al., 2018).

The C/PHN has an opportunity to evaluate the emerging research related to the booster doses, immunization of pregnant women, and cocoon approach and determine if their community could benefit from any of these strategies in reducing VPD outbreaks and poor outcomes for the infant at risk. A number of questions must be addressed in considering whether cocooning is a viable option in a community:

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1. Does the approach actually reduce infections in the target population and where is the evidence?

2. What is the risk to the persons being vaccinated? 3. What is the cost of this program? 4. Are there unintended consequences from this approach, such as

delayed immunizations in the target population?

Source: Di Mattia et al. (2018); Fernandes et al. (2018).

Herd immunity is not only important in relation to limiting exposure of infection but also in reducing risks for cancer. A 4-year study showed a connection between increased vaccination rates of HPV with decreased HPV- related cancers among nonvaccinated women, thereby confirming the potential benefits of herd immunity in reducing HPV-related cancers (Cameron et al., 2016).

Innovations are an important source of improved health-promoting practices and should not be discouraged, but, as always, solid research evidence is vital. With limited health care dollars, efforts must target the most cost-effective and proven methods possible. Only time and research will show which strategy will be an effective tool in the public health arsenal.

Assessing Immunization Status of the Community Immunization rates still need to be improved. Nurses need to work to ensure that all those who need vaccines are receiving them. Laws have been implemented requiring students to receive vaccines prior to entering school. This section reviews approaches to address vaccine hesitancy, which is defined as a “delay in acceptance or refusal of vaccination despite availability of vaccination services” and listed as one of the top ten threats to global health (WHO, 2020g, para. 1). It is important to recognize that all clients who refuse vaccination are not all the same. They may have very different concerns. Refer to Figures 8-13 and 8-14 for the factors associated with vaccine hesitancy.

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FIGURE 8-13 Conceptual Model of Vaccine Hesitancy. (Adapted with permission from Dubé, E., Laberge, C., Guay, M., Bramadat, P., Roy, R., & Bettinger, J. (2013). Vaccine hesitancy: an overview. Human vaccines & immunotherapeutics, 9(8), 1763–1773.)

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FIGURE 8-14 Vaccine Hesitancy Matrix. (Reprinted with permission from WHO. (2014). Report of the Sage Working Group on Vaccine Hesitancy (p. 12). Retrieved from http://www.who.int/immunization/sage/meetings/2014/october/1_R eport_WORKING_GROUP_vaccine_hesitancy_final.pdf)

Vaccine hesitancy is closely connected with the Internet and social media such as Facebook, YouTube, Instagram, blogs, search engines, and Web sites (Schmidt et al., 2018), where much content on the subject decreases the confidence of the individual with regard to safety and need. Many Web sites are highly interactive and allow users to share their information without regard to validity. Antivaccination content ranks high in search engines as it is easy to read. Health institutions now understand the importance of spreading accurate information through the Internet, and the number of sites promoting vaccinations has grown (Mitra, Counts, & Pennebaker, 2016). As health professionals, it is important to understand the sources and quality of content on the Internet, and how to use tools such as Google Trends and HealthMap to monitor trends and help disseminate correct information (Bragazzi et al., 2018; Millard et al., 2018; Rosselli, Martini, & Bragazzi, 2016; Sampri, Mavragani, & Tsagarakis, 2016; Tustin et al., 2018).

Below are three different strategies that can be considered when dealing with vaccine hesitancy:

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Tell, don't ask: research has shown that a presumptive format, in which the health care provider leads the discussion (e.g., “well, we have to do some shots”), is associated with higher vaccination rates than a participatory format (e.g., “How do you feel about vaccines?”; Opel et al., 2018). Motivational interviewing (a brief intervention style developed by Miller and Rollnick): an empathetic, respectful approach in which the health care provider targets information based on the concerns of the parent only after permission has been given may be helpful (Gagneur, Gosselin, & Dube, 2018). See Chapter 10. “CASE” (Corroborate, About, Science, Explain):

Corroborate the concerns and have a respectful conversation with the parent. Tell the parent about yourself and your level of expertise. Refer to the evidence from science. Explain and advise, following the ACIP guidelines (American Academy of Pediatrics, 2019; Domachowske & Suryadevara, 2013).

It is important to engage families who are hesitant about vaccines in open conversation. This may be a challenging task when a parent is confrontational with the health provider or perhaps even attempting to change the mind of the health care provider. Some who seemed adamant about refusing the vaccine may even decide to accept the vaccine after an honest discussion because they felt that they were heard, and their questions were answered (Attwell, Meyer, & Ward, 2018; MacDonald, 2015, WHO, 2014b).

Offering vaccines at home visits and in Women, Infants, and Children program offices has also been found to be effective. Another strategy is to work with providers. The AFIX (assessment, feedback, incentives, and exchange) approach is designed to help providers recognize the problem:

Assess the current immunization rates within the office to show the provider an accurate picture (computer applications from the CDC can help with this process). Give feedback to the provider about progress in increasing vaccination rates in a nonjudgmental way. Offer incentives to help motivate the provider to make the needed changes. Encourage an exchange of information with other providers about what has worked for them (Hamborsky et al., 2015).

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Planning and Implementing an Immunization Campaign Immunization campaigns targeting specific subgroups can be effective if they include the following:

Community assessment for the target group(s) Assessment of and planning for the needs of the target group(s), such as:

Transportation Language interpreters Childcare Literacy

Successful outreach efforts are motivated by the desire to reach the target population, even if specific or unusual accommodations must be made. An online presence, with information about the benefits of vaccines and clinic locations, is helpful. Clinics can be scheduled and held at times and places specifically intended to make the service more accessible and convenient to the target group. Materials in multilingual form can be obtained through the state's immunization agency or the CDC. The CDC and state immunization agencies have campaigns throughout the year for the C/PHN to participate in and provide to the public. Tool kits with the materials and tips for planning and implementation are available through the state immunization agency (Hamborsky et al., 2015). Box 8-7 outlines the process for administering an immunization campaign in a community setting. A 5-minute video on the importance of vaccines for older adults may be helpful for all age groups: https://www.youtube.com/watch?v=hodb65EkorM

BOX 8-7 C/PHN Use of the Nursing Process Administering an Immunization Campaign in a Community Setting

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Source: MacDonald (2015); Martin (2018).

Adult Immunization Many people assume that vaccinations are for children only. Well-advertised influenza vaccination campaigns in recent years have, to some extent, helped to correct this notion.

Adults face risk for becoming infected with a VPD if they are unimmunized or underimmunized. Some of the immunizations that wane, meaning that the protection disappears over time, are tetanus, pertussis, influenza, and pneumococcal. Other vaccines are specific for adults, such as the varicella zoster, otherwise known as the shingles vaccine. The CDC (2020b) provides an adult immunization schedule of recommendations. See Chapter 21 for adult vaccination schedule and adult screenings.

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Substantial numbers of VPDs still occur among adults despite the availability of safe and effective vaccines. C/PHN should be aware of factors that may contribute to low vaccination levels among adults:

1. Cost and reimbursement 2. Lack of a regular place to seek medical care 3. No reminder-recall

system in place 4. Provider's lack of current knowledge of recommended immunizations or

forgetting to ask about vaccinations at the time of the visit, leading to missed opportunities to vaccinate 5. Need for training of health care staff on recommended immunizations for adults 6. Patient's lack of awareness of adult vaccination standards

International Travelers, Immigrants, and Refugees As Americans interact more and more with their neighbors in other parts of the world, the incidence of Americans with tropical or imported diseases also rises. Within about 36 hours of boarding an airplane, one can reach any destination in the world. An average flight can equal the incubation period of some infectious diseases, and before the onset of symptoms is realized, microbial agents could be spread around the globe.

Travelers can take steps to protect themselves prior to embarking on their journey to new and exotic places by:

Visiting the CDC Travelers Health Web site to access advise on staying healthy during and on return from a trip (CDC, 2020m) Making an appointment for a consultation with a tropical medicine or travel clinic to prepare for international travel Being immunized with the recommended vaccines for the particular area of the world Having the necessary chemical prophylaxis on hand (i.e., antimalarial medications as prescribed) Learning about food and water hygiene precautions and basic first aid for simple injuries (CDC, 2020m)

Traveling internationally has grown over the past decade, with 1.2 billion worldwide tourist arrivals in 2015. Promoting a traveler's health is important to safeguard not only the individual's health but also the health of the individual's community (CDC, 2017h).

Refugees and international travelers who arrive in the United States may be unfamiliar with U.S. health systems, health precautions, and practices. Refugees and immigrants must follow prescribed guidelines, including extensive health screening mandated by U.S. immigration laws, immunizations, and treatment, as appropriate (CDC, 2017i). More than ever

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before, C/PHNs have professional contact with these new Americans, whether close to their time of arrival or later, in schools, immunization clinics, or other locations. Visitors from other countries may also require the assistance of other C/PHP. For this reason, C/PHNs are encouraged to develop and maintain a global perspective on communicable diseases. See Chapter 16 for more information on global health.

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SECONDARY PREVENTION

Two approaches to secondary prevention of communicable disease are possible: (a) screening and (b) disease case and contact investigation and notification (previously discussed).

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Screening Screening is a secondary prevention method because asymptomatic cases can be discovered and provided with prompt early treatment. Pregnant women can also be identified and treated to prevent infection to the neonate (Heymann, 2015).

The term screening is used in community/public health and disease prevention to describe programs that provide disease-testing opportunities to detect disease in groups of asymptomatic, apparently healthy individuals. Common screening measures can include prenatal hepatitis B screens, urine Chlamydia and gonorrhea screens, and Mantoux TSTs for TB infection (Heymann, 2015).

Remember that the screening test itself is not diagnostic but rather a method to identify those persons with positive or suspicious test findings who then require further medical evaluation or treatment. C/PHNs working with clients in a screening setting must be prepared to clearly and correctly explain to individuals that screening tests are not definitive and that positive findings require subsequent investigation before diagnostic conclusions can be drawn.

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Criteria for Screening Tests Some important criteria are used in deciding whether to carry out a screening intervention in a community. They include validity and reliability and predictive value and yield.

Validity and Reliability The screening test must be valid and reliable. Validity refers to the test's ability to accurately identify those with the disease. Reliability refers to the test's ability to give consistent results when administered on different occasions by different technicians.

Predictive Value and Yield The predictive value of a screening test is important for determining whether the screening intervention is justified. Yield refers to the number of positive results found per number tested. The predictive value and the yield of screening tests become important in planning screening programs for communicable disease detection and prevention because they can help planners locate screening efforts in areas or within population groups that are known to be at high risk for the disease. The predictive value of screening tests increases as the prevalence of the disease increases. For example, a screening test for TB among refugees would have a greater predictive value and yield than would TB screening in the population at large, owing to a higher endemicity of TB in many countries outside of the United States.

Epidemiologic criteria for screening interventions for the detection of health problems include the following (Trevethan, 2017):

Is the disease an important public health problem? Is there a valid and reliable test? Is there an effective and tolerable treatment that favorably influences the early stages of the disease? After a positive screening result, are facilities for diagnosis and treatment available and accessible? Is there a recognizable early asymptomatic or latent stage in the disease? Do clear guidelines for referral and treatment exist? Is the total cost of the screening justifiable compared with the costs of treating the disease if left undiscovered? Is the screening test itself acceptable? Will screening be ongoing?

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See Chapter 7 for more on epidemiology.

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TERTIARY PREVENTION

The approaches to tertiary prevention of communicable disease include care and treatment of the infected person, isolation and quarantine of the infected person, and safe handling and control of infectious wastes.

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Care and Treatment Communicable diseases require care and treatment specific to the disease, and the nurse needs to:

Understand the disease, the treatment, and follow-up requirements, and the educational component to discuss with the infected person Use information resources such as the CDC, state agency policies, and protocols provided by local public health agencies (Heymann, 2015)

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Providing Services for Special High-Risk Populations The LGBTQ community bears a disproportionate burden of STIs, particularly among men. Gay and bisexual men represent 83% of the cases of primary and secondary syphilis. Whereas men are generally at a lower risk for cancer due to HPV, men who have anal sex are 17 times more at risk for anal cancer (CDC, 2016e, 2020k).

C/PHNs can help alleviate the fear of bias that may be a barrier to accessing screening and treatment services by educating providers about LGBTQ-friendly practices such as nongender questions on patient history forms and nongender bathrooms. By educating medical staff, a more welcoming and supportive environment can be established encouraging LGBT people to seek out health care (Bristol, Kostelec, & MacDonald, 2018; CDC, 2020k).

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Isolation and Quarantine Communicable disease control includes two methods for keeping infected persons and noninfected persons apart to prevent the spread of a disease. Isolation refers to separation of the infected persons (or animals) from others for the period of communicability to limit the transmission of the infectious agent to susceptible persons. Quarantine refers to restrictions placed on healthy contacts of an infectious case for the duration of the incubation period to prevent disease transmission if infection should develop (Heymann, 2015). The CDC has quarantine stations located at land-border crossings and ports of entry, where public health officials determine if international travelers who are ill may be admitted into the United States or held to prevent spreading infectious disease (CDC, 2017d).

In 2020, some Americans who tested positive for a novel coronavirus (COVID-19) were quarantined, and travel bans were instituted in an effort to contain the spread of infection. The earliest reports of the new infection were made in the first week of January 2020, and as of February 29, 2020, there were 85,403 confirmed cases worldwide, with 79,394 reported cases in China, the suspected country of origin. Symptoms and potential spread of the novel virus are somewhat reminiscent of the SARS and MERS epidemics, although these were less widespread and had fewer total confirmed cases and deaths (but higher death rates). The WHO global risk assessment was raised to “very high” as the virus spread to 53 countries and 89 deaths were reported (Offord, 2020; WHO, 2020b). As of June 24, 2020, global cases reached 9,352,696 with 479,777 deaths. Despite statewide and area stay-at- home orders in most states in an effort to flatten the curve and reduce the burden on hospitals and health care workers, US cases reached 2,4224,168 and deaths totaled 123,473 (Mervosh, Lu, & Swales, 2020; Worldometer, 2020).

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Safe Handling and Control of Infectious Wastes The control of infection in C/PH also relies on the proper disposal of contaminated wastes. The CDC and the Occupational Safety and Health Administration (OSHA) support and encourage standard precautions that stress that health care workers think of all blood and body fluids and materials that they may come in contact with as potentially infectious (OSHA, n.d., 2011). Although universal precaution observance is primarily considered while the nurse is giving hands-on treatment or care to a patient, keeping these principles in mind while making community health visits in the primary and secondary setting is paramount to the safety of both the client and the nurse (Heymann, 2015).

Infectious waste is waste capable of producing an infectious disease provided it contains pathogens with sufficient virulence and quantity so that exposure to the waste by a susceptible host could result in an infectious disease (OSHA, n.d.). Requirements for medical waste disposal are for waste to be segregated into categories of:

Used and unused sharps Cultures, specimens, and stocks of infectious agents Human blood and blood products Human pathologic, isolation, and animal waste

Although incineration has long been recognized as an efficient method for disposing safely of sharps and other contaminated medical waste, fewer incinerators are available now because of increasing regulation of emissions and particularly those regulations related to burning chemical wastes (Healthcare Environmental Resource Center, 2015; Heymann, 2015; OSHA, n.d., 2011).

Four key elements of an infectious waste management program are applicable to community practice:

1. Health professionals must be able to distinguish waste that poses a significant infection hazard from waste that does not.

2. The waste management program must have administrative support and authority to institute practice guidelines and provide the containers and other resources needed for safe disposal of infectious wastes.

3. Handling of the infectious wastes must be minimized. Containers should be rigid, leak-resistant (sealed), impervious to moisture, rupture- resistant, and, for sharps, puncture-resistant.

4. An enforcement or evaluation mechanism must be in place to ensure that the goal of reducing the potential for exposure to infectious waste in the community is met.

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LEGAL AND ETHICAL ISSUES IN COMMUNICABLE DISEASE CONTROL

The threats presented by communicable diseases can bring public safety and ethical considerations to a crossroad. Public health interventions to protect the public often overlap individual rights (Gould, King, Wigglesworth, & Purssell, 2018). The communitarianism concept of what is good for the whole is good for the parts might be applied to public health practice. Considerations for ethical public health practice should include overall benefit to society, collective action, communitarianism, fairness in distribution of burden, harm principle, paternalism, liberty-limiting continua, social justice/fairness, and global justice. In addition, ethical issues of autonomy, beneficence, avoidance of maleficence, and justice also need to be taken into consideration (WHO, 2016b).

C/PHN must balance these ethical principles while working with the community to control the spread of infectious diseases. An example of this conflict might occur while conducting contact investigation for STI. The nurse must be mindful to conduct the investigation while maintaining confidentiality of the index case. Another example is mandating immunizations resulting in exclusion of unvaccinated children from a school setting (Gould et al., 2018). Public health practitioners walk a fine line to protect the rights of the individual while also protecting the health and safety of the community. Refer to Chapter 4 (ethical principles) for more details.

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Enforced Compliance Legally, the responsibilities of public health officials in communicable disease control include the police power to enforce compliance with treatment or restrict the activity of infectious people to protect the welfare of others (CDPH, 2020). Regulations that enforce compliance with disease prevention strategies are a justifiable restriction if the measures proposed are demonstrably effective and grounded in ethical principles (CDPH, 2020). However, during the recent Ebola epidemic, health care workers who treated Ebola victims in West Africa found themselves under 21-day quarantine once they returned to the United States even though they did not have symptoms, and some states took additional precautions not required by the CDC. As health care providers, it is important to be guided by scientific proof and not fear (Emrick, Gentry, & Morowit, 2016; Jones, 2020). Due process is crucial to protect individuals from government intrusion, particularly ensuring that fundamental fairness has been implemented in situations requiring imprisonment (CDPH, 2020).

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Confidentiality, Privacy, and Discrimination While carrying out communicable disease interventions, nurses and other health care professionals must ensure clients' confidentiality and privacy. The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, last revised in 2003, seeks to protect patients' confidentiality and privacy by establishing laws that govern how health care providers, insurance companies, and other “covered entities” may use and disclose patients' personal health information. Health care providers may only disclose when necessary to provide care for the patient and then must provide only the minimum amount of information needed to provide that care (USDHHS, 2015). One exception is when disclosure of an individual's information is required to protect another person or people who are at risk of contracting an illness, but even then, the individual's identity is protected.

Human society has a long-standing aversion to infectious diseases. Ostracism, which in the past targeted people with leprosy and other contagious conditions, has shifted to discrimination against people with TB or AIDS (Jones, 2020). An example of this occurred in 2007 when an Atlanta attorney caused an international health scare and found his medical and personal information in the media as a result of flying to Europe after a recent diagnosis of drug-resistant TB (Night, 2007). People are protected from discrimination under the Americans with Disability Act but not with respect to posing a public health treat, such as with the contagious state of TB (U.S. Equal Employment Opportunity Commission, 2017).

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SUMMARY

Communicable diseases pose a major threat to the public's health and are transmitted globally as the result of mobile populations, increased urbanization, and international travel. They can be transmitted through direct contact from one person to another or indirectly through contaminated objects (air, water, food) or a vector (animal or insect; CDC, 2020a). Nurses concerned with communicable disease control must recognize who is at risk, where the potential reservoirs and sources of infectious disease agents are located, what environmental factors promote their spread, and what are the characteristics and vulnerability of community members and groups. Influenza is an evolving virus that is responsible for widespread outbreaks and pandemics as most of the world population do not have the antibodies to protect them from novel (new) strains. TB is one the biggest problems affecting our nation and is becoming more complicated to treat and manage with the introduction of MDR strains, the increasing number of people diagnosed with TB and HIV/AIDS, and the breaking down of international borders due to immigration, refugees, increased travel, poverty, and inadequate access to health care. STIs threaten the health and lives of millions of people. Control of STIs can be accomplished through effective screening, treatment, contact investigation, and aggressive public education. Primary prevention of communicable diseases includes methods such as using mass media education campaigns, one-on-one education, and immunization promotion and programs to reduce risk and help prevent diseases from occurring in the first place. Vaccine hesitancy is one of the ten leading causes of death worldwide. C/PHNs need to work with parents to learn about their concerns and provide education and strategies to assist them. Herd immunity, or community immunity, is central to understanding immunization as a means of protecting community health. Secondary prevention activities of screening and disease investigation are steps taken when primary prevention activities have failed. Tertiary prevention is needed to ensure additional people are not infected and those who are ill receive care and treatment. Ongoing disease transmission can be interrupted through treatment, isolation, or quarantine.

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Ethical issues in communicable disease control include enforced compliance, the justifiability of screening, preservation of confidentiality and privacy, and the avoidance of discrimination against infected people.

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ACTIVE LEARNING EXERCISES

1. The antivaccine movement uses the Internet through social media, Web sites, and blogs to spread their antivaccine information. Find a Web site, social online group, or blog and summarize who they are targeting and why. Create a response to one argument against antivaccination using evidence-based research that could be easily understood by a nonmedical person.

2. Find a case that was publicized in the media in which an individual was mandated to be quarantined due to a communicable disease. Identify how the case became public and whether it could have been prevented. As a C/PHN, what measures could be taken to prevent the enforced quarantine of this person? Explain how three of the 10 essential public health services (see Box 2-2 ) apply to this scenario.

3. In the United States, TB cases are highest among foreign-born individuals. Review your local health department Web site and identify the measures and services provided for the at-risk population. Create a diagram of the service(s) and how they address complacency, confidence, and convenience. What would you do differently, and why would that change be significant to the screening and treatment of latent TB?

4. Identify a WHO or CDC vaccination campaign/program and characterize the target audience. How can the nursing process can be used to plan, execute, and evaluate the success of the campaign/program?

5. How could social media be used by C/PHN in the prevention of vaccine preventable diseases? Provide two examples. What are the advantages and disadvantages of using social media for disease prevention?

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CHAPTER 9

Environmental Health and Safety “When we try to pick out anything by itself, we find it hitched to everything else in the Universe.”

—John Muir (1838–1914), Naturalist

KEY TERMS Bioaccumulation Biomonitoring Brownfields Built environment Climate change Ecosystems Endocrine-disrupting chemicals Environmental epidemiology Environmental justice Epigenetics Exposure pathways Health risk assessment Integrated pest management (IPM) One Health Planetary health Precautionary principle Risk management Social determinants of health Superfund Sustainability Sustainable Development Goals (SDGs) Toxicology

LEARNING OBJECTIVES Upon mastery of this chapter, you should be able to:

1. Apply the ecological perspective to human and environmental relationships.

2. Discuss concepts of prevention and upstream approaches to health impact and environmental health.

3. Discuss the community/public health nurse's role in reducing and managing environmental risk.

4. Discuss guiding documents for public health nursing that pertain to environmental health.

5. Discuss how the core functions of public health can be applied to environmental health.

6. Describe how nurses can collaborate with other professionals, government agencies, and communities to reduce environmental threats

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to health.

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INTRODUCTION

Recent events such as lead contamination in the drinking water in Flint, Michigan; growing piles of plastics in our oceans; wildfires in the western United States and in northern Europe; and hurricanes and severe flooding in the southeast United States remind us of the impact of the built and natural environments on the health of local and global communities, as well as the impact on patients in our care in clinics and hospitals.

The effect on health of environmental factors has been noted in nursing and by national and international agencies. In nursing, the concern for the environment dates back to Florence Nightingale (1960/1969), who reminds us that health depends on clean air, clean water, safe food, control of noise, and exposure to light. More recently, the World Health Organization defined health as “a complete state of physical, mental, and social wellbeing” and environment, as it relates to health, as “all the physical, chemical, and biological factors external to a person, and all the related factors impacting behaviors” (WHO, 2020b, para. 1). In its definition, the WHO was careful to identify environmental factors that could be modified.

The ability to live in a healthy environment increases not only the number of years of a healthy life but also one's quality of life. Thus, nurses, as the largest group of health care professionals globally, can play a key role in supporting environments that sustain health.

In 2015, the United Nations implemented a new set of global goals called the Sustainable Development Goals (SDGs). The SDGs identify the need to care for the natural and built environments that support the health of our planet and its inhabitants (UN, 2020). See Chapter 16 on global health for more on SDGs.

Increasingly, a number of environmental factors have been recognized as detrimental to health, including:

Exposures to hazardous materials in air, water, food, and soil The rise in development and deforestation The use of synthetic chemicals not well tested for safety The adverse effects of natural and human-caused disasters, the built environment, and climate change

The framework for the nation's health in the United States is Healthy People 2030. It addresses the social, economic, and physical factors, as well as behaviors, that can influence exposure to physical, chemical, and biological environmental risks (Office of Disease Prevention and Health

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Promotion, 2019). Our national framework for health is therefore in line with global goals and the WHO definition of health.

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ENVIRONMENTAL HEALTH AND NURSING

Historically, public health and occupational health nurses (OHNs) have been leaders in addressing the impact of the physical and natural environments through their work in homes, in communities, and with governmental organizations. As evidence of environmental impact on our health continues to grow, it is important for nurses in all practice settings to be knowledgeable of environmental risks, the relationship of exposures to disease and illness, prevention measures, and growing scientific evidence to best protect and promote the health of the populations in the nurse's care. Professionally, nurses must be aware of the guiding documents that call for nurses to incorporate environmental health into all areas of practice.

The documents are:

Public health nursing: Environmental Principles for Public Health Nursing in 2005 The American Nurses Association (ANA): ANA's Principles of Environmental Health for Nursing Practice and Implementation Strategies in 2007 (http://ojin.nursingworld.org/MainMenuCategories/WorkplaceSafety/He althy- Nurse/ANAsPrinciplesofEnvironmentalHealthforNursingPractice.pd) The ANA: Nursing: Scope and Standards of Practice, Standard 17 Environmental Health (American Nurses Association, 2015b; Box 9-1)

BOX 9-1 American Nurses Association, Public Health Nursing: Scope and Standards of Practice Standard 17. Environmental Health: “The registered nurse practices in an environmentally safe and healthy manner” (p. 84).

The registered nurse: 1. In nursing practice and the workplace, fosters health and safety. 2. Incorporates concepts of environmental health in nursing practice.

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3. Evaluates the health risk factors present in the environment. 4. Works to decrease environmental health risks for self, nursing

counterparts, and patients. 5. Shares knowledge of environmental risk factors and strategies to

reduce risk of exposure. 6. Acts as an advocate for product safety, as well as proper use and

disposal. 7. Utilizes new technologies to ensure safe environments for nursing

practice. 8. Applies evidence-based practice principles in the use of products or

therapies to decrease environmental risks. 9. Actively works to develop interventions that promote healthier

environments in workplace and community environments. Adapted from American Nurses Association (ANA) (2015b)

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Brief History of the Occupational and Environmental Health Movement in Nursing Florence Nightingale's (1969) work in identifying the relationship between the patient environment and health highlighted the importance of incorporating environmental health into nursing practice. As a result, nurses consider the environment of the home, hospital, or community as a factor to promote and restore health.

However, the specific role of nurses in occupational and environmental health first occurred in the workplace. Initially called industrial nurses, OHNs assess workers' health status and strive to ensure worker safety and prevent adverse health effects from workplace hazards. The American Association of Occupational Health Nurses (2020) cites the need for specific education and training in toxicology, epidemiology, workplace hazards, regulations, and prevention strategies. OHNs can be certified through the American Board of Occupational Health Nurses (see Chapter 29). Public health has included environmental health as a central aspect of health promotion and disease prevention. More recently, the nursing profession has responded to the call for nurses to establish environmental health competencies for nursing practice.

Significant historical milestones in environmental health nursing are:

1995: The Institute of Medicine report Nursing, Health, and the Environment (Pope, Snyder, & Mood, 1995) identified the need for nursing environmental health knowledge, research, and interventions. 1995 to 2008: Many nursing programs incorporated environmental health into the curriculum. Nurses incorporated environmental health into their practice settings to reduce hazardous exposures to both health professionals and patients. Environmental health nursing advanced, and nurses became involved in a number of policy and advocacy efforts (Leffers, McDermott-Levy, Smith, & Sattler, 2014). 2005: Environmental Health Principles for Public Health Nursing was published (APHA, 2005). 2007: ANA Principles of Environmental Health for Nursing Practice was published (ANA, 2007). 2008: The Alliance of Nurses for Healthy Environments (ANHE) was formed—the first professional nursing organization solely focused on environmental health (ANHE, 2019). 2010: ANA, Standard 16: Environmental Health was included in the second edition of Nursing: Scope and Standards of Practice (ANA, 2010) and revised for the 2015 edition (ANA, 2015b). Since the

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publication of the 2010 Standard 16: Environmental Health, all nurses must incorporate environmental health principles into nursing practice.

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Healthy People 2030 Initiatives In addition to guidelines for environmental health in nursing, there are federal guidelines from the Surgeon General Report on Healthy People and the core functions of public health (Centers for Disease Control and Prevention [CDC], 2018a) to support environmental health in nursing practice.

First released in 1990 as Healthy People 2000, Healthy People is the federal document produced every decade to set health goals to promote the health of Americans (Box 9-2). This document provides guidance for nurses to identify targets for health and is used for many public health nursing interventions. The most current version of this document, Healthy People 2030, identifies overarching goals that support environmental health and policies to promote a healthier population. These goals can be found in Chapter 1, Box 1-4 .

(Office of Disease Prevention and Health Promotion, (2020, para. 13).

BOX 9-2 HEALTHY PEOPLE 2030 Objectives for Environmental Health

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Reprinted from U.S. Department of Health and Human Services (USDHHS). (2020). Browse 2030 objectives. Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives

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Importance of Environmental Health for Nursing Nurses are essential to improve environmental health through nursing research, education, advocacy, and practice. We work with diverse populations in homes, workplaces, and communities and are the largest group of health care providers in the United States, with almost 3 million registered nurses.

In addition, we are in one of the most trusted professions, are able to communicate complex information to our patients and communities, interact with many other health care organizations, and serve in policy setting roles (Brenan, 2018). Therefore, nurses are ideally situated to assess for and address environmental health risk.

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CONCEPTS AND FRAMEWORKS FOR ENVIRONMENTAL HEALTH

Ecosystems Ecosystems are dynamic communities of plants, animals, microorganisms, and the nonliving environments in which they live. No organism, including humans, can live removed from its ecosystem or other species. Ecosystems help regulate water, gases, waste recycling, nutrient cycling, pollination, infectious disease, climate, and biology, as well as provide recreational and cultural opportunities for human use (Frumkin, 2016).

The synergistic relationship between humans and the environment has been highlighted through the multidisciplinary approach of One Health. One Health relies on an ecological approach to monitor and control diseases spread through the environment, animals, and humans (CDC, 2018b; Rabinowitz, 2018). Through One Health, botanists, microbiologists, nurses, physicians, and veterinarians have worked closely to understand and address the impact of ecosystem on public health (see Chapter 16).

Community/public health nurses (C/PHNs) find that the science of ecology has been applied to social ecological perspectives that identify not only the physical environment but also the social, political, economic, and cultural factors that exist for populations.

In public health, the ecological model of population health (Fig. 9-1) is used to illustrate that determinants of health (biological, behavioral, and environmental) interact to affect health (Friis, 2019). In addition, the framework of planetary health relies on an ecological perspective to attain health, wellbeing, and equity through stewardship of the political, economic, and social systems as well as natural ecosystems (Haines, 2016; Whitmee et al., 2015). Using the ecological perspective of planetary health, nurses are able to collaborate to address social, political, economic, cultural, and natural environmental factors that influence human health within their practice setting (Kurth, 2017).

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FIGURE 9-1 Ecological model for public health.

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Sustainability Sustainability is based on the principle that human beings and the natural environment must coexist harmoniously for survival (U.S. Environmental Protection Agency [EPA], 2020b). When the concept of sustainability is applied to human systems, it is evident that the public must protect the environment and promote healthy characteristics in the population and in their communities.

Currently, much of human/environment interactions are not sustainable. For example, our food production and energy use create pollution that threatens human life and ecosystems. Solutions to improve sustainability for humans and the environment include strategies that are socially desirable, economically feasible, and ecologically viable (Wright & Boorse, 2016).

One example of how our energy use impacts sustainability is the increased use of fossil fuels for home heating and cooling. Our increased use of natural gas, for example, increases air pollution from the toxic emissions released from gas extraction and distribution. Many of these emissions lead to increases in ground-level ozone, particulates, and greenhouse gases that contribute to climate change. Current estimates indicate that the global need for oil has exceeded available resources that are not sustainable, according to a seminal article by Howarth (2014). Concerns about the depletion of natural resources, disruption of nutrient cycles, widening economic disparities between the rich and poor, and climate change are key issues addressed in the EPA's Framework for Sustainability Indicators at EPA (2012).

Sustainability is an important concept in relationship to nursing practice and the health care setting. The U.S. health care industry is a $2.5 trillion enterprise that contributes to 8% of all greenhouse gases and 7% of all carbon dioxide emissions. Hospitals generate as much as 5 million tons of solid waste annually, much of which is hazardous materials (EPA, 2017c).

Nurses were instrumental in the formation of Health Care Without Harm, a leading organization that promotes environmentally responsible health care (Health Care Without Harm, 2018). The ANA (2015a) has long supported efforts to address medical and pharmaceutical waste. For example, Beth Schenk, PhD, MHI, RN, serves as the Nurse Scientist and Sustainability Coordinator with Providence St. Patrick Hospital in Montana. In this role and in her shared appointment at Washington State University, Dr. Schenk seeks to advance environmental stewardship in health care and promote research for sustainability.

Although this example highlights the work of a nurse leader for a large health care system, nurses who work in community settings must comply with best practices for waste disposal as well as greening their practice

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environments. Pharmaceutical waste is a serious concern for nurses who work in home and school settings. This topic is more fully addressed in the section about water contaminants.

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Upstream Focus C/PHNs incorporate an “upstream” focus into their work with populations. This approach emerged from the seminal publication by John McKinley in 1979, A Case for Focusing Upstream, which identified root causes of disease and the multiple factors that lead to illness. The C/PHN approach to prevention and health promotion relies on an upstream approach to address the root causes that influence health at the institutional and system level rather than looking solely at healthy lifestyle issues; in other words, C/PHN direct their care “upstream” from the identified problem or issue (Butterfield, 2017).

For example, a C/PHN is taking an upstream approach to asthma prevention by working with legislators to strengthen ambient air quality polices. Thus, the nurse is moving up along the system to address a leading factor, outdoor air pollution that causes asthma (Fig. 9-2).

FIGURE 9-2 The influence of upstream factors on midstream and downstream effects. (Source: City of Richmond CA. (n.d.). Health in all policies (HIAP) report. Retrieved from http://www.ci.richmond.ca.us/2575/Health-in-All-Policies-HiAP;

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RAND Health. (2015). Understanding the upstream social determinants of health. Retrieved from https://www.rand.org/content/dam/rand/pubs/working_papers/WR1 000/WR1096/RAND_WR1096.pdf)

Two related concepts for environmental health nursing associated with upstream focus are health disparities and the social determinants of health. This focus for public health and environmental health nursing was introduced in a classic article by Butterfield (1990), who reminds the nursing profession that nurses, particularly C/PHNs, serve to reduce risks. C/PHNs are often the “sentinels of surveillance” (Butterfield, 2002, p. 33), who detect unusual illness patterns and respond to environmental emergencies in work and community settings.

With emphasis on data it is estimated that as much as 33% of disease occurrence is attributable to environmental exposures and that the prevalence of environmentally linked health problems such as asthma, neurological problems, certain cancers, and birth defects are all on the rise, a case can be made for nurses to use an upstream framework to assess, monitor, educate, advocate, and create policies to reduce environmental health risks (Frumkin, 2016). See Chapter 1, Figure 1-2 .

Dr. Butterfield's original work, the Butterfield Upstream Model for Population Health (BUMP), applies an upstream public health nursing approach to environmental risks by giving nurses the framework to address the determinants of health and health inequities that influence health outcomes across the life course of a population (Butterfield, 2017).

Specific points that are part of the BUMP framework are:

Assessing and analyzing the environmental exposures for the community or population Establishing health goals that include a multisector approach Determining where interventions will have the greatest impact Aligning with community partners to carry out the interventions Measuring effectiveness of interventions by process, outcome, and impact evaluations

The BUMP needs to be further tested by communiiy/public health nursing research. However, by using an upstream approach, C/PHNs can impact the prevalence of disease within a population by intervening where the root causes exist (Butterfield, 2017).

Health Disparities

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Health disparities are a serious concern for overall health in the United States and globally. As noted in the discussion of upstream approaches to health, environmental factors are basic determinants of health and wellbeing. However, great inequities occur between the environments of people with higher incomes and those of low-income communities, people of color, and tribal and indigenous populations.

There are complex relationships between genes and environment that are related to social determinants of health (National Institute of Environmental Health Sciences [NIEHS], 2019; World Health Organization, 2020a). Disparities that are directly correlated with environmental exposures include rates of asthma among children, elevated blood lead levels (EBLLs), cancers that are linked to environmental exposures, and lung diseases among adults. Social and economic factors have created disproportionate exposures to pesticides, toxic chemicals in the workplace, poor indoor air quality in schools, and lead in housing.

At the federal level, the U.S. government responds to health disparities related to children's health through the President's Task Force for Environmental Health and Safety Risks to Children. This interagency effort includes 18 federal departments and White House Offices, including the EPA and Departments of Agriculture, Health and Human Services, Education, Energy, Housing and Urban Development, Justice, Labor, Transportation, and Homeland Security (National Institutes of Health [NIH], 2016). Issues that are being addressed include lead exposure, asthma disparities, healthy settings, and chemical exposures.

Social Determinants of Health According to the WHO, social determinants of health are defined as “the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels” (WHO, 2020a, para. 1).

Social determinants of health include a number of social factors that affect families and communities, such as education, housing conditions, options for safe and active transportation, access to health care services, access to healthy food, employment and income, neighborhood environment and safety, and the quality of the built environment, such as parks, buildings, and green spaces (see Chapter 23). These social factors and nonchemical stressors contribute to the inequities in health outcomes, burden of disease, and quality of life (Fig. 9-3).

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FIGURE 9-3 Infographic “What Affects Health.” (Reprinted from https://www.cdc.gov/chinav/docs/chi_nav_infographic.pdf; data from www.countyhealthrankings.org.)

Environmental Justice Closely related to social determinants of health and health disparities is the issue of environmental justice. The EPA defines environmental justice as “the fair treatment and meaningful involvement of all people regardless of race, color, national origin, or income with respect to the development, implementation, and enforcement of environmental laws, regulations, and policies” (EPA, 2020a, para. 1). The key difference between social determinants and environmental justice is that the former addresses social factors that contribute to health disparities, whereas environmental justice is responsive to the inequities in the distribution of environmental hazards and exposure risks. The federal government took action to address environmental injustice though President Clinton's Executive Order 12898 in 1994 (EPA, 2020a, 2020b).

In communities across the United States, people of color, minorities, people with low income, and tribal communities bear a higher burden of exposures to environmental risks where they live (Brugge, 2016; EPA, 2020a). Children are at particular risk in such disadvantaged communities, where they have cumulative risk from exposures in homes, schools, and neighborhoods. Developmental and behavioral factors make children more vulnerable to environmental contaminants, and they have little control over where they live, what they eat, or the socioeconomic factors of their lives (Chakraborty, Collins, & Grineski, 2016).

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Poor and minority children, who are more likely to live in neighborhoods with incinerators, industrial plants, toxic waste sites, and poor-quality housing, show higher rates of asthma, learning disabilities, and EBLLs than do nonminority children and those who come from more affluent families (Leffers, Smith, Huffling, McDermott-Levy, & Sattler, 2016). Cumulative environmental exposures, unique exposure pathways, and chronic psychosocial stress contribute to the environmental health disparities of those living in environmental justice communities (McPartland, Dantzker, & Portier, 2017).

Communities can promote healthier environments through a multifaceted approach to community development, community organizing, and community empowerment by working with advocacy groups, networking, and educational programming (Whitehead, 2015).

Nurses who work in environmental justice communities observe the impact of health disparities and health burdens with their clients who live in poverty or are of minority status. Through community-based participatory research, partnering with local organizations, and collaborating with community members, nurses can build trusting relationships with community members that strengthen their voice to address the environmental risks they face. C/PHNs' skills in building relationships with community members, working collaboratively with community partners, and advocating for change through governmental programs make them important contributors to environmental justice work (Leffers et al., 2016). See Chapter 23 on vulnerable populations and Box 9-3 for further sources of environmental health information and for more in-depth resources.

BOX 9-3 Environmental Health Regulatory Agencies Environmental Protection Agency (EPA) This federal agency was established in December 1970 for the purpose of standard setting, monitoring, and enforcement of environmental protection in order to work for a cleaner and healthier environment for America. EPA is tasked with setting regulations based on scientific evidence that addresses environmental risks in homes, schools, workplaces, and

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natural environments. https://www.epa.gov/history Food and Drug Administration (FDA or USFDA) This is an agency of the USDHHS that regulates food safety, dietary supplements, prescription and over-the-counter pharmaceuticals, veterinary medications, cosmetics, biopharmaceuticals, blood transfusions, medical devices, tobacco products, and products that emit radiation (www.fda.gov/aboutfda/whatwedo/and tobacco products. www.fda.gov/aboutfda/whatwedo/). Consumer Product Safety Commission (CPSC) CPSC was created in 1972 as an agency of the U.S. government to protect the public from risks of injury or death from consumer products. Commonly reported products are cribs, toys, household chemicals, and power tools but include any commercially traded product. As an independent agency, the CPSC does not report to any other agency of the U.S. government (https://www.cpsc.gov/About- CPSC/). Occupational Safety and Health Administration (OSHA) This agency was created in 1970 as a regulatory federal agency of the United States to assure safe working conditions. OSHA sets and enforces standards for health and safety in work environments (https://www.osha.gov/about.html).

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Determining Risk Merriam-Webster dictionary defines risk as “something that creates or suggests a hazard” (2019, para. 2). In the case of environmental health risks, exposure to a toxic substance within the environment creates a hazard to human health and thus increases risk of illness or disease. C/PHN must rely on the existing science to assess and determine environmental risk to communities. Nurses determine risk by relying on risk identification frameworks.

One such framework is the precautionary principle, which states, “When an activity raises threats of harm to human health or the environment, precautionary measures should be taken if some cause and effect relationships are not fully established scientifically. In this context the proponent of an activity, rather than the public, should bear the burden of proof” (Science and Environmental Health Network [SEHN], 2018, para. 6). The precautionary principle relies on credible evidence to determine an action to protect the population from a potential environmental health risk and is rooted in precaution, scientific uncertainly, and human rights.

The ANA and the American Public Health Association adopted the precautionary principle in 2006 as a measure to protect public health, as noted in a classic article by Chaudry (2008). It is used when there is limited evidence to determine risk, but there are concerns of threats to human health. As scientific methods have advanced, public health practitioners, including nurses and policy makers, have sought to better understand the impact of the environment on the health of communities.

Recently, health risk assessments and health impact assessments (HIA) have gained greater use in the United States. These assessments provided a more comprehensive and systematic examination of a potential environmental health risk and thus addressed limitations of the evidence that result in the need to rely on the precautionary principle.

The health risk assessment is a systematic evaluation of risk of a specific exposure. It involves four steps: (1) identification of the hazard; (2) exposure assessment (determining how are people exposed, who is at risk, and who is most vulnerable); (3) characterization of the health risk (determining whether the risk exists, how the exposure presents in humans, and what the toxic levels of exposure are); and (4) risk management: if there is a health risk, identifying how it can be managed and reduced (Finland National Institute for Health and Welfare, 2018).

An HIA is a systematic method of evaluating a planned change to a community before the change occurs. The purpose of a HIA is to inform decision-makers of the impacts of a proposed change on the health of the

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population. An HIA has six steps: (1) screening, (2) scoping, (3) assessment, (4) recommendations, (5) reporting, and (6) monitoring and evaluation (Quattrone, Callahan, Brown, Lin, & Pina, 2018).

Public health nurse Cynthia Stone, DrPH, RN, has identified the HIA as a valuable tool to address the health risks of communities. She has taken leadership in HIAs and developed HIA courses at Indiana University. Dr. Stone is also the editor-in-chief of Chronicles of Health Impact Assessment. An example of the application of HIA (support of a full service grocery store in a food desert neighborhood) can be found at https://pdfs.semanticscholar.org/7d28/bef26232f0ee8796abb1bb788480674e 4c4c.pdf.

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Specific Vulnerabilities Some groups are at more risk during specific periods of physical development or due to existing health issues or from social or environmental exposures related to where they live, work, or attend school. Exposures for pregnant women create a number of risks to both the mother and fetus and can produce lifelong or intergenerational adverse outcomes. Some of these effects include fetal loss, low-birth-weight infants, menstrual abnormalities, recurrent miscarriage, malformations of the reproductive system, reduced fertility, hormonal changes, intrauterine growth restriction, altered semen quality, neurodevelopmental performance, and alterations in onset of puberty (Chan, Chalupka, & Barrett, 2015; Kim et al., 2018; St. Cyr & McGowan, 2018).

Infants and children are at risk due to their stage of physical development, behavioral factors, and specific environments, such as neonatal intensive care units, schools, and homes. Children's exposures begin in utero, when many pollutants reach the developing fetus.

Although breastfeeding is the best source of infant nutrition, many chemicals, such as polychlorinated biphenyls (PCBs), dichlorodiphenyltrichloroethane (DDT), dioxin, and benzene, have been identified in breast milk. The stage of physical development of the respiratory, neurological, and excretory systems can also lead to increased risk of exposure and decreased ability to metabolize toxins.

Childhood behaviors such as hand-to-mouth exploration, crawling and playing on or near the ground, and use of toys all contribute to vulnerability to environmental hazards. Toxic materials on floors, in soil where children play, and in playthings (e.g., pressure-treated wood, toys, and paints) can increase risk for childhood exposures. Exposures to lead, mercury, and PCBs increase the risk for developmental disabilities. Studies suggest that the rise in attention deficit hyperactivity disorder, as well as antisocial and aggressive behavior diagnoses and possibly autism, can be attributed to the harmful effects of neurotoxic agents in the environment (Kalkbrenner, Schmidt, & Penlesky, 2014; Kim et al., 2018; Schmidt et al., 2017).

One specific type of vulnerability involves a chronic disease arising from complex interactions between the environment and the genes. Epigenetics is the field of study that examines the gene–environment interaction to study the processes in which genes are expressed differently as a result of environmental influences (EPA, 2016). Endocrine-disrupting chemicals (EDCs) mimic or block natural hormones in the human body and are linked to changes in genes inherited by offspring (English, Healy, Jagais, & Sly, 2015).

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One example of epigenetic change was the use of diethylstilbestrol (DES) to treat women at risk of miscarriage. Female offspring of mothers who took DES showed increased rates of vaginal adenocarcinoma. Other cancers (breast, pancreatic) may now linked to the estrogen taken by their mothers during pregnancy (Troisi et al., 2019).

In addition, a landmark long-term follow-up study of 4,653 women who were exposed to DES in utero (comparison group of 1,927 women not exposed) found that those women exposed to DES while in utero were 1.42 to 3.77 times more likely to experience reproductive problems such as infertility, spontaneous abortion, preterm delivery, loss of second-trimester pregnancy, ectopic pregnancy, preeclampsia, stillbirth, gynecological conditions such as early menopause, grade 2 or higher cervical intraepithelial neoplasia, and breast cancer at 40 years of age or older (Hoover et al., 2011). Current perspectives on DES show that some of these effects occur in DES- exposed daughters and potentially future generations, as DES is considered a “biological time bomb” that requires continued study (Al Jishi & Sergi, 2017, p. 71).

Experts argue that the genetic changes that result from epigenetic processes because of developmental exposure to environmental stressors create negative effects on the health of future generations and contribute to rising rates of neurological conditions, alterations in reproductive organ development, and cancer (Grandjean et al., 2015).

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Sciences for Environmental Health Environmental health sciences include environmental epidemiology, toxicology, risk assessment, and risk management. In Chapter 7, you learned about the principles of epidemiology. Environmental epidemiology is a particular branch of epidemiology that focuses on environmental exposures and the risks that contribute to adverse health effects such as cancer, developmental disabilities, neurological problems, reproductive health issues, or death. Environmental epidemiology seeks to understand the specific vulnerabilities of population groups, to understand how toxic exposures adversely affect health, and to contribute to public health policies that address risk and risk management (National Cancer Institute, 2018).

Toxicology is the study of the adverse effects of chemical, physical, or biological agents on living organisms and the ecosystem, including the prevention and amelioration of such adverse effects” (Society of Toxicology, 2020, para. 1). Toxicants are those substances that are harmful and made by humans or result from human activities, in contrast to toxins that are naturally produced. By studying the physical properties of chemicals, scientists are able to examine the toxicity of chemicals as manifested by enzyme inhibition, cytotoxicity, inflammation, necrosis, immune hypersensitivity or immune suppression, neoplasia, and mutagenic reactions.

These processes should be familiar to nurses, because they parallel the effects and adverse effects of pharmacotherapeutic chemicals. Chemicals are classified as alcohols, solvents, heavy metals, oxidants, and acids and may be found as industrial wastes, agricultural chemicals, waterborne toxicants, air pollutants, or food additives. Factors such as dose level and timing can make a difference in efficacy or toxicity of a drug; dose and timing can also affect the toxicity of chemicals. Toxicity is affected by factors such as gender, age, lifestyle, diet, genetics, and disease states.

Furthermore, exposure pathways, or the routes by which a chemical enters the body, can affect toxicity, absorption, and metabolism. For example, children have less well-developed metabolic processes and are less able to detoxify chemical exposures. Likewise, older adults have reduced defense mechanisms in their lungs, skin, and other systems that make them more prone to adverse health effects (Gangemi et al., 2016). Nurses can learn more about toxicology and risk of specific toxicants through the National Library of Medicine (2020) TOXNET site, available at http://toxnet.nlm.nih.gov/.

Although health care screening does not test for most hazardous chemicals, some studies highlight the importance of biomonitoring. Biomonitoring refers to the body's burden of toxic chemicals or, more precisely, the “standard for assessing people's exposure to chemicals that may be toxic, and for responding to serious environmental public health

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problems” (CDC, 2017b, para. 1). Nurses can learn more about the CDC National Biomonitoring Program on their Web site: https://www.cdc.gov/biomonitoring/index.html.

Scientists identify health risks from epidemiology and toxicology, which provide information for government agencies to regulate hazards to human health (EPA, 2018b). For example, the EPA uses risk assessments to “characterize the nature and magnitude of health risks to humans (e.g., residents, workers, recreational visitors) and ecological receptors (e.g., birds, fish, wildlife) from chemical contaminants and other stressors that may be present in the environment” (EPA, 2018a, para. 4).

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CORE FUNCTIONS OF PUBLIC HEALTH

The U.S. Department of Health and Human Services has identified 10 essential public health services, which are divided into 3 core functions: assessment, policy development, and assurance (see Chapter 2). These services have become the national Environmental Health Performance Standards (CDC, 2017a). They are used to guide community-level environmental health interventions (CDC, 2016, 2018a).

Assessment: investigation of health hazards, surveillance of health issues, examining causes, and assessing needs. Activities include

Monitoring community environmental health status Diagnosing and investigating community environmental health hazards

Policy development: science-based decision-making and education of the community to create involvement to develop polices:

Informing, educating, and empowering community members regarding environmental health Mobilizing community partnerships and activities to recognize and address environmental health problems Developing policies and efforts that support individual and community environmental health

Assurance: seeks innovative solutions to health issues, guarantees necessary services, and provides oversight to policy implementation:

Enforcement of laws and regulations that protect environmental health and ensure safety Connect people to environmental health services and assure that the services are provided Assure a competent environmental health workforce Evaluate effectiveness, accessibility, and quality of individual and community environmental health services Research to develop new knowledge and solutions to address environmental health problems

C/PHN fulfill these functions but extend them by emphasizing education for health promotion, disease prevention, and integrating nursing knowledge and practice into these functions to advocate for communities (Box 9-4). Additionally, C/PHN work collaboratively with others in the community to promote health. Some of the most common areas of public health nursing

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practice to address environmental impacts on health are schools, homes, and the broader community.

BOX 9-4 Levels of Prevention Pyramid Pesticides Exposures SITUATION: Provide education, resources, and support to prevent and treat pesticide exposures and poisoning. GOAL: Using the three levels of prevention, avoid or promptly diagnose and treat negative health conditions, and restore the fullest possible potential.

School nurses have been leaders in addressing indoor air quality in schools, particularly as rates of asthma in children rise (EPA, 2018h, 2018i), and serving as advocates for integrated pest management (IPM) programs for pest prevention without increasing exposure to harmful toxins.

IPM uses data on life cycles of pests and their environmental impact, along with environmentally friendly, economical methods of pest control, to effectively manage damage done by pests with the least hazardous effects to humans and the environment (EPA, 2017b, 2019f).

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At the community level, C/PHN are involved with efforts to reduce pediatric obesity by participation in efforts to improve the built environment by advocating for safe walking paths, parks, and recreational areas and reducing exposure to pesticides in playgrounds (National Association of School Nurses, 2018).

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Assessment The breadth of environmental health information available exceeds the scope of this chapter. Our discussion is organized around the settings where people live, work, and go to school, the routes of exposure, the types of hazards, and the health effects of environmental toxins (Box 9-5). It is important for nurses working in the community to identify priority environmental concerns where people spend the majority of their time (home, work, school). Although community assessment and epidemiology are essential skills for public health nursing, the ability to perform critical assessments for environmental health requires background in the environmental health sciences.

BOX 9-5 STORIES FROM THE FIELD Chemical Exposure Risks in the Clinical Setting How many chemicals do you come in contact with on a daily basis in your nursing practice? Of particular interest to nurses is the survey conducted by the National Institute for Occupational Safety and Health (NIOSH) that found that American nurses and other health care professionals are at risk of exposure to chemicals in the clinical setting. These chemicals are used to sterilize and disinfect equipment and are the medications, such as chemotherapeutic agents, that are used to treat patients. Exposure to these chemicals can place nurses, their patients, and others in the health care setting at risk of asthma, reproductive problems, and cancer (NIOSH, 2017). Another finding of the NIOSH survey was that health care workers do not know nor do they always follow the proper procedures to reduce the risk

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of chemical exposures in the workplace. These are important environmental health factors for the nurse practicing in the clinical setting to consider. A large-scale study of nurse workplace exposure during pregnancy to sterilizing agents, dangerous drugs, anesthetic gases, and chemicals used in housekeeping found an increase in birth defects among their offspring (Environmental Working Group, 2019). Higher incidences of asthma, contact dermatitis, cancer, and miscarriages were also noted in nurses who reported high exposure rates.

1. How are decisions made about the products used in your facility?

2. Who determines policies and procedures for use of chemicals and medications that can affect the health of staff and patients?

3. Where would you find information about the cleaning chemicals used in your place of practice?

4. Where would you find information to reduce the risk of exposure to chemotherapeutic agents?

5. Develop a plan to share the information you found with other nurses within a health care setting.

Community/Public Health Nursing Assessments In community/public health nursing practice, nurses routinely complete assessments for individuals, families, groups, and communities. There are many assessment tools available to help guide both C/PHN and the people they serve to assess environmental health risks.

Individual Assessments The ecological model of public health offers a framework to consider where to target public health nursing interventions (Fig. 9-1). The framework offers spheres of influence at individual, social sphere or family, community, and national levels. The nurse must first identify the needs of the targeted sphere by assessing the environmental risk.

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At the individual level, individuals should complete a personal environmental health exposure assessment. Ideally, this should be part of every health visit, workplace assessment, or other health history. Though there are some shared characteristics for environmental exposures, individual risks from work, home, school, and recreation all contribute to an individual's overall risk.

The Agency for Toxic Substances and Disease Registry provides continuing education trainings to learn about a variety of environmental risks and how to take an exposure history; see their Web site (https://www.atsdr.cdc.gov/csem/exphistory/docs/exposure_history.pdf; this document includes information on continuing education trainings and, as appendices, an exposure history form and a material safety data sheet).

In addition, they created an environmental exposure history card using the mnemonic “I PREPARE” to aid nurses and other health professionals in adding environmental health exposure questions to patient assessment (Table 9-1). This tool that is both brief and easy to remember can be incorporated into any health assessment easily.

TABLE 9-1 Environmental Health Assessment “I PREPARE”

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Reprinted from Agency for Toxic Substances and Disease Registry. (n.d.). Environmental exposure history. Retrieved from http://www.atsdr.cdc.gov/asbestos/site-kit/docs/IPrepareCard.pdf

While completing an individual assessment, it is important to consider those exposures specific to the workplace, school, or neighborhood. Workplace exposures are often addressed by OHNs and include not only physical hazards such as injuries from machinery, burns, falls, and crushing injuries but also hazardous exposure to toxic chemicals, particulate matter in the form of dust, volatile organic compounds (VOCs) and aerosols, heavy metals, and other chemicals that can contribute to poor indoor air quality (EPA, 2020d). See Chapter 29.

School nurses often address students' exposures in school settings, but it is very important for C/PHNs to identify potential risks to educate parents about environmental hazards in schools. Similar to the workplace, many schools have issues of poor indoor air quality with the increased use of synthetics in building materials and reduced access to outdoor air (EPA, 2020d). Neighborhood exposures affect individual health and are discussed

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in the community assessment section of this chapter. It is especially important to assess for hazards among school-aged children and the routes taken to school and playgrounds. See Chapter 28.

Home Assessments C/PHNs frequently conduct home assessments for case finding, follow-up, screening, or other public health services. Home assessments often involve looking for safety hazards in the home, but do not always include potential environmental exposures. During the home visit, C/PHNs must assess the home for environmental tobacco smoke; the possibility of asbestos, the presence of a carbon monoxide detector and heating sources; lead paint risk; the water source and the possibility of lead pipes (EPA, 2018g); and other potential or actual hazardous materials (Table 9-2). Depending on the region of the country, C/PHNs should ensure that the family has their home tested for radon (EPA, 2019e).

TABLE 9-2 Common Hazards in the Home Setting

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Likewise, family members should be reminded to safely dispose of unused medication and old mercury thermometers. Cleaning products, paints, varnishes, strippers and other home remodeling materials, gardening fertilizers and pesticides (which can be carried into the home on shoes or pets; see Chapter 27), pest management insecticides and other materials, air fresheners, and mold and moisture can all be sources of exposure in the home and land around the home. C/PHN must be well versed in identifying hazardous materials and assess for them in their routine home visits, as noted in a classic, large, two-state study by Butterfield, Hill, Postma, Butterfield, and Odom-Maryon (2011).

Identify everyday products in clients' homes that contain hazardous materials and communicate to them the risk they pose to health and the importance of eliminating them or securing them to minimize risk of exposure (Oneal, Eide, Hamilton, Butterfield, & Vandermause, 2015).

Finally, a home assessment should address nearby environmental hazards or potential hazards such as coal-fired power plants, farms, industries, brownfields (properties where pollutants, contaminants, or hazardous substances may be present), toxic waste sites, highways, and contaminated waterways (EPA, 2018c, 2019g). Frequently, these hazards are visible in the

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neighborhood, but often, there are hidden routes of exposure from contaminated groundwater, ambient air, and contaminated soil. It is important that the C/PHNs is aware of local industry and potential contaminations that can place families at risk in their home.

Below is a list of useful home environmental assessment tools:

A Healthy Home Checklist from the U.S. Surgeon General: https://www.surgeongeneral.gov/library/calls/checklist.pdf Home Environmental Health and Safety Assessment Tool, which is easy to use and addresses key exposure topics (Davis, 2007): https://envirn.org/wp-content/uploads/2017/03/davis-home- environmental-health-and-safety-assessment-tool.pdf Healthy Home Checklist from the Environmental Working Group: https://secure.ewg.org/images/EWG_HealthyHomeChecklist_201710.p df

Community Assessments A comprehensive community health assessment considers environmental factors in a number of ways. In Chapter 15, community health assessment is introduced with a focus on aspects of the community that promote health or provide risks to health. Environmental assessment refers to the natural and built environments.

Community assessment is central to public health nursing practice and to the core functions of public health. Typically, a windshield or walking survey is useful for observation of environmental hazards (see Chapter 15). By knowing likely hazards in the community, C/PHNs can identify many possible environmental risks simply by observation.

Various tools have been developed to help nurses assess for environmental risks. Though most community assessment tools address environment, C/PHNs must also consider specific threats that may not be covered by general community assessments. To assess air quality, for instance, nurses should look for visible sources of air pollution from smokestacks, identify exhaust from vehicular traffic, and learn of significant industries, power sources, and incinerators in the community.

To assess water quality, C/PHNs must identify the source of drinking water as public or private, understand water treatment and quality, recognize evidence of pollution and whether there are fish alerts for local waterways, examine stagnant water and possible waterborne risks, and identify issues related to sewer function and possible contamination, as well as the likelihood of floods and other water emergencies (USGS, 2018b).

To assess land, nurses must consider both current and former land use. Superfund refers to funding made possible by the Comprehensive

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Environmental Response, Compensation, and Liability Act of 1980 to address those contaminated areas of the United States that needed to be remediated; the EPA administers the funding. Well-known examples of Superfund sites in which land contamination caused public health disasters are Love Canal in New York State and Times Beach, Missouri. Nurses must be aware of such sites in their communities, which are listed on the National Priorities List and can be located by searching on the EPA Web site: https://www.epa.gov/superfund/superfund-national-priorities-list-npl (EPA).

Brownfield sites refer to real “property, the expansion, redevelopment, or reuse of which may be complicated by the presence or potential presence of a hazardous substance, pollutant, or contaminant” (EPA, 2018c, para. 1). In 2018, the Brownfields Utilization, Investment, and Local Development (BUILD) Act was ratified to bring more opportunities for sustainable local development and to redevelop brownfield sites that still required remediation (EPA, 2018c, 2019d). Nurses should monitor the impact of the BUILD Act of 2018 and advocate that the goals of this act serve their communities.

Built Environment The built environment refers to all aspects of our environment that are not naturally occurring and includes not only the physical structures (e.g., homes, schools, workplaces, dams, roadways, buildings, energy sources) but also the features that contribute to social cohesiveness or disruption (Fig. 9-4). The impact of the built environment includes indoor and outdoor physical environments, which in turn affect the social environments where people live, work, and engage with others. Considering that Americans spend upwards of 90% of their time indoors, our built environment can have significant impact on our health (Robert Wood Johnson Foundation, 2018).

FIGURE 9-4 Neighborhoods, or the built environment, can contribute to population health or illness.

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In recent years, there has been a shift in community development to consider the influence of the built environment on community health and cohesion. Evidence suggests that many physical and mental health problems are related to the built environment, such as asthma, cardiovascular disease, lung conditions, obesity, and cancer (Ying, Ning, & Xin, 2015). Increasingly, communities are promoting social engagement and human health in the built environment by improving public transportation, promoting areas for walking and biking, enhancing green spaces, and addressing sustainable energy sources (Koehler et al., 2018).

Many U.S. cities are addressing issues related to community/public health and the built environment by implementing the UN SDGs. The UN Sustainable Development Solutions Network ranks U.S. cities in meeting the SDGs, which serves as an indication of impacts of the built environment on community health http://unsdsn.org/resources/publications/leaving-no-u-s- city-behind-the-2018-u-s-cities-sdgs-index/.

Another C/PHN role is to assess the quality of the housing. Buildings that were constructed prior to 1978 are likely to have lead-based paint, and homes built before 1987 may have lead soldering in the plumbing that delivers household drinking water (Hanna-Attisha, LaChance, Sadler, & Schnepp, 2016). Homes or buildings constructed between 1930 and 1950 are likely to have asbestos in the insulation, as well as in the hot water and steam pipes (U.S. Consumer Product Safety Commission, 2018).

The overall condition of the community indicates sanitation factors, safe waste disposal, and potential sources of contamination. The location of schools, playgrounds, and public transportation and access to green spaces should be part of the community assessment. Examination of the overall community environment provides C/PHNs with essential information about how the environment is likely to impact the residents' health (Box 9-6).

BOX 9-6 PERSPECTIVES

A Student Viewpoint on Environmental Health in Health Systems As a nursing student, I was bothered by the amount of waste I saw in the hospital during my clinical rotations. When we

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covered environmental health in class, I learned that while healing patients, health systems also contribute to greenhouse gases, use toxic materials to maintain the patient care units, and generate 29 lb of waste per patient bed per day (Slutzman, 2018). I did not want to be part of a health system that was contributing to pollution and illness.

I spoke to my nursing professor, and we both agreed that education is the way to make the change. With the support of my professor and the simulation lab staff, I developed a waste reduction program for the students within my nursing school's simulation lab. I started with the urinary catheterization lab and taught the sophomore students about hospital waste and what items can be recycled, reused, and must be discarded. By weighing the reusable, recycled, and discarded items from the urinary catheterization lab, I demonstrated the impact that education and end-use product management can have. The faculty, simulation lab staff, and students were excited to see that they could make a difference in the environment by being aware of end-use product management.

As I prepared for the educational session for my fellow nursing students, I learned where to find information about products that are used in the hospital. I looked first at the USDHHS Household Products Database (http://householdproducts.nlm.nih.gov/) to learn more about the types of exposures that the staff and patients might have in the hospital setting. Through my research, I also learned about hospital Green Teams or Sustainability Teams that support institutional sustainability in purchasing, foods for dietary services, energy use, waste management, and product safety. Nurses can serve on these important hospital teams and support green practices on their units. I also learned about two organizations that support this important work:

Practice Greenhealth (https://practicegreenhealth.org/) and Health Care Without Harm (https://noharm.org/) Health Care Without Harm (2020b) (https://noharm.org)

When I look for my first staff nurse position, I am going to seek employment at a hospital where I can serve on the Green Team so I can continue to have an environmental health focus in my nursing career. Source: Slutzman, 2018.

Marina, senior nursing student

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Climate Change Climate change is our greatest global public health threat (Costello, Montgomery, & Watts, 2013; Costello et al., 2009; Desmond, 2016). Climate change “refers to significant changes in global temperature, precipitation, wind patterns and other measures of climate that occur over several decades or longer” (Fig. 9-5; UC Davis, n.d., para. 1).

FIGURE 9-5 Climate change is related to melting ice caps, warming oceans, and increased volatile weather patterns.

Unfortunately, in the United States, instead of addressing the realities of climate change, it has become politicized, leading to inaction and avoidance of our very serious reality. For example, the U.S. EPA has removed most of the documents concerning climate change and its impact on human health from its Web site, and, in 2017, President Trump withdrew the United States from the Paris Climate Agreement.

The Paris Agreement is an international agreement of signatory countries to limit greenhouse gas emissions in an effort to keep temperature rise below 2°C of preindustrial temperatures and to target temperature reduction to 1.5°C. The target of 1.5°C preindustrial temperatures has been further supported by a sobering report from the Intergovernmental Panel on Climate Change (IPCC, 2018), in which the world's leading climate scientist stated that to avoid severe impacts of climate change, the world must reduce carbon emissions by 45% now.In 2018, the National Oceanic and Atmospheric Administration found the average temperature (all land and ocean surfaces) to be 1.42°F higher than the average 20th century temperature. This was the fourth hottest year ever recorded (Lindsey & Dahlman, 2019; EPA, 2020e).Temperature changes affect weather patterns that can result in more frequent extreme weather events, disease outbreaks, food and water shortages, and changing migration patterns (see Boxes 9-7 and 9-8).

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BOX 9-7 What Do You Think?

Climate Refugees In addition to those already affected, it is estimated that by 2050, 143 million people around the globe will be climate refugees. In 2017, between 22.5 and 25 million people were displaced due to sudden severe weather events such as forest fires and flooding. More climate migration will occur as slow-onset changes like rising sea levels and air pollution increase. Eight western Pacific islands have already submerged, with a projected 48 being under water by 2100 (Podesta, 2019).

One example in Louisiana highlights the dire circumstances. Isle de Jean Charles, about 50 miles southwest of New Orleans, was first settled by a Frenchman who described it not as an island, but as a ridge covered with live oak trees and encircled by swampy marshlands. Native American tribes later settled there, hunting, trapping, fishing, raising domestic animals, and growing rice. In 1953, the marshland was linked to the mainland by a 2-mile causeway. Now the island is 98% submerged into the Gulf of Mexico and is only a quarter-mile wide and two miles long. From a high of 300, now there are only 40 residents remaining. Over the last 20 years, six hurricanes have pummeled the island. Although residents are conflicted about being relocated to the mainland, they will eventually become climate refugees (Jarvie, 2019).

1. Is climate change a driver for the increase in Central Americans requesting asylum at the U.S. southern border?

2. How many Puerto Ricans left their island country to resettle to the U.S. mainland? What percentage have returned?

Source: Jarvie, 2019; Podesta, 2019.

BOX 9-8 What Do You Think?

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Pandemics and Pollution Italy is considered a leader in lowering greenhouse gases, having reduced greenhouse gases 30% between 2004 and 2018. In mid-March 2020, satellite readings revealed a rapid drop in nitrogen dioxide levels since January. Because of the COVID-19 outbreak and isolation measures enacted in the northern part of Italy, fewer diesel-powered cars were being used as people remained in their homes. Time-lapse maps showed striking results, similar to even more dramatic results noted earlier in China, where the disease outbreak began (Mooney, Muyskens, Dennis, & Freedman, 2020). Although these changes are temporary, they demonstrate how humans have an impact on their environment. What other changes might occur if the trend continued?

Nurses are in a position to take a lead in addressing climate change through individual, professional, local, and national mitigation, adaptation, and resilience strategies. When assessing communities, the nurse should note vulnerable groups such as pregnant women, infants, children, older adults, people with disabilities, non-English speakers, and the poor. In addition, communities may experience risks related to food and water quality and availability, heat stress for those most vulnerable, increased air pollution, and severe weather-related events. Severe weather events such as flooding, droughts, hurricanes, and tornados require emergency preparedness and disaster response from the public health sector (EPA, 2020e; U.S. Global Change Research Program, 2016, 2018).

Specifically, C/PHNs must be prepared for surge events by developing skills such as the ability to (1) be personally prepared, (2) comprehend state and local disaster plans, (3) conduct a rapid needs assessment, (4) investigate outbreaks, (5) perform public health triages, (6) communicate risk effectively, (7) participate effectively in mass dispensing interventions, and (8) respond after the event to the debriefing and public health impact of the event, as outlined in a seminal article by Polivka et al. (2008, 2012). Nurses

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need to be prepared for inadequate resources and infrastructure, as well as the lack of electricity and technology (Ruskie, 2016).

Nurse leaders are disseminating timely and accurate information for nursing practice through resources and collaboration with national organizations. All nurses must understand the implications of climate change on health.

Together with nine other organizations, including the National Student Nurses' Association and the Public Health Nursing Section of the American Public Health Association, the ANHE (2019) established the Nursing Collaborative for Climate Change and Health to bring leaders and institutions together to advance climate solutions to protect the health of Americans.

In addition, ANHE has cooperated with Health Care Without Harm to offer the Nurses Climate Challenge. This project educates practicing nurses about the health impacts of climate change so that they, in turn, can educate their nurse colleagues about climate health. This program can be accessed at https://nursesclimatechallenge.org. Another valuable resource for nurses is the U.S. Global Change Research Program report, Forth National Climate Assessment (2018). See Box 9-9 for what you need to know about climate change.

BOX 9-9 PERSPECTIVES

A C/PHN Viewpoint on Climate Change In June 2017, President Trump announced that the United States would withdraw from the Paris Agreement to reduce greenhouse gas emissions (Dalton, 2017). However, the United States did sign on to the Paris Agreement rules that were established during COP24, or the Conference of the Parties to the U.N. Framework Convention on Climate Change, in December 2018 in Katowice, Poland. This may have been in response to the

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Intergovernmental Panel on Climate Change (IPCC, 2018) scientific report that the world must come together to keep temperature rise below preindustrial temperature increase of 1.5°C.

The WHO has noted that health professionals globally must be knowledgeable and prepared to respond to the health impacts of climate change. The political volleying of climate change in the national and international arenas can be challenging, especially when trying to maintain a nonpolitical stand and advocate for public health.

As a C/PHN, I feel the best response is to focus on the scientific evidence related to climate change and health. C/PHNs should be aware that the world's leading climate scientists from the IPCC have made recommendations after vetting and reviewing the global scientific evidence. Furthermore, when addressing climate change, a local response makes it easier to avoid the politicization of climate change. Communities in the United States and globally have been affected by unprecedented hurricanes, drought, and wildfires. These events have a direct impact on human health. Other health impacts include poor birth outcomes, malnutrition, water quality and disease, vector-borne diseases, respiratory diseases, and psychological impacts (U.S. Global Change Research Program, 2016). Certain vulnerable populations such as infants, children, and older adults are at higher risk for adverse health outcomes as well at those living in poverty.

This is a global health issue for all nurses. C/PHNs must be prepared to address the health impacts of climate change for the populations they serve (Leffers & Butterfield, 2018). This includes mitigation of climate risk, adaptation to climate health impacts, and building resilient communities and health systems (Leffers, McDermott-Levy, Nicholes & Sweeney, 2017). Communicating climate risk to gain community action can be a challenge. You can find current research and weather trends at the National Oceanic and Atmospheric Administration website (https://www.noaa.gov/categories/climatechange), and EcoAmerica has a climate communication resource that can support a C/PHNs climate work with communities: https://ecoamerica.org/wp- content/uploads/2017/03/5_ea_15_steps.pdf Source: Dalton (2017); IPCC (2018); Leffers & Butterfield (2018); Leffers et al. (2017); U.S. Global Change Research Program (2016).

Land Use

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Topics that must be considered when conducting community health assessment to address land use include zoning regulations and enforcement, industries and their toxic releases, types of transportation, sidewalks, bikeways, public transportation, recreational space including green space, what fertilizers or pesticides are applied to the fields, safe play areas for children, and information regarding a tree ordinance to promote health environments (EPA, 2020b).

School locations should be examined for accessibility by foot or bicycle, the safety of the surrounding area, and the use of pesticides on school fields. The community should be assessed for commercial lots, their safety and use, and vacant lots or unused property. Specific commercial businesses such as gas stations, auto repair shops, and dry cleaners are often common sources of toxic exposures (Leffers et al., 2016).

If the community has agricultural areas, these must be assessed for irrigation practices, use of pesticides, runoff, and land use practices. In addition, waste can be a source of environmental hazards. C/PHNs must assess for the presence of landfills or municipal waste incinerators, medical waste incinerators, and municipal trash collection or dumpsters throughout the community (Leffers et al., 2016).

Land use and transportation patterns and plans can influence the health of the community. The design of a city, community, or neighborhood affects physical activity, automobile dependence, ability of those of older age and those with physical disabilities to navigate the community, and opportunities for children to walk to school. Community design also highlights concerns for environmental justice when those who live in areas of low accessibility and high exposure to pollution are more likely to be of minority status or living in poverty (Leffers et al., 2016).

There is need for further research that includes assessing (Leffers et al., 2016):

Walking as an indicator of community health Physical activity levels and contributory factors The public health consequences of public safety design choices The types and determinants of travel to school The influence of community design on risk of injury The influence of community design on emissions of overall and specific pollutants Physical activity, mobility, and social integration in persons with disabilities Social equity and health outcomes in relation to community design The influence of physical setting characteristics on mental health The impact of community engagement on environmental health

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For example, studies of air quality exposures of bicyclists in urban settings have shown that they are exposed to higher levels of air pollution while biking in areas of heavy vehicular traffic (Cole, 2018; Hofman, Samson, Joosen, Blust, & Lenaerts, 2018). As communities transition to sustainable practices with more walking and biking areas, considerations should be made to reduce environmental risks for walkers and bikers in areas of high vehicular traffic.

Types of Toxic Exposures

Air Air quality is a major variable in the health of populations. People living in areas that have poor air quality experience higher rates of disease and adverse health effects. Climate change contributes to air pollution and adversely affects health.

Ambient air, or outdoor air, can be affected by a number of air pollutants. Air pollution is composed of a variety of materials such as aerosols, criteria air pollutants (carbon monoxide, lead, ground-level ozone, nitrogen dioxide, sulfur dioxide, particulate matter), VOCs, and hydrofluorocarbons, as well as radon and other gases that contain harmful toxins (EPA, 2018d, 2020h).

In response to the Clean Air Act of 1970, air quality is monitored by the EPA. In an effort to inform citizens about the air quality in their own communities, the EPA created the Air Quality Index (AQI) (see ), which is often reported in media sources on a daily basis. The AQI is calculated for four of the six criteria air pollutants (ground-level ozone, particle pollution, carbon monoxide, and sulfur dioxide) to see if they exceed the national air quality standard set by the EPA, with an emphasis on their effect on health (EPA, n.d., 2018f, 2020h).

The EPA's Web site presents a guide for citizens to understand the importance of monitoring the ambient air, what the six criteria air pollutants are and how they affect health, and efforts to monitor air quality to provide public health advisories (EPA, n.d., 2018d, 2020h). Additionally, the EPA offers the AirNow app, which can be used to monitor regional AQI readings.

The EPA publishes a Plain English Guide to the Clean Air Act available on their Web site for the public to learn more about air quality (EPA, 2018f, 2019c).

Reports from the EPA monitoring of air pollution indicate that from 2010 to 2017, the overall levels of the six major pollutants measured by the federal government (carbon monoxide, ozone, sulfur dioxide, nitrogen dioxide, lead, and particulate matter) declined by a high of 80% for lead and a low of 5% for ozone because of cleaner cars, industries, and consumer products.

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However, millions of people live in areas that exceeded the national ambient air quality standard (NAAQS) set by the EPA (2019c).

Our health is influenced by the air we breathe both indoors and outdoors. Ambient air is composed of gases such as nitrogen, oxygen, argon, carbon dioxide, hydrogen, neon, helium, and other gases, which are part of the atmosphere. It also contains moisture and particulate matter. The amount of hazardous material that is contained in ambient air is the reason that the Clean Air Act of 1970 was created (U.S. Environmental Protection Agency [EPA], 2020h).

C/PHNs must understand the adverse effects of ambient air pollution to assess, monitor, and advocate for those most vulnerable, which includes children, people with lung disease, older adults, and even healthy individuals who are active outdoors (EPA, 2020f).

Health effects include irritation of the respiratory system with inflammation of the cell lining. This makes the lungs more susceptible to infection. Air pollution can also exacerbate asthma and cause chronic lung disease, reduced lung function, and lead to permanent lung damage. In addition, air pollution causes increased risk of cardiac disease, in particular acute myocardial infarctions and arrhythmias (EPA, 2019c).

Indoor air quality is particularly important for home, school, and workplace assessments. When the AQI for outside air is high, in order to avoid pollutants, people are instructed to stay inside. However, indoor air quality may be poor and expose people to pollutants, microbials, and particulates that may also lead to adverse health conditions.

Air pollution in homes occurs from exposure to heating or combustion sources such as oil, coal, kerosene or wood, radon gas, secondhand smoke from cigarettes, building materials and furniture that contains pressed wood products, carpeting and adhesives that emit VOCs, asbestos in insulation, cleaning products, paints, varnishes, and paint removers, personal care products, and other sources used around the home such as pesticides (EPA, 2020d).

Mild health effects might be headaches and nausea; the more serious health effects include damage to the liver, kidneys, and central nervous system, as well as cancer. In addition, molds, dust, and known asthma triggers in the home can not only exacerbate asthma symptoms but also cause irritation to those with heart and lung conditions.

Air quality in school buildings is very important for staff, teachers, and students (Box 9-10). More than 56 million children and adults spend up to 6 to 8 hours in elementary and secondary school each day. In particular, children are at increased risk for a variety of reasons. Young children are more likely to spend time on or near the floor where toxins are likely to settle; they use more hand-to-mouth behavior, and they take in more air per

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size than adults. Although exposures can be the same as in the home, those who attend or work in schools are in the same air environment for 6 to 8 hours or more where they are exposed to the toxins for long periods of time (EPA, 2018h).

BOX 9-10 Indoor Air Quality in Schools School environments can influence a child's health. This has been demonstrated in research studies. For example, environmental triggers have been shown to worsen asthma symptoms in children and effect student and staff absentee rates. The U.S. EPA offers a program, Healthy Schools, Healthy Kids. This program offers tools for schools regarding school air quality, building structure, transportation, and chemicals used in the building. The EPA AirNow.gov (n.d.) also offers webinars to address school indoor air quality. In addition, the EPA offers the “Air Quality Flag Program” that uses the flag colors that respond to the current local AQI to alert parents and the school community about ambient air quality. This supports parents, children, and the school community to take proper precautions to reduce asthma symptoms

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in the student population. Nurse scientist Laura Anderko, PhD, RN, has worked with Washington, DC, school nurses on the flag program, and school officials have observed the parents respond to the air quality flags and take appropriate action to reduce asthmatic episodes for their children (Tomkins, Anderko, & Patten, 2016). Source: Tomkins et al. (2016); AirNow.gov (n.d.).

Nurses who work in the school setting can access information through the EPA Web site to aid in assessments and interventions to improve air quality in schools. A comprehensive guide to healthier school environments is available on their Web site (EPA, 2018h).

Water The human body is composed of 50% to 60% water, which illustrates how necessary water is for our survival. In public health, the concern is for safe water consumption; safe lakes, rivers, and streams for recreation; and safe waterways to support animal and plant life necessary for transport of nutrients and ecology of the environment. The availability of clean water is becoming a very serious threat to human survival (U.S. Geological Survey [USGS], 2018a).

Globally, 2.1 billion people lack access to safe water, and in 2017, approximately 4.5 billion did not have access to an improved sanitation facility creating threats to safe water (United Nations, 2018).

Poverty is linked with lack of access to clean water and sanitation. Every day, approximately 1,000 children die from a water and sanitation-related diarrheal disease (United Nations, 2018). The critical importance of this issue is born out by the UN including water and sanitation as one of its SDGs. See Chapter 16.

Drinking water is available in two forms: surface water and groundwater. Both are potential sources of contamination or pollution. Surface water sources include lakes, streams, and municipal reservoirs for water use.

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Underground sources, or groundwater, include aquifers that run beneath the ground level and are reached via wells and springs.

Many municipalities use reservoirs and other surface sources for their water supply, whereas in many areas, people must rely upon wells to provide their source of water. Safe drinking water is essential for human health. Public water systems provide water for community members. More than 90% of Americans are served by public water systems. Public water systems are monitored and regulated through the EPA. These regulations require that public water suppliers protect consumers from microorganisms and contaminants that are harmful to health (Box 9-11; EPA, 2018g).

BOX 9-11 STORIES FROM THE FIELD Flint, Michigan The public health of citizens in Flint, Michigan, was compromised in April 2014 when, in an attempt to save money, the city changed its water supply from Lake Huron water supplied by Detroit to the Flint River. Flint was once a booming automotive manufacturing area and the site of early labor strikes and conflicts. Now, the plants are closed, and jobs are scarce. Flint has some of the highest levels of violent crime, preterm birth/infant mortality, domestic violence, and illicit drug use in the state, as well as some of the poorest health outcomes (Hanna-Attisha et al, 2016). It is also marred by the effects of largely unrestrained industrial pollution from the industries that dominated the area for 80 years, as “huge amounts of lead and other toxins were pumped into the air, water, streams, and ground” (Rosner, 2016, p. 200).

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After the water supply switch, residents noted changes in the taste, odor, and color of their drinking water. Flint's water system was old (with estimates of 10% to 80% of it with lead plumbing), and the city has struggled to maintain basic services in the face of declining tax revenues and high unemployment. City officials claimed that the water was fine. By August 2015, researchers had found high levels of lead in the Flint water supply, noting that the water was likely corroding the plumbing lines (Edwards, 2015). In October 2015, the Flint water supply was switched back to Detroit water from Lake Huron, but by then, Flint residents had been drinking and bathing in the tainted water for over a year. In January 2016, President Obama declared federal emergency status to help resolve the water issues (EPA, 2017a).

In the meantime, researchers from Flint's Hurley Children's Hospital conducted a spatial analysis of risk and pre–/post–water system change blood lead levels for over 700 Flint children tested in their facility. They found statistically significant changes in elevated blood lead level (EBLL) in blood collected between the months of January to September 2014, compared to blood drawn from January to September 2015. Before the water system change, 2.4% of Flint children had EBLL, but after the change, the proportion increased to 4.9%; those children living outside Flint with no change in water source had no significant changes and low levels of lead in both samples. There were also statistically significant changes noted on demographic data, with higher proportions of African American children and greater levels for those with socioeconomic disadvantages. The “preexisting disparity in lead poisoning” broadened for those children living in Flint, especially for those with high levels of lead in their home water supply (Hanna- Attisha et al., 2016, p. 286). High blood lead levels can cause learning problems, lower IQ, behavioral issues, attention problems, aggression, and poor academic achievement, and the damage is irreversible (Keuhn, 2016 & Wood, 2019).

By July 2018, the EPA had filed a report of the Flint water crisis and acknowledged lapses in EPA's, Michigan's, and Flint's oversight of water regulations (EPA, 2018e). The EPA agreed to improve the agency's oversight of the Safe Drinking Water Act and revise the Lead and Copper Rule to improve the effectiveness of drinking water monitoring requirements. Although this revision reduced the amount of lead required to trigger action from 15 to 10 parts per billion, critics note that enforcement requirements still appear weak and do not mandate removal of underground lead pipes (Dennis, 2019; EPA, 2018e, 2020h). Studies following the water crisis found that there was a 26% increase in White mothers delivering low-birth-weight babies (there was no statistical significance for Black mothers) during that time

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(Abouk & Adams, 2018). Additionally, 40% of parents surveyed reported changes in their child's health and 65% reported changes in their own health (Heard-Garris et al., 2017). In 2016, criminal charges were filed against nine city and state officials for tampering with evidence, conspiracy, willful neglect of duty, and misconduct; these were dismissed but may be refiled (Kennedy, 2016). Residents are angry and no longer trust officials at any level of government to provide them with clean water (Wood, 2019).

Other communities will be affected by this issue. In 2019, the city of Newark, New Jersey, finally admitted that the city's water had problems with lead levels and distributed water filters on a limited basis. The filters were ineffective; residents needed bottled water because of “ineffective corrosion treatment” at the water treatment plant that permitted lead to leach into the water supply (Fitzsimmons, 2019, para. 9).

It may be decades until we realize the full health impact of this crisis, as more cities with older buildings and infrastructure discover problems with their water. C/PHNs are among those who continue to be concerned about the current situation as well as the long-term consequences of lead exposure for the citizens of Flint, Michigan. Given the recent findings of the potential for multigenerational epigenetic changes in grandchildren linked to lead exposure in pregnant women, this environmental exposure has exponential potential for harm (Sen et al., 2015).

1. What is the role of the community/public health nurse in addressing this issue? Which primary, secondary, and tertiary interventions could be applied?

2. Describe ethical issues, and potential health and social repercussions, related to this case.

3. List issues related to environmental justice in this case and describe how to address them.

Source: Abouk & Adams (2018); Dennis (2019); Edwards (2015); Fitzsimmons (2019); Hanna- Attisha et al. (2016); Heard-Garris et al., 2017; Kennedy (2016); Keuhn (2016); Rosner (2016); Sen et al. (2015); U.S. Environmental Protection Agency (2017a, 2018e); EPA (2020h); Sen et al. (2015); Wood (2019).

The EPA does not regulate private sources of water from private wells. The individual users must be responsible for monitoring their own wells. Private well owners should test their water annually and anytime there is a risk of contamination such as flooding, repair to the well system, changes in water quality, or local construction (EPA, 2018g).