Family & Societal Nursing

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Family-Focused Care to Meet Population Needs Sue Ellen Bell ● Kelly Krumwiede

C H A P T E R 12

C H A P T E R O B J E C T I V E S

1. Compare and contrast individual, family, and population-based health care. 2. Apply an ecological lens to identify multiple levels of health risks associated with human health. 3. Identify the relationships between population-based health and vulnerable populations, health

disparities, and social determinants of health. 4. Explore societal health challenges from multiple perspectives. 5. Analyze the evidence that supports the need for population-based care.

C H A P T E R C O N C E P T S

● Department of Health and Human Services

● Distributive justice ● Environmental health ● Government regulations ● Health care costs ● Health disparities ● Health equity ● Health Resources and Services

Association ● Healthy People Initiative

● Indian Health Service ● Medicaid ● Medicare ● Population health ● Prevention ● Social justice ● State Children’s Health

Insurance Program ● Surgeon General ● Vulnerability

Introduction

The culture in the United States is strongly influenced by individualism and competition, but it is also useful to understand the importance of population needs. Population needs pertain to those of the larger society. Families are made up of individuals who live in neigh- borhoods, communities, and larger societies. An ecological lens can help identify the many interactions and interdependent complexities of populations, society, and people. All are dynamic. They are affected by many environmental risks (e.g., natural hazards, disasters, legislative policies, politics). Distributive justice, government regulations, professional

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Denham, Sharon, et al. Family Focused Nursing Care, F. A. Davis Company, 2015. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/mnsu/detail.action?docID=1963709. Created from mnsu on 2022-06-26 02:27:32.

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guidelines, standards of care, health promotion, prevention, and at-risk groups are all linked with population health. Social determinants of health, culture, vulnerable popula- tions, and disparities also influence health and illness.

Individual care is tailored to meet the unique health needs of one person and generally aims at cure. Medical care addresses diagnosis, treatment, and rehabilitative options performed by physicians and health care practitioners and uses pharmaceuticals, treat- ments, radiation, and surgery to achieve results. Care evaluation generally involves measuring satisfaction levels and seeing if treatments improved health. Although these findings are useful for individuals, they do not solve population problems. Health care delivery tends to focus on provision of medical services and payments for individual disease treatment with little focus on the impact of the environment or society on families or their communities. This chapter explores ways the lives of individuals and families intersect with the larger society. Some relevant ideas introduced in Chapter 3 are built on in this chapter. Instead of thinking about health care as “fixing” problems, this chapter considers ways to prevent them.

A Brief History of Population Health in the United States

Since the late 1800s, medicine and medical education have been focused primarily on the internal environments of care. Diagnostic tools such as the stethoscope, radiograph, mi- croscope, spirometer, electrocardiograph, and chemical or bacterial tests allowed body assessment (Starr, 1982). Treatments were a few effective medications, immunizations, and surgery. Little medical information was available to nonmedical persons. The American Medical Association asserted its influence and physician authority was the rule. Nurses’ practice was directed by physician orders. Tasks (e.g., medication delivery, injections, in- travenous fluids, vital signs, documentation) were their primary work. Independent nursing actions were few. Nurses attended to activities of daily living and provided phys- ical or psychological comfort measures. Patients were dependent on the medical team for all cures.

In 1945, the Hill-Burton Act, a law signed by President Truman, appropriated funds for building hospitals across the nation. Long underserved people such as African Americans began to demand health care equity; it was 1963 before hospitals in the South were required to treat black persons. Nurses started to focus on cultural differences and varied responses among those getting care. After World War II and the Vietnam War, new immi- grants came to the United States. These immigrants held health care beliefs at odds with the Western views of health and treatments for illness (Bell & Whiteford, 1987; Fadiman, 1997; Tripp-Reimer & Thieman, 1981). Since the 1990s, the push has been for equal health care outcomes, not just equal access (Shi & Stevens, 2010).

Transitions in Caring Practices

Nurses discovered that applying the same interventions to all individuals regardless of culture did not result in the same health outcomes. Nurses began to develop ethnonursing methods (Leininger, 1970, 1990; Tripp-Reimer, 1982), a way to see cultural influences and treat people differently. Cultural competence is now an essential skill for nurses and researchers have found various ways to measure it (Schim, Doorenbos, Miller, & Benkert, 2003). Cultural safety assures accessible and equitable health care for all, as power differences cause health beliefs and behaviors to affect care delivery (Papps & Ramsden, 1996; Polaschek, 1998; Richardson & Carryer, 2005). The social context of illness and health includes system level

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factors (e.g., politics, government, religion, economics) that cause disadvantages for some (Powers & Faden, 2006; Shi & Stevens, 2010). Politics and power influence health and illness, so blame shouldn’t be placed entirely on the victim of ill health (Doutrich, Arcus, Dekker, Spuck, & Pollock-Robinson, 2012).

Medical Interventions

Rates of surgical and medical interventions have varied geographically; studies of this type are called area studies (Song et al., 2010). Medical care is often influenced by availability of hospital beds, numbers and types of practitioners, and access to imaging machines (Baker, Fisher, & Wennberg, 2008; Wennberg, Bronner, Skinner, Fisher, & Goodman, 2009). A study of physi- cians in Morrisville, Vermont, found that they performed tonsillectomies more often than others in the state. Tightened constraints on tonsillectomies significantly lowered the rate. Rates of carotid endarterectomies, cesarean sections, and hysterectomies also differed geographically. For example, coronary angiography was performed at a 53% higher rate in Florida than Colorado. Reviews found that the number of specialists in the region was an important factor in higher use (Hannan, Wu, & Chassin, 2006). We live in a global society and the needs of people vary from place to place and diverse community needs must be considered (Box 12.1).

Insurance and Policy

As a result of these area studies, insurers and others called for consistency in medical treat- ment across the country. Efforts to identify best practices were initiated. Insurers saw con- sistency as a way to control costs. Efforts were made to correct medical practice variations through use of medical practice guidelines (Schneider, 2014), which raised concerns that individuals needed to be empowered to work with medical care providers in deciding best treatment options.

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BOX 12-1

Family Tree

Maria do Cé u Barb ieri Figueiredo (Portugal)

Maria do Cé u Barbieri Figueiredo, RN, MSc, PhD, is a nursing professor at the University of Porto Nursing College in Portugal. Her interest in family nursing was first nurtured by Dr. Dorothy Whyte, supervisor of her master’s degree at the University of Edinburgh, United Kingdom. In 2004, she was awarded a PhD in Nursing Science at the University of Porto, where she had examined the nursing care needs of families of children with heart defects using a systemic family approach, based on the Calgary Family Assessment and Intervention Models (Wright & Leahey, 2013). She has helped move family nursing in Portugal forward through several initiatives that include dissemination of the Family Health Nurse conceptual framework of the World Health Organization (2000) in collaboration with the Nursing National Association of Portugal (Ordem dos Enfermeiros). She organized the first family nursing postgraduate education program in Portugal and has supervised several dissertations and theses with a family nursing focus. She provided leadership for the First (2008), Second (2009), Third (2010), and Fourth (2012) International Symposium in Family Nursing in Porto, Portugal, and co-edited e-books with papers presented in these symposia. Dr. Maria do Cé u Barbieri Figueriedo serves as a member of the Family Nursing Practice Committee of the International Family Nursing Association and is Portugal’s representative to the Collaborative Family Health Nursing Project under way in Europe. Her research currently focuses on the family nursing approach in community care and cultural adaptation and validation of instruments for use in family nursing.

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Infrastructure Elements and Environmental Health

Health policy has mostly focused on decreasing cost and improving access, insurance, and services. To date, nurses have had little influence in these areas. Health is mostly influenced by personal lifestyle choices, the environment, and living or working conditions. A 2008 series called “Unnatural Causes: Is Inequality Making Us Sick?” showed how people’s homes and where they work are backdrops to illness and life expectancy (California Newsreel, 2008).

Starting in the 1970s, researchers identified many environmental influences (e.g., lead, smoke, asbestos, mercury, radon, DDT, polychlorinated biphenyls [PCBs], other persistent organic pollutants [POPs]) as risk factors that can lead to illness and disease (Schneider, 2014). In public health, talk about upstream and downstream risks and solutions for health problems is common. Upstream risks are the source of the problem and the complex social and economic concerns related to health and illness prevention. Downstream risks are closely related to the illness or medical event leading to medical intervention or hospital- ization. Much of U.S. health care delivery, including nursing, is based on downstream think- ing, but upstream thinking focuses on solutions (e.g., behavior, environment, policy, social factors). Upstream solutions have the potential to prevent poor health.

Various environmental areas are places where interventions can influence a more healthy population:

• The social environment � Culture—such as the influence of entertainers on lifestyle choices � Economy—lack of resources may limit healthy choices and treatment options � Religion—certain practices can increase health risks � Politics—beliefs in a certain set of principles and the push to ensure the large

majority follows their beliefs � Policy—creation of laws and regulations that require the population to follow a

specific set of behaviors • The physical environment

� Air—high clean air standards that ensure the population isn’t at risk for health problems

� Water—standards that prevent pollution and support sufficient access to the population

� Land—laws and regulations that ensure that, while private property rights are maintained, property owners do not create hazards for others

� Food—inspections to ensure that growers, processors, and importers do not put the population at risk

� Homes—standards that ensure homes are constructed to withstand the weather and other hazards, such as earthquakes, and regulations to ensure that homes don’t have internal pollution problems, such as mold and asbestos, that are health risks

� Worksites—Occupational Safety and Health Administration (OSHA) regulations to ensure reduced risk of employee injury

� Recreation—regulations and standards to ensure that recreational facilities do not put patrons at risk

• The global environment � Emergency response—state and federal agencies that respond to ensure population

safety in a disaster � Travel—regulations that ensure communicable diseases do not cross national borders � Immigration—laws that restrict persons who may harm citizens from entering the

country

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Recent episodes of terrorism, increased violence in some large population centers, chronic diseases, and pathogens resistant to antibiotics are also risks. These threats call for shifts from individual to more family- and population-focused care. See Table 12.1 for a list of some current laws that regulate population health.

Population Health Perspectives

In the United States, medical care expenditures greatly supersede those for population or public health care. Rather than focus on health promotion and disease prevention, money is primarily spent for intensive and expensive individual care after being stricken by illness or disease (Robert Wood Johnson Foundation, 2011). Yet, many underlying causes of death are pre- ventable. In 2010, the leading causes of death were mostly chronic diseases, unintentional in- juries, Alzheimer’s disease, renal disease, pneumonia/influenza, and suicide (Centers for Disease Control and Prevention, 2013). Risk factors for the 10 leading causes of death were tobacco use, diet, physical inactivity, and alcohol consumption. Upstream thinking would mean aiming to prevent the disease from occurring rather than treating the disease after diagnosis.

The health of populations is often measured by life expectancy, infant mortality rate, and other death rates. Of the world’s nations, the United States has the 50th highest life expectancy but spends more on medical care than any other country (Robert Wood John- son Foundation, 2009). High rates of violence, political instability, and AIDS are partially responsible for the low life expectancy in many nations at the bottom of the life expectancy ranking, but the United States does not have these problems. Some might say the United States spends more but has lower beneficial returns or that some people get too much care and others not enough. Nations that provide health care to all and focus on population health have the highest number of estimated life years. Life expectancy, distribution of care services, and long-term costs could change with a greater prevention focus.

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Regulated hazardous air pollution emissions

Regulated safety and emissions standards within the workplace

Mandated testing of substances for human safety prior to marketing

Outlawed open dumps

Regulated hazardous waste from petroleum refining, pesticide manufacturing, and some pharmaceutical production from “ cradle to grave”

Ruled that environmental tobacco smoke was a carcinogen

Created an integrated FDA plan for prevention, intervention, and response to foodborne illnesses

Shifted the focus of U.S. regulators from reaction to prevention of foodborne illnesses

TABLE 12-1 Ex amples of U. S. Environmental L egislation to Improve Population H ealth

LEGISLATIVE ACT AUTHORITY

Clean Air Act (1970)

Occupational Safety and Health Act (1970)

Toxic Substances Control Act (1976)

Resource Conservation and Recovery Act (1976)

Environmental Protection Agency (1992)

Food Prevention Plan (2007)

The FDA Food Safety Modernization Act (FSMA) (2011)

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Primary, Secondary, and Tertiary Prevention

In population health, there are three levels of prevention:

• Primary prevention describes actions taken before the problem exists, such as immu- nizations, purification of water, sewage treatments.

• Secondary prevention aims for early detection and prompt intervention if a problem is found, such as through screening tests (e.g., mammography and colonoscopy).

• Tertiary prevention acts to minimize further complications once a problem is iden- tified, such as diabetes education after diagnosis, medical management, and use of pharmaceuticals.

Traditional medical care mostly aims at tertiary prevention, which tends to be expensive. Secondary prevention can often involve expensive testing or screening. Primary or upstream prevention is the least expensive.

Access to Medical Care

Some medical treatments are very expensive and not always fully covered by health insurance. Wealth and health have been repeatedly linked through research (Anderson et al., 2008; Avendano, Glymour, Banks, & Mackenbach, 2009). Wealth means healthier living condi- tions, ability to buy more nutritious foods, lower stress, and access to better services (Baum, Garofalo, & Yali, 1999; Bird et al., 2010). Longer life is linked with higher socioeconomic status. These factors affect the vulnerability of individuals, families, and communities. Stage of life, culture, health literacy, and the abilities to speak, read, and write English also influence health risks and outcomes. Neighborhood affects access to clean water, social support, and safety. In 2011, Japan’s families experienced a giant tsunami that killed nearly 16,000 people and destroyed homes and reordered lives of those living 6 to 7 miles away. Drs. Nojima and Hohashi are teaching nurses in this nation ways to give family-focused care (Box 12.2).

Fairness in the Distribution of Goods and Services

The burden of lower life expectancy and higher rates of infant mortality falls dispropor- tionately on the poor. Health disparities exist when certain groups do not have the same health opportunities as others and often result from unequal distribution of social goods. For example, we do not choose the family we are born into and so we acquire by default the heritage of our families. Health equity means fairness in the distribution of services and resources so that all can achieve optimal health. Equity cannot be guaranteed because each patient situation is different, but fair apportionment of resources is the optimal goal. Nations address these needs differently.

Social J ustice

A book about social justice noted needs to address the underlying social determinants vital to overall population health (Powers & Faden, 2006). Social justice implies that principles of fairness exist and people deserve equal chances. Some think social justice should be a fifth metaparadigm concept in nursing due to its importance in achieving population health (Schim, Benkert, Bell, Walker, & Danford, 2007). Social justice implies many ideas. For example, distributive justice refers to initiating and supporting action to meet public needs, especially of vulnerable populations (Grace, 2009). Formal systems and laws exist to help decide who gets goods (e.g., food, shelter, clean environment,

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health care) and services. Nurses who think family can advocate for fair distribution of available resources.

Governments and people disagree about what is fair; national consensus seems impossible. In the United States, self-reliance and individual freedom are valued. Distributive justice is usually viewed as equal access and equal shares but not necessarily equal outcomes. Public health advocates think fair distribution can occur only when all have an “even playing field.” Agreement about inequalities must be addressed before resource distribution will change. Health care financing has implications for the health outcomes of the nation’s families.

Lifestyle B ehaviors

Major causes of illness and disease, in the United States and other developed nations, are mostly linked with behaviors or lifestyle choices. Lifestyle risk factors are attributed to tobacco use, high blood pressure, overweight, physical inactivity, alcohol abuse, and unhealthy dietary intake (Danaei et al., 2009). In 2010, heart disease and malignant neoplasms accounted for 47% of all deaths (Murphy, Xu, & Kochanek, 2012). Other contributors to disease are genetic composition (at least 20% of all infant deaths), mi- crobial agents (6%), and toxic agents (4%) (Mokdad, Marks, Stroup, & Geberding, 2004). When large groups of people act in similar ways, these risks are viewed as social determinants of health. For example, the placement of sugary products near the check- out aisle becomes an environmental factor that influences buyers’ choice. Even knowing that items are unhealthy, people may be highly motivated to choose impulsively the less healthy items.

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BOX 12-2

Family Tree

Sayumi Nojima, RN, PHN, DSN (Japan)

Sayumi Nojima, RN, PHN, DSN, is the vice president at Kochi Prefectural University. After receiving a doctoral degree of Science in Nursing from the University of California, San Francisco, she joined the Faculty of Nursing at Kochi Women’s University and started a master’s program that focused on advanced practice and the preparation of certified nurse specialists in family nursing. Dr. Nojima developed the Family Empowerment Nursing Model, which has been extensively used in nursing education and practice in Japan. She is the Chief Editor (with Hiroko Watanabe) of the J apanese J ournal of Family Nursing (Kango Kyokai Publisher). Dr. Nojima has served for many years as a board member of the Japanese Association for Research in Family Nursing (JARFN) and was the vice president of JARFN (2004–2013). In 2011, Dr. Nojima was awarded an Innovative Contribution to Family Nursing Award from the J ournal of Family Nursing at the Tenth International Family Nursing Conference in Kyoto, Japan.

Naohiro Hohashi, PhD, RN, PHN (Japan)

Naohiro Hohashi, PhD, RN, PHN, is a Professor of Health Care Nursing and Department Director, Kobe University Graduate School of Health Sciences. Dr. Hohashi has research and practice expertise with a wide range of subjects, from inpatient (at hospitals) to outpatient and at-home (community) and is guiding a program leading to certification in Family Health Nursing in Japan. He has conducted comparative research on how the family is affected by culture and values in Japan, Hong Kong, and North America. Dr. Hohashi has developed the Concentric Sphere Family Environment Model and the Family Environment assessment tool to measure family functioning. Dr. Hohashi currently serves on the Board of Directors of the Japanese Association for Research in Family Nursing (JARFN). In 2014, he was identified as Transcultural Nursing Scholar of the Transcultural Nursing Society. Dr. Hohashi has created multiple collegial relationships with members of the International Family Nursing Association.

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Population Health Costs

Upstream interventions that occur before the disease or disability are the most effective means for extending life and influencing spiraling health care costs. In 2012, the Institute of Medicine called for doubling the spending on public health. Finances in medical care are focused on acute care and heroic cures for those already sick and fail to promote balanced treatment of personal or community-based prevention (Institute of Medicine, 2012). Current health care systems are inadequately prepared to address population health needs and this can have serious negative consequences for the nation’s families.

Population-Based Health Actions

A population is a collection of individuals with shared personal or environmental charac- teristics (Minnesota Department of Health, 2001). They might share a common culture, ethnicity, language, values, norms, or risk factors. Individual care only improves care for a single person. A population approach considers broader factors that mold health and lead to illness or disease in the larger population.

Imagine you are a nurse in a critical care unit and for the past 6 months you have noticed more adults being admitted for myocardial infarction (MI). Downstream thinking means that lifesaving measures and medical management take place in an inpatient setting for the person with a MI. Upstream thinking asks: Why are MIs occurring at an increasing rate? Upstream thinking keeps records of those with an MI to see what similarities might explain the increase. Results can help answer the question and could lead to preventing the prob- lem. For example, several years ago New York State implemented a comprehensive smok- ing ban that reduced the number of hospital admissions for MI (Juster et al., 2007). Nurses who think family understand the implications of public health measures and help enact policies to make important changes (Box 12.3).

An example of population-based care that demonstrates the interventions at each level of practice is The Heart of New Ulm project, started in 2008 (Hearts Beat Back, 2010). This project, led and financed by a hospital health care system in Minnesota, used many community partnerships. New Ulm, a small city south of Minneapolis, has many residents of German ancestry. Leaders recognized that beer, brats, and butter were often on the menu of the local families. The project aimed to reduce numbers of heart attacks over 10 years (Hearts Beat Back, 2010). Health-screening programs and a variety of community-based programs were available to assist residents to decrease their risks by improving their diets and physical activity, eliminating tobacco use, and addressing social behaviors. Community education programs (e.g., cooking classes, sharing recipes, grocery shopping tours, tobacco

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BOX 12-3

Population-Based Health Practices

Population health considers three levels of practice to change risky behaviors, improve life expectancy, decrease infant mortality rate, and decrease death rates from preventable diseases and injuries:

● Individual-focused interventions (e.g., vaccinations, lifestyle behaviors) ● Community-focused interventions (e.g., safe air and water, housing, safe places to walk) ● System-focused interventions (e.g., homeland security, relief after disasters, prevention of

type 2 diabetes and obesity and their complications)

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cessation series, chronic disease management classes) were available. Community efforts promoted physical activity (e.g., walking/running events and clubs, dance classes, bike riding, aerobic exercise classes). Environmental changes such as constructing sidewalks to improve walking opportunities, creating parks, and initiating tobacco use restriction policies were instituted. Online resources, blogs, and phone applications were created to support local activities and share successes. They took the perspective that health is a shared community responsibility.

Social Determinants of Health

Population health addresses environmental and lifestyle factors of the community to increase survival and decrease morbidity. Social determinants, both economic and social conditions, influence a population’s state of health (Box 12.4). Risk assessments are a first step toward change; then policies, programs, or projects are planned with strategies for implementation and evaluation (Centers for Disease Control and Prevention, 2011b). Coalitions and part- nerships designed for programs that focus on prevention, health promotion efforts, and medical care interventions must be successful.

Health Care Services

In the United States, health care expenditures were about $2.6 trillion in 2010 compared to $256 billion spent in 1980, and only 3% of this money went for population health (Kaiser Health Foundation, 2012). The question of whether this health care system is actually a sick care system was discussed in a film called “Escape Fire: The Fight to Rescue American Healthcare.” Stakeholders and businesses that benefit from the current system will vigorously work to oppose a transition to a prevention-based system; however, the market, being what it is in this country, will adjust once cost savings and opportunity for other types of service providers increase.

Plans to enact the Affordable Health Care Act (ACA) are under way. The ACA focuses on primary and secondary prevention and lifestyle factors and is designed to benefit all

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BOX 12-4

Health Determinants for Individuals, Families, and Communities

The following factors influence health and illness of individuals, families, and population groups residing in various geographical regions:

● Biology (genetics, family history, physical and mental problems) ● Behaviors (alcohol abuse, tobacco use, lack of regular exercise, level of health literacy, stress

management) ● Social environment (e.g., relationships with family, friends, neighbors, and others; faith

communities; schools; government agencies; safety; availability of resources; culture; media; and public transportation)

● Physical environment (e.g., weather, climate change, buildings, recreational settings, neighborhoods, housing, pollutants, agriculture, toxic substances)

● Access to affordable and quality health care ● Policymaking (e.g., smoking bans, tax increases on tobacco sales, litter ordinances, seatbelt laws)

Source: Healthy People 2020. (2011). Ab out healthy people. Retrieved from http://www.healthypeople.gov/2020/ about/default.aspx

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U.S. citizens with investments in wellness, disease prevention, and public health emergen- cies. The federal government aims to partner with states and communities to control such health problems as obesity, health disparities, tobacco use, vaccine-preventable illnesses, and HIV/AIDS. The goal is to increase the effectiveness of public health and improve access to behavioral health services. Family nurses could lead in the coordination of care across home, community, and institutional settings. Investment in prevention and community pro- grams that increase physical activity, improve nutrition, and prevent tobacco use could mean $5.60 is saved for every dollar spent, a savings of $16 billion in 5 years (Levi, Segal, & Juliano, 2009). Problems of high blood pressure, overweight, and obesity are prevent- able. Obese persons are four times more likely to suffer from progressive knee osteoarthritis and other arthritis. Approximately 20% of all cancer cases can be attributed to obesity (Wolin, Carson, & Colditz, 2010). Currently, it is difficult to have programs or initiatives that focus on preventive care (Mayes & Oliver, 2012). Some raise concerns that you can’t see benefits of preventive actions for years or decades.

The ACA is providing vulnerable or at-risk individuals and families access and payment for medical care (Box 12.5). Some health promotion and disease prevention activities targeted toward the family and community are included. Several primary and secondary prevention services for adults and children are also covered (Box 12.6). Persons covered by Medicare also have preventive services covered (Box 12.7). This is the first time medical coverage for prevention has been legislated.

Differences in Health Care Delivery

Nurses who work within the medical approach focus their care on treating disease and ill- ness in acute care settings for individuals; nurses with a public health approach focus on population needs and societal deficits that may cause disease. Both medical and public health approaches are essential for family-focused care. Nurses need familiarity with med- ical approaches, but also need to recognize ways population care can be integrated. Those

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BOX 12-5

Major Policy Changes in the Affordab le Health Care Act (2010)

The Affordable Health Care Act:

● Prohibits health insurers from refusing coverage based on patients’ medical histories and pre-existing conditions.

● Prohibits health insurers from charging different rates based on patients’ medical histories or gender.

● Repeals insurance companies’ exemption from antitrust laws. ● Establishes minimum standards for qualified health benefit plans. ● Covers adult children under parents’ health insurance until the age of 26. ● Requires most employers to provide coverage for their workers or pay a surtax on the workers’

wages up to 8% . ● Expands Medicaid to include more low-income Americans by increasing Medicaid eligibility

limits to 133% of the federal poverty level and by covering adults without dependents as long as neither population segment falls under the narrow exceptions outlined by various clauses throughout the proposal.

● Provides a subsidy to low- and middle-income Americans to help buy insurance; this change will require most Americans to carry or obtain qualifying health insurance coverage or possibly face a surtax for noncompliance.

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BOX 12-6

Preventive Services Under the Affordab le Care Act

After September 23, 2010, the following preventive services are covered without having to pay a copayment, co-insurance, or meet a deductible when provided by an in-network provider: Adults (16 preventive services):

● Abdominal aortic aneurysm (one time screening for men who have ever smoked) ● Alcohol misuse (screening and counseling) ● Aspirin (use for men and women of certain ages) ● Blood pressure screening (all adults) ● Cholesterol screening (adults of certain ages or high risk) ● Colorectal cancer screening (adults over 50) ● Depression (adults) ● Type 2 diabetes (screening for adults with high blood pressure) ● Diet counseling (adults at risk for chronic disease) ● HIV screening (adults at higher risk) ● Immunizations (doses, ages, populations vary) ● Obesity (screening and counseling for all adults) ● Sexually transmitted diseases prevention counseling (adults at high risk) ● Tobacco use (screening all adults and cessation interventions for tobacco users) ● Syphilis screening (adults at higher risk)

Women and pregnant women (private plans began covering August 1, 2012):

● Well-woman visits ● Gestational diabetes screening (for women 24 to 28 weeks pregnant and those at high risk) ● Human papillomavirus (HPV) DNA testing (women 30+ years testing every 3 years) ● Sexually transmitted infections (STI) counseling (sexually active women) ● HIV screening and counseling (sexually active women) ● Contraception and contraceptive counseling (FDA-approved methods, sterilization

procedures, education, and counseling) ● Breastfeeding support, supplies, and counseling (pregnant and postpartum women) ● Interpersonal and domestic violence screening and counseling

Children (27 services):

● Alcohol and drug use (assessments for adolescents) ● Autism screening (18 and 24 months) ● Behavioral assessments (0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to

17 years) ● Blood pressure screening (0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to

17 years) ● Cervical dysplasia screening (for sexually active females) ● Congenital hypothyroidism screening (for newborns) ● Depression (screening for adolescents) ● Developmental screening (children under 3 years and surveillance throughout childhood) ● Dyslipidemia (higher risk for lipid disorders/0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to

14 years, 15 to 17 years) ● Fluoride chemoprevention (supplements for children with no fluoride in water) ● Gonorrhea (preventive medication for the eyes of all newborns) ● Hearing screening (all newborns) ● Height, weight, and body mass index (0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years,

15 to 17 years) ● Hematocrit or hemoglobin screening ● Hemoglobinopathies (sickle cell screening for newborns) ● HIV screening (adolescents at high risk)

C o n t in u e d

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BOX 12-6

Preventive Services Under the Affordab le Care Act—cont’d

● Immunization vaccines birth to 18 years (doses, recommended ages, and populations vary) ● Iron supplements (children 6 to 12 months at risk for anemia) ● Lead screening (children at risk of exposure) ● Medical history for all children throughout development (0 to 11 months, 1 to 4 years, 5 to

10 years, 11 to 14 years, 15 to 17 years) ● Obesity screening and counseling ● Oral health risk assessment (0 to 11 months, 1 to 4 years, 5 to 10 years) ● Phenylketonuria (PKU) screening for genetic disorder in newborns ● Sexually transmitted infection (STI) prevention and counseling for adolescents ● Tuberculin testing (0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years) ● Vision screening for all children

BOX 12-7

Preventive Services Covered b y Medicare

Several preventive services qualify for those insured through a Medicare plan:

● Tobacco cessation counseling ● Screenings (bone mass, cervical cancer, cholesterol, diabetes, HIV, breast cancer, prostate

cancer, others) ● Influenza shots, pneumonia shots, and hepatitis B shots

Medical nutrition therapy to help people manage diabetes or kidney disease

getting medical care return to households and communities and are affected by social de- terminants of health.

Vulnerable Populations and Family Health

Focus on vulnerable populations is needed for global, social, political, economic, and ethical reasons (Shi & Stevens, 2010). These high-risk groups have great health needs due to poor physical and mental health (Shi & Stevens, 2010). As factors relevant to health disparities are considered, three populations are identified (Aday, 1993, 2001):

• Physically vulnerable—high-risk mothers and infants, chronically ill and disabled, persons with AIDS/HIV

• Psychologically vulnerable—mentally ill and disabled, alcohol or substance abusers, those at risk for suicide or homicide

• Socially vulnerable—abusing families, homeless, immigrants, refugees

Vulnerability can be linked with situations such as HIV status and teen pregnancy, expe- riences individuals might have prevented if risky sexual behaviors were avoided (Shi & Stevens, 2010). Moral judgments and political factors play roles in perpetuating some dis- parities. For instance, when condoms or birth control pills are available without shame, many will access them. Gaps in wealth and power can also create vulnerability. Vulnerability is created and resolved through social actions.

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V ulnerability and Public Policy

Vulnerability is influenced by norms, attitudes, beliefs, and values of individuals and fam- ilies living in communities and also by social and health policies. When broad social agreement occurs, points of view become laws at local, state, and national levels. In 2012, 20 grade school children and six staff members were fatally shot at Sandy Hook Elemen- tary School in Newtown, Connecticut. National debates about laws to limit or prohibit gun ownership and screening followed. Although some support laws for background checks and limited magazine rounds of ammunition, many citizens and the National Rifle Association oppose any restrictions to the constitutional right of Americans to bear arms. Opponents of gun control measures cite statistics indicating increased gun violence in com- munities with the most restrictive gun laws. U.S. homicide rates from firearms is 3.3 deaths per 100,000 people yet other countries with restrictive gun laws have much lower rates (e.g., Canada with 0.5 death per 100,000; United Kingdom with 0.1 death per 100,000) (United Nations Office on Drugs and Crimes, 2012). Moral people often disagree about the ways violence should be addressed. Although one group believes reducing ownership of guns will reduce gun violence, an opposing group believes the cure lies in resolving the underlying community problems that encourage violence.

Some societal views about disease are prone to stigma and victim blaming (Mechanic & Tanner, 2007). Links between socioeconomic disparities, life expectancy, and health risks are often viewed as personal deficiencies or attributes (Shi & Stevens, 2010). Individ- uals are blamed for poor health choices. People begin life with diverse circumstances not always under their control. For example, when persons are discharged from an acute setting with a particular medical diagnosis, the same written and oral instructions are often given to college graduates and grade school dropouts. Reading, language, and innate intelligence influence understanding, ability to follow instructions, and care outcomes; instructions need to account for these factors.

Public and Family Health

Public health is defined as “the practice of preventing disease and promoting good health within groups of people, from small communities to entire countries” (American Public Health Association, 2011, para. 1). Public health nursing is defined as “the practice of promoting and protecting the health of populations using knowledge from nursing, so- cial, and public health sciences” (American Public Health Association, 1996, para. 1). In public health, the population is the client, but work with individuals, families, and systems also occurs. Individual care is only a small portion of practice. Public health nurses usually work in a particular geographical region to improve individual and family health. Public health nurses aim to improve the quality of life for a particular population and the greater society. Equity in service delivery despite age, gender, race, and ethnicity is the goal.

Core Functions of Public Health

Three core functions—assessment, policy development, and assurance—guide public health practice that protects individuals and families in a societal context (Institute of Medicine, 1988). Assessment refers to data collection; monitoring population health status, needs, and problems; and dissemination of information. Assessment might identify trends for children with asthma in a particular community and find the reasons for risks. Policy development refers to leadership in developing national, regional, state, and local policies or statutes.

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Nurses work toward policy development to eliminate environmental factors that make asthma worse. An upstream focus is to decrease air pollutants. Assurance refers to making sure that high-priority services are available. Nurses who think family measure the useful- ness and effectiveness of intervention programs. Assurance makes sure public health work- ers and nurses provide competent care. Besides these core functions, 10 essential public health services also serve to guide practice (Box 12.8).

Social Determinants That Influence Family Health

Social determinants include socioeconomic factors such as social class, family income, levels of education, and employment. These factors influence the affordability and location of where families live. Where people live affects other life aspects, such as quality of schools, per-hour wages, safety, violence, and food access. Overcrowding and unsanitary conditions can increase exposure to diseases. Air pollution increases risks for asthma and lung disease.

Probably one of the best ways to influence good health is good nutrition. Several societal factors work against good nutrition and include lack of access to nutrient-dense foods, so- cial relationships and marketing that influence poor food choices, use of processed and prepackaged foods, routine snacking, and busy lifestyles whereby families rarely eat meals together and are likely to eat meals outside the home. Families who share fewer than three mealtimes a week have poorer health outcomes (Neumark-Sztainer, Eisenberg, Fulkerson, Story, & Larson, 2008). Nurses who think family can help families improve nutrition by teaching the basics of good nutrition, label reading, meal planning, food shopping, budg- eting, preparing fruits and vegetables, and home cooking. Surprisingly, in some households no one knows how to prepare meals without prepackaged, processed foods.

Widespread concerns about mental health exist. According to the National Institute of Mental Health (NIMH), some form of mental illness affects about 60 million Americans (1 in 4 adults; 1 in 10 children). Worldwide, 4 of the 10 leading causes of disability are linked with mental disorders. The World Health Organization (WHO) predicts that by 2020, major depressive illness, including depression, bipolar disorder, and borderline personality disorder, will be the leading cause of disability for the world’s women and

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BOX 12-8

Ten Essential Pub lic Health Services

The strength of the public health service rests on its capacity to deliver effectively the following services:

● Monitor health status to identify community health problems. ● Diagnose and investigate health problems and hazards in the community. ● Inform, educate, and empower people about health issues. ● Mobilize community partnerships to identify and solve health problems. ● Develop policies and plans that support individual and community efforts. ● Enforce laws and regulations that protect health and ensure safety. ● Link people to needed personal health services and ensure the provision of health care when

otherwise unavailable. ● Ensure a competent public health and personal health care workforce. ● Evaluate effectiveness, accessibility, and quality of personal and population-based health

services. ● Research for new insights and innovative solutions to health problems.

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children. Children and adolescents are often affected with autism, attention deficit dis- order, anxiety disorders, eating disorders, and psychosis (National Institute of Mental Health, 2013). Without adequate treatment, the social consequences are overwhelming. Costs linked with untreated mental illness are shocking. Stigma and misunderstandings about mental disorders lead to delays in diagnosis and care, particularly for the uninsured, minority, low income, and elderly groups (National Institute of Mental Health, 2005). Families are generally ill equipped to manage severe conditions. Stigma often leads to resistance to treatment, resulting in poorly managed conditions and school failures, home- lessness, physical or emotional abuse, alcohol and substance abuse, unstable employment, and crime (National Alliance of Mental Health, 2005). Nurses who think family consider social determinants when they give individual and family care.

Theoretical Frameworks for Family and Societal Health Care

Nurses can use theoretical models to address such qualities as resilience (Rew & Horner, 2003), health promotion (Pender, Murdaugh, & Parsons, 2011), and self-efficacy (Bandura, 1997). Other frameworks can address community and vulnerability (Fig. 12.1). For exam- ple, the Vulnerability Model (Flaskerud & Winslow, 1998) identifies resource availability, relative risks, and health status. Community unemployment, poverty, violence and crime, schools, community organizations, and availability of grocery stores and farmers’ markets need to be examined. The Chronic Care Model (CCM) is a way to examine system inter- actions linked with disease management (Wagner, Austin, & Von Korff, 1996). Research using the CCM has demonstrated some improvement in care outcomes (Wallace, 2011).

Nurses who think family know household and social factors need to be assessed. When care is planned, wellness, health promotion, prevention, and care management issues can be considered based upon vulnerability. Students and nurses often recognize individual responsibility without considering social implications. Failure to include social determi- nants ignores circumstances and living environments and may prevent selection of the most effective interventions. Review the Family Circle case and talk with others in your class about the choices, priorities, and decisions that need to be made (Box 12.9).

CHAPTER 12 ● Family-Focused Care to Meet Population Needs 339

FIGURE 12-1 Family-focused care is necessary to meet the needs of vulnerable populations.

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The Role of the Government in Population Health and Its Financing

The idea that government should share some responsibility for health care has a long his- tory. It goes back at least to the Greek city-states, where citizens’ taxes supported public physicians. The idea of compulsory participation in a health insurance system is old. In 1798, a Marine Hospital Service was created and owners of merchant ships contributed 20 cents a month into a sickness fund for each employed seaman (Starr, 1982). In the 19th century, labor unions required workers to join relief funds to cover disease and injury treat- ment. Some payers, policy makers, providers, and purchasers have vested interests in per- petuating the current medical delivery system that favors treatment over prevention. Leadership is needed to help citizens identify benefits of focusing on health promotion and disease prevention. Family nurses can do this with individuals as health counseling and education are tailored to household and community needs.

Department of Health and Human Services

In the United States, the Department of Health and Human Services (DHHS) is the main agency dealing with the issues of poverty, vulnerability, and health disparities. An Office of the Secretary and 11 operating divisions provide a wide range of health services (Box 12.10). These agencies perform many tasks and services such as research, food and drug safety testing, and grant issuing. About half of U.S. citizens receive some form of government-supported health care.

The Surgeon General

In the United States, the Surgeon General is appointed by the president and is the head of the Public Health Service Commission Corps. This is the most widely recognized and respected voice of public health issues. The Surgeon General sees that the public is provided with information about personal health and the nation’s health, reports important medical findings, suggests steps that should be taken to increase health, and oversees the nation’s 6,500 uniformed health officers who serve around the world.

Health Resources and Services Administration

Each state and most cities in the United States have their own Department of Health but the federal government takes the lead in defining health activities and goals to improve the nation’s health. The Health Resources and Services Administration (HRSA) is made

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BOX 12-9

Family Circle

Last night you heard a national evening news report that caught your attention. This morning, the headline of your local newspaper contains the same statement in large letters. You read the headline: “For the first time, a generation of Americans is expected to live shorter lives than their parents.”

1. What kinds of things do you think this article would disclose? 2. What do these headlines mean to you, your family, and Americans? 3. What upstream family and population efforts are needed to turn this tide? 4. What actions might a family or population-focused nurse take to prevent the potential

downstream outcomes?

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up of six bureaus and 10 offices (Box 12.11). Several operating divisions of HRSA provide leadership and financial support (Table 12.2). HRSA grants assist uninsured, those with HIV/AIDS, pregnant women, mothers, and children. Financial supports to train health professionals and improve rural community care systems target four goals:

1. Improve access to quality care and services. 2. Strengthen the health workforce. 3. Build healthy communities. 4. Improve health equity.

CHAPTER 12 ● Family-Focused Care to Meet Population Needs 341

BOX 12-10

Department of Health and Human Services Offices

Agencies of DHHS: ● Health Resources and Services Administration (HRSA) ● Food and Drug Administration (FDA) ● Administration on Aging (AoA) ● National Institutes of Health (NIH) ● Centers for Disease Control and Prevention (CDC) ● Substance Abuse and Mental Health Services Administration (SAMHSA) ● Indian Health Services (IHS) ● Office of the Inspector General (OIG) ● Agency for Healthcare Research and Q uality (AHRQ ) ● Administration for Children and Families (ACF) ● Agency for Toxic Substances and Disease Registry (ATSDR) ● Centers for Medicare and Medicaid Services (CMS)

BOX 12-11

Bureaus and Offices of the Health Resources and Services Administration

The Health Resources and Services Administration has six bureaus:

● Bureau of Clinician Recruitment and Service ● Bureau of Health Professionals ● Bureau of Primary Health Care ● Healthcare Systems Bureau ● HIV/AIDS Bureau ● Maternal and Child Health Bureau

The Health Resources and Services Administration has 10 offices:

● Office of Planning, Analysis, and Evaluation ● Office of Rural Health Policy ● Office of Regional Operations ● Office of Special Health Affairs

● Office of Health Equity ● Office of Global Health Affairs ● Office of Strategic Priorities ● Office of Health Information, Technology, and Q uality ● Office of Emergency Preparedness and Continuity of Operations

● Office of Women’s Health

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342 CHAPTER 12 ● Family-Focused Care to Meet Population Needs

TABLE 12-2 O perating Divisions of th e Department of H ealth and H uman Services

DIVISION PURPOSE

Administration for Children and Families (ACF)

Administration on Aging (AoA)

Agency for Healthcare Research and Q uality (AHRQ )

Agency for Toxic Substances and Disease Registry (ATSDR)

Centers for Disease Control and Prevention (CDC)

Centers for Medicare and Medicaid Services (CMS)

Food and Drug Administration (FDA)

Health Resources and Services Administration (HRSA)

Indian Health Service (IHS)

National Institutes of Health (NIH)

Office of the Inspector General (OIG)

Substance Abuse and Mental Health Services Administration (SAMHSA)

Promotion of the economic and social well-being of families, children, individuals, and communities

Development of a comprehensive, coordinated, and cost- effective system of home and community-based services that helps elderly individuals maintain their health and independence in their homes and communities

Improvement of the quality, safety, efficiency, and effectiveness of health care for all Americans

Assessment of hazardous waste sites, health consultation concerning specific hazardous substances, response to releases of hazardous substances, and education and training concerning hazardous substances

Creation of the expertise, information, and tools that people and communities need to protect their health through health promotion; prevention of disease, injury, and disability; and preparedness for new health threats

Administration of Medicare, Medicaid, and the Children’s Health Insurance Program

Regulation of medical products, tobacco, food safety, global regulatory operations and policies

Improvement of access to quality health care services for people who are uninsured, isolated, or medically vulnerable through strengthening the health workforce, building healthy communities, and improving health equity

Promotion of the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest possible level

Discovery and dissemination of fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce the burdens of illness and disability

Performance of audits, evaluations, investigations, and law enforcement efforts relating to HHS programs and operations

Promotion of economy, efficiency, and effectiveness of HHS programs and prevention or identification of fraud, waste, and abuse

Reduction of the impact of substance abuse and mental illness on America’s communities

The government sponsors programs to ease the effects of race, class, educational sta- tus, and poverty on health outcomes. Examples include the Healthy People Initiative, Medicare and Medicaid programs, Head Start, and the Children’s Health Insurance Program.

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Healthy People 20 20

The United States has goals and objectives that aim to decrease and eliminate illness and health care disparities. The Healthy People Initiative has produced four national reports on the health status of the nation and proposes health objectives for 10-year periods. Progress has been made in reducing coronary heart disease, cancer, incidence of AIDS, and syphilis. Healthy People 2020 (2011) includes four overarching goals aligned with public health, and none include direct medical care delivery (Box 12.12). Attainment of these goals would increase the overall health of the diverse U.S. citizens. Nurses who think family are aware of these objectives and include them in their practice. Family nurses know that their role includes using time with individuals as a way to target disparities and vulnera- bilities linked with family units.

Medicare, Medicaid, and O ther B enefits

Since the 1960s, laws have established several large health care programs. The programs provide health care access and payment for special groups who might otherwise forfeit med- ical care. In 1965, Medicare funding was signed into law to provide health care for citizens over age 65. Medicare Part A covers inpatient hospital care, hospice, home health care, and skilled nursing. Medicare Part B covers doctors, health provider services, home health, and durable medical equipment. Medicare Part C offers health care plans from private insurers. Medicare Part D helps cover the cost of prescription drugs. Many people do not pay for Medicare Part A, but most pay for Medicare Parts B, C, and D. The monthly Social Security income varies based on wages earned and age at the time of retirement. Intended only as a supplement to retirement income, it provides a meager living for those with no savings or pensions, and for those individuals health care coverage takes a large portion.

In 1965, Medicaid, another national health program for low-income persons, was cre- ated. State participation in Medicaid is voluntary; however, all states have participated since 1982. In some states, Medicaid is subcontracted to private companies, but others directly pay providers. States and counties vary in Medicaid provision but in most cases the benefit is closely regulated, time limited, and intended for the poor. Some families have difficulty finding medical providers or dentists who will accept Medicaid because reim- bursement to providers in some areas does not cover the cost of providing the care. Sick individuals often use high-cost local emergency departments as a safety net. Pharmaceutical choices and payments are regulated by a state formulary that identifies what can or cannot be prescribed.

In 1930, the Veterans Health Administration was established and is the largest integrated health care system. The Veterans Health Administration is divided into regions with

CHAPTER 12 ● Family-Focused Care to Meet Population Needs 343

BOX 12-12

Healthy People 2020 Goals

Healthy People 2020 tracks 1,200 objectives in 42 topic areas aimed at accomplishing four goals:

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

● Achieve health equity, eliminate disparities, and improve the health of all groups ● Create social and physical environments that promote good health for all ● Promote quality of life, healthy development, and healthy behaviors across all life stages

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medical centers and community-based outpatient clinics. Most veterans receive services free or with modest copayments. In 1921, the Snyder Act provided health services to Native American tribes. Today, the Indian Health Service (IHS), a division of the DHHS, has an annual appropriation near $4 billion and provides care to nearly 2 million Native Ameri- cans (Shi & Stevens, 2010). The IHS provides care for well over 500 tribal groups. Native Americans also qualify for health care funding through Medicare and Medicaid.

State Children’s Health Insurance Program

The state Children’s Health Insurance Program (CHIP) was enacted as part of the Balanced Budget Act of 1997 (Centers for Medicare and Medicaid Services, 2012). CHIP provides health coverage for children whose families earned too much to qualify for Medicaid benefits but who were still uninsured because of limited income. Like Medicaid, the federal government matches state spending; however, these funds are capped nationwide and each state receives an allotment. Millions of children are enrolled in Medicaid, and CHIP extends coverage to millions more. Yet, many eligible children are still not covered. Family-focused care implies that the complex needs, abilities, and availability of resources will be considered (Box 12.13).

Health Policy Development and Nurses’ Roles

Public policies aim to influence individual, family, population, and institutional behaviors. Health policy begins with agenda setting to guide disease prevention and health promotion initiatives at the local, state, and national levels (Milstead, 2013). Governments respond

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BOX 12-13

Evidence-Based Family Nursing

Clear communication with persons who have low literacy or low health literacy is important. Although information abounds and is easily accessible on the Internet, it is important that those needing specific information can understand it. A project titled Get a Head Start on Asthma developed a family-centered Web-based asthma education program for an urban multisite Head Start program. This is a federally funded child development program for low-income culturally diverse families with preschool children. A partnership was formed with low-income English, Hmong, and Spanish-speaking parents of preschool children (ages 3–5 years). Four project phases were assessment, review of 300 existing Web sites, development of a CD-ROM, and Web site development. Four literacy areas were addressed: functional literacy (acceptable reading level), language literacy (translation), health literacy (simple terminology), and computer literacy (ease of use, access). The goal was to address literacy levels of different families. Many knowledge gaps about asthma were identified. Many families did not have access to computers or the Internet or have any experience using computers. Web site design considered graphic layouts, color, graphics, aesthetics, information density, ease of navigation, and abilities with computer technologies. Asthma education was developed for diverse cultural and linguistic backgrounds. Parents needed support to gain better computer literacy skills. Study findings indicated that Web-based interventions have potential for family nurses to assist families with children with asthma, but also to help families with other chronic conditions.

Source: Garwick, A., Seppelt, A., & Belew, J. L. (2011). Addressing family health literacy to create a family-centered culturally relevant web-based asthma education project. In E. K. Svavarsdottir & H. Jonsdottir (Eds.), Family nursing in action (pp. 251–266). Reykjavik, Iceland: University of Iceland Press.

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to identified problems with legislation, regulation, and programs. Government officials have responsibility to safeguard public health, but local citizens can engage in advocacy that shapes health policy. Nurses can have strong voices and communicate needs to local representatives and elected officials.

The world of health care is a vineyard of intertwined systems that rarely, if ever, interact or communicate with one another. Policies are written by government agencies, independ- ent provider groups, foundations, and advocacy groups. The policy process includes pro- gram implementation and involves such national agencies as the Centers for Medicare and Medicaid Services (CMS). Other state and local health departments, hospitals, and health care delivery systems are part of the process.

Changes in public attitudes and values are often the impetus for policy changes. The Centers for Disease Control and Prevention (2011a) reports that tobacco use is responsible for more deaths than HIV infection, illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders combined. The CDC considers tobacco use to be the leading pre- ventable cause of death in the United States. Although no federal bans have been issued on smoking or production of tobacco products, most states have established laws that ban tobacco use in workplaces, restaurants, businesses, and bars, and on college campuses. Some states have increased their tobacco taxes, making it more difficult to continue tobacco use or for teens to buy tobacco products (U. S. Department of Health and Human Services, 2012). Federal and state laws limit the sale of tobacco products to adults. Yet, the American people continue to use tobacco products, often starting use as early as adolescence.

Public health and other nurses can provide information pertinent to public policies at a variety of stages (Milstead, 2013). Nursing is viewed as one of the most trusted occupa- tional groups. Legislators are willing to meet with and listen to nurses, especially through annual state and national Nursing Day on the Hill venues. Nurses who think family can be strong advocates for the nation’s families. Legislators often have nurses on their staffs to help answer policy issues from their constituents. Registered nurses and student nurses can write their legislators about pending legislation affecting nurses and health care. Organizations such as the American Nurses Association, the National League for Nursing, the American Association of Colleges of Nursing, and the National Student Nurses Asso- ciation often send newsletters and e-mails asking nurses to write to their senators and rep- resentatives about pending legislation. Nurses who think family can be advocates for family health and emphasize the links with individual and community needs.

Family nurses can learn about policy through formal coursework and education. It is useful to stay abreast of current issues affecting individual and family health. Policy in- ternships in Washington, D.C., are available and one can become a member of an advocacy group. Some believe that population health should be a key concern linked to all national policies (Mayes & Oliver, 2012). This means that all policies would focus on the specific ways health needs should be included or addressed. Family nurses can be change agents and important advocates in bringing concerns to local government and regional represen- tatives. Civic responsibility can entail knowledge of one’s neighborhood and acting for positive health outcomes where you live.

Chapter Summary

This chapter discusses community and population perspectives. Ways in which individ- ual, family, and societal health are linked are described. Nurses caring for individuals in acute and primary care settings can easily overlook the ecological factors and influ- ences of larger environments. Thinking family implies awareness of how the ecological

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contexts of neighborhood, community, and society are integral parts of health and illness risks. As individuals and families live in their households, they meet the upstream op- portunities to promote health and prevent disease. People are influenced by many factors outside their volition. Levels of motivation, locus of control, and other personal factors play health and illness roles, but environmental and social factors outside their control are also influential. Nurses who think family recognize that they can empower those they meet to consider the larger picture of what makes people healthy and ways they get sick. If the goal is family-focused care, then it is essential for nurses to see that fam- ilies are equipped to think beyond “medicalized care” as their only resource. Family- focused nurses are adept at assisting individuals to access what they need in their community. Family nurses can teach families how to advocate for fair distribution of health services. Family nurses who are knowledgeable about the community and popu- lation health can be leaders in moving away from a sick care system.

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